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
Suprachoroidal space is a potential space external to choroid, deep to the sclera
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
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).
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.