Role of Suprachoroidal Anti-VEGF Injections in Recalcitrant Serous Pigment Epithelium Detachment

Purpose: Retinal pigment epithelial detachments (PEDs) are characterized by a separation between the RPE and the innermost aspect of Bruch's membrane. Many chorioretinal diseases can lead to pigment epithelial detachment of which the most common is age-related macular degeneration; but a significant number of PEDs are idiopathic in etiology. PEDs can be classified as drusenoid, serous, vascularized, or fibrovascular type.Currently, serous PED has not shown much response to treatment, so no specific treatment guidelines are established. Whereas vascularized PEDs, have several treatment options such as intravitreal anti-Vascular endothelial growth factor (VEGF) therapy, laser photocoagulation, photodynamic therapy (PDT) and intravitreal steroids. Hence, the need of the hour is to formulate a treatment strategy for serous PED.Methods: We report an original study of thirty patients who were diagnosed with serous pigment epithelial detachment on Spectral-domain optical coherence tomography and fundus fluorescence angiography. All the patients presented to our outpatient department with the chief complaint of diminution of vision, central/paracentralscotoma and metamorphopsia. All of them underwent treatment with suprachoroidal anti-VEGF (bevacizumab).The patients were followed 8 weeks.Results: BCVA and Amsler grid assessment was recorded on the 3rd day,1st week, 2nd week, 4th week, 6th week, and 8th week. Post-injection SD-OCT macular scan was performed on the 6thweek. Functional improvement (BCVA) was reported by all patients. All the patients had reduced size and height of PED in SD-OCT.Conclusion: Thus, our result indicates that suprachoroidalbevacizumab is an efficacious treatment for serous PED. It can be hypothesized that as degenerative changes in bruch membrane due to metabolite deposit plays a key role in development of PED; injecting the anti VEGF drug in the suprachoroida space adjacent to the choroid has a superior effect.

A rare ophthalmic complication: Expulsive suprachoroidal hemorrhage

Background: Expulsive suprachoroidal hemorrhage is a rare but dreadful complication of any ophthalmic surgery. Hence an ophthalmologist should know about the various risk factors, methods for preventing such a situation, and be aware of the various options for timely management to tackle the situation. Purpose: To discuss the risk factors, intraoperative signs, and ways of managing expulsive choroidal hemorrhage. Synopsis: We discuss two cases having multiple risk factors, where the patients underwent tectonic penetrating keratoplasty. In view of extensive involvement of ocular structures, the patients were clearly explained about the guarded visual prognosis and the risk of auto-evisceration. Following trephination of host cornea, rise in intraocular pressure was identified by the increasing size of the vitreous seen prolapsing through the wound and markedly visible pulsations, along with subconjunctival bleeding. Suprachoroidal hemorrhage was suspected and immediate tamponade was given. However, bleeding was not controlled, and eventually, expulsion of all the intraocular contents occurred. Highlights: A surgeon must be aware of the risk factors, be prompt to identify the signs, and must take immediate actions for the management of expulsive choroidal hemorrhage, a rare but dreadful complication of intraocular procedures

Safety and efficacy of suprachoroidal triamcinolone acetonide for the management of serous choroidal detachment prior to rhegmatogenous retinal detachment surgery: A Pilot study

Purpose: To study the safety and efficacy of pre?operative suprachoroidal triamcinolone acetonide (SCTA) for achieving reduction/resolution of serous choroidal detachment (CD) associated with rhegmatogenous retinal detachment (RRD). Methods: This was a prospective, noncomparative, interventional pilot study. All consecutive patients presenting with RD and coexisting CD underwent transconjunctival injection of SCTA before proceeding with vitrectomy/scleral buckle surgery. Sequential ultrasound B scans were performed for assessing the change in height of the CD. Results: The mean age of the cohort was 53.8 � 10.8 years (range: 39� years). The CD was present in a median of 3 quadrants; the cumulative mean CD height was 5.59 mm (range: 2.02�42 mm). Following SCTA, a successful response (>50% reduction) was seen in five eyes by day 3 and in two eyes by day 5. Three eyes failed to respond to SCTA and required surgical drainage before proceeding with vitrectomy. No intraprocedural injection?related complications were noted. A transient rise in the intraocular pressure (30 mmHg) was seen in one eye following vitrectomy and was managed successfully with topical antiglaucoma medications. Conclusion: Suprachoroidal administration of triamcinolone appears to be a safe and effective technique to achieve CD resolution in eyes with RRD.

Suprachoroidal hemorrhage after removal of releasable suture with globe massage post-trabeculectomy

A 19-year-old female, having aniridia with secondary glaucoma, presented with uncontrolled intraocular pressure (IOP) in the right eye (RE) on maximal topical and systemic medications. On examination, RE had a subluxated cataractous lens with advanced cupping. She underwent trabeculectomy with mitomycin C. On postoperative day 1, as the IOP was 32 mmHg, one releasable suture was removed followed by gentle bleb massage. On postoperative day 2, suprachoroidal hemorrhage was noted, for which the patient underwent two drainage procedures. Hemorrhagic choroidals resolved completely 4 weeks after drainage.

Suprachoroidal injection of sodium hyaluronate in the treatment of 12 patients with rhegmatogenous retinal detachment / 中华眼底病杂志

Objective To observe the retinal reattachment of suprachoroidal injection with sodium hyaluronate in the treatment of rhegmatogenous retinal detachment (RRD).Methods Twelve eyes of 12 patients with RRD diagnosed by the examinations of B-mode ultrasound,binocular indirect ophthalmoscope,OCT and scanning laser ophthalmoscope in West China Hospital of Sichuan University from October 2018 to February 2019 were included in this study.There were 7 males and 5 females,aged from 15 to 66 years,with the mean age of 32.40± 14.81 years.There were 4 eyes with BCVA＜0.1,4 eyes with BCVA 0.1-0.4,4 eyes with BCVA＞0.4.The extent of retinal detachment involves 1 to 4 quadrants.All eyes were injected with sodium hyaluronate via suprachoroidal space under non-contact wide-angle system.Surgery was performed by the same ophthalmologist with extensive surgical experience.During the operation,the retinal hole was handled with scleral freezing and laser photocoagulation.The follow-up was 2 months.The retinal reattachment was observed.Results Of the 12 eyes,6 eyes (50.00％) were anatomically reattached,4 eyes (33.33％) ere partly anatomically reattached with subretinal fluid,2 eyes (16.67％) were not reattached.The holes in 4 eyes of partly anatomically reattached with subretinal fluid were located on the choroidal pad and the holes were closed,in addition,the subretinal fluid gradually absorbed over time.Two eyes failed in retinal reattachment received vitrectomy with silicone oil tamponade or sclera buckling surgery.No severe complications such as endophthalmitis and choroidal hemorrhage were found at follow-up visits.Conclusion Suprachoroidal injection of sodium hyaluronate is an effective and safe treatment for RRD,which can promote retinal reattachment.

A Case of Suprachoroidal Hemorrhage after Pars Plana Vitrectomy for Rhegmatogenous Retinal Detachment

PURPOSE: To report a case of a 60-year-old female with rhegmatogenous retinal detachment, presenting with suprachoroidal hemorrhage after vitrectomy. CASE SUMMARY: A 60-year-old woman visited our clinic complaining of floaters, flashing, and blurred vision. Best-corrected visual acuity was 0.1 in her left eye, and fundus examination of her left eye revealed macula-involved retinal detachment with a retinal break at the superotemporal quadrant. She underwent cataract surgery, 23-gauge transconjunctival sutureless vitrectomy, and 14% C3F8 gas tamponade under general anesthesia. One hour after anesthesia recovery, she suddenly complained of severe pain in her left eye. The intraocular pressure measured after removal of the pressure patch from her left eye was as high as 58 mmHg. Her ocular pain improved spontaneously within 10 minutes, and the intraocular pressure decreased to 8 mmHg. Fundus examination of her left eye revealed a reddish-brown raised lesion, suggesting suprachoroidal hemorrhage. She was placed in a prone position with a pressure patch over her left eye. Bleeding through the sclerotomy site was observed 1 day after surgery. Subsequently, hemorrhagic choroidal detachment of her left eye continued to decrease without deterioration. Three weeks after surgery, the patient received an intravitreal injection of 100% C3F8 gas into her left eye. At 3 months after surgery, best-corrected visual acuity had improved to 0.8 in her left eye, and the retina was stable. CONCLUSIONS: Suprachoroidal hemorrhage may be suspected in a patient complaining of severe ocular pain after vitrectomy.

Progress in surgical treatment of macular hole retinal detachment in high myopic / 国际眼科杂志(Guoji Yanke Zazhi)

@#Macular hole retinal detachment(MHRD)mainly occurs in high myopic eyes with posterior scleral staphyloma and always causes severe visual impairment. The pathogenesis of MHRD in high myopic eyes is still unclear. It is generally believed that it involves various complex traction. A variety of surgical methods have been tried to remove retina tractionin order to achieve retina reattachment and macular hole closure. This article reviews the current surgical methods and progress of MHRD in high myopic eyes.

A Case of Acute Angle-closure Glaucoma Secondary to Spontaneous Suprachoroidal Hemorrhage

PURPOSE: To report a case of acute angle-closure glaucoma secondary to spontaneous suprachoroidal hemorrhage in a hemodialysis patient. CASE SUMMARY: A 71-year-old man visited our clinic after 3 days of vision loss and ocular pain in the right eye. He had been treated with hemodialysis using heparin due to diabetic nephropathy. Visual acuity (VA) was hand motion in the right eye and 0.2 in the left eye. The intraocular pressure (IOP) was 58 mmHg in the right eye and 15 mmHg in the left eye. Gonioscopic examination revealed a closed angle in the right eye. Fundus examination of the right eye showed a massive hemorrhagic retinal detachment and ultrasound sonography revealed a dome-shaped retinal detachment with suprachoroidal hemorrhage in the right eye. The patient was treated with topical aqueous suppressants and cycloplegics. After two weeks of medical treatment, VA in the right eye was still hand motion and IOP was 8 mmHg. Gonioscopic examination showed a wide-open angle in the right eye. During the two-month observation period, VA in the right eye did not recover, however there was no sign of IOP elevation or symptoms of ocular pain. CONCLUSIONS: Spontaneous suprachoroidal hemorrhage can occur in patients who receive hemodialysis with heparin. This spontaneous suprachoroidal hemorrhage can be subsequently accompanied by acute angle-closure glaucoma. Spontaneous decrease of suprachoroidal hemorrhage, loss of angle-closure, and decline of IOP can be expected by treating with topical aqueous suppressants and cycloplegics.

A Case of Resolved Massive Suprachoroidal Hemorrhage after Sclerotomy in Penetrating Keratoplasty Patient

PURPOSE: To report the resolution of a massive suprachoroidal hemorrhage after penetrating keratoplasty by sclerotomy. CASE SUMMARY: A 64-year-old man with a corneal opacity in the left eye underwent penetrating keratoplasty. On the first postoperative day, a massive suprachoroidal hemorrhage was detected. After two surgical drainage procedures, the suprachoroidal hemorrhage subsided and the graft survived. His visual acuity was 20/240 two months post-operation. CONCLUSIONS: We report a patient with massive suprachoroidal hemorrhage after penetrating keratoplasty that was improved by surgical drainage procedures.

Clinical analysis of suprachoroidal hemorrhage complicated by intraocular surgery / 国际眼科杂志(Guoji Yanke Zazhi)

@#AIM:To explore clinical characteristics of supracho-roidal hemorrhage(SCH)complicated by intraocular surgery and to observe visual prognosis. <p>METHODS:A total of 13 eyes(13 cases)with SCH related to intraocular surgery from June 2005 to June 2015 were included and respectively studied. The age of our cases ranged from 22 to 76. Of all, 4 eyes(31%)were concomitant with hypertension, 6 eyes(46%)with high myopia and 6 eyes(46%)with oculi hypertonia, respectively. Intraoperative expulsive SCH occurred in 8 eyes, while postoperative delayed SCH in 5 eyes. The most SCH(7 eyes)happened during the surgery of removing silicone oil, 4 eyes with SCH were related to extracapsular cataract extraction(ECCE), 1 SCH eye was complicated by ECCE combined with trabeculectomy and 1 SCH eye by lensectomy and vitrectomy. As for treatment, 5 eyes took medication alone, 4 eyes were performed drainage sclerotomy and gas tamponade, while the other 4 eyes were accomplished vitrectomy with adjunctive perfluoro-carbon liquids and silicone oil tamponade. <p>RESULTS:At the 10-month of follow-up, all eyes with SCH were resolved. Except 1 eye with no light perception owing to abandoning treatment, the sights of the other 12 eyes were between light perception and 0.4. <p>CONCLUSION:SCH complicated by intraocular surgery was rare but with devastating outcome. Aged patients, hypertension, high myopia and oculi hypertonia may be risk factors. In addition, surgical methods in the early years were likely correlated to the occurrence of SCH. Certain sight of the patients with SCH may be maintained after positive treatment.

Suprachoroidal space drug delivery C / 中华眼底病杂志

The suprachoroidal space (SCS) is the potential space between the sclera and choroid.Drugs delivered through SCS can bypass the sclera,avoiding clearance by conjunctival and scleral blood vessels and lymphatic circulation,so that more drugs can reach the disease tissues such as choroid and retina.SCS drug delivery does not disrupt the ocular integrity,is safer than the intravitreal drug injection and more effective than trans-scleral drug delivery.In addition,SCS delivery only needs a very small volume of drug,which makes it possible to be carried out in multiple parts of the sclera,and the specific disease area can be more precisely targeted.SCS drug delivery is suitable for the treatment of choroidal and retinal diseases.However,currently SCS drug delivery is still a novel field and many aspects need to be more in-depth studied,including its safety,delivery methods,drug formulation and effectiveness.

Suprachoroidal drainage of aqueous humour with a novel implant: Suprajet / 国际眼科杂志(Guoji Yanke Zazhi)

AIM: To evaluate the efficacy and safety of a new implant, Suprajet ( VSY Biotechnology, Istanbul, Turkey ) , which is developed for supraciliary and suprachoroidal drainage of aqueous humour. ·METHODS: Five rabbits were included in the study. One Suprajet shunt was implanted in one eye of each rabbit. Implantation was performed by a superior clear corneal incision through the anterior chamber into the suprachoroidal space. Proximal end of the implant was placed in the iris root resting against the scleral spur, distal end was placed in the suprachoroidal space. Rabbits were followed for 4wk. Preoperative and postoperative intraocular pressure ( IOP ) levels were measured with Tonopen AVIA. At last follow-up visit animals were sacrificed and eyes were enucleated. Macroscopic and histopathologic evaluation of the eyes were made. ·RESULTS:Mean preoperative IOP was 18. 6±6. 1 mmHg. Mean postoperative IOP was 8. 4 ± 1. 1 mmHg, at one week. At the 2nd week of the follow-up period one rabbit died. Thereafter, only 4 rabbits were followed. Mean postoperative IOP was 11. 0 ± 2. 8 mmHg at the 2nd week, 9. 50±3. 1 mmHg at the 3rd week and 11. 3 ±3. 3 mmHg at 4th week after the operation. When mean preoperative IOP was compared with the postoperative IOP values, only the IOP at the first week was found as significantly lower ( P=0. 042). There was no statistically significant difference between mean preoperative IOP level and mean IOP level at 2, 3 and 4wk postoperatively (P=0. 66, P=0. 66 and P=0. 102, respectively). As an intraoperative complication, minimal hyphema was noted in three eyes during the surgery. However, the next day hyphema cleared completely. Macroscopic evaluation of the enucleated material showed that in one eye the distal end of the implant was in the vitreous instead of suprachoroidal space, in the other 3 eyes the distal end of the implant was noted in the suprachoroidal space. In all eyes, proximal end of the implant was localized in the anterior chamber angle. Histopathologic evaluation of the enucleated eyes showed deposition of irregular collagen bundles and fibroplasia including numerous fibroblastic and histiocytic cells around the implant. ·CONCLUSION: This preliminary animal study showed that implantation of Suprajet in glaucoma is a promising procedure. Further studies are needed to evaluate its efficacy and safety profile.

Case Report: Suprachoroidal Catheterization “ab-interno” for Treatment of Open Angle Glaucoma: “BABLY TECHNIQUE”.

A cataractous and open angle glaucomatous right eye of a 60 year old man was surgically treated in a different way. First, phacoemulsification with posterior chamber intraocular lens was done, then, under gonioscopy, I track, I science microcatheter was introduced in the suprachoroidal space and heavy viscoelastic was injected. Preoperatively, intra ocular pressure was 28 mmHg on three topical medications, Travatan, Cosopt and Alphagan. One month postoperatively, IOP was reduced to 16 mmHg without medications. Suprachoroidal catheterization is a safe, easy and effective technique in treatment of open angle glaucoma. Studies with long-term follow up are needed to assess efficacy and safety of the procedure. Suprachoroidal catheterization should be tried in different types of glaucoma.

Massive Spontaneous Suprachoroidal Hemorrhage in a Patient with Heavy Alcohol Consumption

PURPOSE: To report a case of massive spontaneous suprachoroidal hemorrhage in a middle-aged female with heavy alcohol consumption. CASE SUMMARY: A 48-year-old female with a history of heavy alcohol consumption developed a massive spontaneous suprachoroidal hemorrhage in the right eye. Fundus examination and B-scan ultrasonography of the right eye revealed a hemorrhagic choroidal detachment with kissing choroidal sign. On systemic evaluation, she was diagnosed with alcohol-induced hepatitis, diabetes, and diabetic nephropathy. We performed trans-scleral drainage of the suprachoroidal hemorrhage, trans pars plana vitrectomy and silicone oil injection in her right eye. CONCLUSIONS: To our knowledge, this is the first case report of massive spontaneous suprachoroidal hemorrhage in a patient with heavy alcohol intake.

Spontaneous expulsive suprachoroidal hemorrhage caused by decompensated liver disease.

Expulsive suprachoroidal hemorrhage can be surgical or spontaneous. Spontaneous expulsive suprachoroidal hemorrhage (SESCH) is a rare entity. Most of the reported cases of SESCH were caused by a combination of corneal pathology and glaucoma. We are reporting a rare presentation of SESCH with no pre-existing glaucoma or corneal pathology and caused by massive intra- and peri-ocular hemorrhage due to decompensated liver disease.

Treatment and analysis of risk factors of suprachoroidal hemorrhage induced by intraocular surgery / 中华实验眼科杂志

Background Suprachoroidal hemorrhage (SCH)is a rare but devastating complication of ophthalmic surgery,and it is crucial to be aware of the risk factors and select effective treatment. Objective Present study was to assess the treatment and risk factors of SCH induced by intraocular surgery. Methods Retrospective case series were carried out to investigate the clinical data of 15 eyes from 15 patients with SCH at Peking Union Medical College Hospital.The risk factors of SCH were analyzed.Written informed consent was obtained before any medical examination and treatment.SCH was occurred in 10 eyes during intraocular surgery,while the SCH was diagnosed in other 5 eyes 1-3 days after operation.Surgical drainage was carried out in 8 eyes,of which 3 eyes combined with vitrectomy besides surgical drainage and other 5 eyes were treated with medication alone.Results SCH was completely removed and absorbed in 12 eyes.The visual acuity was improved in 6 eyes,unchanged in 6 eyes and decreased in 3 eyes.Nine eyes complicated with retinal detachment and reattached in 6 eyes after treatment.Seven eyes combined with hypermyopia,6 eyes combined with glaucoma,and 1 eye was aphakia.Four patients combined with hypertension,and 2 patients had diabetes mellitus. Conclusions SCH induced by intraocular surgery develops rapidly and violently,and it can result in vision loss without effective treatment.Suturing surgical incision immediately,applying hypertonic agents and sclerotomy drainage are the urgent approaches to treat SCH.Medicines and/or sclerotomy could be optional according to the amount of bleeding and other ocular complication.The risk factors of SCH include myopia,glaucoma and the instantly dropping of intraocular pressure.

Implantation of a triamcinolone acetonide drug delivery system into the suprachoroidal space for the prevention of traumatic anterior proliferative vitreoretinopathy / 中华实验眼科杂志

BackgroundAnterior proliferative vitreoretinopathy (aPVR)is a tissue injury and repair progress,and treatment of aPVR is very important in clinic.Chitosan drug delivery system is becoming a hot spot for its large lading dose and long acting duration.ObjectiveThe present study was to investigate the curative effect of a triamcinolone acetonide (TA) drug delivery system after implantation into the suprachoroidal space to treat traumatic aPVR.MethodsaPVR models were created in the left eyes of 65 healthy pigment rabbits by performinga 5 mm penetrating incision 2.5 mm posterior to limbum at 10:30-11:30.The animals were randomly divided into 4groups.Blank chitosan was implanted into the suprachoroidal space as the blank control group.Chitosan with 1 mg TA was implanted in the TA + chitosa group.The TA solution ( containing 1 mg TA) was intravitreally injected in the TA injection group.Fifteen models were used as the traumatic control group.Another 15 left eyes of normal pigment rabbits were used as the normal control group.The thickness of the ciliary tissue was measured using a ultrasound biomicroscope(UBM) 3,5 and 8 weeks after operation.The animals were sacrificed by excessive anesthesia and eyeballswereobtainedforhistopathologicalandultrastructuralexaminations.ResultsHistopathological examination showed the edema of the ciliary tissue and inflammatory cells infiltration in the blank control group,TA injection group and model control group,but mild response was seen in the TA + chitosa group.Severe damage in the ciliary tissue and subcellular organelle was found in the blank and model control groups,but mild damage was detected in the TA + chitosa group under the transmission electron microscope.UBM examination revealed that obvious abnormalities were visible in the ciliary and iris tissue in the blank control group,TA injection group and traumatic control group,but a mild abnormality was seen in the TA + chitosa group.Significant differences in ciliary thickness were exhibited among the 5 groups 2,5 and 8 weeks after operation (F =212.938,515.323,447.919,P＜0.01 ).Compared with the normal control group,ciliary thickness significantly increased in the blank control group and normal control group at various time points (all P＜0.05 ),but that in the TA + chitosa group was significantly lower than the normal control group at various time points ( two weeks:0.484±0.075 vs.0.327 ±0.094 ; five weeks:0.422 ±0.089vs.0.327±0.094 ;eight weeks:0.418±0.085 vs.0.327±0.094) (all P＞0.05). ConclusionsThe chitosan drug delivery system with TA suppresses the excessive proliferation of injured ocular tissue after implantation into the suprachoroidal space,which prevents the formation and development of aPVR.

Spontaneous Eyeball Rupture in a 94-Year-Old Patient

PURPOSE: To report a case of spontaneous eye ball rupture without trauma in a 94-year-old patient. CASE SUMMARY: A 94-year-old female patient diagnosed with cataract in both eyes 20 years was referred to this ophthalmologic department for treatment consultation of a painful left eye with spontaneous bleeding. She has used anti-cataract eye drops and artificial tears three times a day for several years without consulting a doctor. Fifteen days prior to presentation, the patient suffered severe left eyeball pain and headache and was diagnosed with acute angle-closure glaucoma secondary to hypermature cataract. She underwnet eviceration after ocular examination and systemic evaluation. Surgical findings included a thin cornea at the inferior limbus and protruding intraocular tissues. Additionally, the eyeball was filled with a blood clot from a choroidal hemorrhage. Morganella morganii were grown in a bacterial swap culture, and a corneal biopsy revealed suppurative inflammation. CONCLUSIONS: In old age, a thin corneal limbus due to infection and complicated acute angle-closure glaucoma can cause massive suprachoroidal hemorrhage with spontaneous eyeball rupture.

Spontaneous Suprachoroidal Hemorrhage Associated with Wet Type of Age-Related Macular Degeneration and Hypertension: Two Cases

PURPOSE: To report two cases of spontaneous suprachoroidal hemorrhage associated with wet type of age-related macular degeneration (ARMD) and systemic hypertension. CASE SUMMARY: Two women, aged 76 and 73 years, with a history of systemic hypertension for more than ten years had been treated in an eye clinic for wet type of ARMD. The 76-year-old woman was scheduled to receive an injection of intravitreal Lucentis(R) but experienced sudden onset loss of vision and ocular pain in her left eye. The 73-year-old woman had received no specific treatment for wet type of ARMD. She also complained of visual disturbance and ocular pain. In these two cases, slit lamp or B-scan examination disclosed suprachoroidal hemorrhage. Surgical intervention relieved the ocular pain and symptoms in both cases. CONCLUSIONS: Even if a patient has not received systemic anticoagulation/thrombolytic therapy, if wet-type ARMD patients are elderly and have systemic hypertension, they should receive regular follow-ups because old age and systemic hypertension are risk factors of spontaneous suprachoroidal hemorrhage.