Expulsive choroidal hemorrhage PK IN Mojtaba aydeizadeh Assistant professor of Kermanshah university of medical science .

The one ‘nontechnical’ complication that may occur during keratoplasty is expulsive choroidal hemorrhage

The incidence of expulsive hemorrhage has been reported from 0 The incidence of expulsive hemorrhage has been reported from 0.47%'' to 3.3%.”

Predisposing factors are advanced age,' myopia," glau-coma,' inflammation (Fig. 117.7), hypotonia, or previous Trauma

This is a devastating complication that may lead to blindness because of the extrusion of intraocular contents

With more aggressive attempts to repair perforated, infected, or severely traumatized eyes, one must be prepared to deal with the expulsive hemorrhage

With the newer small incision keratoplasty techniques (such as DSEK) the incidence of expulsive hemorrhage might be less, and it should be easier to control

Theoretically, preoperative reduction in intraocular pressure and shrinkage of aqueous and vitreous volume with decreased choroidal blood flow should help decrease the possibility of an expulsive hemorrhage

This can be achieved with massage or a compression apparatus

Trephination should be performed gently so that the intraocular pressure is not markedly elevated by downward pressure with the trephine and then rapidly reduced when the anterior chamber is opened

During the open-sky phase of keratoplasty, choroidal detachments or effusions may occur and can be observed through the microscope. These are dark shadows or actual brown masses that may be seen in the red reflex. They do not mean that an expulsive hemorrhage is imminent

Expulsive hemorrhage may occur rapidly with sudden extrusion of intraocular contents (Fig. 117.8) and hemorrhage, or may be a gradual hemorrhage that slowly extrudes the iris, lens, or vitreous and then begins bleeding

Valsalva maneuvers by two patients during keratoplasty led to expulsive hemorrhage

Since blood flow in the choroid is the highest per unit volume of any tissue and since the capillary diameter is four times that of normal capillaries,' one would expect that Valsalva maneuvers with open-sky keratoplasty would further engorge these vessels and predispose them to hemorrhage

The management of expulsive hemorrhage depends on the immediate recognition of its development and prompt action

The rationale of management is to redirect the hemorrhage posteriorly and to restore normal ocular architecture anteriorly

How this is done depends on when the hemorrhage occurs

If the hemorrhage occurs immediately or shortly after entering the globe, an immediate posterior sclerotomy via a stab incision through the conjunctiva and sclera is performed

The inferotemporal quadrant is the most readily accessible

The sclerotomy should be large enough to allow blood and clots to be expressed as needed. Multiple sclerotomies may be required

Once the wound is closed, an attempt should be made to restore proper anterior segment anatomy

If the hemorrhage occurs during the open-sky phase of keratoplasty, management is more difficult. The surgeon should immediately occlude the wound with the thumb or finger, perform a posterior sclerotomy (Fig. 117.9), and replace the recipient (or the donor cornea if it has been prepared) with interrupted silk sutures

The sclerotomy may need to be reopened several times in order to restore anterior segment integrity

If the cornea is secured and the hemorrhage is directed posteriorly, management of the lens, vit-rectomy, iris, and anterior chamber re-formation are then appropriately handled. If intraocular contents have been extruded, it may be best to perform an evisceration primarily rather than require further surgery