FACTORS ASSOCIATED WITH OUTCOMES OF SUPRACHOROIDAL HEMORRHAGE: An Individual Participant Data Systematic Review.

PURPOSE: To determine factors associated with visual and anatomic outcomes of suprachoroidal hemorrhage in studies published between 1990 and 2022. METHODS: Individual participant data systematic review. The protocol was prospectively registered on Open Science Framework ( https://osf.io/69v3q/ ). PubMed, EMBASE, Web of Science, and Google Scholar were searched for peer-reviewed studies of suprachoroidal hemorrhage with ≥3 patients published between January 1, 1990, and September 1, 2022. The primary outcome was the change in logarithm of the minimum angle of resolution visual acuity from the time of suprachoroidal hemorrhage diagnosis to last follow-up. RESULTS: Four hundred thirteen eyes from 49 studies were included, with mean (SD) age 60.8 (22.4) years and mean (SD) follow-up of 13.8 (12.6) months. Among 145 eyes with at least 6 months of follow-up, the mean (SD) gain in visual acuity was -0.98 (0.89) logarithm of the minimum angle of resolution. In multivariable regression, treatment with systemic steroids was associated with greater improvement in logarithm of the minimum angle of resolution visual acuity (adjusted mean [SE] -1.29 [0.09] vs. -0.16 [0.30] for no systemic steroids; P < 0.001) and greater odds of achieving anatomic success (adjusted OR 10.59, 95% confidence interval 2.59-43.3; P = 0.001). CONCLUSION: The use of systemic steroids was associated with better visual and anatomic outcomes for suprachoroidal hemorrhage.

Spontaneous expulsive choroidal hemorrhage in an elderly female with microbial keratitis.

PURPOSE: To report spontaneous choroidal hemorrhage with the expulsion of intraocular contents in an elderly female as a complication of microbial keratitis. METHODS: Retrospective case report along with imaging. RESULTS: A 60-year-old female on treatment for microbial keratitis, presented with protrusion of intraocular contents and no perception of light in the right eye. Ophthalmic ultrasound demonstrated choroidal hemorrhage with coexistent retinal detachment and vitreous hemorrhage. She underwent uneventful evisceration for her condition. CONCLUSION: Microbial keratitis needs aggressive medical treatment to prevent associated stromal infiltration and corneal weakening. In cases of microbial keratitis, if spontaneous choroidal hemorrhage occurs, due to thinning of the cornea and compromised integrity of the eyeball, it can lead to the complete expulsion of intraocular contents with unsalvageable loss of vision.

Suprachoroidal Hemorrhage.

Suprachoroidal hemorrhage (SCH) refers to the accumulation of blood in the suprachoroidal space, a relatively uncommon but significant complication that can occur spontaneously, during ophthalmic surgery, or as a consequence of ocular trauma. If left undiagnosed and untreated, SCH can lead to severe vision loss or even blindness. Therefore, it is crucial for ophthalmologists to have a thorough understanding of this complication, taking proactive measures to prevent it during surgery and being knowledgeable about effective management strategies for patients with SCH. This review article aimed to provide a comprehensive overview of SCH, covering its risk factors, diagnostic approaches, and the best practices for its management. By enhancing awareness and knowledge in this area, we can improve patient outcomes and minimize the impact of SCH in ophthalmic practice.

RARE NON-SURGICAL RELATED MASSIVE SPONTANEOUS SUPRACHOROIDAL HEMORRHAGE. A CASE REPORT.

AIMS: We present two rare cases of non-surgical-related massive spontaneous suprachoroidal hemorrhage. CASE REPORT: The first case was a 73-year-old male with uncontrolled hypertension, who presented with left vision loss, only able to perceive light, with very high intraocular pressure (IOP) and blood pressure (BP), 68 mmHg and 196/106 mmHg, respectively. Ocular examination showed a limited fundus view, and the B-scan revealed near kissing suprachoroidal hemorrhage. The second case was a 59-year-old male, post valve replacement surgery on life-long warfarin, who presented with hand movement vision and IOP of 47 mmHg. The B-scan showed massive submacular and suprachoroidal hemorrhage with therapeutic range International Normalized Ratio (INR). CONCLUSION: Suprachoroidal hemorrhage is one of the rare complications that can be seen in any ocular surgery. However, spontaneous suprachoroidal hemorrhage is a rarer disease. Most of the reported cases are associated with underlying medical conditions. Thus prevention is crucial. This involves ophthalmologists, physicians and general practitioners in managing this group of patients with associated risk factors, for better recognition of this devastating ocular complication in which early detection may reduce ocular morbidity.

Spontaneous Expulsive Suprachoroidal Hemorrhage.

BACKGROUND: Spontaneous Expulsive Suprachoroidal Hemorrhage (SESCH) is an extremely rare phenomenon that leads to atraumatic spontaneous globe rupture. Only a handful of SESCH cases have been reported worldwide, primarily in developing countries. Risk factors associated with SESCH include uncontrolled hypertension, previous eye surgery, glaucoma, atherosclerosis, advanced age, and corneal damage. CASE REPORT: We report a case of expulsive suprachoroidal hemorrhage in a ninety-seven-year-old female. The patient presented to the emergency department with painful bleeding from her right eye. She denied any trauma or injury to the eye. She denied any use of anticoagulation. Physical examination showed a right ocular hematoma with mild active bleeding. She had exophthalmos and proptosis with extrusion of the ocular structures. A computed tomography scan of the orbits demonstrated right globe rupture with diffuse hemorrhage. Ophthalmology was consulted, and the patient subsequently had an evisceration of her right eye. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous expulsive choroidal hemorrhage is exceedingly rare. SESCH predominantly affects diseased eyes in the elderly. Early recognition of impending globe rupture in patients who present with suprachoroidal hemorrhage is necessary and requires prompt ophthalmology consultation. Emergency physicians must be aware that an atraumatic open globe can occur and requires immediate evaluation by an ophthalmologist and emergent repair in the operating suite.

Delayed suprachoroidal hemorrhage after Descemet Stripping Automated Endothelial Keratoplasty (DSAEK).

This study, a case series of 2 patients and a literature review, aims to describe the second and third known cases of delayed suprachoroidal hemorrhage after Descemet stripping automated endothelial keratoplasty. The suprachoroidal hemorrhage is defined as the presence of blood in the suprachoroidal space; final visual acuity is rarely greater than 0.1 (decimal scale). Both cases presented had known risk factors: high myopia, previous ocular surgeries, arterial hypertension, and being under anticoagulant therapy. The diagnosis of delayed suprachoroidal hemorrhage was made at the 24-h follow-up visit, as they recalled a sudden and tremendous acute pain hours after surgery. Both cases were drained through a scleral approach. Delayed suprachoroidal hemorrhage is a rare but devastating consequence that can occur after Descemet stripping automated endothelial keratoplasty. Awareness of the most critical risk factors allows for early identification, which is of paramount importance for the prognosis of these patients.

Management of Suprachoroidal Hemorrhage during Phacoemulsification: A Comprehensive Review.

Suprachoroidal hemorrhage (SCH) is a rare and sight-threatening complication of various intraocular surgeries, including cataract surgery. Although the rate of SCH complicating cataract surgery has decreased in the era of phacoemulsification, most likely due to smaller self-sealing incisions and modern equipment, it remains a challenging complication to manage. The aim of this review is to summarize the current evidence of the pathophysiology and management of SCH complicating phaco surgery. A literature review was performed using the PubMed database searching for diagnosis, therapy, and management of SCH during phacoemulsification. The evidence available on the optimal management of this condition is low, and there is no consensus so far. An early diagnosis is thought to be essential to avoid progression to the devastating stage of expulsion of intraocular contents (expulsive hemorrhage). Sudden intraoperative anterior chamber shallowing, red reflex loss, and a significant increase in intraocular pressure are highly suspicious for this severe complication. A fundus examination and ocular ultrasound are crucial to confirm the diagnosis and, if it is confirmed, stabilize the globe immediately. The initial therapeutic approach includes aggressive topical and systemic medication focused on controlling ocular inflammation and intraocular pressure, whereas the timing and the indications of surgical intervention remain controversial.

Delayed Suprachoroidal Hemorrhage After Xen45 Gel Stent.

PRCIS: In patients with significant preoperative comorbidities, prolonged activity restrictions beyond 2 weeks after Xen45 surgery may mitigate the risks of delayed SCH. PURPOSE: To report the first case to date of delayed suprachoroidal hemorrhage (SCH) not associated with hypotony 2 weeks after the placement of the Xen45 gel stent. CASE SUMMARY: An 84-year-old white man with significant cardiovascular comorbidities underwent uneventful ab externo implantation of a Xen45 gel stent for asymmetric progression of severe primary open angle glaucoma. The patient had a reduction in intraocular pressure by 11 mm Hg on postoperative day 1 and maintained preoperative visual acuity. The intraocular pressure remained stable at 8 mm Hg on multiple postoperative visits until the patient developed a SCH at postoperative week 2 immediately after a light session of physical therapy. The patient was treated medically with topical cycloplegic, steroid, and aqueous suppressants. He maintained preoperative visual acuity throughout the postoperative course and had resolving SCH without the need for surgical intervention. CONCLUSIONS: This is the first report of a delayed presentation of SCH in the absence of hypotony after ab externo implantation of the Xen45 device. The possibility of this vision-threatening complication should be considered as part of the risk assessment and included in the consent process for the gel stent. In patients with significant preoperative comorbidities, prolonged activity restrictions beyond 2 weeks after Xen45 surgery may mitigate the risks of delayed SCH.

Spontaneous suprachoroidal haemorrhage in haemophilia coincident with ChAdOx1 nCoV-19 vaccine.

PURPOSE: To report a case of spontaneous suprachoroidal haemorrhage in a haemophilia patient immediately following ChAdOx1 nCoV-19 vaccination. CASE PRESENTATION: A 60-year-old man with haemophilia developed painful vision loss in his left eye a day following the ChAdOx1 nCoV-19 vaccination due to acute angle-closure glaucoma from a massive suprachoroidal haemorrhage. He had an extremely deranged coagulation profile; activated partial thromboplastin time (APTT): 89 s, normal range 29-35 s After factor VIII transfusion, ocular hypotensive therapy and systemic/topical steroids, the suprachoroidal haemorrhage and glaucoma resolved, but the vision remained poor. CONCLUSION: Spontaneous suprachoroidal haemorrhage may be seen in haemophiliacs with deranged coagulation profiles. In our case, it followed ChAdOx1 nCoV-19 vaccination, and we recommend caution and checking the coagulation profile in such patients apriori.

Applications of the Guarded-Needle External Drainage Technique in Vitreoretinal Surgery.

PURPOSE: To describe the surgical technique using the guarded-needle external drainage for a wide variety of applications in vitreoretinal surgery. METHODS: A step-by-step procedure and a surgical video using the guarded-needle external drainage technique are presented. In addition, a series of representative cases with wide-ranging diagnoses who underwent the technique is reviewed. DESCRIPTION AND TECHNIQUE: The guarded-needle using a 27-gauge thin-walled TSK needle (TSK Laboratory International) and a trimmed 70 buckle sleeve are connected to the active extrusion tubing of the vitrectomy machine. External drainage is performed by actively aspirating subretinal fluid using low active vacuum. The guarded-needle external drainage technique is used in cases with bullous detachments, and small and anterior breaks, when performing scleral buckle, for prevention of underfill when using oil tamponade in cases with choroidal effusion, addressing subretinal gas/air, lysing a subretinal band, draining a suprachoroidal hemorrhage, for diabetic tractional retinal detachments, detachments with no definitive break, and subretinal biopsy in exudative detachments. CONCLUSION: The guarded-needle external drainage has a wide range of applications in vitreoretinal surgery.

A rare ophthalmic complication: Expulsive suprachoroidal hemorrhage.

Background: Expulsive suprachoroidal hemorrhage is a rare but dreadful complication of any ophthalmic surgery. Hence an ophthalmologist should know about the various risk factors, methods for preventing such a situation, and be aware of the various options for timely management to tackle the situation. Purpose: To discuss the risk factors, intraoperative signs, and ways of managing expulsive choroidal hemorrhage. Synopsis: We discuss two cases having multiple risk factors, where the patients underwent tectonic penetrating keratoplasty. In view of extensive involvement of ocular structures, the patients were clearly explained about the guarded visual prognosis and the risk of auto-evisceration. Following trephination of host cornea, rise in intraocular pressure was identified by the increasing size of the vitreous seen prolapsing through the wound and markedly visible pulsations, along with subconjunctival bleeding. Suprachoroidal hemorrhage was suspected and immediate tamponade was given. However, bleeding was not controlled, and eventually, expulsion of all the intraocular contents occurred. Highlights: A surgeon must be aware of the risk factors, be prompt to identify the signs, and must take immediate actions for the management of expulsive choroidal hemorrhage, a rare but dreadful complication of intraocular procedures. Online Video Link: https://youtu.be/UnCH-lWGzwU.

Treatment of Massive Suprachoroidal Hemorrhage by Drainage Surgery with Vitrectomy: Experience of a Single Center.

PURPOSE: The present study assessed the treatment of and risk factors for suprachoroidal hemorrhage (SCH) and reported the outcomes of drainage surgery with vitrectomy in a consecutive series of patients. METHODS: Retrospective case series were carried out to investigate the clinical data of 12 eyes from 12 patients who underwent suprachoroidal hemorrhage drainage with vitrectomy surgery over a 10-year period (from 2010 to 2020). The records of these patients were analyzed, including ophthalmologic examination, ophthalmologic ultrasonography, surgical procedures, and outcome measurements. RESULTS: Twelve consecutive patients with a mean age of 56.5 years were studied. Intraocular surgery, high myopia, glaucoma, hypertension and anticoagulant therapy were the most common risk factors for SCH. All patients underwent external drainage and pars plana vitrectomy surgery. All of the patients were followed up for 10.2 months. Overall, the mean preoperative BCVA improved from 2.3 LogMAR to 1.7 LogMAR at the last follow-up visit (P = .041). CONCLUSIONS: The risk factors for SCH include high myopia, glaucoma, hypertension and anticoagulant therapy. Drainage of SCH with vitrectomy is a valuable approach in the management of SCH.

Valsalva-Induced Spontaneous Suprachoroidal Hemorrhage: A Case Report and Review of the Literature.

We report a rare case of spontaneous suprachoroidal hemorrhage and present a systematic review of the literature using PubMed/Medline databases. Patients that developed a spontaneous suprachoroidal hemorrhage with a history of previous intraocular surgery were excluded. An 82-year-old male patient with no known ocular pathologies or surgical history was referred with acute ocular pain and decreased vision in the right eye (BCVA: 0.6 with hyperopic correction) following a Valsalva maneuver. General history included chronic heart failure and coronary artery disease, treated with anticoagulant and antihypertensive drugs. Dilated fundus examination revealed a posterior red-brown choroidal mass, with a thickness of 1.5 mm on B-scan ultrasonography. The lesion was not visible on fluorescein or indocyanine green angiography and was located under the choroid on B-scan optical coherence tomography. The diagnosis of a spontaneous suprachoroidal hemorrhage was evoked, and the patient was observed. Five months later, BCVA was 1.0 uncorrected, with a normal-appearing fundus. In a literature review, eight cases of spontaneous suprachoroidal hemorrhage following an episode of increased intrathoracic pressure were identified, including our patient. M/F ratio was 1 : 1, with a median age of 66.5 years. All cases presented systemic pathologies. All cases presented with a unilateral suprachoroidal hemorrhage. Only 2/8 patients had ocular comorbidities. Complications requiring treatment were noted in 4/8 cases, including 2 cases that resulted in the loss of the vision following an acute angle-closure glaucoma. Spontaneous resolution of the hemorrhage was observed in the other 4 patients. In 6/8 cases, vision recovered over a mean period of 10 weeks. In conclusion, spontaneous suprachoroidal hemorrhage following a Valsalva maneuver in eyes with no history of ocular surgery or trauma is rare, and has been associated with advanced age, cardiovascular disease and asthma. In severe cases (2/8) the eye was lost, while most cases (6/8) recovered, presenting a good visual outcome.

Clinical features, management, and outcomes of expulsive choroidal hemorrhage during cataract surgery: 13-year experience of a tertiary eye center.

PURPOSE: To study the risk factors, clinical features, management, and outcomes of intraoperative expulsive choroidal hemorrhage (ECH) during cataract surgery. SETTING: Aravind Eye Hospital, Madurai, Tamil Nadu, India. DESIGN: Retrospective hospital-based study. METHODS: Of the 1 167 250 patients who underwent cataract surgery between 2008 and 2020, patients diagnosed with intraoperative ECH were included. Demography, ocular and systemic risk factors, visual acuity, type of ocular anesthesia, intraoperative and postoperative records, management, and surgical outcomes were analyzed. RESULTS: 52 eyes (0.004%) of 1 167 250 patients had ECH. Of the 52 cases, 43 cases (incidence rate 0.006%) were reported in the years 2008 to 2015 and 9 cases (incidence rate 0.002%) in the years 2016 to 2020. The change in the ocular anesthesia from peribulbar and retrobulbar anesthesia (2008 to 2015) to sub-Tenon anesthesia (2016 to 2020) was associated with a reduced rate of ECH ( P = .002). 28 eyes (53.8%) experienced limited ECH and 24 eyes (46.2%) full-blown ECH. The visual outcome was better in eyes with limited ECH compared with full-blown suprachoroidal hemorrhage in all follow-up visits. The median vision (interquartile range) before the cataract surgery and at postoperative day 1 were 1.30 (0.78 to 2.60) and 2.45 (1 to 2.75), respectively. The median final vision (interquartile range) after the secondary surgical intervention was 2.2 (0.60 to 2.60). CONCLUSIONS: This series included 52 eyes with ECH, recognized associations of ECH with different types of anesthesia and with different cataract surgical procedures, and described management of ECH. Postoperative visual outcome was poor.