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.

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.

Managing Delayed Suprachoroidal Hemorrhage After Insertion of XEN45 Glaucoma Device.

A 78-year-old man with angle closure glaucoma and on treatment with oral anticoagulants, underwent phacoemulsification. An early acute suprachoroidal hemorrhage (SCH) occurred and the surgical wound was rapidly sutured without complete soft lens matter removal, nor insertion of intraocular lens. The SCH was managed conservatively and it resolved in 5 weeks; the intraocular pressure was 35 mm Hg despite maximal medical treatment. Secondary soft lens matter removal followed by intraocular lens implantation combined with XEN45 was then performed. After 7 days the patient developed a potentially "kissing" choroidal touch due to significant delayed SCH. This was treated with surgical drainage. Significant suprachoroidal bleeding can occur after minimally invasive glaucoma procedures. Patients on anticoagulant therapy may require careful monitoring while planning glaucoma surgery.

[Spontaneous choroidal hemorrhage associated with novel oral anticoagulants: A report of two cases and literature review]. / Hémorragie choroïdienne spontanée associée à la prise de nouveaux anticoagulants oraux : cas cliniques et revue de la littérature.

New direct oral anticoagulants (DOAC) have been approved for treatment and prevention of some thromboembolic diseases: acute and chronic phase of thromboembolic disease, deep venous thrombosis prophylaxis in orthopedic surgery and prevention of stroke in patients with atrial fibrillation. These molecules are an alternative to heparins and vitamin K antagonists. Among these, rivaroxaban (Xarelto®, Bayer Schering Pharma) is a direct factor Xa inhibitor, and dabigatran etexilate (Pradaxa®, Boehringer Ingelheim) is a direct free thrombin inhibitor. These molecules are almost the ideal anticoagulant: oral administration, few drug and food interactions, wide therapeutic target, and especially no lab monitoring. However, their use remains associated with hemorrhagic complications such as gastrointestinal, intracranial or urinary hemorrhages. We describe two clinical cases of spontaneous choroidal hemorrhage in patients treated with direct oral anticoagulants (rivaroxaban and dabigatran etexilate) for atrial fibrillation. These cases show that an ocular hemorrhagic risk exists with these drugs. Patients treated with DOAC should have the therapeutic dose adjusted based on creatinine clearance. Special monitoring should be performed in patients with age-related macular degeneration or with hypertension even though meta-analysis shows that the risk of intraocular bleeding is reduced by 22% compared with warfarin.

Management of Delayed Suprachoroidal Hemorrhage after Glaucoma Surgery.

PURPOSE: To review the most current treatment recommendations and outcomes for delayed suprachoroidal hemorrhages. METHODS: Article review of management and outcomes of suprachoroidal hemorrhages, with emphasis on delayed suprachoroidal hemorrhages in the setting of glaucoma surgery. CONCLUSION: Time of drainage of suprachoroidal hemorrhages remains controversial. Earlier drainage should be considered with high intraocular pressure, expulsion of intraocular content, or retinal detachment. In clinically stable eyes with suprachoroidal hemorrhage, recommendations range from observation to immediate drainage. Clot lysis occurs at roughly 14 days.

Management of delayed suprachoriodal haemorrhage after intraocular surgery and trauma.

BACKGROUND: [corrected] To indentify surgical risk factors for delayed suprachoroidal haemorrhage (DSCH) and to report the outcomes of an effective intervention in a consecutive of patients. METHODS: The clinical data of ten patients diagnosed with DSCH in our hospital between July 2007 and December 2012 were extracted from hospital records and analyzed, including ophthalmologic examination, ophthalmologic ultrasonography, surgical procedures, and outcome measures including visual acuity and intraocular pressure. RESULTS: Ten eyes of ten patients including six men and four women with mean age of 56.6 ± 17.67 years, with DSCH, were enrolled. After diagnosis, drainage or/and pars plana vitrectomy were performed for eight patients; another two received conservative treatment. All the patients were followed up for 15.2 ± 4.3 months. Intraocular pressure decreased significantly (p < 0.001); the mean final visual acuity improved significantly after intervention (p < 0.001). CONCLUSIONS: We emphasized other great risk factors such as intraoperative mitomycin-C use, systemic anticoagulation or thrombolysis, and chronic kidney disease. It seems that earlier surgical intervention after the diagnosis of DSCH will be beneficial to patients by improving their final visual acuity.

[Suprachoroid hemorrhage without the connection to the surgical procedure]. / Suprachoroidální hemoragie bez souvislosti s operacním výkonem.

The aim of our report is to present 2 cases of patients with suprachoroidal hemorrhage (SH). Suprachoroidal hemorrhage occur relatively infrequently and in our cases are not associated with the surgery or postoperative period. The first case was a patient with suprachoroidal hemorrhage following spontaneous corneal penetration after corneal ulcer. The second case was a patient with a suprachoroidal hemorrhage after severe contusion of the eye globe. The most important is rapid diagnosis of disease, differentiation from other eye diseases and initiation of therapy. We discuss clinical symptomatology, diagnostic and treatment of suprachoroidal hemorrhage.

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.

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.

Rare case of choroidal hemorrhage complicated with hypertension due to chronic renal failure.

BACKGROUND: Choroidal hemorrhage is usually seen as expulsive hemorrhage related to surgical invasion and is rarely observed in the absence of surgery or trauma. In this report, we describe a case of choroidal hemorrhage caused by hypertension related to chronic renal failure. CASE: A 32-year-old man presented with sudden visual loss, eye pain and swelling in his left eye. He had a history of renal failure and hypertension. Eye examination demonstrated choroidal hemorrhage associated with ocular hypertension in his left eye and marked hypertensive retinopathy in his right eye. OBSERVATIONS: He was treated with hemodialysis and antihypertensive drugs. Upon repeat eye examinations, a gradual reabsorption of the choroidal hemorrhage was observed, although vitreous hemorrhage appeared in the left eye. The vitreous hemorrhage was treated with vitrectomy with the patient regaining good visual acuity post-surgery. CONCLUSIONS: This rare case suggests that patients with severe background disease need to be carefully observed.

Risk factors of massive suprachoroidal hemorrhage during extracapsular cataract extraction surgery.

PURPOSE: To estimate retrospectively the incidence, predisposing factors, and possible mechanisms precipitating massive suprachoroidal hemorrhage (MSCH) development during cataract extraction surgery. METHODS: The study was conducted on 6639 consecutive cataract extractions performed between 1994 and 2002. All of the procedures were carried out using traditional nucleus expression methods. The study cases comprised 19 patients who developed intraoperative MSCH. The remaining 6620 patients served as the control group. Baseline systemic and ocular characteristics, as well as intraoperative factors, were analyzed. Categorical variables were analyzed using the chi-square test and the Fisher exact test. RESULTS: The incidence of MSCH during cataract surgery was 0.28%. Highly significant risk factors included high myopia, glaucoma, and diabetes (p<0.01). Atherosclerotic vascular diseases and/or hypertension were less significantly related to the condition (p<0.05). There was no significant relationship between MSCH formation and age, sex, side of the cataract, history of ocular trauma, or inflammation. The incidence of MSCH did not differ between patients operated on with extracapsular or intracapsular cataract extraction. CONCLUSIONS: Attention to multiple preoperative and intraoperative ocular and systemic variables may allow the identification of, and prophylaxis for, patients at greater risk for MSCH.

Suprachoroidal haemorrhage complicating cataract surgery in the UK: epidemiology, clinical features, management, and outcomes.

AIMS: To study the incidence, management, and outcomes of suprachoroidal haemorrhage (SCH) complicating cataract surgery in the United Kingdom. METHODS: Cases were prospectively collected by active surveillance through the British Ophthalmological Surveillance Unit. Details were obtained using an incident questionnaire with follow up at 6 months. RESULTS: 118 cases were reported in 1 year. The estimated incidence of SCH was 0.04% (95% confidence interval 0.034% to 0.050%). Cataract extractions were by phacoemulsification in 76.2%, extracapsular cataract extraction (ECCE) in 11.0%, and phacoemulsification conversion in 12.8%. SCH was "limited" (1 to 2 quadrants) in 48.7%, "full blown" (3 to 4 quadrants) in 43.1%. SCH in phacoemulsification was more likely to be limited (63.2%), compared with ECCE (11.1%) and phacoemulsification conversion (23.1%) (p<0.001, chi(2) test). Visual acuity (VA) was better than 6/60 in 57 of 95 (60%) cases after a median follow up interval of 185 days. 33 of 34 cases (97.1%) with secondary anterior segment revision had VA better than 6/60. VA was worse than 6/60 in 7 of 8 (87.5%) cases that had intraoperative sclerostomy, and in all 6 (100%) cases that had secondary posterior segment intervention. CONCLUSION: SCH is a rare but serious complication of cataract surgery. Poor prognostic factors included full blown SCH, ECCE, phacoemulsification conversion, retinal apposition, and retinal detachment.

Appositional suprachoroidal hemorrhage: a case-control study.

PURPOSE: To identify the risk factors, prognostic factors, and clinical outcomes of patients with perioperative appositional suprachoroidal hemorrhage (ASCH). DESIGN: Case-control study. SETTING: Tertiary referral center. METHODS: Subjects included all patients with perioperative ASCH documented by B-scan ultrasound between May 1990 and March 2001. Two or three control patients were selected for each case, matched by surgeon, procedure, and date of surgery within 1 month. Surgery was performed as necessary. main outcome measures. The odds of ASCH associated with clinical risk factors. secondary outcome measure: visual acuity. RESULTS: Thirty-seven cases with ASCH were identified. Ninety-two procedure- and surgeon-matched control subjects (2.48:1) were selected. Twenty-six cases (71%) of ASCH were related to a glaucoma operation. Risk factors for the development of ASCH included previous vitrectomy (P = .003, odds ratio of 12) and older age (P = .007, odds ratio 1.57/decade of increasing age). Hypertension was found to be protective (P = .02, odds ratio of 0.33). Factors associated with a poor visual outcome in patients with ASCH included apposition >30 days (P = .01), history of uveitis (P = .04), history of dry age-related macular degeneration (P = .05), and history of extracapsular cataract extraction (P = .05). Median pre-ASCH visual acuity was 20/100, and final median visual acuity was 20/1600. CONCLUSIONS: Risk factors for the development of ASCH include previous vitrectomy and older age. Patients with these risk factors should be informed of their greater chance of poor visual acuity and anatomic outcomes secondary to the development of ASCH.

[Suprachoroidal bleeding: review and description of eight cases]. / Révision et description de 8 cas cliniques d'hémorragie choroïdienne.

INTRODUCTION: Suprachoroidal hemorrhage (SCH) is a dramatic complication of intraocular surgery that can result in total loss of vision. METHODS: The records of eight cases of SCH during cataract surgery were reviewed. Six of eight patients were treated by combined radial sclerotomies for suprachoroidal drainage and vitrectomy. Risk factors, therapeutic strategies, and functional and anatomical results were analyzed. RESULTS: The incidence of SCH was 0.45%. Preoperative visual acuity of all eyes suffering from SCH was limited to the perception of light. Postoperatively, six patients showed an increase in visual acuity greater than 0.1; one patient achieved 0.5. Ocular and general risk factors (ocular hypotony, myopia, Valsalva-type maneuvers, intraoperative systemic hypertension) and surgery complications were analyzed. CONCLUSIONS: In spite of using state-of-the-art surgical techniques, the prognosis of SCH remains serious, with a poorer outcome associated with increasing complications due to hemorrhage. Secondary treatment combining radial sclerotomies and vitrectomy should be performed to minimize the damaging effect of choroidal hemorrhage.

Acute suprachoroidal hemorrhage during clear corneal phacoemulsification using topical and intracameral anesthesia.

Shallowing of the anterior chamber and hardening of the eye occurred just before commencement of irrigation/aspiration of cortex in an 80-year-old man having temporal clear corneal cataract surgery under topical and intracameral anesthesia. Nucleus removal had been completed and was uneventful. Intraoperative fundus examination with the indirect ophthalmoscope disclosed a choroidal hemorrhage. The wound was immediately closed with sutures, and intravenous mannitol was administered. The hemorrhage remained localized. The red reflex remained unchanged at all times, and there was no prolapse of intraocular contents. A high index of suspicion is critical to the early diagnosis and management of choroidal hemorrhage.

[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.

Delayed suprachoroidal hemorrhage after glaucoma filtration procedures.

OBJECTIVES: To determine the incidence of, risk factors for, and outcomes of delayed suprachoroidal hemorrhage (DSCH) after glaucoma filtration surgery. DESIGN: Retrospective case-control study. PARTICIPANTS: All patients undergoing glaucoma filtration procedures between 1986 and 2000 at Indiana University who were diagnosed postoperatively with suprachoroidal hemorrhage. A total of 66 patients with DSCH were identified. These were compared with a randomly selected group of patients who underwent similar procedures but did not have suprachoroidal hemorrhage. METHODS: Total cases of DSCH were initially compared with the total number of glaucoma surgeries to determine the overall incidence and the incidence in the different procedures. Subsequently, a case-control study was performed comparing the group with hemorrhage to the control group to identify risk factors. Finally, outcomes and prognostic factors were determined by comparing vision preoperatively and postoperatively and parameters of patients with good and poor outcomes. MAIN OUTCOME MEASURES: Incidence of DSCH, risk factors associated with its occurrence, visual outcomes, and factors important for prognosis. RESULTS: Of a total of 2285 glaucoma filtration procedures, 66 (2.9%) cases of DSCH were identified. It developed in 9 of 615 (1.5%) trabeculectomies without antimetabolite, 30 of 1248 (2.4%) trabeculectomies with antimetabolite, 2 of 72 (2.8%) valved tube shunt implantations, and 25 of 350 (7.1%) nonvalved tube shunt implantations. The increased incidence of DSCH after tube shunts compared with trabeculectomy-associated DSCH was significant (P < 0.0001) with an odds ratio of 3.2. The risk factors for DSCH after glaucoma surgery include white race (P = 0.012), anticoagulation (P = 0.034), severe postoperative hypotony (P = 0.033), and aphakia/anterior chamber intraocular lens (P = 0.002). The visual outcomes of patients with hemorrhage were poor, with a decrease in logarithm of the minimum angle of resolution visual acuity from 0.72 to 1.36, which was statistically significant compared with the controls (P < 0.009). CONCLUSIONS: Delayed suprachoroidal hemorrhage occurs more frequently after tube shunt implantation than after trabeculectomy. Caution should be exercised when operating on patients with known risk factors, because the visual outcomes after DSCH are poor.

Suprachoroidal hemorrhage after Molteno implantation.

PURPOSE: The objective of this study is to identify the rate and the associated risk factors for suprachoroidal hemorrhage (SCH) after Molteno drain implantation. METHODS: Data from the Molteno pilot study and single versus double-plate Molteno study were reviewed retrospectively for the occurrence of SCH. Follow-up intervals, demographic variables, ocular data, and medical history were collected. RESULTS: SCH occurred in 6% of the patients enrolled in the Molteno studies; all cases were delayed and none were intraoperative. Significantly associated factors in a multiple logistic regression for SCH were the extent of intraocular pressure (IOP) drop after surgery, the post-operative IOP, a diagnosis of angleclosure glaucoma, and possibly the number of prior surgeries as well. Eyes with SCH did significantly less well in terms of visual acuity outcomes and were more likely to have inadequately controlled IOP. CONCLUSIONS: This study suggests that SCH occurs at the same frequency after Molteno implantation as after filtering surgery with antimetabolite use and that eyes with SCH do less well.