Suprachoroidal collection of internal tamponading agents through a choroidal hole.

We report two cases of significantly large choroidal holes following penetrating trauma that led to suprachoroidal migration of internal tamponading agents during repair of retinal detachments with proliferative vitreoretinopathy secondary to penetrating trauma. In the first case, choroidal hole was a direct result of the injury and was identified immediately after vitreoretinal surgery which was done for traumatic retinal detachment with hemorrhagic choroidal detachment. In the second case, the hole occurred over a period of several months after the repair of traumatic retinal detachment with silicone oil tamponade. This was attributed to progressive fibrosis exerting traction on the bare choroid/retinal pigment epithelium. Choroidal hole significant enough to cause suprachoroidal migration of internal tamponading agents is a very rare complication seen in eyes with posttraumatic retinal detachment with proliferative vitreoretinopathy.

Choroidal injury can occur following penetrating trauma which can result in serous or hemorrhagic choroidal detachment.1 The sclerochoroidal perforation site is usually associated with considerable fibrosis. However, a patent choroidal hole leading to suprachoroidal collection of internal tamponading agents is a unique event. Our search of literature using the Medline database failed to reveal a similar report. We report two such cases.

Case Reports

Case 1

A 36-year-old male presented 20 days after scleral repair for ruptured globe (left eye) following a traffic accident. Examination at this stage revealed hyphema, aniridia, aphakia and vitreous hemorrhage. Ultrasonography revealed hemorrhagic choroidal detachment and retinal detachment. He underwent pars plana vitrectomy and suprachoroidal blood drainage next day. During surgery, the retina was found bunched up with significant membrane formation on both sides of the retina. After membrane peeling and 360-degree retinectomy, the retina could be attached using perfluorocarbon liquids (PFCL). Perfluorocarbon liquids-silicone oil exchange was done. Shallow choroidal detachment persisted in the periphery, which was attributed to residual choroidal hemorrhage.

On the first postoperative day, a large bubble of PFCL was seen on the retinal surface. He was taken up for resurgery in seven days time and the bubble was removed while injecting additional silicon oil. One day later, another large bubble of PFCL was noted on the retinal surface. At this stage, the choroidal hole was prominently made out with increased extent of choroidal detachment in that quadrant. It was realized that silicone oil and PFCL were trapped in the suprachoroidal space. He was again taken up for surgery two weeks later. Silicone oil and PFCL trapped in the suprachoroidal space were drained externally using a relatively posteriorly placed sclerotomy. The vitreous cavity was reinjected with silicone oil. Eighteen months postoperatively the retina remained attached with recovery of 20/400 vision. However, the choroidal hole remained patent [Fig. 1]. The eye is still soft and hence silicone oil has not been removed.

Figure 1

Color montage of Case 1 at the last follow-up showing the attached retina and choroidal hole (black arrows)

Case 2

A seven-year-old girl presented with a four-day-old penetrating injury (with needle) and endophthalmitis in her right eye. She underwent emergency lensectomy and vitrectomy along with intravitreal injection of antibiotics. The infection was gradually controlled after repeated intravitreal injection of antibiotics based on culture reports. She was seen to have developed rhegmatogenous retinal detachment 10 days after the injury. There was choroidal detachment and significant proliferative vitreoretinopathy. During resurgery, a 360-degree relaxing retinectomy had to be done in view of the incarceration of the retina in the wound. Perfluorocarbon liquid was used to settle the retina and was replaced with 1000 centistokes silicone oil. Ten days postoperatively, a small bubble of PFCL was noted in the vitreous cavity. At this stage, her best-corrected vision was 20/60. Shallow choroidal detachment was also noted with a relatively soft eye but with attached retina. Progressive recurrent fibrosis occurred in the periphery, exerting traction on the retina as well as on the bare choroid/retinal pigment epithelium (RPE). Approximately six months after the first surgery, it was decided to reoperate, in view of the progressive drop in vision due to recurrent fibrosis and tractional retinal detachment. The silicone oil was removed and membrane peeling was done and the fibrosed edge of the previous retinectomy was excised. Perfluorocarbon liquid was used to flatten the retina. It was then noted that PFCL was entering the suprachoroidal space through a choroidal hole located in the area of bare choroid/RPE. Although external pressure at this site brought the PFCL into the vitreous cavity, the space could not be totally evacuated. Similarly, silicone oil, which was exchanged with PFCL, also entered this space. Four months from this surgery, she maintained 20/100 best-corrected vision. The eye was soft with band keratopathy. The retina was attached. The choroidal hole remained open with a pocket of choroidal detachment noted near the hole [Fig. 2]. The silicone oil was seen filling the vitreous cavity and extending into the pocket of choroidal detachment.

Figure 2

Color montage of Case 2 at the last follow-up showing the choroidal hole in the superotemporal quadrant between 9 and 11 O' Clock hours (Black arrows). View of the posterior pole is hazy due to band keratopathy

Discussion

Choroidal involvement in cases of penetrating trauma to eyes can manifest as benign choroidal thickening, suprachoroidal hematoma, choroidal detachment, suprachoroidal hemorrhage, indirect and direct traumatic chorioretinal ruptures.2 The site of the choroidal injury invariably undergoes fibrosis and never remains patent.3 Our two cases illustrate an interesting complication of severe trauma, wherein a patent choroidal hole was noted at some stage in the management of the case. In Case 1, the hole was small initially and went unrecognized. The migration of a large bubble of PFCL into the vitreous cavity postoperatively on two occasions provided a clue to the entrapment of the fluid elsewhere. The choroidal hole became larger and prominent with increasing fibrosis. The fibrosis also prevented sclerochoroidal approximation in the vicinity of the hole, leading to persistent choroidal detachment in the area into which the silicone oil freely migrated.

In the second case, the hole was identified intraoperatively, only during the second surgery done six months after the injury. The hole presumably formed due to the traction by fibrosis that covered the bare sclera/RPE beyond the retinectomy edge, not an uncommon occurrence after large relaxing retinectomies. It is possible that the areas of choroidal atrophy and thinning can give way and progressively enlarge to form a choroidal hole in the presence of significant traction. Presence of silicone oil may not be a special concern but entrapment of PFCL could be problematic, since the surgeon is never sure as to the complete removal of the same at the conclusion of the surgery. Being heavier than water, PFCL gravitates down and could escape notice.

These two cases highlight an unreported occurrence of choroidal hole formation leading to suprachoroidal collection of tamponading agents such as PFCL and silicone oil. Both the cases also had hypotony caused possibly by severe fibrosis on the ciliary body. The combination of penetrating injury leading to choroidal damage and the significant proliferative vitreo-retinopathy that is associated with this situation can potentially lead to choroidal hole formation due to the severe traction. The presence of such a hole can complicate the surgical management of these eyes.