Case Report: Suprachoroidal Hemorrhage after Chiropractic Manipulation of the Neck.

SIGNIFICANCE: The case report highlights the possible complications of undergoing neck manipulation within a critical time period after intravitreal injection. PURPOSE: This study aimed to describe a case of traumatic hemorrhagic choroidal detachment after cervical manipulation during a chiropractic treatment session. CASE REPORT: A 43-year-old male patient with a history of complex rhegmatogenous retinal detachment repair and recurrent cystoid macular edema presented with decreased vision and sudden pain in the right eye after chiropractic manipulation of the neck, status post-intravitreal injection of triamcinolone, which was performed earlier that day. Vision in the right eye was hand motion and 20/20 in the left eye. IOPs were 8 and 11 mmHg, respectively. Slit lamp examination of the right eye revealed blood-tinged steroid residues in the anterior chamber. There was no view to the posterior pole. Ultrasonography showed a lobulated mass with heterogeneous echogenicity consistent with a large hemorrhagic choroidal detachment. No central kissing was observed. Left eye examination was unremarkable. CONCLUSIONS: With the increasing use of complementary and alternative medicine, a better understanding of potential complications to raise awareness is becoming essential.

Ocular bleeding in an undiagnosed hemophiliac neonate causing irreversible loss of vision: A case report with review of the literature.

INTRODUCTION: Suprachoroidal hemorrhage is an unexpected complication after penetrating keratoplasty during childhood. We report the case of delayed suprachoroidal hemorrhage after penetrating keratoplasty in a neonate as the first manifestation of hemophilia. CASE REPORT: A 4-day-old neonate was referred to our hospital because of bilateral corneal opacities present since birth. A diagnosis of bilateral Peter's anomaly type 2 with right eye corneal perforation was made after examination. Appropriate treatment was commenced, and later, right eye therapeutic penetrating keratoplasty combined with lensectomy, and anterior vitrectomy was performed. This was complicated postoperatively with suprachoroidal hemorrhage and retinal detachment. Conservative management was advised due to poor visual prognosis. Three months later, the patient was found to have high intraocular pressure in the left eye and glaucoma surgery was recommended. Proper hematological investigations before glaucoma surgery in the left eye revealed a low level of factor VIII with normal levels of factor IX and von Willebrand's factor antigen. Therefore, a diagnosis of hemophilia type A was established. CONCLUSION: This case serves as a reminder that the occurrence of suprachoroidal hemorrhage, especially in the absence of other predisposing risk factors, should warrant detailed systemic assessment to exclude underlying bleeding disorders.

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.

Massive spontaneous choroidal hemorrhage in a patient with chronic renal failure and coronary artery disease treated with Plavix.

PURPOSE: To report a case of massive spontaneous choroidal hemorrhage in a patient with chronic renal failure and coronary artery disease treated with clopidogrel bisulfate (Plavix). METHODS: Case report. RESULTS: A 75-year-old man presented with pain and loss of vision in the left eye for 1 week. His medical history was remarkable for systemic hypertension, chronic renal failure, and artery coronary disease. For 6 months, he had been taking 75 mg/day of Plavix after coronary angioplasty. Ocular examination revealed the patient to be in angle closure. Ultrasonography and computed tomography scan revealed a massive choroidal hemorrhage pushing the iris-lens diaphragm forward. Pain and intraocular pressure were treated successfully with evacuative sclerotomies, but the final exitus after 6 months was bulbar phthisis. CONCLUSIONS: Massive spontaneous choroidal hemorrhage is an extremely rare event that usually has been described in older patients (65-87 years old) receiving anticoagulants or thrombolytic agents. Systemic hypertension, generalized atherosclerosis, and age-related macular degeneration are additional risk factors. In the present case, massive choroidal hemorrhage was associated with use of clopidogrel bisulfate (Plavix) in a patient with chronic renal failure. Our report indicates that Plavix should be administered with caution in patients with chronic renal failure owing to the risk of serious choroidal bleeding. Chronic renal failure should be also included in the list of risk factors for massive spontaneous choroidal hemorrhage. Evacuative sclerotomies may have value in the relief of pain and elevated intraocular pressure but has not been shown to be beneficial in visual and anatomic outcomes.

Suprachoroidal hemorrhage caused by breakage of a 25-gauge cannula.

A 72-year-old woman had vitreous surgery for epiretinal membrane using the 25-gauge vitrectomy system. During the removal of the cannula at the end of the surgery, half of its tip was noted to be missing. The following day, a severe choroidal detachment associated with a hypotony was found. A second surgery was performed, including drainage of suprachoroidal hemorrhage and choroidal fluid and the removal of the tip of the 25-gauge cannula stuck inside the sclerotomy. The retained cannula tip might have acted as a channel allowing vitreous fluid into the suprachoroidal space, resulting in choroidal detachment, hemorrhage, and hypotony.

Healon5 in the management of intraoperative expulsive hemorrhage.

We present a patient with systemic hypertension, glaucoma, and previous vitrectomy who experienced a large expulsive choroidal hemorrhage during a procedure to reposition and iris fixate a subluxated intraocular lens. Liberal use of sodium hyaluronate 2.3% (Healon5) resulted in cessation of the hemorrhage, allowing completion of the case. Healon5 may cause cessation of bleeding through a tamponade effect and thus be useful in treating patients experiencing an intraoperative expulsive hemorrhage.

Suprachoroidal hemorrhage following removal of releasable suture after combined phacoemulsification-trabeculectomy.

We report a case of suprachoroidal hemorrhage following removal of a releasable suture after combined phacoemulsification-trabeculectomy.

Secondary management and outcome of massive suprachoroidal hemorrhage.

PURPOSE: To present the results of secondary surgical treatment of five patients with massive suprachoroidal hemorrhage (MSCH), which occurred intraoperatively, postoperatively, or following ocular trauma. METHODS: Five patients presenting with MSCH were included in this study during or after phacoemulsification surgery (1 patient), glaucoma surgery (1 patient), combined glaucoma and phacoemulsification surgery (2 patients), and after traumatic sclera rupture (1 patient). Diagnosis was confirmed by ophthalmoscopy and B-scan ultrasonography. Pre-existing risk factors and distance visual acuity were documented. All cases received medical therapy and underwent secondary surgical intervention with radial sclerotomies combined with vitrectomy, use of perfluorocarbon, and silicone oil. Postoperative assessment included visual acuity measurement, ocular examination, and ultrasonography. RESULTS: In all cases, anatomic restoration of ocular structures was achieved. Distance visual acuity improved in all cases (preoperative Snellen visual acuity ranged from light perception to hand motions; postoperative Snellen visual acuity ranged from 0.05 to 0.3). The mean follow-up period was 17 months. CONCLUSIONS: In general, despite the advanced surgical techniques, the prognosis of MSCH remains guarded and the visual outcome poor. However, secondary surgical treatment with combined radial sclerotomies and vitrectomy should be considered in order to minimize the damaging effect and maximize the anatomic and functional restoration.

[Intraoperative choroidal hemorrhage in patient with Osler-Rendu syndrome]. / Sródoperacyjny krwotok naczyniówkowy u pacjenta z zespollem rendu--Oslera.

UNLABELLED: The authors describe a 79-year-old man with Osler-Rendu-Weber syndrome, who developed intraoperative choroidal hemorrhage in left eye. During phacoemulsification under local anesthesia, shallowing of the anterior chamber was observed. Acetazolamide was administered and peribulbar block performed. Phacoemulsification was continued and intraocular lens implanted. Five months postoperatively resolution of the choroidal hemorrhage was observed. Best corrected visual acuity was 0.5. Patient developed retinal embolism in his right eye 16 years earlier. CONCLUSIONS: (1) Choroidal hemorrhage may occur more commonly in patients with Osler-Rendu-Weber syndrome. Recognition of this possible association and institution of appropriate intraoperative precautions may facilitate a good visual outcome. (2) Paradoxical embolization (stroke, retinal embolism) is the most serious consequence of hereditary hemorrhagic telangiectasia.

Delayed suprachoroidal hemorrhage following Nd:YAG laser goniopuncture: a case report.

PURPOSE: To report a delayed suprachoroidal hemorrhage following Nd:YAG laser goniopuncture (LGP) in an eye with a previous deep sclerectomy. METHODS: Case report. RESULTS: A 75-year-old woman with advanced primary open-angle glaucoma underwent LGP due to unsatisfactory intraocular pressure (IOP) in her left eye, 1 month after undergoing deep sclerectomy in the same eye. Delayed suprachoroidal hemorrhage occurred the day after LGP execution. CONCLUSIONS: Nd:YAG laser goniopuncture is often performed to enhance IOP control following deep sclerectomy. Although LGP is usually effective and safe, severe complications, such as delayed suprachoroidal hemorrhage, may occur after its execution.

Restoration of pretrabeculectomy visual acuity and a functioning filtering bleb in an eye with delayed suprachoroidal haemorrhage following trabeculectomy.

A 35-year-old myopic man with juvenile open angle glaucoma was referred to us with fluctuating intraocular pressure (IOP) and progression in his only seeing left eye. He had systemic features suggestive of Marfan's syndrome. He underwent trabeculectomy with low dose mitomycin-C with operative precautions to prevent postoperative hypotony in view of high myopia and scleral thinning. On the second postoperative day, he had severe pain in his left eye, with vomiting, and presented with decreased vision, high IOP and a flat anterior chamber. Ultrasound B scan revealed 360° haemorrhagic choroidal detachment. He was conservatively managed and monitored over the next 1 month with appropriate medical treatment. He not only recovered his pretrabeculectomy visual acuity but also had a well functioning bleb at the end of 2 months.

Massive suprachoroidal hemorrhage with central retinal apposition. A clinical and echographic study.

We reviewed the charts of 18 patients diagnosed with a massive suprachoroidal hemorrhage (MSCH) with central retinal apposition (kissing configuration). Four cases occurred intraoperatively (expulsive), eight after a surgical procedure (delayed), and six associated with blunt or perforating injury (traumatic). In this study, echography was used to monitor the course of MSCH; the mean time for clot lysis was 14 days, and the mean duration of central retinal apposition was 15 days. The expulsive MSCHs were all allowed to resolve spontaneously, with good initial visual outcome in three of the four eyes in which they occurred. In the delayed MSCH group, the majority of patients attained their prehemorrhage visual acuity, with or without early surgical intervention. In the traumatic MSCH group, retinal detachment was a constant complication in all patients. All six patients in the traumatic MSCH group had a poor visual outcome, despite early surgical intervention in five patients. The results of this study suggest that not all MSCHs need to be drained surgically and that, when surgical drainage is indicated, echography may be a useful adjunct in determining the optimal time of drainage.

Intraoperative choroidal hemorrhage in the Osler-Rendu-Weber syndrome.

PURPOSE: To describe a patient with Osler-Rendu-Weber syndrome who developed a nonsimultaneous intraoperative choroidal hemorrhage in each eye. METHOD: Interventional case report. A 65-year-old Caucasian woman with Osler-Rendu-Weber syndrome developed a choroidal hemorrhage in the left eye during vitrectomy for a complicated retinal detachment with a poor visual outcome. Fifteen years later, she developed a macula on retinal detachment in the right eye, which also had a dense cataract. Immediately after uncomplicated phacoemulsification and intraocular lens implantation, under monitored anesthesia care and retrobulbar block, and without valsalva stress, ophthalmoscopy demonstrated a choroidal hemorrhage. A planned scleral buckle was replaced by pneumatic retinopexy. RESULTS: Seven months postoperatively, the retina remained attached with resolution of the choroidal hemorrhage. Visual acuity was 20/30. CONCLUSION: Choroidal hemorrhage may occur more commonly in individuals with Osler-Rendu-Weber syndrome. Recognition of this possible association and institution of appropriate intraoperative precautions may facilitate a good visual outcome.

Choroidal hemorrhage associated with systemic tissue plasminogen activator.

PURPOSE: To determine the cause of spontaneous choroidal hemorrhage in a 67-year-old man after a myocardial infarction and administration of tissue plasminogen activator. METHODS: The patient underwent ocular examination. RESULTS: The patient retained excellent visual acuity and the choroidal hemorrhage resolved completely within two months. CONCLUSION: The administration of tissue plasminogen activator was responsible for the large extent of hemorrhage and should be considered in the differential diagnosis of hemorrhagic choroidal detachment.

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.

Delayed suprachoroidal hemorrhage following viscocanalostomy.

Delayed suprachoroidal hemorrhage is a rare complication of conventional glaucoma surgery. Viscocanalostomy is one of the new surgical techniques used in glaucoma surgery that may theoretically protect against suprachoroidal effusion and hemorrhage due to the nonpenetrating nature of the procedure. Delayed suprachoroidal hemorrhage developed in a 92-year-old white woman following viscocanalostomy. This case demonstrates that the risk of suprachoroidal hemorrhage may not be completely eliminated after a nonpenetrating glaucoma procedure such as viscocanalostomy.

High-frequency ultrasonographic imaging in suprachoroidal hemorrhage after filtering surgery.

A 64-year-old woman with glaucoma had suprachoroidal hemorrhage approximately 6 hours after trabeculectomy. High-frequency ultrasonography revealed high reflectivity in the inner space of a kissing choroidal detachment, which facilitated the differential diagnosis of suprachoroidal hemorrhage resulting from serous choroidal detachment. The ciliary process and iris were anteriorly displaced due to the ciliary detachment and forward pressure of the anterior vitreous. On the basis of the diagnosis, transscleral choroidal drainage was performed without delay and the patient's vision was preserved. After surgery, suprachoroidal hemorrhage disappeared clinically, but high-frequency ultrasonography detected persistence of the choroidal detachment in the peripheral area.

[Vis-à-tergo. Uveal effusion and expulsive hemorrhage in cataract surgery]. / Vis-à-tergo. Uveale Effusion und expulsive Blutung in der Katarakt-Chirurgie.

BACKGROUND: Since introduction of the self-sealing incision for cataract surgery it has been possible to avoid serious complications due to an acute rise in intraocular pressure. Chorioidal effusion (CE) and expulsive hemorrhage (EH) should be determined and treated differently. PATIENTS AND METHODS: The incidence of vis-à-tergo in our patients was 1.7%. CE was ascertained in 0.1%; in one case, the operation had to be interrupted. EH occurred in one patient (0.03%) in the last 3,000 cataract operations. Differential diagnoses were made by ultrasonic examination. RESULTS: Operations in CE cases were completed without further complications. However, in one case the operation was interrupted and the procedure was completed on the following day. A 63-year-old woman with EH had a massive rise in intraocular pressure directly after lens implantation with a peripheral capsular rupture. Postoperatively, a chorioidal hemorrhage in two quadrants, including the macula, was found. One week after surgery a posterior sclerotomy was performed with simultaneous infusion into the anterior chamber with BSS. The nearly complete chorioidal reattachment was achieved after drainage of the liquified blood. Visual acuity has improved to 0.5. CONCLUSION: Vis-à-tergo in modern cataract surgery only rarely results in an ES or EH. Also, in an EH there is an incomplete form. After an adequate therapeutic procedure good visual function can be expected.