EyeWorld Asia-Pacific December 2020 Issue

SECONDARY FEATURE 28 EWAP DECEMBER 2020 A large incision can be a risk factor for this complication. In this case, the red reflex quickly disappeared and the hemorrhage continued without the surgeon knowing. Source: Uday Devgan, MD Although suprachoroidal hemorrhage is rare, it can be a potentially devastating complication. Source: Ramesh Ayyala, MD, and Mark Hankins, MD 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, 4mm posterior to the limbus, a 4mm 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 mmHg. 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,