Reminder of important clinical lesson
CASE REPORT
Visual restoration after suprachoroidal haemorrhage in glaucoma surgery Aparna Rao Department of Glaucoma, LV Prasad Eye Institute, Bhubaneswar, Orissa, India Correspondence to Dr Aparna Rao, [email protected] Accepted 16 January 2014
SUMMARY Suprachoroidal haemorrhage is the most dreaded complication feared by any surgeon during glaucoma surgery. Rapid explosive expulsion of intraocular contents can occur, which makes vision loss almost inevitable in most cases. Yet, adequate preparedness, prompt recognition of the earliest signs and quick closure of the wound can salvage the eye or even prevent loss of vision. This case highlights the successful visual rehabilitation and outcome in a patient with advanced glaucoma who experienced delayed expulsive haemorrhage intraoperatively.
BACKGROUND Suprachoroidal haemorrhage can complicate glaucoma surgery at any step. This may be associated with expulsion of vital organs like the retina and the choroid, if not recognised and treated promptly.1 2 Visual restoration is rare due to the cascade of events necessitating evisceration on the table.1–3 Therefore, promptness is key for salvaging the eye and preventing extensive bleeding or expulsion of ocular contents. This case highlights the favourable outcome of prompt recognition and treatment of the complication during glaucoma surgery which helped restore functional vision.
CASE PRESENTATION A 53-year-old woman, previously diagnosed with chronic angle closure glaucoma of both eyes (status of post-trabeculectomy and cataract surgery in the right eye and laser peripheral iridotomy in the left eye) elsewhere and on treatment for 12 years, presented to us with gradual decrease in vision in the left eye over 1 year. Her best corrected visual acuity was 20/200 (no improvement with pinhole) in the left eye and no perception of light in the right eye. Goldmann applanation intraocular pressure (IOP) was 32 and 45 mm Hg in the right and left eyes on a topical fixed combination of brimonidine and timolol along with topical dorzolamide and systemic acetazolamide inhibitors while gonsicopy showed closed angles in all four quadrants in both eyes. Slit lamp evaluation showed cataractous changes with advanced optic nerve damage in the left eye and total glaucomatous cupping in the right eye, which was pseudophakic. To cite: Rao A. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013203150
INVESTIGATIONS Humphrey visual field in the right eye showed advanced biarcuate scotoma sparing the central island with no macular split (figure 1). She was initiated on systemic glycerol along with
Rao A. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203150
continuation of previous antiglaucoma treatment, and the possibility of combined surgery for the left eye under guarded prognosis was explained for IOP control.
DIFFERENTIAL DIAGNOSIS With closed angles on gonioscopy and high IOP on maximum medical treatment, she was diagnosed as uncontrolled advanced primary angle closure glaucoma with cataract.
TREATMENT She was reviewed 2 weeks later with an IOP of 28 mm Hg on the above treatment and was therefore taken up for phacoemulsification with intraocular lens (IOL) implantation with trabeculectomy with the possible risks explained to her. Preoperatively, she was given intravenous mannitol (1 g/kg body weight) and adequate digital massage to make the eye soft. Intraoperatively, the lens was delivered by phacoemulsification with IOL placement in the bag through a superficial scleral flap. The creation of the ostium (1×1 mm) was made with a vannas scissors at the same site, which was followed by closure of the flap with 10-0 nylon. At this step, there was a sudden loss of vitreous with an abrupt shallowing of the chamber and IOL-corneal touch (video 1). The 10-0 nylon suture was therefore sutured tightly and additional sutures were immediately placed, followed by hardening of the globe, which mandated intraoperative mannitol. The conjunctiva was sutured with 8-0 vicryl interrupted sutures with no evidence of bleeding or further escape of vitreous. A consultation was sought with a retina specialist, who advised no active intervention.
OUTCOME AND FOLLOW-UP Immediate postoperative examination revealed a shallow anterior chamber with mixed blood and vitreous seen peaking towards the superior ostium, which was evident as a tense bulge (figure 2A, arrow). Ultrasound, USG (B), confirmed suprachoroidal haemorrhage, (figure 2B). Her vision was perception of light in all four quadrants with an IOP of 26 mm Hg. Retina consultation was again sought and she was managed conservatively with systemic steroids and topical intensive steroids and cycloplegics. She was closely followed up weekly for 3 weeks and thereafter monthly for 3 months with gradual tapering of systemic and topical steroids. There was a gradual reduction in the anterior chamber inflammation with central deepening, though there was persistence of the pupillary membrane obscuring the 1
Reminder of important clinical lesson
Figure 1 Humphrey visual filed of the left eye showing biarcuate field defect with macular sparing. fundus view (figure 3A, arrow in inset). Repeat USG showed an attached retina with complete resolution of the suprachoroidal hematoma. She was therefore taken up for removal of the pupillary membrane and adherent iris using an automated vitrector with intraoperative chamber maintenance with an anterior chamber maintainer. Postoperatively, she regained a vision of 20/ 60 after refractive correction with a clear visual axis and deep central anterior chamber (figure 3B). She was seen by low vision services to help her in her daily professional work of teaching at school. At 2-year follow-up, her IOP remained controlled at 16 mm Hg on topical antiglaucoma drugs with stable visual fields. 2
DISCUSSION Suprachoroidal hemorrhage is a dreaded complication that can occur during glaucoma surgeries. It is termed the bête noire of ophthalmic surgeries and is more likely in eyes with a history of chronic glaucoma, hypertension, atherosclerosis, choroidal sclerosis or history of previous episode in other eye.2–4 This complication is feared most for the extensive bleeding in the suprachoroidal space with choroidal expansion causing a sudden and rapid expansion of the ocular contents.5–7 This causes loss of vision and even evisceration in some cases with restoration of vision being almost rare. Rao A. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203150
Reminder of important clinical lesson
Video 1 Intraoperative video showing sudden vitreous loss after ostium creation.
and sudden exposure to atmospheric pressure. A closedchamber system using the stay sutures or phacoemulsification also prevents rapid decompression. Despite all these measures in our case, we did encounter delayed haemorrhage during the last step of wound closure. Suprachoroidal haemorrhage can occur at any step of the surgery.6 In our case, it happened after creation of the ostium and closure of the wound. This may have been due to lowering of the IOP by trabeculectomy ostium in an eye with chronic glaucoma with persistently high IOP for many months. Closure of the wound therefore was easy and quick in our case, which helped prevent cascading of vision-threatening conditions. Close follow-up and adequate treatment by removal of the pupillary membrane with a vitrectomy cutter (ensuring a closed chamber during surgery rather than anterior approach through the limbus or cornea) helped restore functional vision to our patient who was a teacher by profession. Despite the advanced glaucomatous optic nerve head and visual field damage and intraoperative suprachoroidal haemorrhage, she resumed her normal
Learning points
Figure 2 (A) First postoperative day after intraoperative suprachoroidal haemorrhage clinical photograph showing shallow chamber and tense bulge (arrow) superiorly which was confirmed on ultrasound (B) scan of the posterior segment.
Creation of preparatory sclerotomies for suprachoroidal drainage in high-risk cases (such as nanophthalmos, chronic glaucoma) has been advocated to drain the suprachoroidal bleed and avoid expulsion of intraocular contents.8–10 Yet, despite all measures, these events can happen rapidly, making any attempt to preserve the eye futile in most cases. This complication can be prevented by adequate IOP lowering preoperatively by intravenous osmotic diuretics and by digital ocular massage.4 5 Slow decompression prevents rapid collapse of the anterior chamber
▸ Suprachoroidal hemorrhage is a dreaded complication that can occur in eyes with chronic glaucoma. ▸ Since this can occur at any stage of surgery, adequate preparedness (in eyes with previous history, chronic glaucoma, hypertension, similar history in other eye) and prompt recognition of its signs during surgery may help in salvaging the eye or even preserving some useful vision. ▸ Adequate lowering of intraocular pressure preoperatively and slow decompression may be helpful in preventing this complication during the early steps of surgery. ▸ Quick and tight closure of the eye on recognition of the earliest signs of this complication (such as sudden collapse of anterior chamber, sudden loss of vitreous or spontaneous expulsion of the lens) may help in avoiding extensive bleeding on the table or expulsion of vital ocular organs including retina and choroid. ▸ Good visual outcomes are possible after delayed suprachoroidal haemorrhage if recognised early. Low vision also plays an important role in restoring functional vision in such cases.
Figure 3 Inset shows clinical photograph on follow-up showing persistent membrane in the pupillary area (arrow). (A) Clinical photograph after removal of the pupillary membrane and adherent iris by automated cutter clearing the visual axis which was maintained at 2 years of follow-up, (B). Rao A. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203150
3
Reminder of important clinical lesson daily life with the help of low-vision aids. This was possible due to prompt recognition of sudden vitreous loss which mandated immediate closure of the wound albeit at the cost of a successful glaucoma surgery. Yet, her IOP is well controlled on topical medications which maintain quality of life without field deterioration over a final follow-up of 2 years. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
2 3 4 5 6 7 8 9
REFERENCES 1
Srinivasan M. Expulsive choroidal haemorrhage. Indian J Ophthalmol 1992;40:100–2.
10
Manschot WA. The pathology of expulsive haemorrhage. Am J Ophthalmol 1955;40:15. Bair HL. Expulsive haemorrhage at cataract operation. Am J Ophthalmol 1966;66:992. Girard LJ, Spak HE, Hawkins RS, et al. Expulsive hemorrhage during intraocular surgery. Trans Am Acad Ophthalmol Otolaryngol 1973;77:119–25. Ruiz ES, Paul PC. Expulsive choroidal effusion: a complication of intraocular surgery. Arch Ophthalmol 1976;94:69–70. Gressel MG, Parrish PK, Hever DK. Delayed nonexpulsive suprachoroidal hemorrhage. Arch Ophthalmol 1984;102:1757–60. Bellows AR, Chylack LT, Epstein DL, et al. Choroidal effusion during glaucoma surgery in patients with prominent episcleral vessels. Arch Ophthalmol 1979;97:493–7. Vail D. Posterior sclerotomy as a form of treatment in suprachoroidal expulsive haemorrhage. Am J Opthalmol 1938;21:256. Duehr PA, Hogenson CD. Treatment of subchoroidal haemorrhage by posterior sclerotomy. Arch Ophthalmol 1947;38:365. Verhoeff FH. Scleral puncture for expulsive subchoroidal hemorrhage following sclerostomy-scleral puncture for postoperative separation of the choroid. Ophthalmol Rec 1915;24:55–9.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
4
Rao A. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203150
CASE REPORT
Visual restoration after suprachoroidal haemorrhage in glaucoma surgery Aparna Rao Department of Glaucoma, LV Prasad Eye Institute, Bhubaneswar, Orissa, India Correspondence to Dr Aparna Rao, [email protected] Accepted 16 January 2014
SUMMARY Suprachoroidal haemorrhage is the most dreaded complication feared by any surgeon during glaucoma surgery. Rapid explosive expulsion of intraocular contents can occur, which makes vision loss almost inevitable in most cases. Yet, adequate preparedness, prompt recognition of the earliest signs and quick closure of the wound can salvage the eye or even prevent loss of vision. This case highlights the successful visual rehabilitation and outcome in a patient with advanced glaucoma who experienced delayed expulsive haemorrhage intraoperatively.
BACKGROUND Suprachoroidal haemorrhage can complicate glaucoma surgery at any step. This may be associated with expulsion of vital organs like the retina and the choroid, if not recognised and treated promptly.1 2 Visual restoration is rare due to the cascade of events necessitating evisceration on the table.1–3 Therefore, promptness is key for salvaging the eye and preventing extensive bleeding or expulsion of ocular contents. This case highlights the favourable outcome of prompt recognition and treatment of the complication during glaucoma surgery which helped restore functional vision.
CASE PRESENTATION A 53-year-old woman, previously diagnosed with chronic angle closure glaucoma of both eyes (status of post-trabeculectomy and cataract surgery in the right eye and laser peripheral iridotomy in the left eye) elsewhere and on treatment for 12 years, presented to us with gradual decrease in vision in the left eye over 1 year. Her best corrected visual acuity was 20/200 (no improvement with pinhole) in the left eye and no perception of light in the right eye. Goldmann applanation intraocular pressure (IOP) was 32 and 45 mm Hg in the right and left eyes on a topical fixed combination of brimonidine and timolol along with topical dorzolamide and systemic acetazolamide inhibitors while gonsicopy showed closed angles in all four quadrants in both eyes. Slit lamp evaluation showed cataractous changes with advanced optic nerve damage in the left eye and total glaucomatous cupping in the right eye, which was pseudophakic. To cite: Rao A. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013203150
INVESTIGATIONS Humphrey visual field in the right eye showed advanced biarcuate scotoma sparing the central island with no macular split (figure 1). She was initiated on systemic glycerol along with
Rao A. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203150
continuation of previous antiglaucoma treatment, and the possibility of combined surgery for the left eye under guarded prognosis was explained for IOP control.
DIFFERENTIAL DIAGNOSIS With closed angles on gonioscopy and high IOP on maximum medical treatment, she was diagnosed as uncontrolled advanced primary angle closure glaucoma with cataract.
TREATMENT She was reviewed 2 weeks later with an IOP of 28 mm Hg on the above treatment and was therefore taken up for phacoemulsification with intraocular lens (IOL) implantation with trabeculectomy with the possible risks explained to her. Preoperatively, she was given intravenous mannitol (1 g/kg body weight) and adequate digital massage to make the eye soft. Intraoperatively, the lens was delivered by phacoemulsification with IOL placement in the bag through a superficial scleral flap. The creation of the ostium (1×1 mm) was made with a vannas scissors at the same site, which was followed by closure of the flap with 10-0 nylon. At this step, there was a sudden loss of vitreous with an abrupt shallowing of the chamber and IOL-corneal touch (video 1). The 10-0 nylon suture was therefore sutured tightly and additional sutures were immediately placed, followed by hardening of the globe, which mandated intraoperative mannitol. The conjunctiva was sutured with 8-0 vicryl interrupted sutures with no evidence of bleeding or further escape of vitreous. A consultation was sought with a retina specialist, who advised no active intervention.
OUTCOME AND FOLLOW-UP Immediate postoperative examination revealed a shallow anterior chamber with mixed blood and vitreous seen peaking towards the superior ostium, which was evident as a tense bulge (figure 2A, arrow). Ultrasound, USG (B), confirmed suprachoroidal haemorrhage, (figure 2B). Her vision was perception of light in all four quadrants with an IOP of 26 mm Hg. Retina consultation was again sought and she was managed conservatively with systemic steroids and topical intensive steroids and cycloplegics. She was closely followed up weekly for 3 weeks and thereafter monthly for 3 months with gradual tapering of systemic and topical steroids. There was a gradual reduction in the anterior chamber inflammation with central deepening, though there was persistence of the pupillary membrane obscuring the 1
Reminder of important clinical lesson
Figure 1 Humphrey visual filed of the left eye showing biarcuate field defect with macular sparing. fundus view (figure 3A, arrow in inset). Repeat USG showed an attached retina with complete resolution of the suprachoroidal hematoma. She was therefore taken up for removal of the pupillary membrane and adherent iris using an automated vitrector with intraoperative chamber maintenance with an anterior chamber maintainer. Postoperatively, she regained a vision of 20/ 60 after refractive correction with a clear visual axis and deep central anterior chamber (figure 3B). She was seen by low vision services to help her in her daily professional work of teaching at school. At 2-year follow-up, her IOP remained controlled at 16 mm Hg on topical antiglaucoma drugs with stable visual fields. 2
DISCUSSION Suprachoroidal hemorrhage is a dreaded complication that can occur during glaucoma surgeries. It is termed the bête noire of ophthalmic surgeries and is more likely in eyes with a history of chronic glaucoma, hypertension, atherosclerosis, choroidal sclerosis or history of previous episode in other eye.2–4 This complication is feared most for the extensive bleeding in the suprachoroidal space with choroidal expansion causing a sudden and rapid expansion of the ocular contents.5–7 This causes loss of vision and even evisceration in some cases with restoration of vision being almost rare. Rao A. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203150
Reminder of important clinical lesson
Video 1 Intraoperative video showing sudden vitreous loss after ostium creation.
and sudden exposure to atmospheric pressure. A closedchamber system using the stay sutures or phacoemulsification also prevents rapid decompression. Despite all these measures in our case, we did encounter delayed haemorrhage during the last step of wound closure. Suprachoroidal haemorrhage can occur at any step of the surgery.6 In our case, it happened after creation of the ostium and closure of the wound. This may have been due to lowering of the IOP by trabeculectomy ostium in an eye with chronic glaucoma with persistently high IOP for many months. Closure of the wound therefore was easy and quick in our case, which helped prevent cascading of vision-threatening conditions. Close follow-up and adequate treatment by removal of the pupillary membrane with a vitrectomy cutter (ensuring a closed chamber during surgery rather than anterior approach through the limbus or cornea) helped restore functional vision to our patient who was a teacher by profession. Despite the advanced glaucomatous optic nerve head and visual field damage and intraoperative suprachoroidal haemorrhage, she resumed her normal
Learning points
Figure 2 (A) First postoperative day after intraoperative suprachoroidal haemorrhage clinical photograph showing shallow chamber and tense bulge (arrow) superiorly which was confirmed on ultrasound (B) scan of the posterior segment.
Creation of preparatory sclerotomies for suprachoroidal drainage in high-risk cases (such as nanophthalmos, chronic glaucoma) has been advocated to drain the suprachoroidal bleed and avoid expulsion of intraocular contents.8–10 Yet, despite all measures, these events can happen rapidly, making any attempt to preserve the eye futile in most cases. This complication can be prevented by adequate IOP lowering preoperatively by intravenous osmotic diuretics and by digital ocular massage.4 5 Slow decompression prevents rapid collapse of the anterior chamber
▸ Suprachoroidal hemorrhage is a dreaded complication that can occur in eyes with chronic glaucoma. ▸ Since this can occur at any stage of surgery, adequate preparedness (in eyes with previous history, chronic glaucoma, hypertension, similar history in other eye) and prompt recognition of its signs during surgery may help in salvaging the eye or even preserving some useful vision. ▸ Adequate lowering of intraocular pressure preoperatively and slow decompression may be helpful in preventing this complication during the early steps of surgery. ▸ Quick and tight closure of the eye on recognition of the earliest signs of this complication (such as sudden collapse of anterior chamber, sudden loss of vitreous or spontaneous expulsion of the lens) may help in avoiding extensive bleeding on the table or expulsion of vital ocular organs including retina and choroid. ▸ Good visual outcomes are possible after delayed suprachoroidal haemorrhage if recognised early. Low vision also plays an important role in restoring functional vision in such cases.
Figure 3 Inset shows clinical photograph on follow-up showing persistent membrane in the pupillary area (arrow). (A) Clinical photograph after removal of the pupillary membrane and adherent iris by automated cutter clearing the visual axis which was maintained at 2 years of follow-up, (B). Rao A. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203150
3
Reminder of important clinical lesson daily life with the help of low-vision aids. This was possible due to prompt recognition of sudden vitreous loss which mandated immediate closure of the wound albeit at the cost of a successful glaucoma surgery. Yet, her IOP is well controlled on topical medications which maintain quality of life without field deterioration over a final follow-up of 2 years. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.
2 3 4 5 6 7 8 9
REFERENCES 1
Srinivasan M. Expulsive choroidal haemorrhage. Indian J Ophthalmol 1992;40:100–2.
10
Manschot WA. The pathology of expulsive haemorrhage. Am J Ophthalmol 1955;40:15. Bair HL. Expulsive haemorrhage at cataract operation. Am J Ophthalmol 1966;66:992. Girard LJ, Spak HE, Hawkins RS, et al. Expulsive hemorrhage during intraocular surgery. Trans Am Acad Ophthalmol Otolaryngol 1973;77:119–25. Ruiz ES, Paul PC. Expulsive choroidal effusion: a complication of intraocular surgery. Arch Ophthalmol 1976;94:69–70. Gressel MG, Parrish PK, Hever DK. Delayed nonexpulsive suprachoroidal hemorrhage. Arch Ophthalmol 1984;102:1757–60. Bellows AR, Chylack LT, Epstein DL, et al. Choroidal effusion during glaucoma surgery in patients with prominent episcleral vessels. Arch Ophthalmol 1979;97:493–7. Vail D. Posterior sclerotomy as a form of treatment in suprachoroidal expulsive haemorrhage. Am J Opthalmol 1938;21:256. Duehr PA, Hogenson CD. Treatment of subchoroidal haemorrhage by posterior sclerotomy. Arch Ophthalmol 1947;38:365. Verhoeff FH. Scleral puncture for expulsive subchoroidal hemorrhage following sclerostomy-scleral puncture for postoperative separation of the choroid. Ophthalmol Rec 1915;24:55–9.
Copyright 2014 BMJ Publishing Group. All rights reserved. For permission to reuse any of this content visit http://group.bmj.com/group/rights-licensing/permissions. BMJ Case Report Fellows may re-use this article for personal use and teaching without any further permission. Become a Fellow of BMJ Case Reports today and you can: ▸ Submit as many cases as you like ▸ Enjoy fast sympathetic peer review and rapid publication of accepted articles ▸ Access all the published articles ▸ Re-use any of the published material for personal use and teaching without further permission For information on Institutional Fellowships contact [email protected] Visit casereports.bmj.com for more articles like this and to become a Fellow
4
Rao A. BMJ Case Rep 2014. doi:10.1136/bcr-2013-203150
