Risk factors and outcomes of management of delayed suprachoroidal haemorrhage following Ahmed glaucoma valve implantation in children.

AIMS: To assess the incidence, risk factors and outcomes of management of delayed suprachoroidal haemorrhage (DSCH) in children who had undergone Ahmed glaucoma valve implantation. METHODS: A retrospective case-control study of eyes which developed DSCH in children <18 years of age who underwent surgery between January 2009 and December 2017 with a follow-up of at least 2 months was performed. Nine cases were compared with 27 age, gender and surgeon matched controls who had undergone surgery during this period. RESULTS: The incidence of DSCH was 4.7% (95% CL 1.5% to 7.7%, 9 eyes of 191 children). There were no significant differences between cases and controls in baseline details except for the number of intraocular pressure (IOP) lowering medications (p=0.01) and follow-up period (p=0.001). Risk factors identified on univariate analysis (p≤0.1) were axial length (p=0.02), diagnosis of primary congenital glaucoma (p=0.05), postoperative hypotony (p=0.07) and aphakia (p=0.1). None of them were found to be significant on multivariate analysis. Five eyes, three with retinal apposition and two with retinal detachment, underwent surgical drainage. There were no significant differences in the outcomes of eyes which underwent drainage compared with those which did not. Failures, defined as IOP>18 mm Hg despite use of medications, loss of light perception, phthisis or removal of the implant were more frequent in cases (three eyes, 33.3%) compared with controls (four eyes, 14.8%) (p=0.002). CONCLUSIONS: None of the risk factors analysed in our series proved to be significant. Failures were more common in eyes with choroidal haemorrhage, despite surgical intervention.

Management and visual outcome of SCH in vitrectomized eye.

Suprachoroidal hemorrhage is a rare complication of all types of intraocular surgery and is always associated with poor visual outcome or even eye enucleation. Better understanding of SCH during various types of intraocular surgery can help surgeons to avoid this devastating complication and to optimally treat patients. We encountered three cases of SCH in vitrectomized eyes and found that there were some common characteristics compared to SCH developed in other intraocular surgeries. We hypothesized that SCH in vitrectomized eye might be localized, not severe and ended up comparably good without surgical intervention. Then we analyzed the risk factors and incidence, characteristics and severity, management and prognosis of SCH in vitrectomized eye to evaluate the hypothesis.

Intravitreal ranibizumab for predominantly hemorrhagic choroidal neovascularization in age-related macular degeneration.

PURPOSE: To evaluate the effects of intravitreal ranibizumab monotherapy on predominantly hemorrhagic choroidal neovascularization with foveal involvement associated with age-related macular degeneration. MATERIALS AND METHODS: Twenty-two consecutive eyes with hemorrhagic neovascularization were treated with 3 monthly intravitreal ranibizumab injections. Additional injections were administered according to retreatment criteria during 12 months of follow-up. RESULTS: A mean of 6.64 ± 1.36 injections was administered. Overall, the mean visual acuity increased from 10.90 ± 6.02 to 12.81 ± 8.34 ETDRS letters (p > 0.05) at 12 months. The 'early treatment group' gained a mean of 2.83 ± 2.24 ETDRS letters (p < 0.05), while the 'late treatment group' gained a mean of 0.30 ± 1.25 ETDRS letters (p > 0.05) with significant differences between the groups (p < 0.05). A progressive resolution of macular bleeding was registered in 20 patients (mean time: 5.3 ± 1.6 months). CONCLUSIONS: Ranibizumab injections can be considered a beneficial approach for the management of predominantly hemorrhagic choroidal neovascularization with foveal involvement associated with age-related macular degeneration. Furthermore, the time interval between hemorrhage and the first injection seems to be an important predicting factor of final visual acuity.

Early controlled drainage of massive suprachoroidal hemorrhage with the aid of an expanding gas bubble and risk factors.

PURPOSE: To assess the visual outcome after massive suprachoroidal hemorrhage managed by early controlled drainage using the aid of an intravitreal expanding gas bubble (100% perfluoropropane). The ocular and systemic risk factors were also reviewed. METHODS: Data were obtained retrospectively from patients with massive suprachoroidal hemorrhage who were treated in Worthing and Southlands National Health Service Trust between January 2003 and December 2008. RESULTS: The study included 10 patients (5 women and 5 men) with a mean age of 73.9 years (range, 54-84 years). All patients underwent early controlled drainage of massive suprachoroidal hemorrhage using 100% perfluoropropane as a tamponade. The mean interval of drainage from the onset was 3.5 days (range, 1-10 days). Anatomical restoration of ocular structures was achieved in 7 patients, with good final visual outcome at mean 9 months (range, 6-14 months). The remaining three patients had poor visual outcome because of retinal detachment with proliferative vitreoretinopathy. The most common risk factor in this case series was glaucoma, which was seen in five patients. Arteriosclerosis was the only risk factor in two patients. CONCLUSION: Early controlled drainage of massive suprachoroidal hemorrhage with 100% perfluoropropane tamponade may help in achieving a good visual outcome. The use of 100% perfluoropropane has the advantage of maintaining positive pressure while facilitating controlled drainage of the hemorrhage as the clot lyses. Retinal detachment however is a poor prognostic indicator. Arteriosclerosis and glaucoma were the most common risk factors seen in this case series.

Prospective one-year study of ranibizumab for predominantly hemorrhagic choroidal neovascular lesions in age-related macular degeneration.

PURPOSE: To determine the safety and effect of ranibizumab on predominantly hemorrhagic choroidal neovascular lesions due to age-related macular degeneration. METHODS: Seven subjects with predominantly hemorrhagic choroidal neovascular lesions were treated with intravitreal injections of ranibizumab at baseline, Month 1, and Month 2. Additional monthly injections were given through Month 11 at the discretion of the examiner for a potential maximum of 12 injections. RESULTS: At 12 months, the median visual acuity letter score was 30 (Snellen equivalent: 20/250), with a median change from baseline to last follow-up of +7 letters. Three of 7 subjects (43%) gained 2 or more lines of vision, while no subject lost 2 or more lines. The median change in OCT central subfield thickness from baseline to Month 12 was -109 microm, with a mean of -120 +/- 158 microm. Two eyes had retinal pigment epithelial tears. No ocular adverse events or systemic adverse events were reported related to the usage of ranibizumab. CONCLUSION: With no subject losing 2 or more lines of visual acuity over 12 months and no new safety concerns identified, these predominantly hemorrhagic lesions treated with ranibizumab appeared to have a better visual acuity outcome than the natural history controls of the submacular surgery trials. While the study is limited by few cases enrolled, the results suggest that ranibizumab is able to penetrate through the subretinal hemorrhage to affect the underlying hemorrhagic choroidal neovascular lesion and the natural history.

Expulsive hemorrhage after glaucoma filtering surgery.

AIMS: To evaluate the incidence, patient risk factors, diagnosis and management of suprachoroidal hemorrhage (SCH) after glaucoma filtering surgery. METHODS: Retrospective case series study comprised 1553 eyes having glaucoma filtering surgery during the last 15 years (between January 1993 and December 2007) at our department. Observations included incidence, patient risk factors, peri and postoperative diagnosis, management, and outcomes of SCH after this procedure. RESULTS: Two cases of SCH were revealed. In one eye SCH developed at the end of surgery, in the other eye in the postoperative period. Both patients had systemic and ocular risk factors (hypertension, high preoperative intraocular pressure, myopia, pseudoexfoliation, aphakia or pseudophakia). Visual functions improved in the case of intraoperative SCH over 2 months withouth surgical intervention, in the eye with delayed postoperative SCH visual outcome was poor despite multiple lavages of anterior chamber and vitreous cavity. CONCLUSION: Suprachoroidal hemorrhage, both expulsive and delayed, is a rare, but severely debilitating complication of glaucoma surgery.

Macular hole closure following intraoperative choroidal hemorrhage.

This interventional case report retrospectively reviews the outcome of a 56-year-old woman who suffered an intraoperative choroidal hemorrhage at commencement of macular hole surgery. Due to the early intraoperative choroidal hemorrhage, vitrectomy was not performed. One month postoperatively, the macular hole was noted to be closed and remained closed 2 years later, leaving the patient with a good visual outcome. The authors postulate that the temporal location of the choroidal hemorrhage may have exerted mechanical displacement of the retina toward the macular hole margins, resulting in closure. Macular hole closure directly following intraoperative choroidal hemorrhage is possible.

Clinical characteristics and visual outcome of non-traumatic suprachoroidal haemorrhage in Taiwan.

PURPOSE: This study aimed to evaluate the clinical features and visual outcomes of non-traumatic suprachoroidal haemorrhage (SH) in Taiwan. METHODS: We report a retrospective, non-comparative, interventional case series study carried out in an institutional setting. Thirty-nine eyes with non-traumatic SH were studied using a new system for grading the severity of SH. The aetiologies of SH were analysed. The correlations between grades and prognoses of SH were studied. Multiple logistic regression was used to assess factors associated with final visual outcome. RESULTS: Conditions causing SH in the eyes considered in this study included cataract surgery (43.59%), age-related macular degeneration (AMD) (17.95%), filtering operation and vitrectomy (both 10.26%), scleral buckling (5.13%) and others. Twelve eyes (12/39, 30.77%) had a final visual outcome of no light perception. Only 12 eyes (12/39, 30.77%) had final visual acuity (VA) > 4/200. Grade of SH correlated significantly with need for surgical drainage and with final visual outcome (Spearman rank correlations 0.313 and - 0.408, p = 0.010 and p = 0.00317, respectively). 'Good' and 'poor' final VA was significantly associated with VA at the time of SH (multiple logistic regression coefficients 2.132 and - 2.809, p = 0.015 and p = 0.008, respectively), as well as initial retinal detachment (multiple logistic regression coefficients - 2.267 and 2.223, p = 0.036 and p = 0.006, respectively). Higher grades of SH and increased age were associated with poor final visual outcome (multiple logistic regression coefficients - 1.332 and - 0.122, p = 0.013 and p = 0.022, respectively). CONCLUSIONS: Suprachoroidal haemorrhage is a devastating ocular problem. Complications of intraoperative surgery and AMD are common causes. The new SH grading system provides a simple method for evaluating the need for drainage and for predicting visual prognosis. Visual acuity and retinal detachment at the time of SH are major factors associated with good and poor final VA, respectively.

Functional and anatomical outcomes of vitreoretinal surgery for posterior segment complications after elective cataract surgery.

PURPOSE: To assess the outcomes in patients who required 1 or more vitreoretinal interventions for posterior segment complications arising from elective uneventful cataract surgery. SETTING: Tertiary referral center, single-center study. METHODS: A retrospective interventional case series included 56 consecutive patients who were referred for surgical correction of posterior segment complications within 6 months of cataract surgery. The study period was between 1996 and 2003, and the minimum follow-up was 5 months. RESULTS: Posterior segment complications were resolved with a single surgical intervention in 40 cases (71.4%). Within 5 months of primary surgical correction, persisting or newly arising posterior segment complications were noted in 16 cases (28.6%). After a mean of 2.1 +/- 1.4 (SD) additional surgeries, the number of eyes with posterior segment problems decreased to 7 (12.5%) (P = .035). Posterior segment complications requiring more than 1 vitreoretinal intervention included retinal detachment, endophthalmitis, and choroidal hemorrhages. After primary correction surgery, the mean best corrected visual acuity increased from 0.15 +/- 0.24 to 0.37 +/- 0.33 (P = .001) after a single intervention and to 0.39 +/- 0.32 (P>.05) after additional interventions. Although the intraocular pressure (IOP) decreased from 21.8 +/- 16.6 mm Hg to 14.9 +/- 3.4 mm Hg (P = .008), 4 (7.1%) consecutive vascular optic atrophies occurred. A reduction in corneal transparency was observed in 46.4% of patients before primary surgical correction and 12.5% after primary surgical correction (P<.001). CONCLUSIONS: In many cases, posterior segment complications arising from cataract surgery could be repaired with favorable functional and anatomical outcomes by a single vitreoretinal intervention. Additional surgery, if requested, provided stabilization of the anatomical and functional outcomes.

Suprachoroidal hemorrhage during cataract surgery in a vitrectomized eye.

We report a case of surprachoroidal hemorrhage (SCH) that occurred during cataract surgery in a previously vitrectomized eye. The only sign of SCH was a progressive shadow obscuring the red reflex. There was no increase in intraocular pressure (IOP), shallowing of the anterior chamber, or iris prolapse. Postoperatively, the SCH gradually resolved without complications, leaving a series of subretinal pigmentary lines. Surgeons should be aware that the signs normally expected in SCH may not develop in vitrectomized eyes. Obscuration of the red reflex may be the only sign of the hemorrhage, and when this happens, it may be prudent to keep the IOP elevated and suture the incision at the end of the procedure.

Surgery for hemorrhagic choroidal neovascular lesions of age-related macular degeneration: ophthalmic findings: SST report no. 13.

PURPOSE: To present best-corrected visual acuity (BCVA) findings and other clinical outcomes from eyes of patients enrolled in one of the Submacular Surgery Trials (SST) evaluating surgical removal versus observation of predominantly hemorrhagic subfoveal choroidal neovascularization (CNV) associated with age-related macular degeneration. DESIGN: Randomized clinical trial (SST Group B Trial). PARTICIPANTS: Eligible patients had subfoveal choroidal neovascular lesions greater than 3.5 disk areas (8.9 mm2) composed of at least 50% blood (either blood or CNV underlying the center of the foveal avascular zone) and BCVA of 20/100 to light perception in the study eye. INTERVENTION: Patients were assigned randomly at time of enrollment to observation or surgical removal of blood and any associated CNV. MAIN OUTCOME MEASURE: A successful outcome was defined a priori as either improvement in visual acuity (VA), no change in VA, or a decline in VA of no more than 1 line (7 letters) from baseline to the 24-month examination based on an intent-to-treat analysis. RESULTS: Of 336 patients enrolled, 168 were assigned to each treatment arm; treatment arms were balanced by baseline characteristics. Of 1501 expected examinations 3 months through 36 months after baseline, 1370 (91%) were performed. Loss of > or =2 lines (> or =8 letters) of VA occurred in 56% of surgery eyes, versus 59% of observation eyes examined at 24 months. Although severe loss of VA was not the primary outcome of interest, surgery more often prevented such loss: 36% in the observation arm versus 21% in the surgery arm at the 24-month examination (chi2 P = 0.004). Of initially phakic eyes, the cumulative percentage that had undergone cataract surgery by 24 months was 44% in the surgery arm, compared with 6% in the observation arm. Twenty-seven eyes (16%) in the surgical arm, compared with 3 eyes (2%) in the observation arm, had a rhegmatogenous retinal detachment (RD). CONCLUSIONS: Submacular surgery as performed in the SST Group B Trial did not increase the chance of stable or improved VA (the primary outcome of interest) and was associated with a high risk of rhegmatogenous RD, but did reduce the risk of severe VA loss in comparison with observation. This article contains additional online-only material available at http://www.ophsource.com/periodicals/ophtha.

[Surgical treatment of traumatic suprachoroidal hemorrhage].

OBJECTIVE: To evaluate the methods and effects of surgery for traumatic suprachoroidal hemorrhage (SH). METHODS: Seventeen cases with SH caused by ocular rupture underwent secondary surgery. With BSS irrigating into vitreous cavity, we drained SH through pars plana incisions and performed routine vitrectomy with gas or silicone oil tamponade. RESULTS: SH drainage was effective in 17 cases. During the follow-up of 3 - 27 months, the eye balls survived and the visual acuities were improved in 15 eyes (88.2%). CONCLUSION: With the surgical treatment of vitrectomy combined with SH drainage, most of the eyes with traumatic SH can be saved and their visual acuities recover for some degrees.

[A new approach towards pathogenesis and treatment of massive suprachoroidal hemorrhage]. / Wspólczesne poglady na patogeneze i leczenie masywnego krwotoku nadnaczyniówkowego.

A massive suprachoroidal hemorrhage is a well-known, possibly serious complication of a variety of surgical procedures such as cataract extraction, penetrating keratoplasty, glaucoma-filtering operation, retinal detachment surgery and pars plana vitrectomy. It is defined as a hemorrhage, in the suprachoroidal space, of sufficient volume either to cause extrusion of intraocular contents outside of the eye or to force the inner retinal surfaces into apposition ("kissing"). Despite surgical interventions to drain the hemorrhage and establish normal anterior and posterior anatomic configurations to return of preoperative visual acuity is hard to prognosticate. This paper presents the current knowledge on the pathogenesis, risk factors, treatment of massive suprachoroidal hemorrhage.

Expulsive hemorrhage before phacoemulsification.

A 65-year-old white man who was scheduled for cataract extraction experienced a sudden increase in intraocular pressure (IOP) with flattening of the anterior chamber immediately after the anterior capsule incision. The eye was sutured, and because no decrease in pressure was noted, surgery was postponed. The presence of the cataract prevented ophthalmoscopic examination. Echographic examination revealed a hemorrhagic choroidal detachment with involvement of the ciliary body. The patient was examined regularly until the choroidal detachment disappeared 4 weeks later. He then had uneventful phacoemulsification and intraocular lens implantation.

[Massive choroidal hemorrhage as a late trabeculectomy complication ]. / Masywny krwotok podnaczyniówkowy jako pózne powiklanie trabekulektomii.

The purpose of this paper was to present the case of an unusual late complication of filtering glaucoma surgery. A massive choroidal hemorrhage occurred 5 years after trabeculectomy and extracapsular cataract extraction. The diagnosis was confirmed by MRI examination. Improvement in choroidal status and in visual acuity (from hand motions to 6/12 with aphakic correction of 12 diopters) was observed during three weeks of medication. The retina and the choroid remained attached during two years of observation.

Suprachoroidal hemorrhage during pars plana vitrectomy.

Suprachoroidal hemorrhage is an uncommon but serious complication of pars plana vitrectomy that can be associated with a guarded visual prognosis. Risk factors for development of suprachoroidal hemorrhage during pars plana vitrectomy include high myopia, history of previous retinal detachment surgery, rhegmatogenous retinal detachment, use of cryotherapy, scleral buckling at the time of pars plana vitrectomy, external drainage of the subretinal fluid, intraoperative systemic hypertension, and bucking during general anesthesia. In eyes with suprachoroidal hemorrhage during pars plana vitrectomy, the final visual and anatomic outcomes may be compromised by persistent retinal detachment, secondary glaucoma, and ocular hypotony. In most cases, intraoperative drainage of suprachoroidal hemorrhage is not associated with a better outcome. The prognosis is more favorable if the suprachoroidal hemorrhage is localized and does not extend in to the posterior pole.

Management of delayed massive suprachoroidal hemorrhage: a clinical retrospective study.

Suprachoroidal hemorrhages, both expulsive and delayed non-expulsive, are among the most devastating complications of intraocular surgery. We reviewed the charts of 13 patients with a delayed non-expulsive suprachoroidal hemorrhage (DNSCH) after cataract extraction (3 patients), glaucoma filtering surgery (6 patients), penetrating keratoplasty (3 patients), or vitrectomy (1 patient). All had large hemorrhagic choroidal detachments with nine eyes presenting kissing choroidal detachment, five eyes with associated retinal detachment, and one eye with intravitreous hemorrhage. All patients were treated with systemic corticosteroids before surgery. Eleven eyes underwent anterior drainage sclerotomy, followed by SF6 gas injection in eight eyes, and pars plana vitrectomy with silicon oil tamponade in three eyes. Mean follow-up was 22 months. These procedures gave good anatomical results in eleven cases and good visual results in nine. The results suggest that not all DNSCH need to be drained surgically but that, when surgical drainage is indicated, the use of gas to maintain internal tamponade appears to be beneficial.

Anterior chamber maintenance during drainage of a suprachoroidal hemorrhage in two phakic eyes.

BACKGROUND AND OBJECTIVES: The authors describe a technique for hemorrhage drainage following glaucoma surgery that uses an anterior chamber maintainer to minimize risk to the anterior lens capsule. PATIENTS AND METHODS: Two patients had suprachoroidal hemorrhages following filtration surgery. Because their eyes were phakic, an anterior chamber maintainer, as opposed to a 23-gauge butterfly needle, was used for aqueous replacement during hemorrhage drainage. RESULTS: The maintainer provided a stable anterior chamber environment during both drainage procedures. No damage to anterior chamber structures occurred, and the postoperative course was unremarkable in both patients. CONCLUSIONS: The use of a sharp-tipped infusion cannula may be contraindicated for the phakic patient who has a suprachoroidal hemorrhage. The anterior chamber maintainer is a useful alternative instrument in such cases.

Delayed suprachoroidal hemorrhage mimicking acute retrobulbar hemorrhage.

The signs and symptoms of an acute retrobulbar hemorrhage include sudden ocular pain, explosive unilateral proptosis, limitation of extraocular movements and loss of vision. Retrobulbar hemorrhage is a well-described complication of retrobulbar anesthetic injection. We report an unusual case of a presumed acute retrobulbar hemorrhage following intraocular surgery which, on further testing, was found to be a delayed suprachoroidal hemorrhage.

[Postoperative choroidal hemorrhage. Surgical indications]. / Les hémorragies choroïdiennes postopératoires. Indications chirurgicales.

PURPOSE: Through analysis of 18 cases of postoperative suprachoroidal haemorrhage, we discuss indications for surgical treatment, especially for vitrectomy. Time of surgery depends on complete lysis of the clot (mean of 7 days) determined by echography. METHOD: Eighteen post-operative cases complicated with supra-choroidal hemorrhages were operated on between January 1988 and July 1992: 7 cases occurred after cataract extraction, 6 after filtering surgery and 5 after retinal detachment repair. Treatment, in all cases, included evacuation of the haematoma. A vitrectomy was associated in 14 cases using internal tamponade in 12 cases: 9 with silicone oil and 3 with SF6. The latest cases treated by vitrectomy benefited by the use of liquid perfluoro-carbons. RESULTS: We had successful anatomical results in 14 eyes. For 12 eyes which kept functional vision, mean postoperative visual acuity was 20/100. We point out the high rate of secondary retinal detachment complicated by PVR (7 cases) and eventually responsible for treatment failure in 4 cases. CONCLUSIONS: Satisfactory results can be obtained in treating post-operative choroidal haemorrage by appropriate use of vitrectomy: indications include incarceration of vitreous in the filtration bleb or in the cataract incision, vitreous haemorrhage, rhegmatogenous and/or traction retinal detachment. The echography is of great value to determine timing of surgery by assessing completeness of clot lysis.