|Year : 2001 | Volume
| Issue : 3 | Page : 191-192
Suprachoroidal haemorrhage. Secondary management
Yog R Sharma1, Amit Gaur2, Raj V. Azad3
1 MD. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
2 MD. FRCS. Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
3 MD. Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
Yog R Sharma
MD. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sharma YR, Gaur A, Azad RV. Suprachoroidal haemorrhage. Secondary management. Indian J Ophthalmol 2001;49:191-2
We report a case of successful management of expulsive suprachoroidal haemorrhage following cataract surgery. This case study highlights the strategy of adequate management
Suprachoroidal haemorrhage (SCH) is a catastrophic complication of intraocular surgery. Though rare, with an incidence of 0.06-0.2% following cataract surgery, It is perhaps the most feared and devastating of complications. SCH can cause immediate loss of vision or loss of the eye. Various studies have shown that vision can be restored with proper management. Prognosis depends on severity of the condition, management of an acute episode on the table, and on secondary surgical management. We report a case where, with successful surgical intervention, not only was the eye salvaged but useful vision restored.
| Case report|| |
A 74-year-old gentleman underwent planned extracapsular cataract extraction in the right eye. Intraoperatively, after the delivery of nucleus, the patient complained of pain and the vitreous started prolapsing with shallowing of anterior chamber and expulsion of iris through the limbal wound. The surgeon attempted anterior vitrectomy with scissors and cellulose sponge when there was a sudden loss of red glow and SCH was recognized as the cause. The wound was rapidly closed with 8-0 nylon sutures. No attempt was made to drain the suprachoroidal blood.
The patient was referred to us two days later. He had vision of light perception only with inaccurate projection of light in two quadrants. Examination showed intraocular pressure (IOP) at 28 mm Hg, incarceration of vitreous in the wound, and an updrawn pupil. There was no fundal glow. An ultrasound examination confirmed the diagnosis of haemorrhagic choroidal detachment and vitreous haemorrhage. Organisation of blood was indicated by a high reflective, solid appearing mass with irregular internal structure and irregular shape.
The patient was started on oral and topical corticosteroids along with anti-glaucoma medication. The projection of rays became accurate in all quadrants with control of IOP. Vitreoretinal surgery was planned when an ultrasound examination revealed liquefaction of blood in the suprachoroidal space as indicated by diffuse, low reflective mobile opacities.
After 12 days, the patient was scheduled for pars plana vitrectomy. The infusion cannula was not placed through the standard pars plana site because of the choroidal detachment; instead it was placed through the limbus. The vitrectomy probe was placed through a similar limbal incision. Vitreous was removed from the anterior chamber and the pupillary area. Further limited vitrectomy was done to remove vitreous haemorrhage, taking care to avoid the anteriorly displaced retina and choroid. Then a standard pars plana vitrectomy port was made at the pars plana inferotemporally. Dark red blood gushed out. To prevent hypotony, the infusion into the anterior chamber was continued to replace the volume drained from the suprachoroidal space. Once drainage from this site was completed, two other ports were made superonasally and superotemporally.
Pars-plana vitrectomy was then carried out to clear the vitreous hemorrhage. When the media became clear residual choroidal swellings were observed, as was a retinal tear located anterior to equator in supero-temporal quadrant. Perfluorocarbon liquid (PFCL) was instilled over the posterior pole, leading to further drainage of blood from the port sites. PFCL was then completely removed. An air-fluid exchange was carried out followed by photocoagulation around the retinal tear. Silicone oil was injected for fear of any missed break(s), and for prolonged internal tamponade.
Postoperatively the retina was attached and patient had a best corrected visual acuity of 6/36 at time of discharge 3 days later. With aphakic correction the vision after 6 weeks was 6/12. The patient was admitted for silicone oil removal and 360° endophotocoagulation anterior to the equator was done. At the same sitting an anterior chamber intraocular lens was implanted. Vision remained 6/12 at one-year follow-up.
| Discussion|| |
An intraoperative SCH is defined as a sudden haemorrhagic swelling of the choroid which develops at time of intraocular surgery, which if associated with expulsion of some or all of the intraocular contents. Various studies have focussed on identifying patients at risk and reduction of risk factors help to reduce the incidence. With proper intraoperative and postoperative secondary surgical management some eyes can recover from SCH with useful vision. Spaeth et al have concluded from their study that occurrence of SCH does not in itself prognosticate a poor long-term outcome. The prognostic factors also include secondary procedures, were vitreous hemorrhage and retinal break/ detachment.
A high index of suspicion should be kept in cases where risk factors for expulsive SCH exist. Intraoperatively early recognization and immediate rapid closure of the wound is important. Prolapsed intraocular contents should be reposited as quickly as possible; if this is not possible; the eye can be softened by performing posterior sclerotomies. In the present case adequate wound closure was achieved along with partial anterior vitrectomy. No sclerotomies were made at primary cataract surgery. The role of sclerotomies at the time of the acute event is controversial. The blood clots rapidly in the suprachoroidal space and so it may not drain through the emergency sclerotomies. On the other hand, the tamponading effect of raised IOP could be unsettled due to ooze through the sclerotomies and could cause rebleed. In a study by Lakhanpal it was concluded that sclerotomies made during the acute event are detrimental to eyes.
Postoperative B-scan ultrasonography is important both for diagnosis and management of SCH. Besides determining the extent and location of a SCH, vitreoretinal status can be determined. Liquefaction of blood in the suprachoroidal space can be seen echographically and it usually occurs between 7 and 14 days. This had been suggested as the ideal time for vitreoretinal intervention.
Indications for secondary surgical management include retinal detachment, and vitreous incarceration into the wound. When vitreoretinal surgery is planned, it is usually preceded by drainage of haemorrhage through sclerotomies before pars plana ports are made to avoid iatrogenic damage to anterior retina, unless the drainage can be accomplished through the standard ports for pars plana vitrectomy as it did in our case. Use of PFCL to facilitate drainage of SCH has been recommended recently. In the present case it considerably facilitated SCH drainage and it avoided drainage sclerotomies because most of the blood percolated through the ports made for the standard pars plana vitrectomy. Tamponade with silicone oil was used for this patient because of uncertainty about the presence of unidentified retinal tears. At the time of silicone oil removal, 360° endophotocoagulation was done for similar reasons. This was also a safety measure against retinal detachment following silicone oil removal. As the fellow eye had 6/9 vision, anterior chamber intraocular lens implantation was done (Figure). To the best of our knowledge this is the first report of secondary IOL implantation in a patient of suprachoroidal hemorrhage successfully managed by vitreo-retinal surgery. At one-year follow up, vision in the operated eye remains 6/12.
We report this case to highlight the fact that though SCH is one of most feared and devastating complications of intraocular surgery, with proper preoperative, intraoperative and postoperative management, the prognosis need not always be poor. A better understanding of SCH not only helps the ophthalmic surgeon to avoid this complication but also treat patients with SCH with good results.
| References|| |
Chu TG, Green RL. Suprachoroidal hemorrhage. Surv Ophthalmol
Spaeth GL. Suprchoroidal hemorrhage: no longer a disaster. Ophthalmic Surg
Speaker MG, Guerriero PN, Met JA, et al. A case-control study of risk factors for intraoperative suprachoroidal expulsive haemorrhage. Ophthalmology
Spaeth GL, Baez KA. Long term prognosis of eyes having had operative suprachoroidal expulsive hemorhage. German J Ophtalmol
Lambrou FH Jr, Meredith TA, Kaplan HJ. Secondary surgical management of expulsive choroidal hemorrhage. Arch Ophthalmol
Lakhanpal V. Experimental and clinical observation on massive suprachoroidal hemorrhage. Trans Am Ophthalmol Soc
Lakhanpal V, Schocket SS, Elman MJ, Nirankari VS. A new modified vitreoretinal surgical approach in the management of massive suprachoroidal hemorrhage. Opthalmology
Desai UR, Peyman GA, Chen CJ: Use of perfluoro-perhydrophenanthrene in the management of suprachoroidal hemorrhages. Ophthalmology
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