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Woman experiences sudden onset of eye pain after coughing
The patient had previously undergone scleral buckle and pars plana vitrectomy to repair retinal detachment.
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John W. Kitchens
Ajay Singh
Patients with a history of intraocular surgery often report eye-related symptoms after surgery associated with coughing, straining, vomiting and other Valsalva-related events. In the early postoperative period, suspicion for a variety of complications is particularly high. Months or years after successful surgery, the possible occurrence of complications from forceful coughing may still result in complications similar to those experienced in the early postoperative period. The physician’s acceptance that rare postoperative complications can develop remotely in some patients is critical to the recognition and treatment of these events.
The case
A 58-year-old woman was referred to our clinic with a macula-off rhegmatogenous retinal detachment. On examination, she had age-appropriate cataracts, mild vitreous hemorrhage, vitreous debris and two large horseshoe tears in the affected eye. The detachment was bullous superiorly and involved the macula. She also had features consistent with progressive high myopia. Her visual acuity was 20/150, fixing eccentrically.
She underwent a scleral buckle and pars plana vitrectomy the next day.
The postoperative day 1 examination showed a completely attached retina with both breaks well supported on the buckle and a 90% gas fill. The patient also had adequate laser on the buckle. Over the next 2 months, she convalesced uneventfully.
The patient was seen 3 months after surgery with complaints of pain and loss of vision in the operated eye that developed immediately after a coughing “fit.” The precipitating event occurred a day before her visit. On examination, her retina was attached in all quadrants. She had developed 360° of hemorrhagic choroidal detachments (Figure 1). We started oral prednisolone and topical atropine. She was evaluated 2 weeks later, and the hemorrhagic choroidals had begun to regress (Figure 2). At this point, we tapered her oral steroids.
On the next clinic visit 6 weeks later, the hemorrhagic choroidals had almost completely regressed (Figure 3). The patient’s final best corrected visual acuity was 20/80+.
Figure 1. Dark areas of spontaneous choroidal hemorrhage extend posterior to the buckle up to the superior and inferior temporal arcades.
Images: Kitchens JW, Singh A
Figure 2. Resolution of some parts of the spontaneous choroidal hemorrhage is seen when compared with Figure 1.
Figure 3. Complete resolution of blood from the suprachoroidal space is seen when compared with Figure 1.
The diagnosis
The patient was diagnosed with a choroidal hemorrhage associated with coughing.
Spontaneous choroidal hemorrhage is a rare event that is often associated with risk factors such as advanced age, anticoagulation, hypertension or age-related macular degeneration. Surgery is also associated with choroidal hemorrhage. Spontaneous choroidal hemorrhage often occurs either intraoperatively or in the immediate postoperative period. Intraoperative spontaneous choroidal hemorrhage has been reported with every form of intraocular surgery, including retinal surgery. The “closed” environment of vitreoretinal surgery may limit the expansion of the hemorrhage and decrease the risk of developing massive, expulsive bleeding.
Coughing has been implicated in the development of spontaneous choroidal hemorrhage in the immediate postoperative period. The mechanism is felt to be an increase in episcleral venous pressure, resulting in a rupture of the wall of the ciliary vessels.
In our patient, the development of a limited suprachoroidal hemorrhage was associated with three risk factors: her coughing episode, her myopia and her prior surgery. Her presentation was unique due to the fact that she developed a hemorrhage months after successful surgical repair of her retinal detachment.