1. GH.Naderian, M.D.

2. Supra choroidal hemorrhage Cystoid macular edema Retinal detachment

3. Supra choroidal hemorrhage Intraoprative Intraoprative Delayed post operative Delayed post operative

4. More common in patients with glaucoma More common in patients with glaucoma Incidence of supra choroidal H. following modern cataract surgery is reported to be between 0.03% and 0.06% Incidence of supra choroidal H. following modern cataract surgery is reported to be between 0.03% and 0.06%

5. The incidence of this complication following glaucoma surgery is reported to be 1.6% to 2% The incidence of this complication following glaucoma surgery is reported to be 1.6% to 2% Source of hemorrhage : Source of hemorrhage : One of the short or long posterior ciliary arteries

6. Acute intraoperative expulsive hemorrhage there is most likely a rupture of a necrotic or weakened vessels wall associated with hypotony during the procedure Acute intraoperative expulsive hemorrhage there is most likely a rupture of a necrotic or weakened vessels wall associated with hypotony during the procedure

7. Predisposing conditions: Advanced aged Advanced aged Hypertension Hypertension Arteriosclerosis Arteriosclerosis Blood dyscrasias Blood dyscrasias Anticoagulation Anticoagulation Glaucoma Glaucoma High myopia High myopia Hypotony Hypotony Trauma Trauma Uveitis Uveitis Suprachoroidal H. in fellow eye Suprachoroidal H. in fellow eye IOP  IOP  Valsalva Valsalva Prolonged hypotony ( wound leakage) Prolonged hypotony ( wound leakage) Inadequate local anesthesia Inadequate local anesthesia

8. Intraoperative supra choroidal hemorrhage : Iris prolapse Iris prolapse Shallowing of AC Shallowing of AC Vitreous prolapse Vitreous prolapse Graping of the incision Graping of the incision Firmness of the globe Firmness of the globe Striae in the cornea Striae in the cornea Change in the red reflex Change in the red reflex *sudden pain * *sudden pain *

9. The first priority following recognition of a possible intraoperative suprachoroidal H. is secure closure of the incision The first priority following recognition of a possible intraoperative suprachoroidal H. is secure closure of the incision

10. Delayed supra choroidal H. This type of H. usually occurs between the third to fifth postoperative day and in most cases is preceded by hypotony and the development of ciliochoroidal serous effusions This type of H. usually occurs between the third to fifth postoperative day and in most cases is preceded by hypotony and the development of ciliochoroidal serous effusions

11. The patient will generally have a history of sudden onset of eye pain, often with nausea, vomiting, decreased vision, headache, tearing and possible lid swelling or chemosis The patient will generally have a history of sudden onset of eye pain, often with nausea, vomiting, decreased vision, headache, tearing and possible lid swelling or chemosis

12. At times the patient may be awakened from sleep with these symptoms At times the patient may be awakened from sleep with these symptoms

13. On examination IOP ( may be  ) IOP ( may be  ) Shallowing of the AC ( often) Shallowing of the AC ( often) Vitreous prolapsed Vitreous prolapsed Loss of the red reflex Loss of the red reflex

14. If the supra choroidal H. is large, the choroidal detachments may be visible on slit lamp examination behind the lens If the supra choroidal H. is large, the choroidal detachments may be visible on slit lamp examination behind the lens

15. The presence of blood in the vitreous or the AC should be noted The presence of blood in the vitreous or the AC should be noted

16. If there has been break through bleeding to beneath or through the retina, the prognosis for recovery of vision is diminished If there has been break through bleeding to beneath or through the retina, the prognosis for recovery of vision is diminished

17. Initial treatment Analgesics Analgesics Control of IOP Control of IOP Cycloplegics Cycloplegics Topical and oral steroids Topical and oral steroids

18. The diagnosis of a suprachoroidal H. is usually made based on the clinical presentation and ophthalmic examination The diagnosis of a suprachoroidal H. is usually made based on the clinical presentation and ophthalmic examination

19. The use of ultrasonography may aid in the diagnosis, especially when there is media opacification or blood present The use of ultrasonography may aid in the diagnosis, especially when there is media opacification or blood present

20. Complete clot lysis will generally require 5 to 14 days, although this time may be variable in different individuals Complete clot lysis will generally require 5 to 14 days, although this time may be variable in different individuals

21. Several factors may influence the decision to consider drainage of a supra choroidal effusion Several factors may influence the decision to consider drainage of a supra choroidal effusion

22. It is well established that most suprachoroidal H. will eventually clear spontaneously It is well established that most suprachoroidal H. will eventually clear spontaneously

23. It also appears that the final visual outcome may be similar whether early drainage is performed or the hemorrhage is allowed to resolve on its own It also appears that the final visual outcome may be similar whether early drainage is performed or the hemorrhage is allowed to resolve on its own

24. Indication of drainage Massive kissing effusion Massive kissing effusion Intractable pain Intractable pain Persistent or recurrent flat AC Persistent or recurrent flat AC Prolapse of intraocular contents Prolapse of intraocular contents Suspicion of RD Suspicion of RD Vit. H Vit. H Retained lens fragments Retained lens fragments

26. Cystoid Macula Edema Irvine – Gass syndrome = Irvine – Gass syndrome = CME following cataract surgery

27. Risk factors Post capsular rupture Post capsular rupture Vitreous loss and incarceration Vitreous loss and incarceration Anterior chamber and secondary IOL Anterior chamber and secondary IOL Diabetes Diabetes History of CME in other eye History of CME in other eye Uveitis Uveitis

28. Peak incidence is at 6-10 weeks Peak incidence is at 6-10 weeks Spontaneous resolution occurring clinically in approximately 95% of uncomplicated cases usually within 6 months Spontaneous resolution occurring clinically in approximately 95% of uncomplicated cases usually within 6 months

29. CME diagnosed by clinical exam, FA & OCT CME diagnosed by clinical exam, FA & OCT

35. Treatment Correction of the underlying cases Correction of the underlying cases Systemic carbonic anhydrase inhibitors Systemic carbonic anhydrase inhibitors Topical & systemic Indometacine Topical & systemic Indometacine Steriods ( topical, oral, subtenon) Steriods ( topical, oral, subtenon) IVB & IVT IVB & IVT Parsplana vitrectomy Parsplana vitrectomy

36. Retinal detachment The incidence of retinal detachment following cataract surgery is approximately 1% The incidence of retinal detachment following cataract surgery is approximately 1%

37. When cataract surgery is accompanied by vitreous loss, the incidence of RD increase to 5% or more When cataract surgery is accompanied by vitreous loss, the incidence of RD increase to 5% or more

38. Another risk factor for pseudophakic RD is YAG capsulotomy Another risk factor for pseudophakic RD is YAG capsulotomy In one reported study the performances of YAG laser capsulatomy doubled the incidence of RD In one reported study the performances of YAG laser capsulatomy doubled the incidence of RD

39. Flashing and floatering are important Flashing and floatering are important

40. What to do for this problem ? 1- Complete fundus examination before surgery 2- Any predisposing pathology must be treated 3- Decreased any manipulation during surgery 4- Any complication  retinal surgeon examination