Choroidal Rupture

Signs and Symptoms
Patients who experience choroidal rupture are often younger and involved in activities, such as ball sports, which expose them to potential high-rate impact trauma to the eye or adenexa. Patients have a history, either recent or antecedent, of direct or contrecoup injury to the eye and surrounding structures.

Choroidal ruptures may be single or multiple and may affect any part of the posterior segment. In recent trauma, there may be hemorrhage in any layer ranging from the choroid to the vitreous. However, if the trauma was many years antecedent, there will be no hemorrhage unless choroidal neovascularization has developed. Visual acuity and visual field may be dramatically reduced or may be normal and the patient is asymptomatic.

Ophthalmoscopically, you will note a linear disruption that may be crescent-shaped. Often, the rupture will have the concave aspect toward the disc. There is usually significant reactive RPE hyperplasia, giving the rupture a pigmented appearance.

Pathophysiology
Direct or contrecoup injury can precipitate a choroidal rupture. Hemorrhage and edema may be present initially, but will resolve. Typically, reactive hyperplasia gives the rupture a heavily pigmented appearance. Often, the overlying retina is undisturbed in choroidal rupture. However, if the RPE is disturbed and becomes hyperplastic and invades the sensory retina, visual dysfunction ensues.

Due to the subsequent disruption of Bruch’s membrane that occurs in choroidal rupture, choroidal neovascular membranes may develop within the rupture. This may be a late development that can occur up to five years after the precipitating trauma.

 

Management
There is no direct intervention in the acute phase of choroidal rupture. Educate patients about their condition and prescribe protective eye wear. Monitor the patient funduscopically for at least five years for the development of choroidal neovascularization within the rupture scar. Any late bleeding should receive a fluorescein angiogram to determine if a choroidal neovascular membrane has developed. Choroidal neovascular membranes resulting from choroidal rupture have a tendency to spontaneously involute. For this reason, laser photocoagulation is indicated only if there is imminent threat to vision.

Clinical Pearls

Choroidal neovascularization can occur five years after the initial trauma.

Sub-retinal hemorrhage from choroidal neovascularization is the most common cause of late vision loss.

As the retina overlying a choroidal rupture may be unaffected, patients may retain excellent visual function and present asymptomatically years after the trauma. A patient may have a rupture between the disc and macula, yet retain normal acuity.