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LARGEST STUDY ON CHINESE AMERICANS PUBLISHED

LARGEST STUDY ON CHINESE
AMERICANS PUBLISHED

USC Ophthalmology Researchers Find More
Effective Treatments For Blinding Eye Diseases

EDUCATION

Case Study: It Swells but Ends Well (this time)

Patel Reznik
Presenter: Luv Patel, MD Discussant: Alena Reznik, MD
 

History

  • 70-year-old woman with history of juvenile idiopathic arthritis (JIA), chronic smoldering uveitis controlled on Remicade (infliximab) infusions, topical prednisolone
  • Advanced uveitic glaucoma OD
  • History of cataract extraction OU at four years of age with aphakia, complicated by retained lens fragment OS
    • OS lens fragment migration to visual axis with central macular edema
  • Post-op week six status post (s/p) pars plana vitrectomy (PPV) OS with removal of lens fragment
    • Persistent postoperative pressure spike OS on maximally tolerated topical anti-hypertensive drops, and oral methazolamide 25 mg TID
  • s/p Ahmed Glaucoma Valve OS without complications
  • POD1 exam unremarkable with patent tube
  • POD2 patient with acute onset blurry vision OS, acute 10/10 eye pain presents to outside hospital emergency department
    • Found to have OS intra-ocular pressure (IOP) of 50 decreased to 15 with topical regimen of Xalatan (latanoprost), CoSopt (timolol+dorzolamide), Alphagan (brimonidine) and oral Diamox (acetazolamide)

Exam Findings (POD3)

  • OS VA Light perception (pre-operative 20/100)
  • OS IOP 10 (max drops, Diamox)
  • Ant. Segment Exam OS
    • Lids, lashes: Within Normal Limits (WNL)
    • Conjunctiva/Sclera: supratemporal tube covered with subconjunctival hemorrhage
    • Cornea: Decreased tear film; clear
    • Anterior Chamber: 3 mm inferior hyphema with large central blood clot; tube in position, patent
    • Iris: Superior surgical peripheral iridectomy; iris transillumination defects
    • Lens: Aphakia

Differential Diagnosis

  • Suprachoroidal hemorrhage
  • Choroidal effusions
  • Endophthalmitis
  • Retinal detachment

Additional Investigations

Figure 1
Figure 1: B-scan of the left eye L0300 showing appositional membranes (white arrows). Submembrane region is filled with hyperechoic matter (red arrow).

 

Diagnosis

  • Suprachoroidal hemorrhage

Pathophysiology

  • Suprachoroidal space is a potential space external to choroid, deep to the sclera
Figure 2
Figure 2: Significant pressure changes during intraocular surgery can cause shearing trauma to the highly vascularized choroid, resulting in hemorrhage of the posterior ciliary vasculature. (Image from BCSC Fundamentals).

 

Treatment

  • If an intraoperative suprachoroidal hemorrhage is suspected, prompt closure of the surgical sites is recommended
  • Increased IOP is managed with topical medications and oral carbonic anhydrase inhibitors
  • Trans-scleral drainage is often performed to decompress the hemorrhage
  • Primary data on timing of decompression is limited, but our department consensus suggests close monitoring for clot liquefaction on B-scan (seen as less echogenic than active clot) with drainage afterward
  • Patient underwent successful trans-scleral drainage
Figure 3
Figure 3: Left image is post-op week two B-scan (T600) showing temporal hemorrhage. Right image is color fundus at post-op month two showing residual temporal hemorrhage. Final best corrected visual acuity at post-op month four: 20/200.

 

Prognosis and Future Directions

  • Classical risk factors of suprachoroidal hemorrhage include advanced age, glaucoma, myopia, aphakia, arteriosclerotic cardiovascular disease, hypertension, choroidal hemangiomas associated with Sturge-Weber syndrome, and intraoperative tachycardia.
  • Delayed suprachoroidal hemorrhage occurs most often after glaucoma surgery, although it can occur after cataract extraction and posterior segment surgeries.
  • Modern retrospective studies have determined risk factors for delayed suprachoroidal hemorrhages after glaucoma filtration procedures. Significant risk factors in these studies include type of procedure (tube shunt higher risk than trabeculectomy), anticoagulation, axial myopia, and prior intraocular surgery.
  • Prognosis is guarded. Glaucoma studies with delayed suprachoroidal hemorrhage show that patients had a pre-operative mean VA logMAR of 0.8 (~20/125), with a post-event mean VA logMAR of 1.34 (Count Fingers to Light Perception range).

References

  • Chandra A, Xing W, Kadhim MR, Williamson TH. Suprachoroidal Hemorrhage in Pars Plana Vitrectomy: Risk Factors and Outcomes Over 10 Years. Ophthalmology. 2014;121(1):311-317.
  • Jeganathan VSE, Ghosh S, Ruddle JB, Gupta V, Coote MA, Crowston JG. Risk factors for delayed suprachoroidal haemorrhage following glaucoma surgery. Br J Ophthalmol. 2008;92(10):1393-1396.
  • Ling R, Kamalarajah S, Cole M, James C, Shaw S. Suprachoroidal haemorrhage complicating cataract surgery in the UK: a case control study of risk factors. Br J Ophthalmol.2004;88(4):474-477.
  • Tuli SS, WuDunn D, Ciulla TA, Cantor LB. Delayed suprachoroidal hemorrhage after glaucoma filtration procedures. Ophthalmology. 2001 Oct;108(10):1808-11.

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Produced by: Monica Chavez, John Daniel, Joseph Yim and Dr. Vivek Patel
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