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   Table of Contents      
ORIGINAL ARTICLE
Year : 1992  |  Volume : 40  |  Issue : 4  |  Page : 100-102

Expulsive choroidal haemorrhage


Aravind Eye Hospital, Annanagar-Madurai 625 020, India

Correspondence Address:
M Srinivasan
Aravind Eye Hospital, Annanagar-Madurai 625 020
India
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Source of Support: None, Conflict of Interest: None


PMID: 1300298

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  Abstract 

Expulsive choroidal haemorrhage is a dramatic and serious complication of cataract surgery that occurred in five patients out of ten thousand consecutive cataract surgeries performed by the author during the year 1989 and 1990. Report about this dreaded complication after cataract surgery are scanty and as far as I can remember I have not seen any report in Indian ophthalmic literature recently. Since cataract surgery forms the major part of intra ocular surgeries performed in our country, I thought it would be appropriate to report about this rare complication which may occur to all of us. Out of five cases 3 were males and 2 were females in the age group ranging between 45-72 years. Two eyes regained vision up to 6/12 after intra operative expulsive haemorrhage. All the eyes were salvaged by doing anterior sclerotomy. Diabetes, hypertension, glaucoma and myopia are the commonest predisposing factors.


How to cite this article:
Srinivasan M. Expulsive choroidal haemorrhage. Indian J Ophthalmol 1992;40:100-2

How to cite this URL:
Srinivasan M. Expulsive choroidal haemorrhage. Indian J Ophthalmol [serial online] 1992 [cited 2019 Oct 20];40:100-2. Available from: http://www.ijo.in/text.asp?1992/40/4/100/24387



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  Introduction Top


Expulsive choroidal haemorrhage is a rare and dreadful complication of cataract surgery that usually results in either loss of vision or loss of the eye. It is most frequently associated with cataract surgery but it can occur spontaneously or in association with glaucoma surgery, corneal transplantation, traumatic rupture of the globe, perforation of a corneal ulcer, retinal surgery, macular degeneration, systemic an­ticoagulation and necrosis of the choroidal melanoma. Even though it is rare it happens to all of us. The first report of expulsive choroidal haemorrhage associated with cataract surgery was reported in 1786 [1].


  Material and methods Top


Ten thousand cataract surgeries were performed in the same institute by the author during 1989 and 1990. Out of these 6657 were performed using magnifying loupes and 3343 were done under operating microscope. The age group was ranging from 45-80 years. 49.1% were males and 50.9% were females. 20% of 3343 cataract surgeries were performed as planned extra capsular technique. The standard preoperative evaluation of a cataract patient was done in all. All the surgeries were performed under local anaesthesia using 2 ml of 2% lidocaine for retrobulbar anaesthesia and 3-4 ml of the same for facial block. Hyaluronidase and 1:1000 epinephrine were added to the anaesthetic solution. Epinephrine was avoided in cardiac and hypertensive patients.250 mg of acetazolamide was given 1 hour before surgery. Digital massage was given for 5 minutes after retrobulbar injection. All procedures were per­formed consecutively as and when they were admitted. Intra capsular cataract surgery was performed using cryo in most of these patients except in patients who had high myopia; eyes with proliferative diabetic retinopathy, and retinal detachment in the fellow eye had planned extracapsular cataract surgery, adopt­ing can opener capsulotomy technique and manual aspiration of cortical material with the help of regular Simcoe cannula. Lid speculum and superior rectus suture was routinely applied. Ab externo technique using limbal based conjunctival flap was done in all intra capsular techniques. Fornix based flap was made in extra capsular cataract surgery procedures. Out of ten thousand cataract procedures 6657 were performed using operating loupes. Three interrupted corneoscleral sutures were applied using 8-0 silk. 3343 cases were done under the operating microscope using 10-0 nylon as five interrupted corneoscleral sutures. Limbal based conjunctival flaps were deposited and not sutured. 20 mgs of gentamycin was given sub-conjunctivally in the lower fornix. Congenital cataracts, complicated cataracts and surgeries per­formed in the eye camps were excluded from this report. 80% of the patients were above the age of sixty years. Routine systemic evaluation for respiratory disorders, cardiac problems, diabetes and hypertension was done in all cases. Appropriate therapy was given for the above systemic disorders before scheduling for surgery. All patients were kept as inpatients for 5 days. Topical antibiotics and steroids were applied twice a day and cycloplegics once a day. The operated eye was bandaged with plastic or metal shield and patients were ambulatory from the first post operative day. Systemic antibiotics or antiinflammatory drugs were not given. Visual acuity with +10.00 D spherical glasses and fundus examination was done routinely during discharge.

Out of ten thousand cataract procedures five had expulsive haemorrhage. All the eyes were salvaged by performing anterior sclerotomy. None of the eyes were excised. All the five patients had expulsive haemorrhage intra-operatively after removal of the lens. Out of the five eyes two had intra capsular cataract surgery and three had planned extra capsular cataract surgery. One patient who was high myopic had expulsive haemorrhage intra operatively and post operatively in the room after 12 hours; resulting in gaping of the wound, and iris prolapse which required resuturing. Two eyes which had extra capsular cataract surgery regained post operative visual acuity up to 6/12 and rest of the three eyes had only light perception. Fundus examination with indirect ophthalmoscope during the first and 6th week of post operative period showed vitreous haemorrhage in two eyes and no retinal details were made out. The last case as shown in

[Table - 1] had fundus examination on 7th post operative day. There were dense vitreous opacities and only a red glow could be seen. The five cases who had intra operative expulsive haemorrhage are sum­marized in [Table - 1]. Out of 6657 cases using three 8-0 silk interrupted sutures using loupes, one had expulsive haemorrhage and out of 3343 cases done under operating microscope with 10-0 nylon sutures, four had this complication. Among these four eyes two occurred even after extra capsular cataract opera­tion, which has not been mentioned in earlier literature.


  Discussion Top


The first report of expulsive haemorrhage associated with cataract surgery was reported in 1786. Verhoeff [2] reported the first instance of an eye that was saved with, preservation of some vision after an expulsive haemorrhage during a sclerectomy for glaucoma. The incidence varies between 0.5% to 0.4% reported by different authors [3]. The average incidence was 0.2%. The incidence of expulsive haemorrhage in this study was 0.05%. The source of the haemorrhage is one of the numerous arteries supplying the uveal tract. Most anatomic studies have implicated one of the short posteriorciliary arteries. Manschot [4] reported anatomical studies in six eyes removed because of expulsive haemorrhage associated with cataract surgery. In five cases this resulted from ruptured necrotic posterior ciliary arteries. In the sixth case, sclerosis and thrombosis of the choroidal artery was the source of haemorrhage. It is unknown whether the rupture of the vessel occurs at a site of previous necrosis or without previous pathologic condition. Manschot's study favours the former view because he demonstrated that degeneration of vessel wall occurred before the onset of haemorrhage. However in cases in which an expulsive haemorrhage occurs during or after cataract surgery in infants and children, vascular degeneration is an unlikely factor. Local factors within the eye may be important and include a high degree of myopia, choroidal sclerosis, and perhaps congenital and familial weakness of choroidal sclerosis, and perhaps congenital and familial weakness of choroidal vessels. Some of the predisposing factors are given in [Table - 2] [5].

The risk factors mentioned in [Table - 2] was associated with all cases reported here. Among five cases two patients had systemic disorders and four eyes had local disorders like high myopia, glaucoma and choroidal sclerosis. In the same institute 4000 intra capsular cataract surgeries were performed by five surgeons from October 1989 to February 1991, as a project to study the efficacy of 8-0 virgin silk and 50 u stainless steel sutures. It was a random, double masked study. 5 interrupted sutures were applied. The age of the patients ranged between 45 - 70 years. Patients with hypertension, diabetes, bronchial asthma complicated cataract, glaucoma and corneal disorders were excluded from the project. There was no incidence of expulsive haemorrhage. This again proves that the predisposing factors men­tioned in [Table - 2] might be the probable causative factors in producing expulsive haemorrhage. The mode of anaesthesia has also been implicated. How­ever, this implication is doubtful because it occurs with local and general anaesthesia and regardless of whether epinephrine is used or not A sudden precipitous fall in intraocular pressure resulting from surgical decompression of the globe may be a favor in some cases. This catastrophe was seen more frequently in eyes with elevated intra ocular pressure. Among the five Gases reported by the author two eyes had glaucoma. Theoretically sudden decrease in intra ocular pressure should predispose more to a rupture of a posterior ciliary or choroidal artery because the difference between the intra vascular and extra vascular pressure is greater. However, a significant number of expulsive haemorrhages occur several days after surgery, when extreme hypotension is usually not a contributing factor. Jain [6]sub has postulated some association between expulsive haemorrhage and black cataract, the latter being in his opinion an indicator of the degree of arteriosclerosis. But there was no association in this series.

During expulsive haemorrhage many patients complain of severe ocular pain, headache, nausea and vomiting if anaesthesia was wearing off. But all these five patients never had these symptoms. The signs of intra operative expulsive haemorrhage are bulging forward of the iris diaphragm, vitreous starts welling out of the limbal section and the iris prolapses out. If the haemorrhage is severe one could see the black mass through the pupil pushing the retina out. The author also had similar signs but in less severe form. The constant signs were seeping of vitreous through the wound, spreading of pupillary border of iris over the sclera at 12 0' clock and easy breaking of sutures while closing the wound. It occurred in the same way both in intracapsular cataract extraction and planned extracapsular cataract extraction. In both techniques the eye behaved normally until the removal of either whole the lens or nucleus. In contrast to posterior sclerotomy at the inferotemporal quadrant by other authors, anterior sclerotomy either one or two about 10-12 mm posterior to the limbus on either side of the superior rectus muscle also had similar effect and it is easy to perform. Some prefer to choose the site of sclerotomy as per light perception in the patient. This could be possible in late haemorrhages . Vail [7]sub was the first to report the use of sclerotomy to save the eye from expulsive haemorrhage. Duehr and Hogenson [8] reported the saving of an eye by posterior sclerotomy and tight closure of the incision when the subchoroidal haemor­rhage occurred during cataract surgery.


  Summary Top


Expulsive subchoroidal haemorrhage as complication of cataract surgery has been reported only occasionally. Even though the incidence seems to be very low, I am sure that all ophthalmologists during their practice will definitely get this complication and they must have the knowledge to manage it. I had five cases of expulsive haemorrhages out of ten thousand cataract procedures performed in two years. No eye was excised. Two patients regained 6/12 vision and three had only light perception. The incidence in this report was 0.05%. This complication can occur during planned extra capsular cataract surgery also. Anterior sclerotomy saves the eye. All the five cases had either systemic or local predisposing factors.

 
  References Top

1.
de Wenzel MJB: Trait de la cataracts Paris, 1786. P.J Duplain.   Back to cited text no. 1
    
2.
verhoeff FH. Scleral puncture for expulsive sub-choroidal haemorrhage ophthalmol Rec 1915, 24:55.  Back to cited text no. 2
    
3.
Jaffe NS: Cataract surgery and its complications-page:497, 5th edition B.I Publications LTD, New Delhi 1990.  Back to cited text no. 3
    
4.
Manschot WA: The pathology of expulsive haemorrhage Am.J. Ophthalmol, 1955, 40:15  Back to cited text no. 4
    
5.
Bair HL: Expulsive haemorrhage at cataract operation-Am. J. Ophthalmol, 1966, 66:992  Back to cited text no. 5
    
6.
Jain IS: Expulsive haemorrhage and black cataract - orient Arch Ophthalmol, 1965, 3:141  Back to cited text no. 6
    
7.
Vail D Posterior sclerotomy as a form of treatment in subohoroidal expuisive haemorrhage-Am. J. opthalmol 1938, 21:256  Back to cited text no. 7
    
8.
Duehr PA and Hogenson CD: Treatment of subchoroidal haemorrhage by posterior sclerotomy -Arch. ophthalmol 1947, 38:365  Back to cited text no. 8
    



 
 
    Tables

  [Table - 1], [Table - 2]


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