IN THE NAME OF GOD 17 September 2018

GLAUCOMA SURGERY WITH SUPRACHOROIDAL HEMORRHAGE Dr.Fariba Shaikhi Assistant Professor Department of Ophthalmology Kermanshah University of Medical Sciences 17 September 2018

Surgical Therapy for Glaucoma  Primary approach congenital glaucoma angle-closure glaucoma Secondary approach primary open-angle glaucoma 17 September 2018

Surgery for Congenital Glaucoma Goniotomy Trabeculotomy ab externo Trabeculectomy Cyclophotocoagulation with Nd.YAG or diodlaser Cyclocryotherapy Trans scleral Endoscopic cyclophotocoagulation 17 September 2018

Surgery for Angle Closure Glaucoma Laser Iridotomy Incisional Iridectomy Laser Gonioplasty Peripheral Iridoplasty Chamber deepening & Goniosynechiolysis 17 September 2018

Surgery for Open-Angle Glaucoma Laser Trabeculoplasty - argon laser trabeculoplasty (ALT) - selective laser trabeculoplasty (SLT) Trabeculectomy Combined cataract and filtering surgery 17 September 2018

Other Procedures to Lower IOP drainage device Implantation Cyclodialysis Viscocanalostomy Canaloplasty 17 September 2018

Complications of Filtering Surgery Early Complications Late Complications Infection Leakage or failure of the filtering bleb Hypotony Cataract Shallow or flat anterior chamber Blebitis Aqueous misdirection Endophthalmitis/bleb infection Hyphema Symptomatic bleb (dysesthetic bleb) Formation or acceleration of cataract Bleb migration Transient IOP elevation Hypotony Cystoid macular edema Ptosis Hypotony maculopathy Eyelid retraction Choroidal effusion Suprachoroidal hemorrhage Persistent uveitis Dellen formation Loss of vision 17 September 2018

Risk factors for Suprachoroidal Hemorrhage Expulsive Choroidal Hemorrhage High preoperative IOP Increased axial length Prior vitrectomy Intraoperative tachycardia Clotting disorders Arteriosclerosis Valsalva during extubation Delayed Suprachoroidal Hemorrhage High preoperative IOP Low postoperative IOP Serous choroidal effusion Aphakia Prior ocular surgery Myopia Increased age System hypertension Atherosclerosis Anti-coagulation Ischemic heart disease Respiratory disease White race   17 September 2018

Symptoms and signs of Intraoperative SCH Acute onset of pain Patient agitation Sudden increase IOP Darkening of red reflex A forward displacement of iris-lens diaphragm Incision gape Iris prolaps 17 September 2018

Symptoms and signs of DSCH sever pain occasional nausea marked reduction in vision ↑ IOP shallow or flat AC large choroidal detachmant 17 September 2018

High frequency ultrasonography in eyes with DSCH high reflectivity in the inner space of a choroidal detachment ciliary processes and iris anteriorly displaced 17 September 2018

Intraoperative suprachoroidal hemorrhage “Expulsive” 0.19% in 35459 intera ocular procedures 0.15% in filtering surgeries 0.16% in cataract surgeries 0.41% in vitroretinal surgeries 0.56% in full-thickness corneal transplants (Speaker et al.) 17 September 2018

Delayed suprachoroidal hemorrhage after filtering surgery Typically present two to three days after surgery  On the basis of retrospective studies (383 patients) un common (2%)  In a prospective study involving ulterasonagraphic evaluation of (158 patients) after filtering surgery (7%) Relative incidence varied depending on the type of procedure on one study (385 patients) -trabeculectomies without antimetabolite (1.5%) -trabeculectomies with antimetabolite (2.4%) -implantation of valved glaucoma drainge divice (2.8%) -implantation of nonvalved glaucoma drainge divice (7%) -in aphakic eyes (13%) -in aphakic and vitrectomized eyes (33%) 17 September 2018

Management of SCH Intraoperative -immediate closure of fistula -some surgeons make a incision in the infero-temporal quadrant for drainage Postoperative (DSCH or PSCH) -not all cases require surgical collection -drainage of hemorrhage after 7-10 days -Vitrectomy 17 September 2018

Indication for surgical intervention Kissing choroidal detachment Vitreous incarceration Vitreoretinal adhesion 17 September 2018

Drainge 7-10 days from onset of hemorrhage Retrobulbar or peribulbar block Paracentasis and viscoelastic injection to AC Constant infusion with an AC maintainer The bleb should be inspected for over filtering or leakage Traction suture in the inferior peripheral cornea Limited congunctival incision 3-5 mm from limbus in two inferior quadrants A radial or tangential sclerotomy using a 67 or 69 blade which 2-3 mm in length (sharp & rounded) Two forceps hold the wound open a cyclodialysis spatula need for depress one edge of sclera and elevate the other Coutry may be applied to both sides of the wound A Kelly punch may be used to create a scleral opening The sclerostomy should be left open Conjunctival closed with 7-0 vicryl Subconjunctival injection of dexamethasone and antibiotic A drop of atropine administered 17 September 2018

Drainage of massive SCH AC paracentesis + sclerotomy Suprachoroidal space evacuation Cyclodialysis spatula facilitates evacuation Healon injected into AC and conjunctiva is closed and leaving the sclerotomies open 17 September 2018

scleral incision kelly punch completed sclerotomy three-week post operation 17 September 2018

Visual outcome (DSCL) Visual outcome is poor Visual outcome is worse with -retinal detachment -360 degree SCH 17 September 2018

one study 10 patients developed (PSCH) 2% overall 500 patients underwent filtration procedures 10 patients developed (PSCH) 2% overall the incidence is high in -aphakic patients 6.62% -high myopia 1o% PSCH is related to prolonged hypotonia and inflammation Drainage of SCH followed by vitrectomy and scleral buckling  4 eyes (40%) obtained final VA, 20/200 or beter  4 eyes (40%) obtained final VA, CF or HM  2 eyes (20%) obtained final VA, NLP 17 September 2018

Prevension Control of hypertention DC anticoagulants Control of inflammation Control of IOP AC maintainer Pre-placement of scleral flap sutures Viscoelastic or Long-lasting gas bubbles may be left in the AC Decrease the concentration and duration of application of antimetabolite Tight scleral flap closure An internal stent with an external ligature may be used for a non-valved implant ↓ valsalva maneuvers The head of bed should be elavated Wear eye shield for one month post operative 17 September 2018

Tissue Plasminogen Activator (TPA) Subconjunctival injection no effect in early lysis of clot Intravenous injection accelerated lysis of clot Two case reports success when injected to suprachoroidal space directly 17 September 2018

Beautiful images of cave Ghori Ghale Thank you Beautiful images of cave Ghori Ghale 17 September 2018