Eyeworld

I OCTOBER 2020 | EYEWORLD | 57 Contact Ayyala: rayyala@usf.edu Devgan: devgan@gmail.com Hankins: mhankins@usf.edu Weng: Christina.Weng@bcm.edu 2. Use an anterior chamber maintainer to sta- bilize 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 cyclo- dialysis 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 conjunc- tiva over them to allow continued drainage. Postoperatively, patients often feel signifi- cant pain relief due to the lowered intraocular pressure. A few days later, the patient's choroid- als had significantly improved, her IOP normal- ized, and her visual acuity returned to baseline. However, the best way to manage a su- prachoroidal 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 impor- tance 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 pres- sure 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, wrin- kling of the posterior capsule, loss of red reflex, or abnormal fluidics; early recognition is key and if any of these occur, immediate- ly withdraw your instruments and suture all wounds. This patient demonstrated many of the typ- ical signs and symptoms of an acute supracho- roidal hemorrhage: 1. Severe pain 2. Decreased vision 3. Increased IOP 4. Nausea/vomiting or headache 5. Shallow anterior chamber/expulsion of intra- ocular contents 6. Loss of red reflex 7. Dome-shaped lobules of choroid and over- lying 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 acetazol- amide) 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 hemor- rhagic 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 supracho- roidal 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 inci- sions. 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

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