Management of Suprachoroidal Hemorrhage with Concurrent Rhegmatogenous Retinal Detachment


ABSTRACT

Diagnosis/Main Symptom:

Severe pain and loss of vision in left eye after fall

Medical History:

86-year-old monocular female with congenital syphilis resulting in multiple ophthalmic surgeries and NLP vision in her right eye presented with severe 10/10 pain in her left eye (OS) and loss of vision after a fall. Her ophthalmologic history included multiple penetrating keratoplasties (her most recent one was 3 days prior to presentation), an inferonasal tube shunt graft, and pseudophakia. Additionally, she had a significant cardiovascular history and was taking a full-dose aspirin daily.

Her visual acuity was hand motion (HM) in her left eye (baseline of 20/125). Intraocular pressure (IOP) OS was 85 mm Hg. Slit-lamp examination revealed severe conjunctival injection, inferonasal tube shunt, an intact corneal graft, flattened anterior chamber with iris abutting the cornea, prolapsed iris nasally through the graft-host junction, and pseudophakia. There was no view posteriorly.

B-scan ultrasound showed a large suprachoroidal hemorrhage in her left eye. No retinal detachment was seen. Decision was made to wait 10 days for the suprachoroidal hemorrhage to liquefy and to proceed with planned suprachoroidal hemorrhage drainage with possible vitrectomy and gas tamponade. Maximum medical therapy to lower IOP was initiated, and she obtained permission from her cardiologist to discontinue her aspirin for 5 days prior to surgery.

Treatment/Surgical Approach:

I have excellent video footage to demonstrate surgical intervention which reveals placement of anterior chamber infusion line and my technique of suprachoroidal drainage (scleral cut-down 8 mm posterior to the limbus with utilization of a cyclodialysis spatula to remove clots). During pars plana vitrectomy, I discovered a small horseshoe tear and localized retinal detachment. Given the elevated choroidals—even after drainage—it made the vitrectomy extremely challenging. After surgery, patient’s IOP normalized and her vision improved back to baseline. Unfortunately, she re-detached two months post-operatively. I repeated vitrectomy (her choroidals were nearly resolved this time) and she has remained attached for the past year.

Conclusion:

The presence of a suprachoroidal hemorrhage and a concurrent rhegmatogenous retinal detachment is a rare situation and management is not well-described in the literature. I learned many surgical pearls from this case that may benefit the audience. Some of these include my technique for suprachoroidal hemorrhage which includes use of an anterior chamber infusion as well as a cyclodialysis spatula, strategy for trocar placement, and application of B-scan ultrasonography to follow the liquefaction of a suprachoroidal hemorrhage.


CONTACT DETAILS

 

Christina Y. Weng
United States of America
Email : Christina.Weng@bcm.edu
Work Phone: +15862914400