Eyeworld

I MY WORST COMPLICATION N FOCUS 54 | EYEWORLD | OCTOBER 2020 by Ellen Stodola Editorial Co-Director S uprachoroidal 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 choroi- dal hemorrhage can be a potentially devastating complication, though he noted that he has not experienced it personally in 20 years of practic- ing. He shared a video from his teaching web- site, 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 hypoto- ny, 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 ante- rior 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 clos- ing 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 complica- tion one can experience during a surgical proce- dure, 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, com- pleting 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 suprachoroi- dal hemorrhage in the same eye or the other eye is also a risk factor. Symptoms: Pain breaking through an- esthesia 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 be- comes 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 pres- surize 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 hypere- choic 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 Managing suprachoroidal hemorrhage At a glance • Risk factors for suprachoroidal hemorrhage include older age, multiple ocular comorbidities, recent intraocular surgery, hypertension or other vas- culopathy, 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 overly- ing retina. • Many cases of suprachoroidal hemorrhage do well, but poor outcomes may be associated with eyes that have vitreous hemorrhage, hemorrhage be- hind the macula, and recurrent suprachoroidal hemorrhage.

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