ciliochoroidal detachment and pseudop hakos imp la ntation Lyle Moses, M.D. Cleveland, Ohio The combination of hypotony and trauma (e.g., surgery) may lead to ciliochoroidal detachment.! Swelling and elevation of choroidal tissue results from a sudden decrease of external pressure. This in turn leads to an engorgement of anterior uveal blood sinuses, and a serum-like transudation through the thin-walled sinuses. 2 ,3 Presence of a ciliochoroidal detachment with a wound leak can be understood on the basis of an absence of external pressure. Less easily comprehended is the forward pressure of vitreous and iris when a wound leak is absent. Ciliochoroidal detachment within the first postoperative" week is frequently overlooked and is probably rather common.4 Detachment during weeks 2 and 3 may have a 5 to 8% incidence, s and is commonly associated with wound leak, slow wound healing, or wound rupture. There is usually a shallow anterior chamber, lobular choroidal detachment, and hypotony. Detachment occurring months or years after surgery has a similar picture. While a ciliochoroidal detachment frequently disappears in 2 to 3 weeks, persistance of a shallow or flat anterior chamber for more than 7 days may lead to permanent peripheral anterior synechiae and secondary glaucoma. An adequately-sutured wound, free of iris, vitreous, and lens remnants, is the best prophylaxis. A soft eye preoperatively will avoid a precipitous fall of intraocular pressures. Medical treatment with cycloplegics, Diamox, and/or hyperosmotics is of relatively little help. If the problem persists for more than 7 days, surgery is usually indicated, namely, suprachoroidal tap, air injection into the anterior chamber, and repair of the wound leak, if present. Ciliochoroidal detachment with a pseudophakos in the anterior chamber takes on an added dimension. Mechanisms for the detachment would naturally be the same with or without an implant. However, if the anterior chamber shallows and plastic touches posterior cornea, endothelial cells are destroyed, resulting in loss of corneal clarity at the site of touch. 6 If the implant touches cornea centrally, the anterior chamber must be deepened immediately, even if that necessitates removal of the lens. If the implant touches only at small peripheral areas of the cornea, correction is still needed, but perhaps not as quickly. I have observed 2 cases of ciliochoroidal detach-
ment out of 648 pseudophakos implantations (0.3% incidence) with up to 38 months follow-up. Case Report #1 L.K.: 61 year-old female. Uncomplicated intracapsular extraction. Iris-plane lens. No vitreous loss. Wound closed with 9 interrupted 9-0 silk sutures. Quiet post-op course (mild iritis; APL 10) until 3'h weeks: shallow anterior chamber; APL 6; no wound leak; no vitreous attached to wound; increased iritis and corneal edema; inferior ciliochoroidal detachment; lips of the anterior lens haptics touched peripheral cornea. Treated with oral and topical steroids. The chamber gradually deepened in 7 days and the cornea cleared in another 3 days; detachment gone. Final vision 20/25; APL 14. Fig. 1 shows the eye after resolution: A small vertical corneal opacity is seen near the 9:00 limbus (the tip of the nasal haptic touched endothelium at this point); a similar opacity is present at the 3 :00 position.
Fig. 1 (Moses, L.) Case #1. Corneal opacity from lens touch after resolution of choroidal detachment.
Case Report #2 F .E.: 86 year-old female. Uncomplicated intracapsular extraction. Binkhorst iris-clip lens. No vitreous loss. Wound closed with 12 interrupted 9-0 silk sutures. 9 days post-op: moderate iritis; deep chamber; APL 12. From 2nd to 4th post-op weeks: shallower anterior chamber; lens not touching cornea; no wound leak; no vitreous attached to wound; no choroidal detachment seen; APL 12. 5th post-op week: painful, injected eye; edematous cornea; flat anterior chamber; optical portion of lens touching corneal endothelium; APL 70; choroidal detachment present by B-scan ultrasonography (Fig. 2). Treatment: hyperosmotics; suprachoroidal tap; removal of implant. The intraocular pressure subsequently normalized, but the cornea remained cloudy. Case #1 resolved itself, as do most cases of ciliochoroidal detachment. The two peripheral areas 57
ment must be contemplated. Depending upon the type of implant and its relationship to the corneal endothelium, early surgical intervention may be indicated. Bibliography
Fig. 2 (Moses, L.) Case #2. Bronson B-scan of choroidal detachment.
of lens-cornea touch were no threat to the corneal integrity and the resultant small opacities were well away from the visual axis. There was no need for surgical intervention. Case #2 apparently had an early, non-visible detachment during weeks 2 to 4; however, in the absence of a wound leak or lens-cornea touch, surgical intervention was not indicated. During the following week, the detachment enlarged, pushing vitreous, iris, and lens forward. Without a wound leak and in the presence of a closed chamber angle, the intraocular pressure rose. When the eye was softened with hyperosmotics and the chamber failed to reform, the suprachoroidal space was tapped. When the chamber didn't deepen spontaneously, there was a choice of forming the chamber with air or saline and leaving the implant in place, or of opening the chamber and removing the lens. Since the eye had sustained a very high pressure with possible angle damage, the decision was made to remove the implant, even though a keratoplasty was in the future with or without implant removal. "Looking through the retrospectroscope," since the pressure had normalized postoperatively, perhaps the implant could have peen left in place--??? Summary Ciliochoroidal detachment perhaps occurs more frequently than is actually recognized and/or looked for. The majority of cases spontaneously resolve without sequelae. A pre-operatively soft eye and a well-closed, clean wound are the best prophylactic measures; even then, detachment may not be prevented. Perhaps something could be said for the lower incidence of wound separation when the limbal incision is small. Extreme caution and care must be exercised when the plastic lens approaches corneal endothelium. The possibility of ciliochoroidal detach58
1. Capper, S.A., and Leopold, I.H.: Mechanism of serous choroidal detachment; a review and experimental study, Arch. Ophthalmol, 55:101-113, 1956. 2. Spaeth, E.B., and DeLong, P.: Detachment of the choroid. A clinical and histopathologic analysis, Arch. Ophthalmol. 32:217-238,1944. 3. Hagen, S.: Die serose postoperative Chorioidealablo surg und ihre Pathogenese, Klin, Mbl. Augenheilk, 66:161-211, 1921. 4. O'Brien, C.S.: Further observations on detachment of the choroid after cataract extraction, Arch. Ophthalmol. 16:655-656, 1936. 5. Jaffe, N.S.: Cataract surgery and its Complications, St. Louis, 1976, The C. V. Mosby Co., p. 215. 6. Katz, J.; Kaufman, H.E., Goldberg, E.P., and Sheets, J.W.: Prevention of endothelial damage from intraocular lens insertion, Trans. Am. Acad. Ophthalmol. Otolargyngol. 83:204,1977.
ment out of 648 pseudophakos implantations (0.3% incidence) with up to 38 months follow-up. Case Report #1 L.K.: 61 year-old female. Uncomplicated intracapsular extraction. Iris-plane lens. No vitreous loss. Wound closed with 9 interrupted 9-0 silk sutures. Quiet post-op course (mild iritis; APL 10) until 3'h weeks: shallow anterior chamber; APL 6; no wound leak; no vitreous attached to wound; increased iritis and corneal edema; inferior ciliochoroidal detachment; lips of the anterior lens haptics touched peripheral cornea. Treated with oral and topical steroids. The chamber gradually deepened in 7 days and the cornea cleared in another 3 days; detachment gone. Final vision 20/25; APL 14. Fig. 1 shows the eye after resolution: A small vertical corneal opacity is seen near the 9:00 limbus (the tip of the nasal haptic touched endothelium at this point); a similar opacity is present at the 3 :00 position.
Fig. 1 (Moses, L.) Case #1. Corneal opacity from lens touch after resolution of choroidal detachment.
Case Report #2 F .E.: 86 year-old female. Uncomplicated intracapsular extraction. Binkhorst iris-clip lens. No vitreous loss. Wound closed with 12 interrupted 9-0 silk sutures. 9 days post-op: moderate iritis; deep chamber; APL 12. From 2nd to 4th post-op weeks: shallower anterior chamber; lens not touching cornea; no wound leak; no vitreous attached to wound; no choroidal detachment seen; APL 12. 5th post-op week: painful, injected eye; edematous cornea; flat anterior chamber; optical portion of lens touching corneal endothelium; APL 70; choroidal detachment present by B-scan ultrasonography (Fig. 2). Treatment: hyperosmotics; suprachoroidal tap; removal of implant. The intraocular pressure subsequently normalized, but the cornea remained cloudy. Case #1 resolved itself, as do most cases of ciliochoroidal detachment. The two peripheral areas 57
ment must be contemplated. Depending upon the type of implant and its relationship to the corneal endothelium, early surgical intervention may be indicated. Bibliography
Fig. 2 (Moses, L.) Case #2. Bronson B-scan of choroidal detachment.
of lens-cornea touch were no threat to the corneal integrity and the resultant small opacities were well away from the visual axis. There was no need for surgical intervention. Case #2 apparently had an early, non-visible detachment during weeks 2 to 4; however, in the absence of a wound leak or lens-cornea touch, surgical intervention was not indicated. During the following week, the detachment enlarged, pushing vitreous, iris, and lens forward. Without a wound leak and in the presence of a closed chamber angle, the intraocular pressure rose. When the eye was softened with hyperosmotics and the chamber failed to reform, the suprachoroidal space was tapped. When the chamber didn't deepen spontaneously, there was a choice of forming the chamber with air or saline and leaving the implant in place, or of opening the chamber and removing the lens. Since the eye had sustained a very high pressure with possible angle damage, the decision was made to remove the implant, even though a keratoplasty was in the future with or without implant removal. "Looking through the retrospectroscope," since the pressure had normalized postoperatively, perhaps the implant could have peen left in place--??? Summary Ciliochoroidal detachment perhaps occurs more frequently than is actually recognized and/or looked for. The majority of cases spontaneously resolve without sequelae. A pre-operatively soft eye and a well-closed, clean wound are the best prophylactic measures; even then, detachment may not be prevented. Perhaps something could be said for the lower incidence of wound separation when the limbal incision is small. Extreme caution and care must be exercised when the plastic lens approaches corneal endothelium. The possibility of ciliochoroidal detach58
1. Capper, S.A., and Leopold, I.H.: Mechanism of serous choroidal detachment; a review and experimental study, Arch. Ophthalmol, 55:101-113, 1956. 2. Spaeth, E.B., and DeLong, P.: Detachment of the choroid. A clinical and histopathologic analysis, Arch. Ophthalmol. 32:217-238,1944. 3. Hagen, S.: Die serose postoperative Chorioidealablo surg und ihre Pathogenese, Klin, Mbl. Augenheilk, 66:161-211, 1921. 4. O'Brien, C.S.: Further observations on detachment of the choroid after cataract extraction, Arch. Ophthalmol. 16:655-656, 1936. 5. Jaffe, N.S.: Cataract surgery and its Complications, St. Louis, 1976, The C. V. Mosby Co., p. 215. 6. Katz, J.; Kaufman, H.E., Goldberg, E.P., and Sheets, J.W.: Prevention of endothelial damage from intraocular lens insertion, Trans. Am. Acad. Ophthalmol. Otolargyngol. 83:204,1977.
