Expulsive Suprachoroidal Hemorrhage Research Articles

A rare ophthalmic complication: Expulsive suprachoroidal hemorrhage.

Expulsive suprachoroidal hemorrhage is a rare but dreadful complication of any ophthalmic surgery. Hence an ophthalmologist should know about the various risk factors, methods for preventing such a situation, and be aware of the various options for timely management to tackle the situation. To discuss the risk factors, intraoperative signs, and ways of managing expulsive choroidal hemorrhage. We discuss two cases having multiple risk factors, where the patients underwent tectonic penetrating keratoplasty. In view of extensive involvement of ocular structures, the patients were clearly explained about the guarded visual prognosis and the risk of auto-evisceration. Following trephination of host cornea, rise in intraocular pressure was identified by the increasing size of the vitreous seen prolapsing through the wound and markedly visible pulsations, along with subconjunctival bleeding. Suprachoroidal hemorrhage was suspected and immediate tamponade was given. However, bleeding was not controlled, and eventually, expulsion of all the intraocular contents occurred. A surgeon must be aware of the risk factors, be prompt to identify the signs, and must take immediate actions for the management of expulsive choroidal hemorrhage, a rare but dreadful complication of intraocular procedures. https://youtu.be/UnCH-lWGzwU.

A rare case of spontaneous expulsive suprachoroidal haemorrhage in a glaucomatous eye treated with topical alpha-adrenergic agonist.

Spontaneous expulsive suprachoroidal hemorrhage is a rare ocular condition, which usually occurs after sudden decompression of the eyewall. Most of the cases of expulsive hemorrhage reported had a predisposing glaucoma with the combination of corneal pathology. We are reporting a case of spontaneous expulsive suprachoroidal hemorrhage in a glaucoma patient probably due to perpetuated inflammatory reaction and frequent eye rubbing induced by allergic reaction to topical alpha adrenergic agonist in a compromised cornea.

Suprachoroidal hemorrhage associated with pars plana vitrectomy

PurposeTo analyze the characteristics, related risk factors, and prognosis of suprachoroidal hemorrhage (SCH) associated with pars plana vitrectomy (PPV).MethodsCases of SCH associated with PPV excluding trauma were retrospectively analyzed in Beijing Tongren Hospital between January 2010 and June 2020. The data collected included general data, myopia status, axial length, state of the crystalline lens, SCH onset time, range, treatment method, visual prognosis, and methods of operation and anesthesia. Patients were divided into those with SCH related to the first PPV (Group 1), and SCH related to second intraocular surgery in the vitrectomized eye (Group 2). Patients were also classified by the SCH onset time into either the expulsive suprachoroidal hemorrhage group (ESCH) and the delayed suprachoroidal hemorrhage group (DSCH). The general data, related risk factors, and the visual prognosis of SCH in the different groups were analyzed.ResultsSCH associated with PPV was studied in 28 cases with an incidence of 0.06 %; 16 males and 12 females. The mean age of the patients was (53.51 ± 10.21) years old, the mean follow-up time was (24.94 ± 14.60) days, and the mean axial length was (28.21 ± 3.14) mm. Of these cases, 21 were classified as high myopia, 25 as aphakia/ pseudophakic, and 7 as focal hemorrhage. Silicone oil removal occurred in 12 cases (43 %). Patients in Group 2 were younger than Group 1 (P = 0.005). In terms of treatment and prognosis, 5 eyes were simply closely observed, 4 were given single suprachoroidal drainage, 15 were given suprachoroidal drainage combined with silicone tamponade, 2 underwent anterior chamber puncture, and 2 gave up treatment. A follow-up vision: NLP ~ 20/30; among them, 2 eyes with NLP (7.14 %), 6 of ≥ 20/200 (21.43 %). The final outcomes presented a significantly positive correlation with baseline vision but no significant correlation with age or axial length.ConclusionsSCH has a higher incidence rate after a second intraocular surgery in a vitrectomized eye which is associated with the lack of vitreous support and easier fluctuation of intraocular pressure. SCH associated with PPV is more localized and has a relatively good prognosis; high myopia and aphakic/ pseudophakic eyes are risk factors. Active treatment can effectively improve visual prognosis.Trial registrationRetrospective case series study, not applicable.

Comparative evaluation of the safety of the lens and the ora serrata during vitrectomy with scleral incisions at 5.0 mm or 4.0 mm posterior to the limbus

Objective To investigate the lens and ora serrata safety during 23G vitrectomy with sclera incisions at 5.0 mm or 4.0 mm posterior to the limbus. Methods A prospective case-controlled study was adopted. From April 2016 to January 2018, 290 consecutive primary 23G vitrectomy patients (300 eyes) with vitreoretinal disease in Department of Ophthalmology of Subei People’s Hospital Affiliated to Yangzhou University were enrolled in this study. Among them, 146 patients (150 eyes) received 23G pars plana vitrectomy (PPV) with scleral incisions at 5.0 mm posterior to the limbus (5.0 mm group), and 144 patients(150 eyes) at 4.0 mm (4.0 mm group). No statistically significant difference was found in age, axial length(t=−1.324, 0.867; P=0.186, 0.387) and in gender, right/left eyes, proportion of indications (χ2=1.366, 2.615, 10.195; P=0.242, 0.106, 0.070) between the two groups. The incidence rate of complications between the two groups were comparatively observed, such as lens injury, retinal tears close to the scleral incision, retinal hemorrhage, supra-choroidal expulsive hemorrhage and iatrogenic retinal detachment. Independent sample t test and χ2 test were performed for comparison between the two groups. Results Lens injury was observed in 4 eyes(2.67%) and 14 eyes (9.33%) respectively in the 5.0 mm and 4.0 mm group during surgery (χ2=5.910, P=0.015). Retinal tears close to the scleral incision sites were observed in 5 eyes (3.33%) and 6 eyes (4.00%) respectively in the 5.0 mm and 4.0 mm group during surgery (χ2=0.094, P=0.759). The mean time of removing the vitreous base was 6.17±2.76 min and 10.03±5.56 min respectively in the 5.0 mm and 4.0 mm group (t=7.599, P <0.01). No other surgical complications occurred in any group, such as retinal hemorrhage, supra-choroidal expulsive hemorrhage and iatrogenic retinal detachment, etc. Conclusion In primary 23G PPV, the safety of ora serrata with incisions at 5.0 mm posterior to limbus is similar to that at 4.0 mm, but the safety of lens and the efficiency of vitreous resection is higher with incisions at 5.0 mm. Key words: Vitrectomy; Lens, crystalline/injuries; Retinal perforations

Preliminary evaluation of the safety of the lens and the ora serrata during vitrectomy with scleral incisions at 5.0 mm behind the limbus

Objective To evaluate the safety to perform 23G vitrectomy with scleral incisions at 5.0 mm behind the limbus. Methods This is a prospective uncontrolled case study. The data of 140 consecutive primary 23G vitrectomy patients (145 eyes) were enrolled in this study. There were 56 males (59 eyes) and 84 females (86 eyes), with the mean age of (56.34±9.98) years and axial length of (23.99±2.57) mm. There were 139 phakic eye and 6 aphakic eyes. All the eyes received 23G pars plana vitrectomy with scleral incisions at 5.0 mm behind the limbus. To measure the normal Chinese adult parameters of anteroposterior axis of the eyeball, lens thickness and scleral distances from the limbus to the plane passing through the lens posterior apex, the head CT scans of 105 patients without eye diseases in our hospital were studied during the same period of time for these vitrectomy surgeries. Pearson correlation analysis was used to analyze the relationship between age, anteroposterior axis of eyeball, lens thickness and scleral distances from the limbus to the plane passing through the lens posterior apex. Results Surgical related complications included retinal tears close to the scleral incision sites (3/145 eyes, 2.1%) and lens injury (3/121 eyes, 2.5%). No other surgical complications occurred, such as retinal hemorrhage, supra-choroidal expulsive hemorrhage and iatrogenic retinal detachment. Based on CT images, the average scleral distance from limbus to the plane passing through the lens posterior apex, anteroposterior axis of eyeball and lens thickness was (6.72±0.81), (24.39±0.97), (4.22±0.47) mm, respectively. The results of Pearson correlation analysis showed that age and lens thickness had statistically significant correlation (r=0.328 9, P=0.000 6). Conclusion Primary 23G pars plana vitrectomy with incisions at 5.0 mm posterior to the limbus is safe. Key words: Lens, crystalline/injuries; Retinal perforations; Vitrectomy/adverse effects

Securing the Anterior Chamber in Penetrating Keratoplasty

Conventional penetrating keratoplasty (PK) is an open-sky procedure, carrying a worrisome risk of expulsive suprachoroidal hemorrhage and vitreous prolapse in high-risk cases. The authors propose an innovative surgical technique that secures the intraoperative anterior chamber and should reduce the risk of vitreous complications. In the new stabilized procedure, a deep anterior corneal lamella is excised. A small puncture is made in each quadrant along the groove of the stromal bed, and the anterior chamber is maintained by viscoelastic injection. The viscoelastic-coated graft is sutured near the 4 puncture sites. After sequential cutting of the stromal bed and suturing of the graft, the residual stromal bed is excised and drawn out before the last suture is placed. Fifteen PK patients have undergone this procedure without complications. Satisfactory vision recovery was achieved in all 15 of the stabilized PK eyes, and the mean postoperative endothelial cell loss was comparable to studies performed for open PK. The authors believe that the reduced risks and limited endothelial cell loss verify the significance and practicability of the stabilized PK. This innovative new technique adds security for keratoplasty candidates who are at high risk for vitreous prolapse or suprachoroidal hemorrhage.

内眼手术中发生驱逐性脉络膜上腔出血的临床观察

目的：分析发生在内眼手术中驱逐性脉络膜上腔出血的原因和治疗转归。方法：收集内眼手术中发生驱逐性脉络膜上腔出血患者11例，男性6例，女性5例，分析其原发病种类，手术类型，治疗方法和治疗效果。结果：在11例患者中手术前合并高眼压7例，其中2例是玻璃体切割术后；4例眼压正常。手术类型分别是小梁切除术3例，青光眼白内障联合手术4例，白内障手术2例，II期人工晶体植入2例。4例实施了玻璃体切割硅油填充 + 后巩膜放液手术，7例保守治疗。随访6~12个月，2例眼球萎缩，3例无光感，光感1例，2例手动，最佳矫正视力：3例0.02~0.1，1例0.2，1例0.4。结论：手术前高眼压是内眼手术中发生驱逐性脉络膜上腔出血的高危因素；对于出血严重患者行玻璃体切割联合引流脉络膜上腔积血是处理驱逐性脉络膜上腔出血的有效方法。 Objective: To analyze the causes and therapeutic outcome of expulsive suprachoroidal hemorrhage during surgery. Methods: This study collected 11 cases (6 male and 5 female, 11 eyes) with expulsive suprachoroida hemor- rhage during intraocular surgery. The primary disease type, surgery type, intraocular pressure, and therapeutic methods and effect were analyzed. Results: Pre-surgery high intraocular pressure occurred in 7 eyes. In 11 eyes, 3 eyes were performed trabeculectomy, 4 eyes were performed cataract extraction combined with trabeculectomy, 2 eyes were per- formed cataract surgery, and 2 eyes were performed phase II IOL implantation. In 11 cases, 4 cases underwent secondary surgical intervention with radial sclerotomies combined with vitrectomy and silicone oil filling, and the rest cases underwent conservative treatment. These cases were followed up for 6 to 12 months, and finally atrophy occurred in 2 eyes, no light sensor occurred in 3 eyes, light sensors occurred in 1 eye, hand move occurred in 2 eyes, best corrected vision acuity (BCVA) 0.02 to 0.1 occurred in 3 eyes, BCVA 0.2 occurred in 1 eye, and BCVA 0.4 occurred in 1 eye. Conclusion: Preoperative high intraocular pressure is a risk factor for expulsive suprachoroidal hemorrhage during sur- gery. Radial sclerotomy combined vitrectomy and silicone oil filling can effectively treat severe expulsive suprachor- oidal hemorrhage.

Spontaneous expulsive suprachoroidal hemorrhage caused by decompensated liver disease

Expulsive suprachoroidal hemorrhage can be surgical or spontaneous. Spontaneous expulsive suprachoroidal hemorrhage (SESCH) is a rare entity. Most of the reported cases of SESCH were caused by a combination of corneal pathology and glaucoma. We are reporting a rare presentation of SESCH with no pre-existing glaucoma or corneal pathology and caused by massive intra- and peri-ocular hemorrhage due to decompensated liver disease.

Delayed-Onset Expulsive Suprachoroidal Hemorrhage Due to a Trauma after Removal of Penetrating Keratoplasty Suture

Delayed-Onset Expulsive Suprachoroidal Hemorrhage Due to a Trauma after Removal of Penetrating Keratoplasty Suture

Poster 58: Bilateral Angle Closure Following Cataract Extraction

PURPOSE: To report a case of infusion misdirection syndrome, simulating an intraoperative suprachoroidal hemorrhage, in an eye undergoing trabeculectomy for primary trabeculodysgenesis.METHODS: A 21-year-old woman underwent trabeculectomy for primary trabeculodysgenesis. Congenitally abnormal intraocular anatomy led to intraoperative and postoperative complications.RESULTS: Intraoperative anterior chamber irrigation was followed by vitreous prolapse. Eye pain, globe hardening, and shallowing of the anterior chamber were caused by infusion misdirection into the posterior segment. The eye was rapidly closed after a limited wound-site vitrectomy. Intraoperative and postoperative management led to a successful outcome.CONCLUSION: Altered intraocular anatomy set the stage for infusion misdirection syndrome, a rare but manageable complication that mimicked an expulsive suprachoroidal hemorrhage.

Descemet Stripping with Endothelial Keratoplasty

Corneal transplants are the oldest, most common, and arguably the most successful form of solid tissue transplantation in the world. Since the first full-thickness corneal transplant was performed in 1905 by Eduard Zirm, penetrating keratoplasties (PKs) have been performed to provide a clear, optically functional visual pathway to improve vision, provide tectonic support for an eye, alleviate pain from corneal decompensation, and eliminate an infection in danger of spreading intraocularly. Corneal disease processes requiring transplantation may involve either the anterior cornea (e.g. scars, ectasias) or the posterior cornea (e.g. bullous keratopathy, endothelial dystrophies). In the past 10 years, a new and evolving alternate technique, known as Descemet stripping with endothelial keratoplasty (DSEK), has come about in which only the diseased portion of the posterior cornea is replaced by healthy posterior donor tissue. Important advantages of DSEK over PK are that the host cornea remains structurally intact and more resistant to injury, intra-operative and post-operative suture management issues are non-existent, and concerns about late wound dehiscence after suture removal are virtually absent. Furthermore, the risk of expulsive intra-operative suprachoroidal hemorrhage is minimized because the wound is small and can be closed quickly. Of importance to the patient are the rapid visual recovery, minimal induced astigmatism, and relative safety of topical anesthesia. This article will provide a brief overview of DSEK, an elegant technique for selective replacement of dysfunctional corneal endothelium that is constantly evolving and rapidly revolutionizing corneal transplantation.

Infusion misdirection syndrome during trabeculectomy for primary trabeculodysgenesis

PURPOSE: To report a case of infusion misdirection syndrome, simulating an intraoperative suprachoroidal hemorrhage, in an eye undergoing trabeculectomy for primary trabeculodysgenesis. METHODS: A 21-year-old woman underwent trabeculectomy for primary trabeculodysgenesis. Congenitally abnormal intraocular anatomy led to intraoperative and postoperative complications. RESULTS: Intraoperative anterior chamber irrigation was followed by vitreous prolapse. Eye pain, globe hardening, and shallowing of the anterior chamber were caused by infusion misdirection into the posterior segment. The eye was rapidly closed after a limited wound-site vitrectomy. Intraoperative and postoperative management led to a successful outcome. CONCLUSION: Altered intraocular anatomy set the stage for infusion misdirection syndrome, a rare but manageable complication that mimicked an expulsive suprachoroidal hemorrhage.

Suprachoroidal Hemorrhage in Penetrating Keratoplasty

Nine cases of intraoperative expulsive suprachoroidal hemorrhage occurred in a series of 2011 consecutive penetrating keratoplasties (an incidence of 0.45%). In four cases, the complication was directly related to the anesthesia technique. The incidence of hemorrhage was 1.0% in the eyes with preoperative anterior chamber intraocular lenses (IOLs), an incidence significantly higher than for any other associated condition (P < .02). Four of the nine patients recovered a postoperative visual acuity of 20/70 or better. We discuss reasons for the relatively high incidence of hemorrhage during penetrating keratoplasty; its occurrence in relation to the type of anesthesia used, prior intraocular surgery, types of surgery performed together with the penetrating keratoplasty, and the presence of an anterior chamber IOL; and the risks introduced by hemorrhage in a fellow eye and by a previous hemorrhage in the same eye.

A Case-control Study of Risk Factors for Intraoperative Suprachoroidal Expulseve Hemorrhage

The authors performed a case-control study of risk factors for suprachoroidal expulsive hemorrhage (SEH); the study involved 68 SEH cases at their institution from 1981 to 1986. The authors examined 113 variables in the study group and a procedure-matched control group of 217 patients randomly selected from the 35,459 patients who underwent intraocular surgery during this period, and subjected them to bivariate and conditional logistic regression analysis. The incidence of SEH was 0.19% overall, 0.16% for lens-related procedures, 0.15% for glaucoma surgery, 0.41% for retinal and vitreous procedures, and 0.56% for keratoplasty. Statistically significant risk factors for SEH in ageadjusted bivariate analyses included: glaucoma (P < 0.0001), increased axial length (P < 0.0001), elevated intraocular pressure (IOP) (P < 0.0001), generalized atherosclerosis (P = 0.007), and elevated intraoperative pulse (P = 0.0001). Conditional logistic regression analysis with frequency matching on age identified significant independent risks associated with a history of glaucoma, elevated IOP, increased axial length, and intraoperative tachycardia. One of the models predicts a 752-fold increased theoretical relative risk of SEH for a patient with axial length greater than or equal to 25.8 mm, a history of glaucoma, preoperative IOP greater than 18 mmHg, and intraoperative pulse greater than or equal to 85 beats per minute. The visual outcome after SEH was best in cases of extracapsular cataract extraction (ECCE), compared with other procedures. Results suggest that attention to multiple preoperative and intraoperative ocular and systemic variables may allow identification and prophylaxis of patients at risk for SEH.

Complications of Surgery in Glaucoma: Suprachoroidal Expulsive Hemorrhage in Glaucoma Patients Undergoing Intraocular Surgery

A retrospective study of suprachoroidal expulsive hemorrhage in 1638 consecutive cases of intraocular surgery in patients with glaucoma identified 12 cases. A brief summary of each is presented. The pathogenesis of suprachoroidal expulsive hemorrhage is discussed, emphasizing the increased risk of this surgical complication in patients with glaucoma.