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49 year old man with 6 months of swelling around the right eye
Digital Journal of Ophthalmology 1998
Volume 4, Number 20
July 6, 1998
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Jay C. Rudd, M.D. | Wills Eye Hospital, Philadelphia, PA
Differential Diagnosis
Choroidal detachments may be caused by:

Anterior and Posterior Scleritis
Usually presents with pain and redness that often awakens the patient FROM sleep. The conjunctival, episcleral, and scleral vessels are inflamed, leading to a bluish discoloration of the sclera. Scleritis is more common in women and is often unilateral. Work-up is routinely negative in the unilateral cases. B-scan ultrasonography shows diffuse thickening of the choroid, sclera, and episcleral tissues. Classically, the T-sign is present in cases of posterior scleritis. The T-sign is created by the fluid beneath Tenon's capsule that creates a squaring off of the interface between the optic nerve and the sclera. Fluoroscein angiography may SHOW punctate areas of leakage. The choroidal detachment is felt to be a result of the congested sclera. This congestion increases resistance to flow in the vortex veins and through the intact sclera, leading to choroidal effusions.
Uveal Effusion Syndrome
Bilateral choroidal effusions in males. Can present with injected episcleral vessels but has minimal associated pain. Fundus examination reveals multiple foci of hyperpigmentation at the level of the RPE ("leopard skin" spots). B-scan ultrasonography reveals diffuse choroidal thickening. Poor response to corticosteroids. The choroidal detachment is secondary to an anatomical abnormality in the sclera, leading to increased resistance to flow in the vortex veins.
Rhegmatogenous Retinal Detachment
On clinical examination, the presence of a rhegmatogenous retinal detachment is usually obvious.
Post-operative
Easily ruled out by clinical history.
Malignancy
Malignancies presenting as choroidal detachment include malignant melanoma, metastatic, and lymphoproliferative disorders. The presentation is usually without pain (unless necrotic), and various clinical findings help in the diagnosis. The presence of sentinel vessels on the conjunctiva can localize an intraocular tumor. Decreased transillumination is usually found in intraocular tumors, whereas choroidal effusions can demonstrate increased transillumination (Hagen's sign). B-scan ultrasonography will aid in the diagnosis, revealing an intraocular mass.
Vascular Etiology
Vascular causes include carotid-cavernous fistula and dural-sinus fistula. These vascular communications cause reversal of flow in the episcleral venous plexus, thus obstructing drainage FROM the suprachoroidal space. Clinical clues to fistulas are dilated, and often "arterialized" conjunctival vessels, elevated intraocular pressure, and dilated retinal veins. Historical clues include a history of head trauma, pulsatile tinnitus, and abrupt onset.
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