Choroidal Rupture: Causes, Diagnosis, and Treatment
Understanding Choroidal Rupture
The choroid is a layer of tissue between the retina and the white outer wall of the eye, called the sclera. It is rich in blood vessels. It plays a critical role in nourishing the outer layers of the retina, including the photoreceptor cells responsible for sharp central vision. Damage to this layer can disrupt blood flow and threaten the health of the overlying retina.
A choroidal rupture occurs when the choroid, along with the overlying Bruch membrane, tears apart. Bruch membrane is a thin barrier between the choroid and the retina. The break typically appears as a crescent-shaped streak beneath the retina. The rupture itself can cause bleeding under the retina. It may also damage the retinal pigment epithelium (RPE), a layer of cells that supports retinal function.
Over time, abnormal blood vessels called choroidal neovascularization (CNV) can grow through the break. This new vessel growth can leak fluid or blood under the retina, leading to further vision loss.
Choroidal ruptures are classified based on how they form. Direct ruptures occur at the exact point of impact to the eye. Indirect ruptures, which are more common, form away from the impact site. They result from shock waves that travel through the eye. Indirect ruptures are often located near the macula, the central part of the retina responsible for detailed vision. This is why they frequently affect central eyesight.
Who Is Affected and Risk Factors
Choroidal rupture is found in an estimated 5 to 10 percent of eyes that experience blunt ocular trauma (AAO EyeWiki, 2024). It is one of the more significant injuries that can occur from a direct blow to the eye. The condition can affect people of any age. It is most frequently seen in younger adults and adolescents who are more likely to sustain eye injuries from sports, accidents, or physical altercations.
The most frequent cause of choroidal rupture is blunt trauma to the eye or the area around it. Common causes include:
- Sports injuries, such as being struck by a ball, elbow, or piece of equipment
- Motor vehicle accidents
- Falls or physical assaults
- Workplace accidents involving flying objects
- Airbag deployment during vehicle collisions
Not everyone with a choroidal rupture develops serious vision problems. However, certain factors increase the risk of complications such as choroidal neovascularization. Ruptures that pass through or near the fovea, the very center of the macula, carry a higher risk of lasting central vision loss. Larger ruptures and those with significant subretinal bleeding may also lead to worse outcomes. Younger patients may have a higher lifetime risk of developing CNV. It can appear months or even years after the original injury.
Signs and Symptoms
When a choroidal rupture occurs, it may be masked by other injuries from the trauma. The eye may be swollen, bruised, or filled with blood. This can make it difficult to see the rupture at first. Common symptoms at the time of injury include:
- Sudden decrease in vision in the affected eye
- Pain around or within the eye
- A dark or blurry spot in the central or peripheral vision
- Seeing floaters, which are small dark spots or strands that drift through vision
In some cases, a person may not notice significant vision changes at first. This is especially true if the rupture is small or away from the center of the macula. Weeks, months, or even years later, a new decrease in vision may develop. This delayed vision loss is often caused by CNV growing through the old rupture site. Symptoms of CNV include a new blurry spot in the central vision, straight lines appearing wavy or distorted, and difficulty reading or recognizing faces.
Any blunt injury to the eye that causes pain, vision changes, or visible damage should be evaluated as soon as possible. If you notice a sudden increase in floaters, flashes of light, a curtain or shadow moving across your vision, or sudden vision loss in one eye, see a retina specialist or go to the emergency room immediately. These symptoms could indicate a serious complication that requires urgent treatment.
Diagnosis and Testing
After an eye injury, a retina specialist or ophthalmologist will perform a thorough examination. This includes checking visual acuity, measuring eye pressure, and using a slit lamp to examine the eye. The doctor will dilate the pupils with eye drops to get a clear view of the retina and choroid. In the acute phase after trauma, blood or swelling inside the eye may obscure the choroidal rupture.
Several imaging tools help confirm the diagnosis and assess the extent of damage. These may include:
- Optical coherence tomography (OCT): a non-invasive scan that creates detailed cross-sectional images of the retina, showing breaks in Bruch membrane and any fluid
- Fluorescein angiography (FA): a dye-based test that reveals leaking new blood vessels in the retina
- Indocyanine green angiography (ICG): similar to FA but uses a different dye that highlights choroidal blood vessels more clearly
- Fundus autofluorescence (FAF): an imaging technique that shows damage to the retinal pigment epithelium
Because CNV can develop long after the initial injury, regular follow-up visits are important. A retina specialist may ask a patient to use an Amsler grid at home. This simple chart with a grid of straight lines can help detect distortion or missing areas in central vision. These changes may signal new blood vessel growth. Any new distortion should be reported promptly.
Treatment Options
Not all choroidal ruptures require active treatment. If the rupture does not involve the center of the macula and there is no evidence of CNV, a retina specialist may recommend careful monitoring. The eye can form a scar at the rupture site over time. As long as vision remains stable and no new blood vessels develop, regular check-ups may be the only intervention needed.
When abnormal blood vessels grow at the rupture site, anti-VEGF therapy is the primary treatment. These medications block vascular endothelial growth factor, a protein that drives abnormal blood vessel growth. They are injected directly into the eye in a procedure called an intravitreal injection. Commonly used anti-VEGF agents include:
- Eylea (aflibercept): typically given every 4 to 8 weeks after an initial loading phase
- Lucentis (ranibizumab): often administered every 4 weeks
- Avastin (bevacizumab): used off-label for eye conditions, as it is FDA-approved only for cancer treatment, given every 4 to 6 weeks
- Vabysmo (faricimab): a bispecific antibody that may allow intervals of 4 to 16 weeks after loading doses
Studies have shown favorable visual outcomes with anti-VEGF therapy for CNV secondary to choroidal rupture. A review found that eyes treated with anti-VEGF injections for traumatic CNV gained an average of two or more lines of visual acuity. Many patients required fewer total injections compared to CNV from other causes (Retina journal, 2015).
Photodynamic therapy (PDT) is a light-activated drug treatment used more commonly before anti-VEGF injections became available. In PDT, a medication called verteporfin is injected into a vein. A special laser is then directed at the abnormal blood vessels to activate the drug and close them. PDT may still be considered in certain cases. However, anti-VEGF therapy has largely replaced it as the first-line treatment for CNV related to choroidal rupture.
In rare cases where CNV is located away from the center of the macula, thermal laser photocoagulation may be an option. This procedure uses a focused beam of light to seal the leaking blood vessels. However, the laser creates a lasting blind spot in the treated area. It is only appropriate when the abnormal vessels are far enough from the fovea to avoid damaging central vision.
What to Expect
In the days and weeks following the initial trauma, vision may be quite poor. Swelling, bleeding, and inflammation inside the eye contribute to this. As these issues resolve, vision often improves. A retina specialist will schedule follow-up appointments to track healing and watch for complications. During this period, it is important to avoid activities that could lead to further injury.
The long-term visual outcome depends on several factors. These include the location and size of the rupture, whether the fovea is involved, and whether CNV develops. Ruptures that do not cross the fovea generally have a better prognosis. A study found that approximately 65 to 80 percent of eyes with choroidal rupture not involving the fovea maintained good visual acuity over time (British Journal of Ophthalmology).
When CNV does develop, early detection and treatment with anti-VEGF injections can help preserve or improve vision in many cases. Patients should understand that some degree of scarring at the rupture site is expected. Even with successful treatment of CNV, the scarred area may cause a persistent blind spot or mild distortion.
A retina specialist will typically see the patient frequently in the first few months after injury. The intervals between visits are then gradually extended if the eye remains stable. Because CNV can develop years after the initial trauma, periodic monitoring may continue for an extended period. Patients should keep all follow-up appointments and report any new vision changes between visits.
Living With Choroidal Rupture
After experiencing a choroidal rupture, protecting both eyes from future injury is essential. Wearing polycarbonate safety glasses or sports goggles during physical activities can help prevent further damage. These lenses are impact-resistant and provide a strong barrier against blunt trauma. Use them during work involving tools or machinery and any situation where eye injury is possible.
Using an Amsler grid daily can help detect early signs of CNV. To use the grid, hold it at reading distance, cover one eye, and look at the center dot. If any lines appear wavy, broken, or missing, contact a retina specialist promptly. This simple habit takes only a few seconds and can make a significant difference in catching complications early.
Coping with vision changes from a traumatic eye injury can be stressful. If vision loss affects daily activities such as reading, driving, or working, low vision rehabilitation services may help. These services teach adaptive techniques and provide assistive devices to help maintain independence. Speaking with a counselor or joining a support group for people with vision loss can also be beneficial.
When to See a Retina Specialist
Any significant blow to the eye or surrounding area should be evaluated by an eye care professional. Even if vision seems normal immediately after the injury, internal damage may not be apparent without a dilated eye exam. A referral to a retina specialist may be necessary for a more detailed evaluation.
If you have a history of eye trauma and notice new blurring, distortion, or a dark spot in your central vision, schedule an appointment with a retina specialist as soon as possible. These symptoms may indicate that CNV has developed at the site of an old choroidal rupture. Early treatment offers the best chance of preserving vision.
Questions and Answers
The rupture itself forms a scar over time, and in many cases no active treatment is needed for the break. However, the scar does not restore the tissue to its original state. The main concern is whether complications such as choroidal neovascularization develop at the scar site. Regular monitoring by a retina specialist is the best way to ensure that any complications are caught and treated early.
CNV can develop at any point after a choroidal rupture. It may appear within weeks of the injury or emerge years or even decades later. This is why long-term follow-up is recommended for anyone diagnosed with a choroidal rupture, even if vision is currently stable and no complications are present.
Before the injection, numbing drops are placed on the eye to reduce discomfort. Most patients describe the injection as a brief pressure or mild sting rather than sharp pain. Some soreness, mild redness, or a gritty feeling may be present for a day or two afterward. Serious complications from the injection itself are uncommon but should be discussed with a retina specialist before treatment begins.
Choroidal rupture typically occurs in the eye that sustained the trauma. However, if both eyes are injured in the same event, both could be affected. It is not a condition that spreads from one eye to the other. After a choroidal rupture in one eye, wearing protective eyewear is strongly recommended to safeguard the uninjured eye from future trauma.
The treatment course varies from person to person. CNV from choroidal rupture often responds well to anti-VEGF therapy. Some patients need only a limited number of injections. Unlike CNV associated with age-related macular degeneration, traumatic CNV may stabilize after a shorter course of treatment. A retina specialist will adjust the treatment plan based on how the eye responds and whether the abnormal blood vessels remain inactive.