Moran CORE

Suprachoroidal Hemorrhage as a Complication of Routine Cataract Surgery

Title: Suprachoroidal Hemorrhage as a Complication of Routine Cataract Surgery

Authors: Chris Wallace-Carrete, BS; Paul Israelsen, MD; Iqbal Ike K. Ahmed, MD; Jeff Pettey, MD

Date: 7/11/2024

Keywords/Main Subjects: Suprachoroidal hemorrhage (SCH), phacoemulsification, expulsive hemorrhage, cataract, cataract surgery, surgical complications

Diagnosis: Suprachoroidal Hemorrhage

Description of Case: An 85-year-old male with a history of age-related cataract in both eyes presented for cataract surgery in the right eye (OD). The patient had a history of cutaneous melanoma and basal cell carcinoma but was otherwise healthy. He was not taking any medications and had no known drug allergies. His baseline eye examination OD was notable for visual acuity (VA) of 20/70 with correction, intraocular pressure (IOP) of 8 mmHg, 2-3+ nuclear sclerotic cataract, and a manifest refraction with spherical equivalent of -3.75 diopters. Fundus examination OD demonstrated a cupless disc as well as an engorged vortex vein with pigmentary changes in the periphery. Preoperative examination demonstrated normal vital signs except for an elevated blood pressure at 152/81. On biometry OD, his axial length was 24.21 mm.

The patient was scheduled for routine cataract extraction with IOL insertion OD. The surgery progressed in the expected manner until the epinuclear removal stage when it was noted that subtle folds were developing in the posterior capsule (1. Epinuclear Removal_MORAN_07112024). The operating surgeon recognized that the posterior capsular folds were likely indicative of increased posterior pressure; therefore, viscoelastic was used to deepen the anterior chamber (2. Viscoelastic Insertion_MORAN_07112024). As viscoelastic was being injected into the anterior chamber, there was a large egress of viscoelastic back out through the primary wound, as well as mild iris prolapse. The eye was noted to be firm despite minimal viscoelastic remaining in the anterior chamber. The red reflex remained unchanged. When asked, the patient endorsed an aching pain in the right eye that began at roughly the same time that the posterior capsular folds appeared. His blood pressure was noted to be elevated at 153/62. The operating surgeon made the decision at this point to stop the surgery due to concern for suprachoroidal hemorrhage. The surgical wounds were quickly sealed by hydration (3. Wound Hydration_MORAN_07112024) and the remaining viscoelastic was removed from the eye (4. Viscoelastic Removal_MORAN_07112024). A fundus examination was performed with indirect ophthalmoscopy while the patient was still on the operating table, and a suprachoroidal hemorrhage in the temporal periphery was confirmed. The surgery was concluded, and the patient was left aphakic. The patient was then transferred to the post-anesthesia care unit.

During a same-day post-operative examination of the right eye, the patient was noted to have a VA of count fingers at four feet. His IOP was elevated at 41 mmHg and a dilated fundus examination (DFE) demonstrated a stable temporal choroidal hemorrhage. The patient was prescribed oral Diamox (acetazolamide) along with prednisolone and moxifloxacin eyedrops and was given instructions to return the following day for a repeat examination. On post-operative day (POD) 1, the patient’s VA was unchanged; however, his pressure had returned to his baseline of 8 mmHg. The suprachoroidal hemorrhage remained unchanged on DFE. Diamox was discontinued, and the patient was scheduled for follow-up in one week. On POD 4, the patient’s eye exam remained unchanged from POD 1. He received a B-scan ultrasound which confirmed a focal choroidal hemorrhage temporally OD. The patient’s SCH was monitored over a period of several weeks with plans for IOL insertion upon resolution of the hemorrhage.

A suprachoroidal hemorrhage (SCH) is a rare complication of intraocular surgery that develops when blood accumulates in the potential space that exists between the sclera and choroid. Intraoperative SCH is not a common occurrence of cataract surgery. There is an incidence of 0.03 – 0.13%, which has decreased over the last 25 years with the introduction of less invasive phacoemulsification techniques.¹ Risk factors for the development of an intraoperative SCH include advanced age, uncontrolled hypertension, prolonged intraocular hypotony, increased surgical time, high myopia, nanophthalmos, and a history of SCH.^2,3 Although the pathophysiology of SCH is not completely understood, it is hypothesized that low intraocular pressure during ocular surgery leads to an environment where the long and short posterior ciliary arteries and veins stretch and can eventually rupture, leading to rapid accumulation of blood in the suprachoroidal space.⁴ Major signs and symptoms of intraoperative SCH include shallowing of the anterior chamber, bulging of the posterior capsule, loss of the red reflex (5. SCH with Loss of Red Reflex_AHMED), sudden onset of ocular pain and/or headache, and expulsion of intraocular contents (6. Expulsive Hemorrhage_ISRAELSEN).^2,4 Prompt intervention at the onset of SCH is vital to prevent progression and preserve vision. As soon as a SCH is suspected, the surgeon should immediately pressurize the eye to tamponade the ensuing hemorrhage.^4,5 This is typically accomplished through prompt closure of all surgical wounds with either hydration or sutures. Additional perioperative management includes addressing systemic blood pressure with pharmacologic intervention as well as controlling IOP, allowing for normotonic or slightly hypertonic pressures.^4,6

Management in the postoperative period includes a combination of pharmacotherapy and close monitoring with B-scan ultrasound and dilated fundus examination.^4,7 A SCH is confirmed on B-Scan if there is hyperechoic material within a choroidal detachment. Often, a SCH will resolve over time with observation. Surgical management may be indicated in cases where the SCH is particularly severe (i.e. kissing choroidals), when the hemorrhage continues to progress despite initial management, the IOP remains uncontrollably elevated, or if the patient experiences intractable pain.⁸ Surgery to drain a choroidal hemorrhage is typically performed 7-14 days after the initial occurrence to allow for liquefaction of blood in the suprachoroidal space. Surgery is performed by creating a full thickness sclerotomy in the area of the greatest accumulation of suprachoroidal blood to allow for drainage. This is often followed by pars plana vitrectomy.

Prophylactic measures to mitigate the risk of SCH are focused on managing patient risk factors such as uncontrolled hypertension, atherosclerosis, and the use of anticoagulant or antiplatelet medications.⁴ The outcome of SCH varies depending on the severity of the hemorrhage and promptness of intervention.⁹ In some cases, such as phacoemulsification-related SCH, the visual prognosis is often excellent.¹⁰ Severe SCH often portends a poor prognosis with irreversible vision loss.¹¹

To help minimize the risk of vision loss from SCH, all ophthalmic surgeons should attempt to mitigate any significant preoperative risk factors, be able to recognize signs of intraoperative SCH, and react promptly when a SCH is suspected to prevent progression.

Images or video:

• Epinuclear Removal: (1. Epinuclear Removal_MORAN_07112024)
  • Cortical cleaving hydrodissection is used to remove the remaining portions of the lens cortex. At the end of phacoemulsification, subtle folds begin to develop in the posterior capsule with concurrent capsule bulging, indicating increased posterior segment pressure.

     

• Viscoelastic Insertion: (2. Viscoelastic Insertion_MORAN_07112024)
  • Viscoelastic is inserted into the lens capsule via cannula to deepen the anterior chamber. As viscoelastic is inserted into the eye, there is a large egress of viscoelastic back through the primary wound, further indicating increased posterior segment pressure. There is also a subtle iris prolapse toward the primary wound. The cannula is removed from the eye and used to check eye firmness. The eye is noted to be very firm and IOP is elevated at 40 mmHg. Due to the positive pressure in the eye and inadequate space to place the intraocular lens, no lens was inserted into the eye, and the decision was made to end the surgery.

     

• Wound Hydration: (3. Wound Hydration_MORAN_07112024)
  • Pressurization of the eye is reestablished as the two surgical wounds are promptly closed via hydration.

     

• Viscoelastic Removal: (4. Viscoelastic Removal_MORAN_07112024)
  • To prevent post-operative IOP spikes, the I/A handpiece was used to extract the viscoelastic. The corneal wounds were again sealed and subsequently checked with a weck-cel and were found to be watertight.

     

• Example of Intraoperative Suprachoroidal Hemorrhage during Phacoemulsification (5. SCH with Loss of Red Reflex_AHMED)
  • Complicated cataract surgery demonstrating a suprachoroidal hemorrhage. A classic yet not always present sign of SCH is loss of the red reflex, which can be seen during this procedure as the ensuing hemorrhage extends toward the equator. (Video courtesy of Iqbal Ike K. Ahmed M.D.)

    
     

• Example of Expulsive Hemorrhage (6. Expulsive Hemorrhage_ISRAELSEN)
  • A severe outcome of a suprachoroidal hemorrhage is expulsion of intraocular contents through the surgical wounds. An example of an expulsive hemorrhage can be seen during this complex corneal transplant. (Video courtesy of Paul Israelsen, M.D.)

     

Summary of the Case: An 85-year-old male with a history of age-related cataract in both eyes underwent routine cataract surgery in the right eye. He developed a suprachoroidal hemorrhage (SCH) during the intraoperative period shortly after the cataract was removed. Initial signs of the SCH included posterior capsule bulging, anterior chamber shallowing, mild iris prolapse, and right-sided ocular pain. Recognition of these signs and prompt closure of the surgical wounds prevented further progression of the SCH, which was confirmed with fundus examination before the patient left the operating room. B-scan ultrasound in the postoperative period allowed for characterization and monitoring of the hemorrhage. The patient’s risk factors included advanced age and elevated intraoperative blood pressure.

Suprachoroidal hemorrhage is a rare complication of intraocular surgery. Prompt recognition of the intraoperative signs of SCH and immediate intervention whenever a SCH is suspected are necessary to prevent irreversible vision loss. Key intraoperative signs of SCH include anterior chamber shallowing, loss of the red reflex, posterior capsule bulging, patient discomfort, and expulsion of intraocular contents. Immediate management of a SCH typically consists of pressurization of the eye by closure of all surgical wounds. B-scan ultrasound is important for diagnosis and monitoring in the postoperative period. In some instances, surgical management through drainage of suprachoroidal blood may be indicated. Prognosis varies based on the severity of the hemorrhage and the promptness of intervention.

Format: Video

References:

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Faculty Approval by: Dr. Jeff Pettey

Copyright statement: Chris Wallace-Carrete, Paul Israelsen, Iqbal Ike K. Ahmed, Jeff Pettey, ©2024. For further information regarding the rights to this collection, please visit: http://morancore.utah.edu/terms-of-use/