Hemorragia coroidea expulsiva espontánea. Caso clínico / Spontaneous expulsive choroidal hemorrhage. Case report

CASO CLÍNICO: Se presenta el caso de una paciente de 85 años de edad, procedente de un centro geriátrico, que acudió a urgencias con un cuadro de hemorragia ocular masiva aparentemente de forma espontánea en ojo izquierdo (OI). No había constancia de antecedentes oftalmológicos en su historial clínico. La paciente refería haber sido operada de catarata en ambos ojos hacía más de 25 años y llevar varios años sin visión por el OI. DISCUSIÓN: La hemorragia coroidea expulsiva espontánea (HCEE) no quirúrgica es una entidad clínica devastadora muy rara. Los factores predisponentes implicados en su desarrollo incluyen: edad avanzada, enfermedades vasculares (arterioesclerosis sobre todo), glaucoma y daño corneal severo

CLINICAL CASE: A case is presented of an 85-year-old woman living in a geriatric residence, who was admitted to the emergency department of our hospital with a spontaneous expulsive choroidal hemorrhage in her left eye. There was no a history of ophthalmic disease, and the patient only reported having intracapsular cataract surgery in both eyes 25 years ago, and that she also became blind in her left eye in the past few years. DISCUSSION: Non-surgical spontaneous expulsive choroidal hemorrhage is a very rare and disastrous clinical event. The predisposing factors involved are: advancing age, vascular illness (especially atherosclerosis), glaucoma, and severe corneal damage

Three cases of corneal perforation caused by noncontact tonometry.

PURPOSE: The purpose of this study was to report 3 clinical features of corneal perforation induced in 3 separate patients by noncontact tonometry (NCT). METHODS: Three cases are discussed along with the relevant literature. RESULTS: The first patient had a necrotic cornea for a month after penetrating keratoplasty (PK) and developed a central corneal perforation induced by NCT. The wound in the first patient opened in the corneal center, and air bubble filled the anterior chamber. The wound was self-sealed after the administration of antibiotic eyedrops for 4 weeks. The second patient developed a traumatic corneal wound dehiscence after PK by NCT and underwent graft resuturing. The third patient developed expulsive choroidal hemorrhage after extracapsular cataract surgery by NCT and underwent the wound repair, iris reposition, anterior chamber reformation, and anterior vitrectomy the same day. CONCLUSIONS: NCT does not seem sufficiently safe in patients with a thin and necrotic cornea, or suture loosening after PK during the early postoperative period.

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.

Suprachoroidal hemorrhage as an intraoperative complication of 25-gauge pars plana vitrectomy.

PURPOSE: To describe a case of suprachoroidal hemorrhage occurring during 25-gauge vitrectomy. METHODS: Retrospective case review. RESULTS: An 80-year old pseudophakic man developed intraoperative suprachoroidal hemorrhage during a vitreous biopsy procedure for chronic intraocular inflammation. Despite drainage of the choroidals, visual outcome was poor. CONCLUSIONS: 25-gauge vitrectomy is often referred to as a "less-invasive" procedure than 20-gauge vitrectomy, but it is not necessarily less risky and probably carries a similar risk profile.

[The role of ultrasound examinations in diagnosis of massive suprachoroidal hemorrhage occurring as a postoperative complication of intraocular surgery ]. / Rola badan ultrasonograficznych w diagnostyce masywnego krwotoku nadnaczyniówkowego, wystepujacego jako powiklanie operacji wewnatrzgalkowych.

This article presents importance of the ultrasound examinations (standard A- and B-scan ultrasonography, Colour Doppler and Power Doppler ultrasonography) in early and late diagnosis of massive intraoperative suprachoroidal hemorrhage. Standardized echography can help establish an accurate diagnosis. Echography can determine the location and extent of expulsive hemorrhage, as well as determine the status of the retina and vitreous. Furthermore, differentiation between hemorrhagic choroidal detachment and serous choroidal effusion can be made only by A- and B-scans. Colour and Power Doppler imagings of orbital vessels are relatively new sonography methods of ocular diagnosis. Using them, we can evaluate all blood flow disturbance, which occur in eye with massive suprachoroidal hemorrhage. These methods are also useful in differentiation of retina from other tissues, especially in the presence of opaque media.

Massive spontaneous choroidal hemorrhage.

PURPOSE: To describe the course, management, and prognosis of massive spontaneous choroidal hemorrhage. METHODS: The presenting visual acuity, ocular findings, duration to surgical intervention, and outcomes of five patients were retrospectively reviewed. RESULTS: Five eyes from four patients (median age, 80 years; range, 66-85 years) were studied. The patients were observed from 4 to 72 months (median, 33 months). Three patients were on anticoagulation therapy with warfarin; one patient had bilateral involvement with no history of anticoagulation therapy. Three patients were hypertensive, and three of the four had been diagnosed with age-related macular degeneration. Four eyes underwent choroidal drainage procedures, and one was observed. In all patients whose choroids were drained, the final vision was no light perception. CONCLUSIONS: Massive spontaneous choroidal hemorrhage may be associated with hypertension, systemic anticoagulation, advanced age, and age-related macular degeneration. Final visual acuities are generally poor.

[Suprachoroidal haemorrhage and acute glaucoma associated with systemic fibrinolysis]. / Hemorragia supracoroidea y glaucoma agudo asociado a fibrinolisis sistémica.

PURPOSE/METHOD: To describe the clinical case of a patient with acute myocardial infarction and an ocular haemorrhage as a complication of the use of systemic thrombolytic agents. RESULTS/CONCLUSIONS: A patient who received therapy with tissue plasminogen activator for an acute myocardial infarction developed three hours later a massive suprachoroidal haemorrhage with secondary acute angle closure. In patients who have undergone systemic thrombolytic agents, the presence of loss of vision and pain must alert to the possibility of secondary ocular haemorrhage. These patients may benefit from continuous control (Arch Soc Esp Oftalmol 2002; 77: 459-462).

[Best's vitelliform dystrophy with complications of a neovascular membrane and hemorrhage]. / Bestova viteliformní dystrofie komplikovaná neovaskulární membránou a krvácením.

UNLABELLED: The objective of the paper is to draw attention to an uncommon picture of Best s vitelliform dystrophy of the macula (BVD) complicated by a choroidal neovascular membrane (CNVM) and haemorrhage. In an 8-year-old boy where incidentally at the age of 5 years cystic changes in both maculars were found and a reduced central visual acuity (CVA) of the left eye, the CVA of the so far asymptomatic right eye suddenly deteriorated. In the right macula a vitelliform focus was present the lower half of which was formed by a vascularized scar with subretinal haemorrhage on the margin. In the left macula was a round chorioretinal scar with hyperplasia of the pigmented epithelium (RPE) and remnants of macular yellow. Fluoroangiographic examination (FAG) visualized classical CNVM, optical coherence tomography (OCT) ablation of the RPE. The electrooculogram (EOG) was bilaterally reduced, CVA of the right eye was 6/60, of the left eye 6/36. Examination of the mother revealed though the ophthalmological finding was normal, a significantly reduced EOG and in an older brother there was a small vitelliform focus in both maculae and reduced EOG with CVA of 6/6. CONCLUSION: CNVM with haemorrhage is a rare complication of BVD. This complication markedly extends the polymorphism of findings, is a risk of the CVA and makes the diagnosis more difficult. EOG examination is decisive for the diagnosis of less common forms of BVD.

Massive choroidal hemorrhage associated with low molecular weight heparin therapy.

An 84-year-old woman with unstable angina pectoris was treated with subcutaneous enoxaparine (Clexane) for several days before presenting with severe pain and decreased vision in her left eye. The intraocular pressure was 70 mmHg, and fundus examination showed a pigmented choroidal lesion and associated choroidal and retinal detachment. Ultrasonography was consistent with choroidal hemorrhage, and she was diagnosed as having acute glaucoma secondary to massive subchoroidal hemorrhage. Medical control of the intraocular pressure resulted in a significant clinical improvement. Intraocular hemorrhage and angle-closure glaucoma are rare and previously unreported complications in patients treated with low molecular weight heparin. It is important to be aware of this ocular complication as these drugs are so often used.

[Idiopathic polypoidal choroidal vasculopathy leading to blindness]. / Forme cécitante de vasculopathie choroïdienne polypoïdale idiopathique.

Idiopathic polypoidal choroidal vasculopathy (IPCV) has recently been recognized as a distinct cause of recurrent subretinal hemorrhages and exudates as well as multiple hemorrhagic retinal pigment epithelium detachments in the macula. IPCV is usually considered to have a good visual prognosis. We report the case of a 44-year-old woman with particularly severe bilateral macular and peripheral IPCV. The patient was followed for 13 years and had final visual acuity of counting fingers in the right eye and 20/400 in the left eye. Patients with IPCV with macular choroidal neovascularization tend to have a poor visual prognosis. This case of IPCV should alert the physician to be particularly attentive to the follow-up of these patients.

Choroidal detachment and expulsive choroidal hemorrhage.

ECH occurring during open globe surgery is no longer synonymous with loss of the eye. If the eye is closed immediately (i.e., the hemorrhage does not become expulsive) and modern secondary reconstruction techniques are applied, the prognosis is good. Prophylaxis, however, is the ultimate goal, achieved by a conscious consideration of all risk factors and planning of the surgical intervention accordingly ECH nevertheless can occur, for which the surgeon must be mentally prepared and then act swiftly, based on a previously designed strategy. All ophthalmologists performing (especially open globe) surgery should remain alert. Although new techniques such as small, self-sealing incisions and phacoemulsification have lowered the ECH risk, it is still not zero. (3,44,71) Once the wound is closed and the bleeding has stopped, maneuvers such as drainage or even proceeding with the original surgery can be considered, but the risks of such a course must be carefully analyzed first. Comprehensive secondary reconstruction is best placed in the hands of specialists.

Massive suprachoroidal hemorrhage with retinal and vitreous incarceration; a vitreoretinal surgical approach.

Suprachoroidal hemorrhage(SH) may cause the expulsion of the intraocular contents. Vitreous incarceration in the wound and retinal detachment with SH are extremely poor prognostic signs. Treatment modalities depend on the severity of eye damage. This particular patient had "kissing" hemorrhagic choroidal detachment which completely filled the vitreous cavity after cataract surgery. It seemed to be inoperable. Secondary surgery was delayed 3 days to lower IOP to normal levels. The eye underwent anterior drainage sclerotomy under constantly-maintained limbal or pars plana infusion fluid line pressure. The authors performed a pars plana vitrectomy, followed by perfluorocarbon liquid injection and a silicone oil tamponade. After this surgical approach, the patient attained an attached retina and a visual acuity of 5/200 at the 3 month follow-up.

Suprachoroidal hemorrhage: outcome of surgical management according to hemorrhage severity.

OBJECTIVE: To report the visual and anatomic outcome after surgical drainage of suprachoroidal hemorrhage according to hemorrhage severity. DESIGN: A retrospective chart review. PARTICIPANTS: Forty-eight consecutive eyes undergoing surgical drainage of a suprachoroidal hemorrhage at The Medical College of Wisconsin were examined. INTERVENTION: Demographic and clinical data were abstracted from patients' medical records. Eyes were classified into four categories of increasing hemorrhage complexity: (1) nonappositional choroidal hemorrhage without vitreous or retinal incarceration in the wound (12 eyes); (2) centrally appositional choroidal hemorrhage without vitreous or retinal incarceration in the wound (17 eyes); (3) choroidal hemorrhage with associated vitreous incarceration in the wound (11 eyes); and (4) choroidal hemorrhage with associated retinal incarceration in the wound (8 eyes). MAIN OUTCOME MEASURES: Visual acuity, rate of persistent hypotony, and incidence of irreparable retinal detachment after surgical drainage for four classes of suprachoroidal hemorrhage were defined. RESULTS: Overall, 11 (23%) of 48 eyes had no light perception (NLP) vision develop, 9 (19%) of 48 eyes had persistent postsurgical hypotony (intraocular pressure < 6), and 21 (64%) of 33 eyes with retinal detachment enjoyed successful retinal reattachment surgery. A definite trend toward an increased rate of NLP vision (P < 0.02), persistent hypotony (P < 0.05), and irreparable retinal detachment (P = 0.11) was observed with increasing suprachoroidal hemorrhage complexity. Eyes with retinal incarceration, compared to eyes without retinal incarceration, had an increased rate of NLP vision (63% vs. 15%; P < 0.01), persistent postsurgical hypotony (50% vs. 13%; P < 0.05), and irreparable retinal detachment (50% vs. 20%; P = 0.07). CONCLUSIONS: Eyes requiring surgical drainage of a suprachoroidal hemorrhage have a guarded prognosis, with a poorer outcome associated with increasing hemorrhage complexity. A classification system incorporating choroidal apposition, and vitreous and retinal incarceration in the wound, provides a format for reporting and assessing the efficacy of management strategies in this condition.