EyeWorld India December 2020 Issue

EWAP DECEMBER 2020 29 SECONDARY FEATURE 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. EWAP Editors’ note: Dr. Ayyala is the James P. and Heather Gills Chair in Ophthalmology, University of South Florida Eye Institute, Tampa, Florida, and declared no conflicting interests. Dr. Devgan is Chief of Ophthalmology, Olive View UCLA Medical Center, Los Angeles, California, and declared interests with CataractCoach.com. Dr. Hankins is a Glaucoma Fellow, University of South Florida Eye Institute, Tampa, Florida, and declared no conflicting interests. Dr. Weng is Associate Professor of Ophthalmology, Baylor College of Medicine, Houston, Texas, and declared no conflicting interests. 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