Scleral Hydraulic Conductivity and Macromolecular Diffusion in Patients with Uveal Effusion Syndrome

CLINICAL CHARACTERISTICS, TREATMENT MODALITIES, AND THEIR ASSOCIATION WITH LONG-TERM VISUAL OUTCOMES IN UVEAL EFFUSION SYNDROME

PURPOSE

Uveal effusion syndrome (UES) is a rare eye condition characterized by fluid accumulation in the uveal layer. We investigated its clinical characteristics and treatment modalities and their association with long-term visual outcomes.

METHODS

This retrospective cohort study included patients with UES treated at two tertiary hospitals between November 2005 and June 2023. Clinical characteristics and treatment outcomes by modality were compared between nanophthalmic Type 1 UES (UES-1) and non-nanophthalmic Type 2 UES (UES-2), and between initial and final visits. Logistic regression analysis was used to identify factors associated with vision loss.

RESULTS

Twenty-three eyes were included (UES-1, n = 10; UES-2, n = 13). Retinal pigment epithelium mottling was significantly more common in UES-1 than in UES-2 ( P = 0.043); no other between-group differences were observed. Post-treatment, in UES-1, best-corrected visual acuity ( P = 0.028) and central macular thickness ( P = 0.046) significantly decreased; in UES-2, best-corrected visual acuity significantly improved ( P = 0.021), and subfoveal choroidal thickness ( P = 0.048), central subretinal fluid height ( P = 0.011), and central macular thickness ( P = 0.010) significantly decreased. UES-2 was associated with a lower risk of vision loss (odds ratio, 0.024; P = 0.044). No other associated factors were identified.

CONCLUSION

The UES type was the sole independent prognostic factor for vision loss, whereas treatment modalities had no significant impact on visual outcomes.

Management and follow-up of uveal effusion syndrome: a case report

BACKGROUND

We present the management and follow-up of a case of uveal effusion syndrome (UES).

CASE PRESENTATION

We study the relevant recent literature reports and review the aetiology, clinical classification, pathogenesis, diagnostic characteristics, treatment methods, and prognosis of this disease. When we encounter UES patients clinically, we can classify them according to their clinical characteristics and adopt different treatment plans for different types. The retina of this patient reattached 5 months after receiving eight periocular injections of triamcinolone acetonide (TA).

CONCLUSIONS

For type III UES patients, local hormone therapy can be applied, and follow-up should be done to optimize the clinical outcome.

Medical Therapy and Scleral Windows for Uveal Effusion Syndrome: A Case Series and Literature Review

INTRODUCTION

Uveal effusion syndrome (UES) is a rare ocular disease causing idiopathic uveal effusion, often with associated ciliochoroidal and retinal detachment. UES diagnosis is challenging because of overlapping features with other ocular inflammatory, neoplastic, iatrogenic, and drug-induced causes of uveal effusion. While several successful surgical treatments have been described, such as full-thickness or partial-thickness sclerectomy, medical therapies may also have a therapeutic role.

OBJECTIVE

To provide an updated review of the published literature on the course of the disease, medical and surgical management strategies, as well as newer treatment modalities.

Clinical presentation and treatment outcomes of an algorithmic approach to uveal effusion syndrome

Purpose

To describe the clinical features and treatment outcomes in spontaneous uveal effusion syndrome (UES).

Methods

A 10-year retrospective chart review of UES patients from a tertiary eye center was carried out. Optical coherence tomography (OCT), fundus fluorescein angiography, and ultrasound biomicroscopy (UBM) scans were performed. UES was managed based on presenting best-corrected visual acuity (BCVA), symptoms, and fundus findings. Patients with secondary causes of uveal effusion were excluded.

Results

Twenty-five eyes of 16 patients were included. Of the 16 patients, 14 (88%) were male and 9 (56%) had bilateral disease. Fifteen of 25 affected eyes had nanophthalmos (axial length (AL) <20.5 mm) and 6 had hyperopia with AL >20.5 mm. The presenting mean distance BCVA was 0.74 ± 0.64 logMAR (mean Snellen: 20/100). Eleven eyes had exudative retinal detachment, and 4 also had exudative choroidal detachment (CD). Choroidal thickness (CT) was increased in 11 eyes on B-scan ultrasonography, and the mean CT was 1.74 ± 0.38 mm. Sub-retinal fluid (SRF) and retinal folds were the most common OCT findings. UBM findings included shallow angles, peripheral CD, and supra-ciliary effusion. A combination of local and systemic corticosteroids was used to successfully treat 12 eyes, 6 needed surgery, and 7 were observed. Partial sclerectomy with anterior chamber maintainer-assisted SRF drainage was the favored surgery. The median period of follow-up was 6.5 months (0.1-76 months), and the mean distance BCVA at the last follow-up was 0.58 ± 0.42 logMAR (mean Snellen: 20/80).

Conclusion

UES can be suitably managed both medically and surgically based on clinical presentation.

A report on a series of nanophthalmos with histopathology and immunohistochemistry analyses using light microscopy

We aimed to study the histopathological and immunohistochemistry features in clinically diagnosed cases of nanophthalmos using light microscopy. This was an observational comparative study. We enrolled four eyes of four consecutive patients with nanophthalmos and visually significant cataract, who underwent cataract surgery with prophylactic posterior sclerostomy. Histological analysis of the excised scleral tissue was done and compared with age-matched cadaver controls between January 2021 and October 2021. Hematoxylin and Eosin (H&E) stains were used for histological analysis, and was further supplemented with immunohistochemistry (IHC) and immunofluorescence (IF) analyses using a simple light microscope. The immunostained sections were analyzed using confocal microscope for the fibronectin expression level. The main outcome measure was demonstration of histological changes of sclera in nanophthalmic eyes undergoing cataract surgery. Light microscopic features of nanophthalmos revealed thick fibers with fraying and lightly stained cores, irregular serrated edges, and randomly interspersed fibroblasts compared to regular arrangement of collagen fibers seen in cadaver controls. Immunohistochemistry analysis with anti-fibronectin antibody showed strong positivity in clustered fibers in nanophthalmos, and less intense diffuse staining in cadaver tissue. Histoclinical correlation was observed in one nanophthalmic scleral tissue with axial length less than 17 mm showing severe disorganization with diffuse collagenization, loss of fibrillary architecture compared to another specimen with axial length more than 17 mm. Simple, cost-effective light microscopy using basic stains was effective in identifying the characteristic histopathological features in nanophthalmic eyes, and this was further highlighted by immunohistochemistry and immunofluorescence analyses.

Uveal Effusion Syndrome: Clinical Characteristics, Outcome of Surgical Treatment, and Histopathological Examination of the Sclera

Purpose

In this study, we aimed to investigate clinical characteristics and histopathology and evaluate surgical outcomes of quadrantic lamellar-sclerectomy with sclerostomy for uveal effusion syndrome (UES).

Design

Retrospective, cohort study.

Participants

Overall, 106 eyes of 66 patients diagnosed with UES were treated at the Beijing Tongren Hospital between January 1, 2001 and June 26, 2021.

Methods

Patients were examined by routine ophthalmologic examinations, fluorescein and indocyanine green angiography (FFA/ICGA); axial length determination; color Doppler ultrasound (CDU); ultrasound biomicroscopy (UBM), optical coherence tomography (OCT), and optical coherence tomographic angiography (SD/SS-OCTA). Quadrantic lamellar-sclerectomy with sclerostomy was performed at the equator in all patients and histopathological examination of the excised sclera was analyzed in all samples.

Main Outcome Measures

The reattachment of the choroid and retina with resolution of the serous fluid, best corrected visual acuity (BCVA), choroidal thickness, and recurrence of ciliochoroidal detachment were the main outcome measures.

Results

Two subgroups were identified: (1) type 1 (nanophthalmic eye), wherein the eyeball was small (average axial length 15.83 ± 1.45 mm) with high hypermetropia (average 12.6 diopters) and (2) type 2 (non-nanophthalmic eye), wherein the eyeball size was normal (average axial length 23.45 ± 1.68 mm) with or without refractive error, combined with or without systemic symptoms. Histopathologically, types 1 and 2 demonstrated similarly abnormal sclera with the disorganization of collagen fiber bundles and deposits of proteoglycans in the matrix. Quadrantic lamellar-sclerectomy with sclerostomy was effective in both types 1 and 2, inducing post-operative resolution of the subretinal fluid accumulation and increasing the useful BCVA. The choroidal thickness was significantly different before and after surgery (P < 0.05). Approximately 98.1% of cases attained permanent reattachment within 6 months after one operation through this procedure. The single operation success rate was 96.2%, and success with one or two operations was 100%.

Conclusions

UES is caused by abnormalities of the sclera and increased resistance to transscleral fluid outflow, combined with increased choroidal thickness. Quadrantic lamellar-sclerectomy with sclerostomy is an effective treatment for UES that can rescue correct the useful visual acuity.

Treatment of Nanophthalmos-Related Uveal Effusion with Two- vs. Four-Quadrant Partial-Thickness Sclerectomy and Sclerotomy Surgery

Objectives

To report visual and anatomical outcomes following two- or four-quadrant partial-thickness sclerectomy and sclerotomy surgery to treat nanophthalmos (NO)-related uveal effusion (UE).

Materials and Methods

Consecutive patients with NO-related UE were treated with four-quadrant or two-quadrant (for those with associated glaucoma) partial-thickness sclerectomy and sclerotomy surgery. Axial length, extent of UE, preoperative, postoperative, and final best corrected visual acuity (BCVA), time to retinal reattachment, and rates of retinal reattachment and recurrence were noted.

Results

Fourteen eyes of 10 patients with NO-related UE were operated. Retinal detachment (RD) involved mainly the peripheral retina in 7 (50%) eyes, macula in 2 eyes (14.2%), both macula and peripheral retina in 4 eyes (28.6%), and the whole retina in 1 eye. Eleven eyes had four-quadrant surgery, and 3 eyes with associated glaucoma had two-quadrant surgery. External subretinal drainage was performed in one patient who had total RD. The mean preoperative logMAR BCVA of 1.50±0.53 increased significantly to 0.92±0.49 after surgery (p=0.002). Resolution of RD could be achieved with two-quadrant surgery in only 1 of 3 eyes. In the other 2 eyes, retinal reattachment was achieved after a secondary surgery for the remaining two quadrants to complete four-quadrant sclerectomy. Final outcome was total reattachment of the retina in 11 eyes (78.6%), partial reattachment in 1 eye (7.1%), and recurrence of macular detachment in 2 (14.3%) eyes.

Conclusion

Quadrantic partial-thickness sclerectomy and sclerotomy surgery seems effective for treating UE in eyes with NO. Twoquadrant surgery may be tried for mild UE associated with glaucoma to preserve the superior quadrants for future possible glaucoma surgeries, but secondary surgery for the superior quadrants may be needed. External drainage of subretinal fluid may be an option in severe cases to achieve quicker resolution.

Bilateral Pachychoroid disease with type 3 Uveal effusion syndrome in one eye and central serous Chorioretinopathy in contralateral eye: a case report

Background

We report a case of bilateral pachychoroid disease with type 3 uveal effusion syndrome (UES) in one eye and central serous chorioretinopathy (CSC) in the contralateral eye.

Case presentation

A 65-year-old man presented to our department because of decreased vision. Visual acuity was 16/20 in the right eye and 2/20 in the left eye, with normal axial lengths. The left eye was diagnosed with CSC and underwent photocoagulation 8 years ago. The right eye showed inferior non-rhegmatogenous retinal detachment and peripheral choroidal detachment. Macular optical coherence tomography showed submacular fluid in the right eye, pachychoroid in both eyes, and choroidal thickness of 565 μm in the right and 545 μm in the left eye. In both eyes, fluorescence angiography showed window defects and mild fluorescence leakage, and indocyanine green angiography showed dilated choroidal vessels, mild choroidal hyperpermeability, and mild dye leakage. The left eye was diagnosed with chronic CSC. Initially, chronic CSC was also suspected in the right eye. However, photodynamic therapy failed, with worsened retinal detachment and visual acuity. Pachychoroid in the peripheral fundus (choroidal thickness 820 μm) was observed only in the right eye. Based on these findings, UES was diagnosed in the right eye. Sclerectomies were performed. The absence of scleral thickening and glycosaminoglycan deposition led to a final diagnosis of type 3 UES. The procedure was not effective, due to connective tissue regeneration at the sclerectomy sites. In the revision surgery, mitomycin-C was used with sclerectomies. One month after surgery, retinal and choroidal detachment disappeared, visual acuity recovered to 8/20, pachychoroid in the macula and peripheral fundus decreased, and choroidal thickness decreased to 352 μm in the macula and 554 μm in inferior peripheral fundus.

Conclusions

Pachychoroid in the posterior pole was the common finding in type 3 UES and CSC, although extensive pachychoroid in the peripheral fundus may have caused retinal and choroidal detachment in the eye with type 3 UES. Full-thickness sclerectomies with mitomycin-C improved pachychoroid in the peripheral fundus and resolved retinal and choroidal detachment, clearly indicating that the sclera was the main cause of type 3 UES.

UVEAL EFFUSION SYNDROME. CASE REPORT

PURPOSE

Purpose of this article is to present a case report of a patient with uveal effusion syndrome who underwent deep posterior sclerotomy.

CASE REPORT

A 73-year-old patient with unilateral decrease in the best corrected visual acuity, ablation of choroid and secondary retinal detachment in the right eye was admitted to our clinic for examination in November 2017. At the first examination, the best corrected visual acuity in the right eye was 0.3, in the left eye 1.0. Intraocular pressure was 16 mmHg in the right eye and 21 mmHg in the left eye. After performing ultrasound biomicroscopy of the anterior segment (Accutome, Keeler, USA), ultrasound sonography of the affected eye (Accutome, Keeler, USA), magnetic resonance imaging, computed tomography, abdominal ultrasound and blood tests, we concluded the finding as uveal effusion syndrome. We initiated a conservative treatment consisting of oral administration of carbonic anhydrase inhibitor in combination with topical use of prostaglandin analogue. Despite conservative treatment the best corrected visual acuity of the affected eye decreased to 0.05 so we proceeded to a surgical procedure - deep posterior sclerotomy with perioperative scleral sampling for histological examination (detection of glycosaminoglycans in the sclera wall by Alcian blue staining), which was negative. This histological result ranks the patient as the third type of uveal effusion syndrome (ie, non-nanophthalmic with a normal sclera). After the operation both the ablation of choroid and retinal detachment reattached and the best corrected visual acuity in the right eye improved to 0.3. After the subsequent cataract surgery, the ablation of choroid and retinal detachment occurred again, this time with spontaneous recovery. Postoperatively, the best corrected visual acuity in the right eye was 0.5 and at the last check-up at our clinic 0.6.

CONCLUSION

Deep posterior sclerotomy is a method of choice of surgical treatment for uveal effusion syndrome that does not respond to conservative therapy.

Surgical Management of Choroidal Diseases

Accumulation of serous fluid in the suprachoroidal space, known as uveal effusion, and choroidal or suprachoroidal haemorrhage (SCH) following rupture of ciliary blood vessels are considered rare, but serious, events with extremely poor functional prognosis. As a result, uveal effusion, and expulsive suprachoroidal haemorrhage in particular, continue to be considered as more or less fatal complications. However, clinical experience demonstrates that both clinical entities can be managed by conservative as well as surgical strategies, depending on their severity and localisation, with sometimes surprisingly favourable visual outcome. In addition to prognostic factors, timely recognition and prompt, if possible preventive, acute care, as well as carefully considered timing of adequate surgical measures taking advantage of the specific characteristics of the choroidal tissue, are crucial to treatment success. Along with technical advances in the field of vitreoretinal surgery, numerous variants of therapeutic approaches to the treatment of choroidal effusion and suprachoroidal haemorrhage have been proposed to date. This review presents some of the most important surgical techniques and strategies in the field.

A Retrospective Case Series of Uveal Effusion Syndrome

PURPOSE

This study aimed to describe the clinical findings and management of eyes affected by uveal effusion syndrome.

METHODS

We retrospectively evaluated the charts of 13 eyes of 8 consecutive patients diagnosed with uveal effusion syndrome attending the Ophthalmology Unit of the University Hospitals Leuven, Belgium, between 2007 and 2018. The presenting features, investigations, management, and outcomes were analyzed for each case.

RESULTS

Cataract surgery was the predisposing factor for uveal effusion in 6 eyes, 2 bilateral uveal effusions (4 eyes) were considered to be medication-induced, and in 3 eyes, the uveal effusion was described as idiopathic. Fundus examination of 5 of 13 eyes showed bullous choroidal detachment, treated with pars plana vitrectomy with superotemporal sclerectomy or transscleral punction. Fundoscopy showed uveal effusion without serous retinal detachment in 3 eyes. Serous retinal detachment accompanied by uveal swelling was observed in 3 eyes and the 2 remaining eyes presented with uveal swelling only. The 8 nonbullous choroidal detachments were treated in a conservative way. A rapid resolution of subretinal fluid and uveal effusion was observed in all cases.

CONCLUSIONS

A conservative approach with acetazolamide treatment or just observation was used in our case series in choroidal detachment without substantial visual loss if, over time, slow improvement was documented. However, further studies are needed to verify the effectiveness of the reported therapy.

A prospective, population-based, surveillance (BOSU) study of uveal effusion syndrome in the UK

PURPOSE

To determine the incidence and demographic profile of uveal effusion syndrome (UES), and to describe the visual and anatomic outcome following deep sclerectomy or vortex vein decompression.

METHODS

The British Ophthalmological Surveillance Unit (BOSU) mails reporting cards monthly to 1149 senior UK ophthalmologists, who are requested to report incident cases of specified rare diseases. UES was included in the reporting system from October 2009 to October 2011. If UES was identified, ophthalmologists were mailed a questionnaire to collect anonymized clinical data at baseline, and 12 months after.

RESULTS

Over 2 years, 29 cases were reported. Two cases were duplicates and 12 failed to meet the eligibility criteria. Of the 15 eligible cases, age ranged from 11 to 91 years (mean 62) and nine were males (60%). Ten patients were hypermetropic; three had an axial length of 19.0 mm or less. Estimated annual incidence was 1.2 per 10 million population. Seven cases were managed nonsurgically, including observation (one case), topical steroids (two cases), systemic steroids (three cases), and cyclodiode laser (one case). Eight cases (11 eyes) underwent full-thickness sclerectomy; the elevated flap was retained in four. The sclera was noted to be thick and rigid during surgery in five cases. Median preoperative visual acuity was 6/18, changing slightly to 6/21.5 at final review, with three eyes showing complete anatomic response, five showing some improvement, and three failing to respond.

CONCLUSIONS

UES is extremely rare. It occurs in a range of ages, but is most common in middle-aged, hypermetropic men. Visual acuity can be materially reduced. The most commonly used surgical treatment in the UK is deep sclerectomy.

Unusual non-nanophthalmic uveal effusion syndrome with histologically normal scleral architecture: a case report

Background

To report an unusual case of non-nanophthalmic uveal effusion syndrome (UES) with histologically normal sclera but responsive to scleral resection.

Case presentation

A73-year-old man presented with a bullous retinal detachment without ciliochoroidal detachment on funduscopic examination of the right eye. The axial length of both eyes was normal. Extensive investigations for possible causes of exudative retinal detachment were performed with unremarkable results except for choroidal hyperpermeability on indocyanine green angiography (ICGA). Ultrasound biomicroscopy (UBM) revealed scleral thickening with peripheral choroidal elevation leading to the diagnosis of UES.

Partial thickness sclerectomy and sclerotomy was performed resulting in complete retinal reattachment, reduction of choroidal hyperpermeability on ICGA and improvement of visual acuity. However, histological studies of the excised sclera revealed no scleral architectural changes or abnormal deposits.

Conclusions

The diagnosis of UES in non-nanophthalmic eyes is challenging. Thorough systemic and ocular investigations are critical to rule out other etiologies. UBM can be helpful to evaluate scleral thickness and anterior choroid in equivocal cases. Our case was unique in that, although the sclera was thick, no abnormal microscopic scleral architecture could be identified. Misdiagnosis may lead to different surgical procedures such as vitrectomy resulting in unfavorable outcomes.

Scleral thinning surgery for bullous retinal detachment with retinal pigment epithelial tear in central serous chorioretinopathy: a case report

Background

Bullous serous retinal detachment (RD) with retinal pigment epithelial (RPE) tear is a rare and severe variant of chronic central serous chorioretinopathy (CSC). Due to its atypical presentation, it may raise diagnostic issues, leading to inappropriate therapeutic procedures. The optimum treatment for this CSC variant is still uncertain.

Case presentation

A 65-year-old male was referred for vitreo-retinal surgery with a provisional diagnosis of rhegmatogenous RD in his right eye. Dilated fundus examination showed an inferior bullous RD with no evidence of retinal breaks, while a large RPE tear was detected in the temporal quadrant. Ocular ultrasound showed no mass lesion. The axial length was 23.63 mm. Enhanced depth imaging optical coherence tomography (EDI-OCT) revealed a pachychoroid pattern in both eyes. The patient referred a history of CSC in the right eye and the recent use of intravenous corticosteroids for bronchitis. Laser therapy and photodynamic therapy were not applicable due to the extension and elevation of the RD. Two months after oral treatment with eplerenone, the subretinal fluid increased significantly. The patient underwent two 4 × 4 mm deep lamellar sclerectomies in the inferior quadrants. The surgical treatment resulted in complete RD resolution.

Conclusion

A correct diagnosis of bullous variant of chronic CSC with RPE tear is critical to avoid inappropriate procedures and to prevent severe visual loss as a result of neuroretinal damage. Scleral thinning surgery may be considered a valid option, resulting in rapid and long-lasting resolution of RD.

Contact Lens Based Drug Delivery to the Posterior Segment Via Iontophoresis in Cadaver Rabbit Eyes

PURPOSE

A drug loaded contact lens combined with electrodes positioned diametrically opposite and beyond the limbus can potentially deliver ionic drugs directly to the vitreous.

METHODS

Commercial lenses are loaded with nile blue or fluorescein as the drug analogs and placed on cadaver rabbit eyes. Electrodes (19.6 mm²) are placed atop at opposite sides of the sclera to apply a constant current (0.125-0.250 mA) for 1-2 h. COMSOL simulations are conducted to determine the field distribution and the potential drop across various tissue layers and equivalent circuit model is developed to calculate the electrophoretic velocity and estimate the drug flux.

RESULTS

The device delivered both hydrophobic and hydrophilic dyes to the tissue. The amount of fluorescein delivered to the vitreous directly correlated with the applied current and time duration. The electrophoretic mobility from the experimental data agreed with the model estimates. Confocal microscopy showed that nile blue penetrated through the conjunctiva-sclera barrier to reach the retina showing that the electric field can transport molecules through the ocular tissue and into the vitreous. The ex vivo model neglects transport into flowing capillaries in the choroid. However, the time scale for electrophoretic transport across the choroid was found to be 550-1300 fold shorter than that for uptake into the choroidal capillaries.

CONCLUSION

Incorporation of an electric field with multiple electrodes on a single lens can effectively deliver ionic drugs to the posterior region at levels comparable to current methods with the benefits of being safer and less invasive.

PERIPAPILLARY PACHYCHOROID SYNDROME

PURPOSE

To describe the features of peripapillary pachychoroid syndrome (PPS), a novel pachychoroid disease spectrum (PDS) entity.

METHODS

Medical records of 31 eyes (16 patients) with choroidal thickening associated with intraretinal and/or subretinal fluid in the nasal macula extending from the disk were reviewed (patients with PPS). Choroidal thickness was compared with 2 age-matched cohorts: typical PDS (17 eyes with central serous chorioretinopathy or pachychoroid neovasculopathy) and 19 normal eyes.

RESULTS

The patients with PPS were 81% men aged 71 ± 7 years. Peripapillary pachychoroid syndrome eyes displayed thicker nasal versus temporal macular choroids, unlike PDS eyes with thicker temporal macular choroids (P < 0.0001). Peripapillary intraretinal and/or subretinal fluid was often overlying dilated Haller layer vessels (pachyvessels). Fundus autofluorescence and fluorescein angiography illustrated peripapillary pigmentary mottling without focal leakage. Most PPS eyes (70%) exhibited other PDS findings including serous pigment epithelial detachment or gravitational tracks. Indocyanine green angiography illustrated dilated peripapillary pachyvessels and choroidal hyperpermeability. The disk was usually crowded, with edema noted in 4/31 (13%) eyes and mild late fluorescein disk leakage identified in half of the cases. Choroidal folds (77%), short axial lengths (39% less than 23 mm), and hyperopia (86%) were common.

CONCLUSION

Peripapillary pachychoroid syndrome is a distinct PDS variant, in which peripapillary choroidal thickening is associated with nasal macular intraretinal and/or subretinal fluid and occasional disk edema. Recognition of PPS is important to distinguish it from disorders with overlapping features such as posterior uveitis and neuro-ophthalmologic conditions.

Choroidal detachments: what do optometrists need to know?

Choroidal detachments occur when there is an accumulation of fluid or blood in the suprachoroidal space, a potential space situated between the choroid and the sclera. They are an uncommon ocular pathology. The most common cause of choroidal detachment is secondary to trabeculectomy; however, there are other causes such as trauma and inflammation. Clinically, choroidal detachments may vary in presentation from asymptomatic, to very poor vision, severe ocular pain, vomiting and nausea. Ocular findings associated with choroidal detachments include serous retinal detachment, secondary angle closure, and a very shallow anterior chamber. Optometrists, as primary eye care providers, need to be aware of the clinical signs and symptoms associated with choroidal detachments and ensure that appropriate and timely management, with a referral to an ophthalmologist, is instigated for optimal visual outcomes. In this review, the pathophysiology, detection, and associated risk factors for choroidal detachments are discussed, and evidence-based management recommendations in an optometric context are provided. The characteristics and management of uveal effusion syndrome are also reviewed, as this can cause idiopathic exudative choroidal detachments distinct from classical choroidal detachment.

Uveal effusion syndrome in 104 eyes: Response to corticosteroids - The 2017 Axel C. Hansen lecture

Purpose:

The purpose of the study was to investigate the corticosteroids for uveal effusion syndrome (UES).

Methods:

Retrospective series of 104 eyes with UES treated with oral corticosteroids (OCS), periocular corticosteroids (PCS), topical corticosteroids (TCS), or observation (OBS). Main outcome measure was UES resolution.

Results:

Of 104 eyes, treatment included OCS (n = 27), PCS (n = 12), TCS (n = 11), and OBS (n = 54). A comparison of the four groups (OCS vs. PCS vs. TCS vs. OBS) revealed differences in those managed with OCS versus OBS as younger (66 vs. 72 years, P = 0.049), PCS versus OBS as male (100% vs. 54%, P = 0.002), PCS versus OBS with decreased visual acuity (VA)/visual field (91% vs. 51%, P = 0.018), and OBS versus OCS as asymptomatic (28% vs. 0%, P = 0.001). Of the 59 with follow-up information, management included OCS (n = 21), PCS (n = 12), TCS (n = 6), and OBS (n = 20). There were differences in initial VA <20/400 in PCS versus OBS (42% vs. 5%, P = 0.018), effusion thickness in TCS versus OCS (7 vs. 3 mm, P = 0.004), and serous retinal detachment in PCS versus OBS (100% vs. 30%, P < 0.001) and PCS versus OCS (100% vs. 57%, P = 0.012). Regarding outcomes, VA showed less worsening in OCS versus OBS (0% vs. 30%, P = 0.008) and OCS versus PCS (0% vs. 33%, P = 0.012). There was no difference in rate of effusion resolution or effusion recurrence. Overall, using combination of corticosteroid therapies, effusion resolution was achieved in 56/59 (95%) cases and the need for surgical management with scleral windows was necessary in only 3/59 (5%) cases. Complications included cataract (n = 9) and no instance of steroid-induced glaucoma.

Conclusion:

Management of UES is complex and depends on disease severity. Using various corticosteroid delivery routes, UES control was achieved in 95%, and scleral window surgery was required in only 5%. A trial of corticosteroids can benefit patients with UES.

Unconventional aqueous humor outflow: A review

Aqueous humor flows out of the eye primarily through the conventional outflow pathway that includes the trabecular meshwork and Schlemm's canal. However, a fraction of aqueous humor passes through an alternative or 'unconventional' route that includes the ciliary muscle, supraciliary and suprachoroidal spaces. From there, unconventional outflow may drain through two pathways: a uveoscleral pathway where aqueous drains across the sclera to be resorbed by orbital vessels, and a uveovortex pathway where aqueous humor enters the choroid to drain through the vortex veins. We review the anatomy, physiology and pharmacology of these pathways. We also discuss methods to determine unconventional outflow rate, including direct techniques that use radioactive or fluorescent tracers recovered from tissues in the unconventional pathway and indirect methods that estimate unconventional outflow based on total outflow over a range of pressures. Indirect methods are subject to a number of assumptions and generally give poor agreement with tracer measurements. We review the variety of animal models that have been used to study conventional and unconventional outflow. The mouse appears to be a promising model because it captures several aspects of conventional and unconventional outflow dynamics common to humans, although questions remain regarding the magnitude of unconventional outflow in mice. Finally, we review future directions. There is a clear need to develop improved methods for measuring unconventional outflow in both animals and humans.

A CASE OF POSTERIOR UVEAL EFFUSION SYNDROME MASQUERADING AS UVEITIS

PURPOSE

To report a case of posterior uveal effusion syndrome presented and treated as posterior uveitis.

METHODS

We report one case of a 73-year-old woman with posterior uveal effusion syndrome who developed bilateral chorioretinal folds, treated as uveitis, who did not resolve on oral steroids.

RESULTS

Nasal choroidal thickening and intraretinal fluid were present in both eyes, along with choroidal folds and yellowish pigmentary changes in the macula.

CONCLUSION

Posterior uveal effusion syndrome can present with features that can mimic uveitis.

USE OF FIBEROPTIC-GUIDED CO2 LASER IN THE TREATMENT OF UVEAL EFFUSION

BACKGROUND/PURPOSE

To report a new technique for treating patients with uveal effusion syndrome by the fiberoptic-guided CO2 laser.

METHODS

Interventional case report. A 74-year-old man presented with exudative detachment of the choroid secondary to uveal effusion syndrome. Partial-thickness sclerotomy and full-thickness sclerotomy were performed to treat the disease using a fiberoptic-guided CO2 laser.

RESULTS

After the surgery, the patient's visual acuity improved and choroidal folds disappeared.

CONCLUSION

This technique allows concomitant coagulation and cutting, thereby reducing the risk of bleeding and providing better depth control.

Uveal effusion syndrome mimicking severe chronic posterior uveitis: a case series of seven eyes of four patients

PURPOSE

To describe the clinical findings and management of eyes affected by uveal effusion syndrome (UES) presenting with clinical features mimicking inflammatory ocular diseases, treated using individualized surgical approaches.

METHODS

We report a consecutive interventional case series of seven eyes of four patients affected by UES. On presentation in our clinic, all patients showed signs of steroid effects as a consequence of a presumptive diagnosis; one eye had undergone vitrectomy for retinal detachment (RD), without benefit. Diagnosis of UES was based on ophthalmic examination, ultrasonography, fluorescein angiography, biometry and magnetic resonance imaging. Five eyes with active disease were treated using scleral thinning surgical procedures based on the extent and characteristics of the disease: sclerectomy sites were ultrasound-guided to the area of maximal choroidal swelling, associated with evacuative puncture in the case of bilateral funnel-shaped RD.

RESULTS

One patient was diagnosed with type 1 UES, two with type 2, and one with type 3. Mean postoperative follow-up was 26 months. In all eyes, surgery resolved the ciliochoroidal and retinal detachment and improved visual acuity. In two eyes, visual restoration was limited by a prolonged disease course.

CONCLUSION

UES may be mistaken for other sources of ciliochoroidal effusion. Early diagnosis and treatment is critical to avoid unnecessary procedures and to prevent severe visual loss as a result of neuroretinal damage. Surgical treatment based on the extent and characteristics of the disease may be effective for the resolution of ciliochoroidal effusion, even in type 3 UES, where conventional surgery has proved unsuccessful.

A porohyperelastic finite element model of the eye: the influence of stiffness and permeability on intraocular pressure and optic nerve head biomechanics

Progressively deteriorating visual field is a characteristic feature of primary open-angle glaucoma (POAG), and the biomechanics of optic nerve head (ONH) is believed to be important in its onset. We used porohyperelasticity to model the complex porous behavior of ocular tissues to better understand the effect variations in ocular material properties can have on ONH biomechanics. An axisymmetric model of the human eye was constructed to parametrically study how changes in the permeabilities of retina-Bruch's-choroid complex (k(RBC)), sclera k(sclera), uveoscleral pathway (k(UVSC)) and trabecular meshwork k(TM) as well as how changes in the stiffness of the lamina cribrosa (LC) and sclera affect IOP, LC strains, and translaminar interstitial pressure gradients (TLIPG). Decreasing k(RBC) from 5 × 10(- 12) to 5 × 10(- 13) m/s increased IOP and LC strains by 17%, and TLIPG by 21%. LC strains increased by 13% and 9% when the scleral and LC moduli were decreased by 48% and 50%, respectively. In addition to the trabecular meshwork and uveoscleral pathway, the retina-Bruch's-choroid complex had an important effect on IOP, LC strains, and TLIPG. Changes in k(RBC) and scleral modulus resulted in nonlinear changes in the IOP, and LC strains especially at the lowest k(TM) and k(UVSC). This study demonstrates that porohyperelastic modeling provides a novel method for computationally studying the biomechanical environment of the ONH. Porohyperelastic simulations of ocular tissues may help provide further insight into the complex biomechanical environment of posterior ocular tissues in POAG.

Medical therapy for uveal effusion syndrome

PURPOSE

To report a case series of three patients with bilateral uveal effusion syndrome (UES), treated conservatively with oral carbonic anhydrase inhibitors and topical prostaglandin analogues (PAs).

METHODS

Three patients with bilateral UES were treated with the same initial therapy. Topical PA latanoprost 0.005% and acetazolamide 250 mg were administered in order to reduce intraocular pressure, improve uveoscleral outflow, and facilitate resolution of uveal effusion.

RESULTS

The chorioretinal detachment resolved within 3 months in two reported patients while the third one underwent surgery on his left eye. After clinical improvement, further oral therapy with acetazolamide was stopped, while topical prostaglandins were continued for at least the next 3 months. All patients were free from recurrence during the follow-up period.

CONCLUSION

Although the usually recommended UES therapy is partial or full-thickness sclerectomy, our case series showed apparent resolution of chorioretinal detachment in two patients on medical therapy alone. Conservative therapy may be the first step before the standard recommended surgical approach, but further studies are needed to verify the effectiveness of reported therapy.

Bilateral nanophthalmic uveal effusion syndrome: clinical presentation and surgical management

PURPOSE

To describe the clinical presentation and surgical management of bilateral uveal effusion syndrome in a type 1 diabetic patient with nanophthalmos.

METHODS

A 38-year-old man presented with decreased visual acuity. Fundus examination revealed exudative retinal detachment and choroidal folding. Ultrasound examination confirmed thickened sclera, choroidal effusion, and nanophthalmos. Partial thickness scleral windows and subscleral sclerectomy were performed. The patient returned 2 years postoperatively with the same presentation in the contralateral eye.

RESULTS

After subscleral sclerectomy, intraocular pressure remained stable and the patient recovered premorbid vision in both eyes. At 4 years of follow-up, the patient's vision had remained stable without the need for further treatment.

CONCLUSION

The association of uveal effusion syndrome with diabetes and other autoimmune disorders is unclear, warranting further research. Uveal effusion syndrome can be managed effectively by partial thickness scleral windows and sclerectomy with improvement and maintenance of visual acuity.

A modified ultrasound-guided surgical technique for the management of the uveal effusion syndrome in patients with normal axial length and scleral thickness

PURPOSE

The purpose of this study was to describe a modified surgical technique for the management of the uveal effusion syndrome (UES).

METHODS

A consecutive interventional case series of six eyes with UES is reported. The diagnosis of the UES was based on detailed ophthalmic examination, fluorescein angiography, B-scan ultrasonography, biometry, and magnetic resonance imaging. All eyes underwent an ultrasound-guided placement of the sclerostomies subjacent to the area of maximal choroidal swelling using a scleral punch without scleral flaps or vortex vein decompression.

RESULTS

All patients were men with a mean age of 53 years. The mean postoperative follow-up was 16.25 months. Five eyes had normal axial lengths (22.54-23.05 mm) by ultrasound and normal sclera thickness on magnetic resonance imaging. One eye had a shorter axial length (21.65 mm) and mild scleral thickening on magnetic resonance imaging. All six eyes had anterior peripheral choroidal swelling. Three eyes had associated serous retinal detachment, and three eyes had acute appositional angles. After surgery, five eyes had total resolution of the peripheral choroidal swelling and retinal detachment or normalization of the angle. One eye had partial resolution of the retinal detachment. Of the three eyes with retinal detachment, two eyes experienced improvement in visual acuity after surgery. No complications were noted.

CONCLUSION

This modified ultrasound-guided surgical technique for sclerostomy placement seems to be effective in the management of the UES, including eyes with normal axial length and scleral thickness, a subset of the UES that has been previously reported not to respond to surgery.

Transscleral albumin diffusion and suprachoroidal albumin concentration in uveal effusion syndrome

PURPOSE

To test the hypothesis that uveal effusion syndrome is caused by reduced transscleral albumin permeability.

METHODS

Surgical scleral specimens were obtained from a 55-year-old patient with nanophthalmic uveal effusion syndrome. Specimens were clamped in a modified Ussing chamber, and the rate of transscleral diffusion of fluorescein isothiocyanate-albumin was measured over 12 hours, using a spectrophotometer and predetermined standard curves. The diffusion coefficient was determined at 20°C, and then adjusted to body temperature using Einstein's equation. Results in 3 scleral samples were compared with 10 age-matched controls. Albumin and total protein concentration were measured in choroidal fluid and serum.

RESULTS

Histologic staining with Alcian blue showed interfibrillary acid mucin deposits. Transmission electron microscopy showed deposits measuring 1 μm to 10 μm and collections of expanded, degenerate collagen fibrils. The mean (±SD) albumin diffusion coefficient was 12% of that in controls (1.22 ± 0.67(-8) × 10 vs. 10.3 ± 7.0 × 10(-8) cm2/second) and below the lower 95% confidence limit of the control group. The diffusion coefficient was calculated to increase 53% to 1.87 ± 1.03 × 10(-8) cm2/second at 37°C. Choroidal albumin concentration was much higher than physiologic levels, measuring 200 g/L (total protein 321 g/L), 5 times the serum albumin concentration of 42 g/L (total protein 70 g/L).

CONCLUSION

Nanophthalmic uveal effusion syndrome can be associated with reduced scleral permeability to albumin, and a very high concentration of retained suprachoroidal albumin. This will lead to an osmotic gradient that retains fluid and may partly explain the pathogenesis of uveal effusion syndrome in some patients.

Relationship of stokes radius to the rate of diffusion across Bruch's membrane

PURPOSE

To determine the effect of Stokes radius (R(S)) on the diffusion of molecules through Bruch's membrane (BM), and to establish a system suitable for the analysis of diffusion through small (<2 mm(2)) samples of BM.

METHODS

Porcine BM/choroid (BM/Ch) was mounted in a modified Ussing chamber. A concentration gradient was simultaneously established for four tracers with R(S) values ranging from <1.0 to 6.15 nm. Samples were collected from both chambers at various time points up to 36 hours and the amount of each tracer was determined using quantitative gel exclusion chromatography. The integrity of samples was determined using scanning electron microscopy.

RESULTS

BM/Ch mounted in the chamber exhibited no obvious damage even after 36 hours in the chamber. Flux was significantly (P < 0.05) greater in the BM to Ch direction than that in the Ch to BM direction for only two of the tracers: cytosine and RNase A. Flux also was dependent on R(S); cytosine, the smallest tracer (R(S) < 1 nm), exhibited the greatest flux and ferritin (R(S) = 6.15 nm) the least. Permeability coefficients for each tracer were determined and exhibited a power relationship with R(S).

CONCLUSIONS

Flux was dependent on the direction of the concentration gradient and the R(S) of the individual tracers. We have successfully demonstrated that quantitative gel exclusion chromatography can be used to follow diffusion of a mixture of tracers across BM/Ch, and that we can measure flux across BM/Ch preparations with an exposed surface area as small as 1.8 mm(2).

Alteration of the serine protease PRSS56 causes angle-closure glaucoma in mice and posterior microphthalmia in humans and mice

Angle-closure glaucoma (ACG) is a subset of glaucoma affecting 16 million people. Although 4 million people are bilaterally blind from ACG, the causative molecular mechanisms of ACG remain to be defined. High intraocular pressure induces glaucoma in ACG. High intraocular pressure traditionally was suggested to result from the iris blocking or closing the angle of the eye, thereby limiting aqueous humor drainage. Eyes from individuals with ACG often have a modestly decreased axial length, shallow anterior chamber and relatively large lens, features that predispose to angle closure. Here we show that genetic alteration of a previously unidentified serine protease (PRSS56) alters axial length and causes a mouse phenotype resembling ACG. Mutations affecting this protease also cause a severe decrease of axial length in individuals with posterior microphthalmia. Together, these data suggest that alterations of this serine protease may contribute to a spectrum of human ocular conditions including reduced ocular size and ACG.

Scleral punch method with topical mitomycin C for safe revision of failed deep sclerectomy in nanophthalmic uveal effusion syndrome

PURPOSE

To describe a novel surgical technique for revision of deep sclerectomy surgery in nanophthalmic uveal effusion syndrome.

METHODS

A 46-year-old woman with recessively inherited nanophthalmos and chronic uveal effusions underwent a revision of previous failed deep sclerectomy surgery. In the presence of scar tissue, revision of sclerectomies was greatly facilitated by the use of a Kelly scleral punch (Katena Products, Inc., Denville, NJ, USA). To inhibit further scarring, mitomycin-C (MMC) was applied topically in each quadrant posterior to the equator.

RESULTS

The scleral punch allowed outward scleral dissection from the suprachoroidal space, and brisk enlargement of sclerectomies in all quadrants without perforation of choroidal tissue. Post-operative conjunctival wound healing appeared unimpeded by the posteriorly placed MMC sponges. Near-total resolution of the effusions had occurred by 3 months.

CONCLUSIONS

The scleral punch provides a safe and effective method for constructing and revising full-thickness sclerectomies in the nanophthalmic eye, minimizing the risk of choroidal trauma. The use of topical MMC may reduce the risk of late failure of trans-scleral outflow due to fibrosis.