Choroidal rupture

From EyeWiki
Original article contributed by: Sharon Fekrat, MD
All contributors: Koushik Tripathy, MD, Sharon Fekrat, MD and Theodore Leng, MD, MS
Assigned editor: Theodore Leng, MD, MS
Review: Assigned status Update Pending by Theodore Leng, MD, MS on December 19, 2015.



Choroidal rupture
Classification and external resources
ICD-10 H31.3
DiseasesDB 31303


Disease Entity

A choroidal rupture is a break in the choroid, Bruch membrane, and the retinal pigment epithelium (RPE) that results following a closed globe injury from blunt trauma.

Disease

A choroidal rupture is not associated with systemic disease. However, relatively insignificant trauma can cause choroidal rupture in pseudoxanthoma elasticum patients with choroidal rupture.[1]

Etiology

The etiology of a choroidal rupture is a closed globe injury resulting from blunt trauma.

Risk Factors

A closed globe injury following blunt trauma is a risk factor for the development of a choroidal rupture.

General Pathology

Histopathologically, a choroidal rupture demonstrates a disruption in the choriocapillaris, the RPE, and Bruch membrane. The overlying neurosensory retina is intact.

Pathophysiology

During a closed globe injury, the eyeball is first mechanically compressed and then rapidly hyperextended. The sclera's tensile strength resists this compression. The retina is elastic and stretches during such an injury. However, Bruch membrane breaks because it does not have sufficient tensile strength or elasticity. The choriocapillaris is injured and bleeds into the subRPE and/or subretinal space. Such hemorrhage may hide the choroidal rupture initially. Over days, the blood clears and a whitish/yellowish, curvilinear, crescent-shaped subretinal streak is visible and concentric to the optic disc. Over time, choroidal neovascularization (CNV) can develop. In most, the CNV involutes over time. In about 30%, the CNV may recur, with a serous or hemorrhagic pigment epithelial detachment, anytime following formation of the choroidal rupture. If the rupture or CNV does not involve the foveal center, vision may not be affected.

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Primary prevention

In order to prevent the development of a choroidal rupture, avoidance of a closed globe injury is necessary. Avoiding high risk activities and wearing polycarbonate eye protection may prevent the development of a choroidal rupture.

Diagnosis

The diagnosis of a choroidal rupture is made based on the history of a closed globe injury in an eye with a crescent shaped yellowish/whitish subretinal streak that is concentric with the optic disc.

History

A history of recent or remote blunt trauma resulting in a closed globe injury to the eye is a necessary component to the history in order to make the diagnosis of a choroidal rupture.

Physical examination

A complete ocular examination is needed and would include a dilated examination of the fundus to detect the choroidal rupture(s).

Signs

A choroidal rupture may be evident in the posterior pole as a white or yellow crescent-shaped streak that is subretinal in location. It is usually concentric to the optic nerve. There may be one or more choroidal ruptures present. Initially after a closed globe injury, the rupture may not be evident to the physician because it may be obscured by associated hemorrhage. As the blood reabsorbs, the choroidal rupture may be observed. In rare cases, the choroidal rupture may be oriented radially. Choroidal neovascularization may develop from the choroidal rupture. The choroidal rupture may be partial thickness or full thickness. According to the mechanism of development either direct or indirect choroidal ruptures can be seen. Direct choroidal rupture is seen at the peripheral fundus (mostly temporal) at the site of impact parallel to the ora serrata. Indirect choroidal ruptures are seen at the posterior pole due to a countercoup effect of the trauma. Indirect choroidal ruptures are commoner. Associated trauma to globe, orbital bones and retinal dialyses should be ruled out.

Symptoms

Symptoms of a choroidal rupture are dependent on the location of the rupture within the eye. An individual with a choroidal rupture may indeed be asymptomatic if the rupture and any associated hemorrhage does not involve the fovea or parafoveal retina. If the rupture and/or hemorrhage involves the fovea or adjacent retina, decreased vision may be the first symptom noted.

Clinical diagnosis

The clinical diagnosis of a choroidal rupture can be made during ophthalmoscopic examination of the fundus.

Diagnostic procedures

No specific diagnostic procedures are necessary. In the scenario of recent onset vision loss and metamorphopsia, development of intra or subretinal fluid or subretinal bleed in an old rupture, an underlying choroidal neovascularization can be documented by fluorescein angiogram and optical coherence tomography.

Laboratory test

No laboratory evaluation is necessary since eyes with choroidal rupture have a history of recent or remote blunt trauma to that eye.

Differential diagnosis

Lacquer cracks in an eye with high myopia are in the differential diagnosis of choroidal rupture. Lacquer cracks are often bilateral and the eyes have other signs of high myopia including a scleral crescent adjacent to the tilted disc and a posterior staphyloma. Angioid streaks are often in the differential diagnosis and are bilateral subretinal streaks that emanate from the optic disc and may be associated with CNV.

Management

Observation is recommended. An Amsler grid may be given to the patient and any changes in the grid should be reported to the patient's eye care provider since a change may indicate the development of CNV.

General treatment

Observation is recommended with Amsler grid monitoring.

Medical therapy

There is no medical therapy available to cause resolution of a choroidal rupture.

Medical follow up

Followup is indicated one to two times per year or as dictated by symptoms.

Surgery

There is no surgical procedure available that would result in resolution of a choroidal rupture. Isolated case reports of successful management of recent onset thick subretinal hemorrhage at fovea with intravitreal gas (SF6), tissue plasminogen activator (rtPA) exist in literature.[2]

Complications

Subretinal and subRPE hemorrhage can result at the time the choroidal rupture develops.

Choroidal neovascularization (CNV) can develop from the choroidal rupture where choroidal neovessels proliferate and grow in the subretinal space, leading to hemorrhage and fibrosis and decreased vision if untreated.

Prognosis

A choroidal rupture by itself does not change over time. The vision that results following the development of a choroidal rupture is the vision that remains. However, there is a risk of CNV formation from the choroidal rupture due to the rupture in Bruch membrane and that CNV could lead to decreased central vision in an eye where the fovea was spared by the choroidal rupture. Subfoveal ruptures and associated traumatic optic neuropathy denote a poor visual prognosis.

Additional Resources

References

  1. Agarwal A. Gass’ atlas of macular diseases. Vol. 1. St. Louis, Mo.: Elsevier; 2012
  2. Migdal E, Helemejko I, Misiuk-Hojlo M. rtPA with SF6 gas usage in traumatic macular subretinal hemorrhage: a case report. Acta Ophthalmol (Copenh). 2010 Sep 1;88:0–0.