1. IN THE NAME OF GOD
17 September 2018

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

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

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

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

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

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

8. 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

9. 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

10. 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

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

12. 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

13. Intraoperative suprachoroidal hemorrhage “Expulsive”
0.19% in 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

14. 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

15. 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

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

17. 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

18. 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

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

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

21. 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

22. 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

23. 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

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