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Choroidal Effusion/Detachment

URGENT — Retina

Symptoms

Presentation

  • Decreased vision or asymptomatic (common in serous cases).
  • Significant vision loss if the detachment involves the macula or extends posteriorly.

Hemorrhagic features

  • Sudden onset of red eye.
  • Moderate-to-severe ocular pain.

Clinical Findings

Hallmark appearance

  • Smooth, bullous, lobular elevations of the peripheral retina and choroid.
  • Serous: Orange-brown hue; Hemorrhagic: Dark reddish-brown hue.
  • Lobular configuration (four quadrants) separated by vortex vein ampullae distinguishes this from retinal detachment.

Classic clinical signs

  • Ora serrata visible without scleral depression: The detached choroid displaces the peripheral retina anteriorly.
  • "Kissing choroidals": Large lobules touch centrally in the vitreous cavity; apposing retinas may suffer secondary damage.

Serous detachment

  • Low intraocular pressure (IOP), often <6 mmHg (hypotony).
  • Shallow anterior chamber (AC) with mild cell and flare.
  • Positive transillumination (fluid allows light to pass).

Hemorrhagic detachment

  • Variable IOP (may be elevated) with acute pain.
  • Negative transillumination (blood blocks light).
  • Associated with rapid onset, typically intra- or postoperatively.

B-scan ultrasound

  • Confirms suprachoroidal fluid between the choroid and sclera.
  • Distinguishes serous (echolucent/black) from hemorrhagic (hyperechoic/white) material.
  • Detects the "T-sign" in Tenon’s space if posterior scleritis is present.

Etiology

Serous causes

  • Postoperative: Wound leak, over-filtering blebs, or cyclodialysis clefts.
  • Inflammatory: Posterior uveitis or scleritis.
  • Traumatic: Associated with globe rupture or scleral perforation.
  • Other: Nanophthalmos, uveal effusion syndrome, or carotid-cavernous fistula.

Hemorrhagic causes

  • Intraoperative: Anterior displacement of ocular contents causing rupture of short posterior ciliary arteries.
  • Spontaneous: Associated with corneal ulcer perforation, uncontrolled hypertension, or anticoagulation use.

Red Flags

  • Appositional ("kissing") retinas: Mandates urgent surgical drainage to prevent permanent damage.
  • Postoperative flat AC with hypotony: Requires immediate management to protect the cornea and lens.
  • Spontaneous hemorrhagic detachment: Rule out underlying intraocular tumor (melanoma).
  • Nanophthalmic eyes: High risk for uveal effusion; requires specialized surgical approaches.

Investigations

Clinical examination

  • Slit-lamp: Perform Seidel test to identify wound/bleb leaks.
  • Gonioscopy: Inspect the angle for a cyclodialysis cleft.
  • Dilated fundus exam: Check for concomitant retinal detachment or underlying tumors.

Imaging

  • B-scan ultrasound: Essential to differentiate serous vs. hemorrhagic and track resolution.
  • Transillumination: To help distinguish fluid from solid masses or blood.

Treatment

Medical management

  • Topical cycloplegic: Atropine 1% TID to deepen the AC and rotate the ciliary body.
  • Topical steroid: Prednisolone acetate 1% (4–6×/day) to reduce inflammation.
  • Systemic: Consider oral steroids if the cause is primary inflammatory disease.

Underlying cause

  • Repair wound leaks or revise filtering blebs.
  • Close cyclodialysis clefts via laser or surgery.

Surgical drainage

  • Indications: Persistent kissing choroidals, appositional retina, or corneal decompensation from lens-cornea touch.

Clinical Pearl

Kissing choroidals with a flat AC after surgery are usually driven by hypotony. Management focuses on deepening the chamber and fixing the leak; drainage is reserved for persistent appositional retinas.

Differential Diagnosis

  • Melanoma of the ciliary body or choroid
  • Rhegmatogenous retinal detachment (RRD)
  • Exudative retinal detachment
  • Suprachoroidal hemorrhage
  • Choroidal metastasis

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