What is the treatment and management for progression of choroidal detachment with retinal detachment?

Management of Choroidal Detachment with Retinal Detachment

Combined rhegmatogenous retinal detachment (RRD) with choroidal detachment requires aggressive surgical intervention with pars plana vitrectomy, scleral buckling, and preoperative systemic corticosteroids, achieving 90.5% retinal reattachment rates compared to only 53% with scleral buckling alone. 1

Preoperative Medical Management

Initiate systemic corticosteroids before surgery to reduce choroidal detachment and improve surgical outcomes 1:

• Oral prednisone 1 mg/kg/day is the recommended first-line therapy 2
• Preoperative steroids achieve complete choroidal detachment regression in approximately 62% of cases before surgery 1
• This medical preparation significantly improves the surgical field and reduces intraoperative complications 1

Surgical Approach

Primary pars plana vitrectomy combined with scleral buckling or encircling is the definitive treatment for this combined pathology 1:

Intraoperative Decision-Making

• Use fluid-air exchange behavior to guide surgical steps and understand the pathogenesis of the detachment 3
• Perform endolaser photocoagulation around retinal breaks and along pathologic borders 3
• Drain persistent suprachoroidal fluid intraoperatively if choroidal detachment has not resolved with preoperative steroids 1

Tamponade Selection

• Silicone oil tamponade is superior to gas tamponade for combined RRD and choroidal detachment 3, 1:
  • Silicone oil-filled eyes have 16.3% recurrent detachment rates 3
  • Gas-filled eyes have 60% recurrent detachment rates 3
  • Gas tamponade has limited indications in this setting 3
• Silicone oil can be safely removed in 80% of cases after retinal reattachment is stable 3
• After silicone oil removal, only 15.6% develop recurrent detachment 3

Special Surgical Considerations

For cases with severe anterior vitreoretinal adhesions (particularly with hemorrhagic choroidal detachment):

• Bimanual vitrectomy through anterior sclerotomy sites may be necessary 4
• Careful dissection within the anterior segment is required to release anterior retinal adhesions 4
• These complex cases may require multiple surgical interventions 4

To minimize choroidal detachment risk during initial retinal detachment surgery 5:

• Design notches in explants overlying vortex veins to prevent venous congestion 5
• Minimize extent of anteriorly placed explants 5
• Avoid excessive intraoperative hypotony 5
• Consider avoiding subretinal fluid drainage when possible 5

Postoperative Management and Monitoring

Close follow-up is essential as treatment failures can occur despite appropriate initial therapy 6:

• Examine at 1-2 weeks post-surgery to assess initial treatment response 6
• Repeat examination at 2-6 weeks with indirect ophthalmoscopy and scleral depression to verify adequate chorioretinal adhesion 6
• Continue monitoring as 10-16% of patients develop additional retinal breaks during long-term follow-up 6

Instruct patients to report immediately 6:

• Increased floaters
• New flashes of light
• Peripheral visual field loss
• Decreased visual acuity

Expected Outcomes

With aggressive combined medical and surgical management 1:

• 90.5% achieve retinal reattachment at mean 11.4-month follow-up
• 81.2% maintain attached retina long-term 3
• 69.4% recover visual acuity of 10/200 or better 3

Critical Pitfalls to Avoid

• Do not attempt scleral buckling alone for combined RRD and choroidal detachment—this achieves less than 53% success 1
• Do not use gas tamponade as primary choice—it has a 60% failure rate versus 16.3% with silicone oil 3
• Do not skip preoperative corticosteroids—they resolve choroidal detachment in 62% of cases before surgery 1
• Do not delay surgical intervention once medical therapy is initiated—combined pathology requires definitive surgical repair 1