Spontaneous progressive supra-choroidal haemorrhage in a patient undergoing haemodialysis

Abstract

We present a case of spontaneous and progressive suprachoroidal haemorrhage in a patient undergoing haemodialysis. A 27-year-old female patient with insulin-dependent diabetes presented to eye casualty complaining of sudden onset of pain in her only eye, starting 45 min after haemodialysis with first time use of tissue plasminogen activator (tPA); 8 mg of tPA in 80 ml of saline had been administered over 4 h in order to overcome a thrombosed port. The left eye had a history of laser treatment (panretinal photocoagulation, PRP), cataract extraction with lens implant, vitrectomy and delamination with visual acuity of 6/9. Her right eye was enucleated secondary to rubeotic glaucoma. At presentation visual acuity dropped from 6/9 to CF with raised intraocular pressure (IOP) at 48 mmHg. Ophthalmoscopy revealed peripheral 360° choroidal haemorrhages. The IOP settled initially for 2 days on maximum medical treatment. A computed tomography (CT) scan ruled out orbital haemorrhages and showed choroidal detachments (Fig. 1). On the 3rd day, after another session of haemodialysis (with minimal heparin), the patient developed secondary angle-closure glaucoma with shallow anterior chamber and IOPs of 56 mmHg. The choroidal haemorrhages were observed to have increased. The visual acuity dropped to PL. A B scan showed dome-shaped choroidal haemorrhages with liquefied blood. Progression of the supra-choroidal haemorrhage induced angle-closure glaucoma and threatened the macular architecture. Surgical intervention involved emergency vitrectomy with perfluorocarbon liquid (PFCL)assisted external drainage of the haemorrhage. Silicone oil was used as internal tamponade. Post-operatively, systemic blood pressure was uncontrolled at 230/130 mmHg requiring appropriate anti-hypertensive therapy. Post-operatively the IOP settled to 14 mmHg but rose again to 56 mmHg 24 h later. The supra-choroidal haemorrhages were observed to have increased again. Repeat drainage of choroidal blood was performed through large radial sclerostomies, which were left open underneath the conjunctiva. On a haematologist’s advice, the patient received transfusion of platelets. She continued to have daily dialysis with minimal heparin. Vision recovered 1 month after discharge to 6/12 (aided) (Fig. 2). To the best of our knowledge, only one case of spontaneous supra-choroidal haemorrhage secondary to tPA has been reported in the literature [1]. In contrast to the case by Khawley et al., our case showed progression, threatening the posterior pole along with raised IOP. Spontaneous supra-choroidal haemorrhages have also been reported following thrombolysis with heparin and low molecular weight (LMW) derivatives for myocardial infarction [2, 3]. Choroidal haemorrhages are usually associated with intraocular surgery, mostly with cataract or glaucoma surgery [4]. If necessary, drainage surgery is advised 7–25 days later in order to allow the blood to Graefe’s Arch Clin Exp Ophthalmol (2007) 245:1741–1742 DOI 10.1007/s00417-007-0653-y