In the name of God

Suprachoroidal Hemorrhage Farid Daneshgar M.D Associate professor K.U.M.S

A hemorrhage in the suprachoroidal space that occurs spontaneously, intraoperatively, or traumatically, or is associated with intraocular vascular anomalies.

 One or more dome-shaped choroidal protrusions.  Forward movement of the iris, lens, and vitreous body.  Elevated intraocular pressure.

Choroidal hemorrhage occurs in :  3% of ICCE,  2.2% of nucleus-expression ECCE,  0.04% of phaco-surgery and  0.73% of glaucoma filtering procedures.

Causes of SCH  Impeding vortex vein outflow. (retrobulbar hemorrhage, retrobulbar anesthesia, pressure during surgery, scleral buckle)  Fluctuations in intraocular fluid dynamics and pressure. (sudden compression and decompression events)  Hypotony (leads to choriocapillaris effusion and stretching of suprachoroidal space, tension on and rupture of posterior ciliary vessels).

Differential diagnosis  Choroidal effusion  Retinal detachment  Melanoma or metastatic tumor of choroid or ciliary body

Serous choroidal detachment Hemorrhagic choroidal detachment  low IOP  transilluminates  usually no pain  usually pre equatorial  resolution within three weeks  resorbs without change in visual aquity  high IOP  no transillumination  almost always painful  may be more voluminous posteriorly  liquifies in 6_26 days and resorbs in 1 to several months  usually results in vision loss

Risk factors  Systemic: Advanced age, arteriosclerosis, DM, HTN, anticoagulation, ischemic heart disease  Ocular: Previous laser photocoagulation, ocular surgery (PPV), aphakia glaucoma,uveitis, high myopia, recent trauma  Intraoperative: High IOP, open sky procedures, valsalva maneuvers, intraoperative tachycardia, sudden drop in IOP, vitreous loss  Post Op: Postoperative trauma, ocular hypotony,

Intraoperative signs and symptoms ssudden unset of sever intraoperative pain eexcessive iris movement and iris prolapse fforward movement of lens and vitreous body ddarkening / loss of red reflex eexcessive bleeding of conjunctiva and episclera vvitreous hemorrhage ttachycardia rretinal detachment cchoroidal elevation protruding into operative field eexpulsion of intraocular content

Management of intraoperative massive suprachoroidal hemorrhage  Rapid wound closure (prevents loss of intraocular contents and incarceration)  reform anterior chamber with viscoelastic  After PK consider the use of temporary keratoprosthesis  Posterior sclerotomy only if necessary to allow for wound closure (reduces tamponading effect of sealing the eye and may result in larger SCH)  Post op: control IOP, inflamation and pain

When to operate on SCH LLens-cornea touch kkissing choroidals mmassive choroidal hemorrhage with sever pain ppersistently elevated IOP ppersistently flat AC SSCH under macula eextension of hemorrhage into subretinal space or vitreous cavity ssignificant vitreous incarceration rretinal incarceration

Course and outcome Good prognosis more likely in:  delayed, limited hemorrhage especially > 7 days after inciting surgery  SCH resulting from cataract surgery  higher visual aquity just after SCH poor prognosis more likely if:  retinal detachment hemorrhage in 4 quadrants  extension into posterior pole  vitreous and/or retinal incarceration  low visual aquity just after SCH

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