October 2020

IN FOCUS

My Worst Complication
Managing suprachoroidal hemorrhage


by Ellen Stodola Editorial Co-Director


Dr. Devgan noted that a large incision can be a risk factor for this complication. Here, the red reflex quickly disappeared, and the hemorrhage continued without the surgeon knowing.
Source: Uday Devgan, MD

Though suprachoroidal hemorrhage is rare, it can be a potentially devastating complication.
Source: Ramesh Ayyala, MD, and Mark Hankins, MD

Suprachoroidal hemorrhage on B-scan ultrasonography of left eye in a patient who fell in the immediate postop period following a penetrating keratoplasty

Postoperatively, choroidals have nearly resolved, IOP normalized, and patient’s visual acuity returned to baseline.
Source (all): Christina Weng, MD, MBA

Suprachoroidal hemorrhage, though rare, is a very serious complication, and several experts discussed how to look out for and manage this issue if it occurs.

A potentially devastating complication

Uday Devgan, MD, said that expulsive choroidal hemorrhage can be a potentially devastating complication, though he noted that he has not experienced it personally in 20 years of practicing.
He shared a video from his teaching website, CataractCoach.com, which discussed a case of expulsive choroidal hemorrhage. Dr. Devgan emphasized again that this type of complication is very rare, noting in his video commentary that it occurs in less than 1 in 1,000 cataract cases. It may, however, be more common in cataract surgery than other surgery.
It is also more common when you have a large incision and the eye is hypotonous for a long time. In the anonymous case he shared, Dr. Devgan noted the big incision and hypotony, with a very low pressure (close to zero).
As the surgeon was working on inserting a lens, the red reflex quickly disappeared, and the hemorrhage continued without the surgeon knowing. This can cause shallowing of the anterior chamber, loss of viscoelastic, and potential expulsion of the lens and vitreous.
Once this problem occurs, Dr. Devgan said it becomes very important to place sutures to close the eye and reestablish pressure. By closing the eye and restoring intraocular pressure, this can help stop further bleeding, Dr. Devgan said.

Recognizing and reacting to suprachoroidal hemorrhage

Expulsive hemorrhage is the worst complication one can experience during a surgical procedure, according to Ramesh Ayyala, MD, FRCS, and Mark Hankins, MD. This is typically seen during full thickness corneal transplantation, soon after trephination and removal of the host cornea, they said. At that moment, the patient can experience sudden severe pain followed by bleeding into the suprachoroidal space that will push the retina, vitreous, and lens out, completing the expulsion of intraocular contents. “Fortunately, this is a very rare occurrence in the modern era,” Dr. Ayyala and Dr. Hankins said. “It’s more likely to occur in patients with glaucoma with poorly controlled intraocular pressure, prior history of multiple surgeries, aphakia, severe coughing in the middle of surgery, poorly controlled blood pressure, and arteriosclerosis.” Prior history of suprachoroidal hemorrhage in the same eye or the other eye is also a risk factor.
Symptoms: Pain breaking through anesthesia is an important symptom that one should pay attention to, Dr. Ayyala and Dr. Hankins said. If a glaucoma patient who has been comfortable under monitored anesthesia suddenly complains of severe eye pain, think suprachoroidal hemorrhage. “Always watch the eye. Never take your eye off the microscope, especially while operating on high-risk patients,” they said.
Signs to watch out for: If the eye becomes hard with or without a dark shadow showing up in the red reflex, with or without iris prolapse, think suprachoroidal hemorrhage.
When you suspect suprachoroidal hemorrhage:
Step 1: Close the wound immediately and pressurize the eye with viscoelastic or balanced salt solution via the sideport to limit the size of the hemorrhage.
Step 2: Watch and see what happens to the eye pressure. In the absence of a dark shadow or loss of red reflex, if the pupil is still dilated, once you can do an indirect exam, you should do so. If you have access to a B-scan, perform an ultrasound exam to confirm suprachoroidal hemorrhage, which would show up as hyperechoic choroidal detachment (as opposed to the hypoechoic choroidal effusion). Often times, B-scan is not possible for a variety of reasons. It is reasonable to watch the eye and monitor the patient for the next few minutes. If the pain subsides, the eye softens, and the red reflex is normal, consider vitreous hydration as a possible cause. If the pain continues, the eye remains hard, and red reflex remains dark or B-scan confirms choroidal hemorrhage, consider a scleral cut-down.
Step 3: Perform scleral cut-down to drain the hemorrhage. This is the only window of opportunity one has to potentially drain the hemorrhage before it clots. A delay at this stage of more than 30–60 minutes could result in the blood forming a clot, in which case one would have to wait for 2 weeks before attempting to drain.
Step 4: The scleral cut-down should ideally be performed in the quadrant of the hemorrhage. If diffuse (four-quadrant hemorrhage) or the location is unknown, typically choose the inferior temporal quadrant as the go-to place. Following conjunctival dissection and cautery, 4 mm posterior to the limbus, a 4-mm radial scleral incision is performed with a sharp blade. The scleral dissection is carried down into the suprachoroidal space gently. Once in the space, if there is blood, one would see it escaping. While doing this process, one should maintain the eye pressure on the higher side by using an anterior chamber maintainer to prevent recurrent bleeding during the procedure. Leave the sclerotomy open and close the conjunctiva.
Step 5: Control the eye pressure (with acetazolamide), decrease the inflammation (with topical and oral prednisone), dilate and paralyze the ciliary muscle and dilate the pupil, and administer pain medications.
These patients should be followed on day 1, 7, and 14, being examined for eye pressure, vision, and ultrasound emanation. If the hemorrhage is receding with improving vision, observe on medications. Increasing pain, worsening vision, and persistent hemorrhage means one should take the patient back to the operating table after 10–14 days to drain the blood.
According to Dr. Ayyala and Dr. Hankins, most of these cases do well with improvement in the pain, eye pressure, and restoration of vision. Worse outcomes are associated with eyes that have vitreous hemorrhage, hemorrhage behind the macula, and recurrent suprachoroidal hemorrhage. In these situations, one should consult a retina surgeon, they said.

Case of a massive suprachoroidal hemorrhage

One of the worst complications Christina Weng, MD, MBA, has ever managed happened in an 86-year-old monocular female who suffered a fall 3 days after her fourth penetrating keratoplasty (PK) surgery (done by an anterior segment colleague) that developed a massive suprachoroidal hemorrhage. She had previously lost right eye vision (no light perception) from congenital syphilis, and her left eye had already undergone the following surgeries: tube shunt, cataract surgery, four PKs, and a tarsorrhaphy for exposure keratopathy. The patient had hypertension, diabetes mellitus, and coronary artery disease status post-four heart surgeries, Dr. Weng said.
She took multiple medications, including a full-dose aspirin daily. In other words, she had nearly all the risk factors for developing a suprachoroidal hemorrhage.
In general, risk factors for suprachoroidal hemorrhage include:
1. Older age
2. Multiple ocular comorbidities
3. Recent intraocular surgery
4. Hypertension or other vasculopathy
5. Blood thinner use
6. Trauma
7. High myopia
Three days after the patient’s fourth, uncomplicated PK, she suffered a fall. While she did not lose consciousness, she immediately had nausea and 10/10 eye pain in her left eye. Upon presenting to the emergency room, she was found to be systemically stable but had a decreased visual acuity of hand motion and an intraocular pressure of 85 mm Hg.
Ocular exam revealed her iris and other ocular contents expulsed through her cornea host-graft junction, a completely flat anterior chamber, and no view of the posterior segment. B-scan ultrasonography revealed a diffuse suprachoroidal hemorrhage.
This patient demonstrated many of the typical signs and symptoms of an acute suprachoroidal hemorrhage:
1. Severe pain
2. Decreased vision
3. Increased IOP
4. Nausea/vomiting or headache
5. Shallow anterior chamber/expulsion of intraocular contents
6. Loss of red reflex
7. Dome-shaped lobules of choroid and overlying retina (visualized either on exam or on B-scan ultrasonography)
In patients who present in this way with acute suprachoroidal hemorrhage, immediate surgical intervention is not typically ideal. Since this particular patient had expulsion of uveal contents, she was taken to surgery to reposit tissue, reform the anterior chamber, and secure the PK graft. Following this, she was treated according to the recommendations below.
In an acute suprachoroidal hemorrhage, management should include:
1. Control IOP (topical drops, oral acetazolamide)
2. Treat pain (systemic analgesics, topical or oral steroids, topical cycloplegics)
3. Address anticoagulation (stop blood thinners with approval from managing cardiologist/prescriber; this may not be possible)
4. Delay suprachoroidal hemorrhage surgical drainage for 7–10 days to allow for hemorrhagic liquefaction
5. Perform serial B-scan ultrasounds (will assist in determining when the clot has liquefied and can guide drainage approach by showing where the choroidals are highest)
While surgical intervention for suprachoroidal hemorrhage is not always necessary, it is for those whose pain and IOP cannot otherwise be controlled. It is critical to counsel the patient and family on the guarded prognosis of this condition regardless if surgical intervention is pursued. One week later, Dr. Weng performed a suprachoroidal drainage in this patient.
The following are a few surgical tips:
1. Know where the choroidals are highest so you know where to make your scleral incisions.
2. Use an anterior chamber maintainer to stabilize the globe and provide counterpressure against the choroidals.
3. Perform a 360-degree conjunctival peritomy.
4. Make radial scleral cut-downs in the intended quadrants approximately 8 mm posterior to the limbus (the equator is generally where the choroidals are highest); you will know you are deep enough when blood begins to egress.
5. Use gentle pressure and manipulate the wound lip to express the hemorrhage; a cyclodialysis spatula also hugs the scleral wall well to help evacuate any clots.
6. Once drainage is complete, consider leaving the sclerotomies open and close the conjunctiva over them to allow continued drainage.
Postoperatively, patients often feel significant pain relief due to the lowered intraocular pressure. A few days later, the patient’s choroidals had significantly improved, her IOP normalized, and her visual acuity returned to baseline.
However, the best way to manage a suprachoroidal hemorrhage is to prevent it from happening in the first place, Dr. Weng said.
While this condition may not be completely avoidable, here are some pearls for prevention or mitigation of suprachoroidal hemorrhage:
1. In high-risk patients, emphasize the importance of minimizing fall or trauma risk.
2. Optimize risk factors preoperatively (e.g., hypertension, anticoagulant regimen, etc.).
3. Ask high-risk patients to shield their eye full-time in the postoperative period.
4. Ask patients to minimize cough and strain postoperatively.
5. Avoid postoperative hypotony.
6. If administering retrobulbar block, hold pressure on the globe for a few seconds before proceeding with surgery.
7. A suprachoroidal hemorrhage can also develop intraoperatively (e.g., during cataract surgery) and may present with a shallowing anterior chamber, firming of the eye, wrinkling of the posterior capsule, loss of red reflex, or abnormal fluidics; early recognition is key and if any of these occur, immediately withdraw your instruments and suture all wounds.

At a glance

• Risk factors for suprachoroidal hemorrhage include older age, multiple ocular comorbidities, recent intraocular surgery,
hypertension or other vasculopathy, blood thinner use, trauma, and high myopia.
• Some typical signs of suprachoroidal hemorrhage include severe pain, decreased vision, increased IOP, nausea/vomiting or headache, shallow anterior chamber/expulsion of intraocular contents, loss of red reflex, or dome-shaped lobules of choroid and overlying retina.
• Many cases of suprachoroidal hemorrhage do well, but poor outcomes may be associated with eyes that have vitreous hemorrhage, hemorrhage behind the macula, and recurrent suprachoroidal hemorrhage.

About the doctors

Ramesh Ayyala, MD, FRCS
James P. and Heather Gills Chair in Ophthalmology
University of South Florida
Eye Institute
Tampa, Florida

Uday Devgan, MD
Chief of Ophthalmology
Olive View UCLA Medical Center
Los Angeles, California

Mark Hankins, MD
Glaucoma Fellow
University of South Florida
Eye Institute
Tampa, Florida

Christina Weng, MD, MBA
Associate Professor of Ophthalmology
Baylor College of Medicine
Houston, Texas

Relevant disclosures

Ayyala: None
Devgan: CataractCoach.com
Hankins: None
Weng: None

Contact

Ayyala: rayyala@usf.edu
Devgan: devgan@gmail.com
Hankins: mhankins@usf.edu
Weng: Christina.Weng@bcm.edu

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