Concurrent ciliary body detachment in patients presenting with serous choroidal detachment following glaucoma surgery.

PURPOSE: To examine the rate of ciliary body detachment in patients with choroidal detachment following glaucoma surgery and its effect on the clinical course, management, and prognosis. METHODS: A prospective observational case-series study. Patients with choroidal detachment following glaucoma surgery in 2018-2019 were included. All underwent complete ophthalmological examination and ultrasound biomicroscopy for evaluation of the presence and extent of ciliary body detachment. Follow-up examinations including ultrasound biomicroscopy scans were performed at 1 week, 1 month, 3 months, and 6 months. RESULTS: Eight patients (8 eyes) were enrolled, 4 male and 4 female, of mean age 72 years (range 60-83). Five patients underwent trabeculectomy with mitomycin C (0.02%), which was combined with phacoemulsification cataract extraction in one; two underwent Ahmed glaucoma valve implantations, and one underwent ab-interno Xen45 gel stent implantation with mitomycin C (0.02%). The mean intraocular pressure was 26.0 ± 7.65 mmHg preoperatively, dropping to 6.9 ± 2.64 mmHg on first postoperative day one. Mean time from surgery to diagnosis of choroidal detachment was 11.6 ± 5.73 days. Ciliary body detachment was identified by ultrasound biomicroscopy in all patients, ranging between one and four quadrants. All patients were treated with topical steroids and cycloplegics; three (37.5%) received oral steroids. No surgical intervention for the choroidal or ciliary body detachments was indicated. CONCLUSIONS: In this real-world prospective study, concurrent ciliary body detachment was identified in all patients who presented with choroidal detachment following glaucoma surgery. This observation may deepen our understanding of the mechanism underlying the hypotony that is often seen after glaucoma surgery.

Spontaneous resolution of long-standing choroidal effusion after glaucoma drainage implant surgery without significant visual deterioration : a case report.

BACKGROUND: Choroidal effusion is a common complication of glaucoma surgery. Although most cases of choroidal effusions resolve spontaneously with observation or medical management alone as intraocular pressure normalizes, surgical drainage might be needed in severe or persistent cases. Herein, we report a case of spontaneous resolution of long-standing severe choroidal effusion after Ahmed glaucoma valve implantation. CASE PRESENTATION: An 85-year-old man with uncontrolled primary open-angle glaucoma and medical history of chronic kidney disease underwent uneventful Ahmed glaucoma valve implantation. On postoperative day 8, transient hypotony occurred, and large 360° peripheral choroidal detachments developed. Although the intraocular pressure increased to normal levels on postoperative day 15, choroidal effusion did not resolve. Fundus examination over 8 months showed that the large choroidal effusion persisted despite a well-controlled intraocular pressure. Laboratory test performed at preoperatively and follow-up period revealed persistently elevated potassium and creatinine levels. On postoperative 9 months, the lesion resolved spontaneously without any surgical intervention. We found that the patient's creatinine level was normalized, pre-existing hyperkalemia was corrected, and accordingly his general condition was improved. CONCLUSIONS: Considering the underlying medical condition may be helpful in patients with persistent choroidal effusion of an unclear etiology following glaucoma filtering surgery.

Prospective cohort study of risk factors for choroidal detachment after trabeculectomy.

PURPOSE: To investigate risk factors for choroidal detachment after trabeculectomy. METHODS: We prospectively evaluated 97 patients with open-angle glaucoma who underwent primary trabeculectomy to investigate risk factors for choroidal detachment after trabeculectomy. The primary outcome measure was risk factors for the occurrence and severity of choroidal detachment after trabeculectomy. Choroidal detachment severity was quantified as the number of fundus quadrants with choroidal detachment. RESULTS: Sixteen patients (16.5%) had choroidal detachment. Mean period between surgery and occurrence of choroidal detachment was 7.9 ± 5.7 days. Mean intraocular pressure (IOP) on the first day of choroidal detachment was 6.1 ± 3.0 mm Hg. Multivariable analyses revealed that the exfoliation glaucoma, greater ΔIOP between preoperative and lowest postoperative IOPs, and thicker cornea were associated with choroidal detachment (P = 0.022, P = 0.002, and P = 0.013, respectively). These factors were also associated with the severity of choroidal detachment (exfoliation glaucoma; P = 0.013, greater ΔIOP; P < 0.001, and thicker cornea; P = 0.006). CONCLUSIONS: Exfoliation glaucoma, more IOP reduction, and thicker cornea are associated with the occurrence and severity of choroidal detachment after trabeculectomy.

Quadrantic vortex vein decompression with subretinal fluid drainage for manangement of Nanophthalmic choroidal effusions- a review of literature and case series.

BACKGROUND: Uveal effusion syndrome is a rare entity of idiopathic exudative detachments of uveal tissues and retina. Medical treatments with systemic steroids and antimetabolites have been tried but with variable results. Scleral windows or vortex decompressions are usually performed and surgeons usually perform partial sclerectomy in all the quadrants. CASE PRESENTATION: For the first time, we report 2 cases of nanophthalmic uveal effusion syndrome managed with our technique. CONCLUSION: Quadrantic vortex vein decompression with external drainage for nanophthalmic uveal effusion can provide immediate and stable gain in vision.

Angiographic features of drug-induced bilateral angle closure and transient myopia with Ciliochoroidal effusion.

BACKGROUND: To report five cases of acute drug-induced angle closure and transient myopia with ciliochoroidal effusion and to analyze angiographic findings of these cases. METHODS: This study is an observational case series. Five patients with acute drug-induced angle closure and transient myopia with ciliochoroidal effusion were examined by fluorescein angiography, indocyanine green angiography (ICGA) and ultrasound biomicroscopy (UBM). RESULTS: Five patients presented with bilateral visual loss and ocular pain after intake of topiramate, methazolamide, phendimetrazine tartrate or mefenamic acid. All patients showed elevated intraocular pressure (IOP) with shallow anterior chamber and myopic shift from - 0.5 to - 17.0 diopters (D). UBM showed ciliochoroidal effusions with diffuse thickening of the ciliary body in all cases. Rapid normalization of IOP and decrease of myopic shift occurred in all patients after discontinuing the suspected drugs. We classified the ICGA findings into 2 major signs (hypofluorescent dark spots, hyperfluorescent pinpoints) and 3 minor signs (diffuse choroidal hyperfluorescence, early hyperfluorescence of choroidal stromal vessel, and leakage and dilated retinal vessels). CONCLUSIONS: The pathogenesis of acute drug-induced angle closure and transient myopia with ciliochoroidal effusion may be idiosyncratic reaction of uveal tissue to systemic drugs. Accumulation of extravascular fluid in the ciliochoroidal layer had a major role in the pathogenesis. ICGA could be a useful method to examine the pathophysiology of this condition by imaging of the choroidal layer.

Appositional Choroidal Detachment Following XEN45 Gel Stent Requiring Surgical Drainage.

An 82-year-old man with severe primary open-angle glaucoma on maximal medical therapy underwent an ab externo closed conjunctival Xen45 device insertion with mitomycin C. The surgery was uncomplicated, with a first postoperative day intraocular pressure of 4 mm Hg and visual acuity of 20/40 OD. Ten days later, the patient presented with an intraocular pressure of 5 mm Hg and a visual acuity of counting fingers at 5 feet. Examination showed Seidel negative bleb, shallow anterior chamber, and large nonappositional choroidal detachments. Medical therapy with steroids and cycloplegia was initiated. One week later, the serous choroidal detachments became appositional, and Xen explantation and surgical drainage of the choroidal detachment was performed. Postoperatively, the vision improved to 20/60. Significant choroidal detachments can occur after XEN45 implantation requiring surgical intervention.

Unilateral Idiopathic Choroidal Effusion in a Patient Who Takes Sulfonamides.

Purpose: To report a challenging case of unilateral choroidal effusion.Methods: A case report about patient who presented with unilateral choroidal effusion and who was taking sulfonamides. Patient has been under care of a multidisciplinary team of uveitis consultant, ocular oncology consultant, and systemic oncology consultant. A comprehensive workup was done (blood tests, Spectralis OCT, FFA, chest X-rays, MRI, PETCT).Results: Baseline visual acuity on the affected (right) eye was 6/12. Patient is amblyopic and hypermetropic on that eye. Blood test results were negative on syphilis, tuberculosis, or sarcoidosis. MRI showed no mass lesions. PETCT scan showed no signs of malignant process out of the eye. Suprachoroidal drainage was done and analysis of the drainaged fluid showed no presence of malignant cells. Overall workup period patient's vision was stable.Conclusion: Definite diagnosis of unilateral choroidal effusion was done. A comprehensive workup is needed to exclude potential malignant process.

Choroidal Detachment following an Intravitreal Injection in a Patient with Vogt-Koyanagi- Harada Disease.

Purpose: To report a unique case of choroidal detachment following an intravitreal injection in a patient with Vogt-Koyanagi-Harada (VKH) disease.Methods: A 33-year-old male, a known case of chronic VKH disease for 9 years developed an inflammatory choroidal neovascular membrane (CNVM) in the right eye. Following an intravitreal ranibizumab injection, he reported loss of vision 2 days later. Clinical examination revealed hypotony with annular serous choroidal detachment.Results: Following an intensive systemic corticosteroid therapy, there was a complete resolution of choroidal detachment and restoration of visual acuity at 1 week of follow up. The subretinal fluid and cystic spaces due toCNVM also resolved completely.Conclusion: This is the first report of a patient with VKH disease developing choroidal detachment following an uncomplicated intravitreal injection of ranibizumab for an inflammatory CNVM.

Acute angle-closure glaucoma with choroidal effusion revealing a hantavirus infection: Description of ultrasound biomicroscopy imagery and optical coherence tomography Visante.

PURPOSE: To report a case of bilateral angle-closure associated with systemic hantavirus infection. MATERIALS AND METHODS: A 32-year-old Caucasian man was referred with blurred vision, fever, cough, dyspnea and thrombocytopenia. Ophthalmologic examination revealed myopic shift, elevated intraocular pressure (30 mmHg right eye and 24 mmHg left eye), corneal edema, iridocorneal angle closure and shallow anterior chamber. Ciliochoroidal effusion was detected on anterior segment optical coherence tomography and ultrasound biomicroscopy. Serologic test and polymerase chain reaction confirmed the diagnosis of hantavirus infection and the serotype Puumala. On the sixth day after he started topical anti-glaucoma and cycloplegic medications, the anterior chamber and iridocorneal angles were normalized with disappearance of ciliochoroidal effusion. CONCLUSION: Puumala hantavirus infection is an exceptional cause of acute bilateral angle-closure combined with ciliochoroidal effusion.

Familial Nanophthalmos Presenting with Spontaneous Uveal Effusion Syndrome.

Purpose: To report two unique cases of spontaneous uveal effusion syndrome (UES) from the same family.Methods: The patients included father (54 years old) and a daughter (23 years old). The father presented 7 years ago with bilateral exudative retinal detachment, nanophthalmic eyes (axial length 16.11 mm and 16.43 mm in right and left eyes, respectively) with hypermetropia, and a thickened sclera on MRI. The daughter presented with left eye peripheral exudative annular retinal detachment with bilateral nanophthalmos (axial length 20.7 mm and 20.33 mm, in right and left eyes, respectively), with MRI showing ciliochoroidal detachment, suprachoroidal effusion and mild thickening of the sclera in left eye.Results: The father underwent subscleral sclerectomy in the left eye that led to resolution of submacular fluid. Scleral biopsy confirmed the deposition of glycosaminoglycans on Alcian blue stain. The daughter was kept under observation, because of absence of any macular subretinal fluid, and counselled about the familial nature of the disease and possible need for future intervention.Conclusion: This is the first report of familial nanophthalmos presenting with spontaneous UES.

A Retrospective Case Series of Uveal Effusion Syndrome.

PURPOSE: This study aimed to describe the clinical findings and management of eyes affected by uveal effusion syndrome. METHODS: We retrospectively evaluated the charts of 13 eyes of 8 consecutive patients diagnosed with uveal effusion syndrome attending the Ophthalmology Unit of the University Hospitals Leuven, Belgium, between 2007 and 2018. The presenting features, investigations, management, and outcomes were analyzed for each case. RESULTS: Cataract surgery was the predisposing factor for uveal effusion in 6 eyes, 2 bilateral uveal effusions (4 eyes) were considered to be medication-induced, and in 3 eyes, the uveal effusion was described as idiopathic. Fundus examination of 5 of 13 eyes showed bullous choroidal detachment, treated with pars plana vitrectomy with superotemporal sclerectomy or transscleral punction. Fundoscopy showed uveal effusion without serous retinal detachment in 3 eyes. Serous retinal detachment accompanied by uveal swelling was observed in 3 eyes and the 2 remaining eyes presented with uveal swelling only. The 8 nonbullous choroidal detachments were treated in a conservative way. A rapid resolution of subretinal fluid and uveal effusion was observed in all cases. CONCLUSIONS: A conservative approach with acetazolamide treatment or just observation was used in our case series in choroidal detachment without substantial visual loss if, over time, slow improvement was documented. However, further studies are needed to verify the effectiveness of the reported therapy.

Pembrolizumab-related Bilateral Ocular Hypotony, Uveitis, Cataracts, Exudative Retinal, and Choroidal Detachments: An Unusual Success Story.

Here, we report the presentation and management of a rare case of sight-threatening bilateral panuveitis with secondary chronic hypotony, subcapsular cataracts, exudative retinal detachments, and choroidal detachments, following initiation of pembrolizumab immunotherapy for metastatic melanoma. An 82-year-old white woman presented with painful, blurry vision 3 days after initiation of pembrolizumab immunotherapy. She had developed a marked panuveitis causing secondary hypotony. The fundal view was entirely limited by acutely dense cataracts and small, uveitic pupils unresponsive to topical dilation. Urgent cataract surgery with intravitreal dexamethasone implant (Ozurdex) was completed successfully and allowed a fundal examination. This revealed bilateral, symmetrical, inferior exudative retinal detachments, and choroidal detachments secondary to chronic hypotony. After 3 months of observation and cessation of oral steroids, the panuveitis remains quiescent, hypotony persists, and the choroidal and retinal detachments are showing progressive self-resolution. The current best-corrected visual acuity is 6/24 OU. She remains under close monitoring. The immune checkpoint inhibitor, pembrolizumab, has been reported to cause sight-threatening adverse effects. We report a rare case of profound bilateral complications treated successfully with oral and intravitreal steroids. To the authors' knowledge, this has not previously been reported in the literature. Ophthalmologists and oncologists should be aware of the ocular effects of pembrolizumab and be able to identify various complications early. Here, cataract surgery with a steroid implant has been an effective sight-saving intervention. The promising visual outcome makes this an unusual success story.

A Case of Delayed-onset Hemorrhagic Choroidal Detachment After PreserFlo Microshunt Implantation in a Glaucoma Patient Under Anticoagulant Therapy.

PURPOSE: To describe a case of delayed-onset hemorrhagic choroidal detachment (HCD) in a patient affected by primary open-angle glaucoma (POAG) undergone PreserFlo Microshunt implantation. CASE REPORT DESCRIPTION: A 76-year-old patient with POAG, under treatment with Dabigatran (a novel oral anticoagulant), underwent an uncomplicated PreserFlo Microshunt implantation in the left eye. In the first postoperative day, intraocular pressure (IOP) was 6 mm Hg, conjunctival bleb was diffuse, anterior chamber (AC) deep, and device correctly positioned. Twelve days after surgery, the patient had emergency access complaining severe ocular pain and sudden vision loss. Ophthalmological evaluation revealed shallow AC and an IOP of 50 mm Hg. The fundus examination revealed almost kissing HCD. OUTCOME: Immediate topical treatment with atropine, aqueous humor suppressants, and corticosteroids was started. Because of high IOP, ocular pain, and the presence of almost kissing HCD, surgical drainage of suprachoroidal hemorrhage and removal of PreserFlo Microshunt were performed. An improvement of the clinical condition was observed in the following postoperative days, with partial resolution of the HCD and a decrease of the IOP. On the third postoperative day, there was a worsening of the HCD, with a reduction of the AC depth and IOP elevation. HCD was drained through the previously performed sclerotomies, associated with pars-plana vitrectomy and silicone-oil tamponade. HCD completely resolved during the following 6 weeks, with IOP reduction and partial improvement of visual acuity. CONCLUSION: Great attention must be taken in patients with glaucoma under treatment with a novel oral anticoagulant, also when planning PreserFlo Microshunt implantation.

Late Choroidal Effusion after Phacoemulsification in Eyes with Previous Trabeculectomy.

AIM: To present 5 cases of late choroidal detachment occurring spontaneously in pseudophakic glaucomatous eyes with previous trabeculectomy before cataract surgery. We discuss the causes, risk factors, frequency, diagnostic methods, differential diagnosis, and treatment of this disease. MATERIALS AND METHODS: In the presented 5 cases the choroidal effusion is proved by ophthalmoscopy and echography. Late choroidal detachment occurs after phacoemulsification 6 months at the earliest and 9 years at the latest (mean period 2.5 years) in glaucomatous eyes with previous trabeculectomy. To prove choroidal detachment we accomplished routine ophthalmological examination including medical history, visual acuity, tonometry, examination of anterior segment (AS) and fundus. We have done B-scan echography using А/В Ocular Ultrasound Aviso Quantel Medical. RESULTS: One of the patients had hemorrhagic detachment confirmed by B-scan echography, the other four patients had serous detachment. The examined patients had the glaucomatous disease for 10.4±6.11 years (mean±SD). Mean age at the time of choroidal effusion diagnosis was 76.8±7.6 years (68-87 years). The period between the trabeculectomy and the following phacoemulsification was 6±3.08 years (from 1 to 9 years). All patients received anti-glaucomatous topical therapy, including carbonic anhydrase inhibitors, before the occurrence of the effusion. In all cases conservative treatment with corticosteroids and cycloplegics was enough to overcome the detachment and restore visual acuity. CONCLUSION: Late choroidal effusion after phacoemulsification in eyes with previous trabeculectomy is associated with an application of unjustified powerful hypotensive topical medications after cataract surgery associated with an additional reduction of intraocular pressure in most cases.

Anatomic Outcomes and Prognostic Factors of Vitrectomy in Patients with Primary Rhegmatogenous Retinal Detachment Associated with Choroidal Detachment.

PURPOSE: This study was undertaken to assess the associations between the anatomic outcomes of patients who underwent vitrectomy for rhegmatogenous retinal detachment associated with choroidal detachment (RRDCD) and their preoperative variables. METHODS: A total of 175 patients with RRDCD who underwent vitrectomy in one eye were included in the analysis. The primary outcome measured was the retinal status after primary vitrectomy and at the end of follow-up. RESULTS: The retinal reattachment rate was 72.57% after primary surgery, and the final total reattachment rate was 89.14% after follow-up. Binary logistic regression analysis identified that the retinal reattachment rate after primary vitrectomy was significantly associated with older age (odds ratio = 1.03, p = 0.02), mild proliferative vitreoretinopathy (PVR) (PVR grade C vs. PVR grades A-B: odds ratio = 0.31, p = 0.04; PVR grade D vs. PVR grades A-B: odds ratio = 0.03, p < 0.01), and intravitreal steroid treatment (odds ratio = 4.60, p = 0.02), and that the final retinal reattachment rate was independently associated with older age (odds ratio = 1.05; p = 0.01). CONCLUSIONS: Vitrectomy is a good surgical option for RRDCD. Older age, mild preoperative PVR, and perioperative intravitreal triamcinolone acetonide injections increase the primary reattachment rates after one operation. Older age was the only independent prognostic factor for the final retinal reattachment in patients with RRDCD.

Choroidal detachments: what do optometrists need to know?

Choroidal detachments occur when there is an accumulation of fluid or blood in the suprachoroidal space, a potential space situated between the choroid and the sclera. They are an uncommon ocular pathology. The most common cause of choroidal detachment is secondary to trabeculectomy; however, there are other causes such as trauma and inflammation. Clinically, choroidal detachments may vary in presentation from asymptomatic, to very poor vision, severe ocular pain, vomiting and nausea. Ocular findings associated with choroidal detachments include serous retinal detachment, secondary angle closure, and a very shallow anterior chamber. Optometrists, as primary eye care providers, need to be aware of the clinical signs and symptoms associated with choroidal detachments and ensure that appropriate and timely management, with a referral to an ophthalmologist, is instigated for optimal visual outcomes. In this review, the pathophysiology, detection, and associated risk factors for choroidal detachments are discussed, and evidence-based management recommendations in an optometric context are provided. The characteristics and management of uveal effusion syndrome are also reviewed, as this can cause idiopathic exudative choroidal detachments distinct from classical choroidal detachment.

Transient ciliochoroidal detachment after 360-degree suture trabeculotomy ab interno for open-angle glaucoma: 12-month follow-up.

OBJECTIVES: To investigate the effects of ciliochoroidal detachment (CCD) after 360-degree suture trabeculotomy ab interno (360S-LOT ab interno) on intraocular pressure (IOP) and postoperative complications during a 12-month follow-up. METHODS: We prospectively examined 44 eyes of 44 patients for 12 months after 360S-LOT ab interno surgery. Inclusion criteria were open-angle glaucoma including primary open-angle glaucoma, normal tension glaucoma, and exfoliation glaucoma without previous glaucoma surgeries. CCD was detected by swept-source anterior segment optical coherence tomography. Outcome measures were the course of IOP, the number of medications, and the postoperative complications of the CCD group compared with those of the non-CCD group. RESULTS: CCD appeared in 21 eyes (47.7%) within postoperative day 7 and disappeared within postoperative month 1 in 19 of 21 eyes. Although the IOP on postoperative day 1 in the CCD group (11.9 ± 7.7 mmHg) was significantly lower than that in the non-CCD group (19.2 ± 12.8 mmHg) (P = 0.020), the difference in the postoperative IOP between the groups decreased with time. No significant difference was seen in the number of medications and postoperative complications. CONCLUSIONS: CCD occurred in approximately half of patients after 360S-LOT ab interno and may have the transient effect of lowering the IOP immediately after surgery. Postoperative CCD had no effect on the later IOP, the number of medications and postoperative complications throughout 12-month of follow-up.