Description
The most common cause of choroidal rupture is blunt ocular trauma. Such trauma affects not only the choroid, but also Bruch’s membrane and the retinal pigment epithelium (RPE). Sclera and retina tend to be less affected by blunt trauma because these tissues are either stronger (sclera) or more elastic (retina). Indirect choroidal rupture refers to the situation where the impact of trauma sends a shockwave to the posterior eye, resulting in rupture of the posterior tissues. Direct choroidal rupture is more likely to involve the anterior choroid and is the local result of the direct impact of trauma causing tissue necrosis.
Symptoms
The patient may be asymptomatic or have decreased vision. There will usually be a history of ocular trauma.
Signs
The appearance of choroidal rupture will depend upon the time since the ocular trauma occurred and the degree of trauma. Initially there may be choroidal, retinal or vitreous hemorrhages, usuatly unilateral. After days or weeks the blood will usually resolve. In milder trauma, a small choroidal hemorrhage may appear as a rounded, dark red-blue mound with paler edges. The choroidal rupture may be single or multiple and appears as a yellow or white subretinal streak, which may be linear or curved in shape.
After some months the rupture usually becomes fibrosed, with associated RPE changes and overlying retinal atrophy. Persistent choroidal neovascularization (CNV) occasionally occurs, particularly secondary to larger lesions or if the rupture is closer to the fovea. Other traumatic signs may be present, including subconjunctival hemorrhage, periocular bruising, commotio retinae, traumatic optic neuropathy or retinal breaks or tears. Massive choroidal bleeding may lead to choroidal detachment.
Prevalence
Rare (approximately 1/10000), except in patients with a history of ocular trauma.
Significance
Sight threatening; requires prompt investigation and treatment.
Differential diagnosis
Commotio retinae; angioid streaks; retinal break or tear.
See also
Traumatic optic neuropathy; Choroidal neovascularization; Choroidal detachment
Management
There is no specific treatment for choroidal rupture, although the condition must be assessed and complications managed.
Urgent All cases of blunt ocular trauma require urgent assessment.
Ocular tests, imaging, additional Investigations Orbital fracture or globe rupture must be ruled out, which may require computed tomography or magnetic resonance imaging MRI. Fluorescein angiography may be indicated if CNV is suspected as a secondary complication.
Laser and incisional surgery Argon laser treatment is mainly used for extrafoveal CNV, to avoid affecting vision. Subfoveal CNV may require consideration of verteporfin photodynamic treatment (PDT), or incisional surgery for membrane removal.
Review and advice The visual prognosis depends on the proximity of the lesion to
Fig. 32.1
Several choroidal ruptures and superficial hemorrhages in the left fundus of a young male who was punched in the left eye during a football match. Vision was markedly reduced.
Fig. 32.2
A large choroidal rupture of the teft fundus after a head injury in a car accident. Optic atrophy was present and vision was severely reduced.
the fovea, possible involvement of the optic nerve or other traumatic effects. Patients at risk of CNV or other complications may be provided with an Amsler (grid) chart for home use to setfassess the vision in each eye for distortion. The patient may be reviewed every 3 months in the first year, but encouraged to attend immediately if signs of reduced vision or distortion are noted. Annual review thereafter may be adequate.