What is the diagnostic work‑up for suspected choroidal detachment after recent intra‑ocular surgery, trauma, or exposure to sulfonamides/topiramate?

Diagnosis of Choroidal Detachment

Choroidal detachment is diagnosed primarily through dilated fundus examination revealing smooth, dome-shaped elevations that extend to the ora serrata (unlike retinal detachment), combined with B-scan ultrasonography when media opacity prevents direct visualization. 1, 2, 3

Clinical Presentation

The clinical presentation varies widely and should guide your diagnostic approach:

• Visual symptoms: Range from asymptomatic to severe vision loss 1
• Pain and systemic symptoms: Severe ocular pain, nausea, and vomiting may occur 1
• Hypotony: Present in approximately 75% of post-surgical cases (6 of 8 cases in one series) 2
• Anterior chamber changes: Flat or shallow anterior chamber is a hallmark finding 1, 2, 4

Essential Examination Components

Visual Acuity and External Examination

• Measure visual acuity under standard lighting conditions with and without correction 5
• Assess pupil shape, size, and position for irregularities suggesting trauma 5
• Look for sphincter rupture, iris transillumination defects, or synechiae as evidence of past trauma or inflammation 5

Intraocular Pressure Measurement

• Critical finding: Hypotony is common but not universal 2
• Use alternative tonometry methods (pneumotonometer, handheld electronic applanation, rebound tonometer) if corneal abnormalities are present 6, 5
• Important caveat: Some cases present with normal or even elevated IOP due to secondary angle closure from the detachment 4

Slit-Lamp Biomicroscopy

• Use sclerotic scatter, specular reflection, and indirect illumination techniques 5
• Document healed or recent corneoscleral wounds and areas of scleral thinning 5
• Assess anterior chamber depth carefully—shallow or flat chamber is characteristic 1, 2

Fundus Examination

• Key distinguishing features on ophthalmoscopy: 1, 3
  • Smooth, dome-shaped elevations (not corrugated like retinal detachment)
  • Extend anteriorly to the ora serrata
  • Often multiple, separated by areas where vortex veins penetrate the sclera
  • Immobile with eye movement (unlike retinal detachment which shifts)

B-Scan Ultrasonography: The Definitive Diagnostic Tool

When fundus examination is limited by media opacity, cataracts, miotic pupil, or synechiae, B-scan ultrasonography is the most reliable method to confirm choroidal detachment. 2, 3, 4

Ultrasonographic Characteristics

• Static findings: Smooth, dome-shaped elevations that extend to the ora serrata but do not cross the optic nerve 3
• Dynamic findings: Choroidal detachments remain relatively immobile during eye movement, unlike retinal detachments which shift and undulate 3
• Repeat imaging: If initial findings are equivocal, repeat ultrasonography within 1-2 weeks 5

Differentiating from Retinal Detachment

The sonographic appearance differs critically from retinal detachment:

• Choroidal detachments have smooth contours vs. corrugated appearance of retinal detachment 3
• Choroidal detachments extend to ora serrata; retinal detachments insert at the optic nerve 3
• Choroidal detachments show minimal movement; retinal detachments are highly mobile 3

Gonioscopy

• Perform gonioscopy to assess for secondary angle closure 1
• Look for peripheral anterior synechiae or appositional angle closure 6
• Critical pitfall: Annular peripheral choroidal detachment can cause secondary angle closure with elevated IOP, mimicking aqueous misdirection—ultrasonography distinguishes these conditions 4

Context-Specific Diagnostic Considerations

Post-Surgical Cases

• Most common after trabeculectomy (especially with mitomycin C) or combined cataract-glaucoma surgery 2, 7
• Typically occurs within 2 weeks post-operatively, though can occur years later 2
• Associated with hypotony and postoperative inflammation 7

Trauma-Related Cases

• Document any history of blunt or penetrating ocular trauma 1, 3
• Examine for associated findings: hyphema, lens dislocation, or globe rupture 3

Drug-Induced Cases (Sulfonamides/Topiramate)

• These medications cause ciliary body edema and anterior rotation, leading to secondary angle closure 1
• Look for bilateral presentation and shallow anterior chambers 1

Common Diagnostic Pitfalls

• Mistaking for aqueous misdirection: Annular peripheral choroidal detachment causes shallow anterior chamber with normal/high IOP, mimicking malignant glaucoma—ultrasonography is essential to differentiate 4
• Assuming hypotony is always present: While common, some cases present with normal or elevated IOP due to secondary angle closure 4
• Relying solely on fundoscopy: Media opacity, cataracts, or miotic pupils often prevent adequate visualization—maintain low threshold for ultrasonography 2, 3