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Abstract #15596 Published in IGR 1-3
Management of chronic choroidal effusions
Migdal CJournal of Glaucoma 1999; 8: 325-327
In this "cases in controversy" series the editor Clive Migdal presents a case with chronic choroidal effusions to two glaucoma experts: Todd W Perkins and Louis Pasquale. The case is a 71 years old man with chronic angle closure glaucoma and visual acuity of 20/30 in both eyes. He has patent laser iridectomies and his pressure is 36 mmHg in the right eye and 16 mmHg in the left eye. On gonioscopy occasional anterior peripheral synechiae are seen, more in teh right than in the left eye. There is glaucomatous optic neuropathy with corresponding visual field defects in the right eye, whereas the left eye is normal. An uneventful trabeculectomy with 5-fluorouracil was performed and three weeks after surgery the visual acuity is still 20/30, the anterior chamber is deep with a wide, diffuse pale filtering bleb and a pressure of 4 mmHg. There are low-lying choroidal effusions. The editors asks three questions: 1. At what level of IOP do you begin to become concerned about the sequelae of hypotony and choroidal effusions. What is your management, 2. if over the next two months IOP ranges from 3-8 mmHg and choroidal effusions are moderately elevated, 3. three months later IOP is 6 mmHg and still there are moderate choroidal effusions. There is no evidence of hypotonous maculopathy, subcapsular cataract has developed and visual acuity is 20/40. Again how would you manage the patient.First answer comes fromPerkins who states that problems rarely occur when IOP is more than 6 mmHg. However variations in susceptibility of the eye may be large. Longer periods of choroidal effusions may cause problems like kissing effusions or permanent retinal folds and maculopathy. In the early stages this author would reduce topical steroids and observe the situation. If the effusions are still present at three months, IOP is 6 mmHg and there is no maculopathy he would still wait as long as 6 months. If choroidal detachments are large enough to be noticed or vision decreased or to much cataract is developing he would intervene. The first option would be cataract extraction. If there are large choroidals he would drain at the time of surgery. Other option would be revision of the trabeculectomy flap. Other options for decreasing filtration like autologous blood injection are also available. Unlike hypotonous maculopathy which may lead to permanent visual sequellae, choroidal effusions are well tolerated. There is no hurry.The second answer comes from Pasquale who is an advocate of external tamponade with a bandage contact lens. He also uses autologous blood injections or application of thermal energy to the bleb. Furthermore he mentions compression sutures and surgical modifications of the sclerostomy. He would also watch for a cyclodialysis cleft. Some specialists would argue that after 4 months the choroidal detachment are unlikely to resolve spontaneously. Hypotony contributes to cataract formation. The editor of this series concludes by mentioning the precipitating factors for the choroidal effusions. Generally in the absence of sight threatening problems a conservative approach is adapted. He would only resort to more aggressive surgical treatment if choroidals were appositional, anterior chamber shallowed or vision threatened.
Clive Migdal, MD, FRCS, FRC Ophth, Consultant Ophthalmologist, The Western Eye Hospital, Marylebone Road, London NW1 5YE, England
Classification:
12.8.11 Complications, endophthalmitis (Part of: 12 Surgical treatment > 12.8 Filtering surgery)
