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Mainstay of treatment for suprachoroidal hemorrhage is prevention, surgeon says
Once the events leading to a choroidal effusion begin, early recognition of this condition is of extreme importance to prevent further damage.
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MEXICO CITY — The best way to manage suprachoroidal hemorrhage is to prevent it, according to José Dalma, MD, in practice here.
“The mainstay of treatment of this condition is still its prevention,” Dr. Dalma said.
“Suprachoroidal hemorrhage involves a continuum that begins with the accumulation of fluid in the suprachoroidal space, known as an effusion, to the sudden and severe arterial bleeding, which results in the much feared transoperative expulsive hemorrhages,” Dr. Dalma said.
Dr. Dalma said suprachoroidal hemorrhage occurs in open globe surgery or trauma, or some days after these events. He also mentioned that post-traumatic incidence may be higher than postoperative incidence, which is reported to occur in between 0.03% and 1.8% of patients, depending on the type of surgery and hemorrhage.
Decreased IOP
A decreased intraocular pressure (IOP) unbalances the transmural perfusion pressure of the choroid, favoring the entrance of fluid into the suprachoroidal space. In some cases this fluid accumulates to the point of stretching and breaking the anterior and long posterior ciliary arteries, causing a fast accumulation of blood into this space. Hence, any entity responsible for weakness of these vessels predisposes the eye to this condition. Dr. Dalma stressed that “recognition of these factors and their proper management and control is the first and most important step in prevention.”
Early recognition important
Once the events leading to a choroidal effusion begin, the early recognition of this condition is of extreme importance to prevent further damage. During surgery, the sudden hardening of the globe with forward displacement of the iris, IOL, lens or vitreous, along with loss of red reflex, is the first sign of problems occurring in the posterior segment. Constant iris prolapse of the wound, changes in pupillary shape and the inability to maintain a formed anterior chamber also may be a warning of imminent danger. Once bleeding occurs, events evolve so quickly that it may be difficult for the surgeon to keep up with the changes, leading to unavoidable loss of intraocular contents.
Management controversial
Management of an acute suprachoroidal hemorrhage is controversial. The most important step is prompt, watertight closure of the globe.
According to Dr. Dalma, the procedure is to be done quickly, “with a strong suture and with little regard for the replacement of vitreous or iris into the eye.
“The vitreous should not be handled at the risk of delaying closure, exerting retinal traction and relieving its possible tamponading effect,” Dr. Dalma continued. “Once the wound is closed, the anterior chamber may be repressurized and reformed, and the iris and vitreous dealt with. This should be accompanied by the administration of systemic hyperosmotic agents, corticosteroids, sedation and the control of systemic hypertension and tachycardia.”
Immediate choroidal drainage incision
Regarding the immediate choroidal drainage incision, Dr. Dalma said, “I believe the immediate choroidal drainage incision is seldom to be of benefit for two reasons. The first is that choroidal blood clots rapidly, so drainage is seldom accomplished. And the second is that drainage of intraocular fluid may further drop IOP, reactivating the bleeding,” Dr. Dalma said.
According to Dr. Dalma, delayed choroidal hemorrhage usually occurs in a hypotonous eye, after Valsalva maneuvers or trauma leading to wound dehiscence. A sudden, deep pain is usually felt, associated with severe visual loss, a hard eye and a shallow anterior chamber.
Dr. Dalma stated that “they are usually self-limited and easily managed by IOP and inflammation control, cycloplegia and pain medication.” Secondary surgery may be indicated in some cases of either acute or delayed hemorrhage, but each case has to be evaluated independently. He stressed that “vision of no light perception is not an indication to withhold surgery.”
According to Dr. Dalma, repair usually entails reformation of the anterior chamber and drainage of the suprachoroidal hemorrhage along with infusion of balanced salt solution, air or perfluorocarbon liquids through the limbus. Although the technique often does not eliminate all of the suprachoroidal blood, it gives enough space to place a pars plana infusion line to perform a vitrectomy to re-establish normal posterior segment anatomy. Silicone oil tamponade is often required to maintain a retinal attachment. The timing of the procedure is best determined by an echographic evidence of clot lysis and is usually within 14 days of the original event.
Prognosis
“Prognosis is still far from adequate in acute hemorrhages and varies widely in delayed hemorrhages depending on extent, severity and duration,” Dr. Dalma said. “Several series have described approximately a 25% incidence of no light perception, while 30% maintain a visual acuity of 20/200 or better, or at least their pre-hemorrhage visual acuity.
“Surgical choroidal drainage should probably be considered on an individual basis according to a patient’s general anatomic and functional status,” he continued. “Well-defined surgical criteria are still needed. But the mainstay of treatment of this condition is still its prevention.”
For Your Information:
- José Dalma, MD, can be reached at Av Palmas 745-1202, Mexico City, 11050, Mexico; +(52) 5-540-3428; e-mail: jdalma@data.net.mx. Dr. Dalma has no direct financial interest in any of the products mentioned in this article, nor is he a paid consultant for any companies mentioned.