18
QUESTION
HOW DO I MANAGE A SUPRACHOROIDAL HEMORRHAGE?
Odette Margit Houghton, MD
Nicholas Farber, MD
A suprachoroidal hemorrhage (SCH) is a potentially devastating complication of intraocular surgery caused by rupture of the posterior ciliary arteries. Though commonly associated with anterior segment surgery, it can occur with any intraocular procedure. SCHs are typically stratified as acute, with occurrence during the procedure, or as a postoperative complication. Risk factors thought to be associated with SCH include advanced age, previous pars plana vitrectomy, history of elevated intraocular pressure (IOP) and/or glaucoma, increased axial length, and atherosclerosis.1
The key to preserving an eye with an acute intraoperative SCH is early recognition and prompt action prior to the expulsion of intraocular contents. Acknowledge and prepare yourself for the possibility prior to every intraocular surgical procedure and craft a management strategy in advance in order to have all of the necessary tools immediately available.
Early signs of a SCH include eye pain; increased posterior pressure; loss of the red reflex; enlargement of the pupil; shallowing of the anterior chamber with forward displacement of the iris, lens, or lens implant; and vitreous prolapse. If a SCH is suspected, all surgical wounds should be closed immediately. The purpose is to elevate the IOP sufficiently to tamponade the suprachoroidal bleeding. Ideally, close the wound with 8-0 sutures. If there is no time to place sutures, approximate the wound edges with digital pressure or toothed forceps. Wound closure is much faster with preplaced sutures and well-constructed incisions. If you have a penetrating keratoplasty incision, close the globe with a temporary keratoprosthesis.
The risk of vitreous incarceration may be reduced with maintenance or reformation of the anterior chamber with saline or air, but a highly cohesive viscoelastic substance is usually required. Tissue incarceration is usually best managed during a secondary procedure. However, if you are convinced the hemorrhage is limited and there is no further bleeding, then reopening, cleaning, and closing small sections of the wound in sequence may be considered, but is not generally recommended.2
Figure 18-1. B-scan ultrasound showing choroidal detachment with hyperechogenic suprachoroidal material, indicating likely hemorrhage.
If extrusion of intraocular contents limits the ability to close all wounds, external drainage via sclerotomies may be necessary to reposition the tissue; however, primary drainage is hazardous and should be avoided if possible. Acute drainage could reverse the tamponade effect of the secondarily elevated IOP and result in additional suprachoroidal bleeding. Conversely, drainage may be unsuccessful due to the extremely fast clotting of a SCH, usually before an emergency sclerotomy can even be performed. Following external drainage, if performed, the sclerotomies should be sutured closed, and the anterior chamber should be reformed, if possible.
Most limited intraoperative and delayed postoperative choroidal hemorrhages resolve with observation within weeks to a few months. They should be followed with serial echography to monitor for apposition and liquefaction (Figure 18-1). Appositional, or kissing, hemorrhagic choroidals are thought to have a worse prognosis. A case-control study from the Cleveland Clinic showed no difference in outcomes with observation vs surgery in this appositional group.1 During the postoperative period, topical and oral prednisone (1 mg/kg/day) is recommended to control inflammation and reduce the likelihood of intraocular tissue adhesion. Elevated IOP requires aggressive topical, and sometimes oral, therapy. Eye pain due to stretching of the posterior ciliary nerves can be managed with topical cycloplegia and oral analgesia.
With nonappositional detachments, not all patients benefit from a secondary procedure. Indications for surgical management and choroidal drainage include development of central retinal apposition that does not resolve within 1 to 2 weeks, shallow/flat anterior chamber with secondary IOP elevation, hypotony, persistent flat anterior chamber, or intractable eye pain. First address any causes of hypotony, such as wound leak, shallow retinal detachment, or ciliary body detachment. Drainage may need to be combined with a vitrectomy if there is rhegmatogenous or tractional retinal detachment, incarceration of intraocular tissues, retained lens material, vitreous hemorrhage, or extensive subretinal hemorrhage.
An SCH is easier to drain after 10 to 14 days because the clotted blood has a greater chance of being liquefied. Recombinant tissue plasminogen activatior injected into the suprachoroidal space has been used to enhance liquefaction prior to surgery.3 Echographic characteristics of liquefaction include reduced reflectivity on A-scan and a more echolucent pattern on B-scan.4 Many surgeons believe that the optimal drainage location is the highest point of choroidal elevation, as determined by echography or ophthalmoscopy. Good exposure of the drainage site can usually be achieved with a conjunctival peritomy, followed by isolation of a rectus muscle with a silk tie or placement of a scleral traction suture. Drainage sclerotomies should be radial and created with a cut-down incision, at least 6 mm posterior to the limbus (Figure 18-2). Alternatively, an anterior sclerotomy created in a similar fashion as for pars plana vitreous surgery may be used. More than one sclerotomy may be required in opposite quadrants. Drainage can be promoted by manipulating the sclerotomy with forceps, cotton-tip applicators, or a cyclodialysis spatula within the wound. Alternatively, 6-0 traction sutures can be placed on the wound edge. Active aspiration under direct visualization using a guarded 26-gauge needle attached to the extrusion line from the vitrectomy console has also been described.5
Figure 18-2. Intraoperative photo during drainage of a suprachoroidal hemorrhage. A 6-0 silk traction suture is utilized for exposure and an anterior chamber infusion maintains consistent IOP. A radial cutdown is being performed, making sure to be at least 6 mm posterior to the limbus.
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