Eyeworld

I OCTOBER 2020 | EYEWORLD | 55 subsides, the eye softens, and the red reflex is normal, consider vitreous hydration as a possi- ble cause. If the pain continues, the 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 hemor- rhage. 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, 4 mm posterior to the limbus, a 4-mm 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 recur- rent bleeding during the procedure. Leave the sclerotomy open and close the conjunctiva. Step 5: Control the eye pressure (with acetazol- amide), decrease the inflammation (with topical and oral prednisone), dilate and paralyze the ciliary muscle and dilate the pupil, and adminis- ter pain medications. These patients should be followed on day 1, 7, and 14, being examined for eye pres- sure, vision, and ultrasound emanation. If the hemorrhage is receding with improving vision, observe on medications. Increasing pain, wors- ening vision, and persistent hemorrhage means one should take the patient back to the operat- ing 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 continued on page 56 Though suprachoroidal hemorrhage is rare, it can be a potentially devastating complication. Source: Ramesh Ayyala, MD, and Mark Hankins, MD Dr. Devgan noted that a large incision can be a risk factor for this complication. Here, the red reflex quickly disappeared, and the hemorrhage continued without the surgeon knowing. Source: Uday Devgan, MD

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