FACTORS ASSOCIATED WITH OUTCOMES OF SUPRACHOROIDAL HEMORRHAGE: An Individual Participant Data Systematic Review.

PURPOSE: To determine factors associated with visual and anatomic outcomes of suprachoroidal hemorrhage in studies published between 1990 and 2022. METHODS: Individual participant data systematic review. The protocol was prospectively registered on Open Science Framework ( https://osf.io/69v3q/ ). PubMed, EMBASE, Web of Science, and Google Scholar were searched for peer-reviewed studies of suprachoroidal hemorrhage with ≥3 patients published between January 1, 1990, and September 1, 2022. The primary outcome was the change in logarithm of the minimum angle of resolution visual acuity from the time of suprachoroidal hemorrhage diagnosis to last follow-up. RESULTS: Four hundred thirteen eyes from 49 studies were included, with mean (SD) age 60.8 (22.4) years and mean (SD) follow-up of 13.8 (12.6) months. Among 145 eyes with at least 6 months of follow-up, the mean (SD) gain in visual acuity was -0.98 (0.89) logarithm of the minimum angle of resolution. In multivariable regression, treatment with systemic steroids was associated with greater improvement in logarithm of the minimum angle of resolution visual acuity (adjusted mean [SE] -1.29 [0.09] vs. -0.16 [0.30] for no systemic steroids; P < 0.001) and greater odds of achieving anatomic success (adjusted OR 10.59, 95% confidence interval 2.59-43.3; P = 0.001). CONCLUSION: The use of systemic steroids was associated with better visual and anatomic outcomes for suprachoroidal hemorrhage.

Spontaneous expulsive choroidal hemorrhage in an elderly female with microbial keratitis.

PURPOSE: To report spontaneous choroidal hemorrhage with the expulsion of intraocular contents in an elderly female as a complication of microbial keratitis. METHODS: Retrospective case report along with imaging. RESULTS: A 60-year-old female on treatment for microbial keratitis, presented with protrusion of intraocular contents and no perception of light in the right eye. Ophthalmic ultrasound demonstrated choroidal hemorrhage with coexistent retinal detachment and vitreous hemorrhage. She underwent uneventful evisceration for her condition. CONCLUSION: Microbial keratitis needs aggressive medical treatment to prevent associated stromal infiltration and corneal weakening. In cases of microbial keratitis, if spontaneous choroidal hemorrhage occurs, due to thinning of the cornea and compromised integrity of the eyeball, it can lead to the complete expulsion of intraocular contents with unsalvageable loss of vision.

Suprachoroidal Hemorrhage.

Suprachoroidal hemorrhage (SCH) refers to the accumulation of blood in the suprachoroidal space, a relatively uncommon but significant complication that can occur spontaneously, during ophthalmic surgery, or as a consequence of ocular trauma. If left undiagnosed and untreated, SCH can lead to severe vision loss or even blindness. Therefore, it is crucial for ophthalmologists to have a thorough understanding of this complication, taking proactive measures to prevent it during surgery and being knowledgeable about effective management strategies for patients with SCH. This review article aimed to provide a comprehensive overview of SCH, covering its risk factors, diagnostic approaches, and the best practices for its management. By enhancing awareness and knowledge in this area, we can improve patient outcomes and minimize the impact of SCH in ophthalmic practice.

RARE NON-SURGICAL RELATED MASSIVE SPONTANEOUS SUPRACHOROIDAL HEMORRHAGE. A CASE REPORT.

AIMS: We present two rare cases of non-surgical-related massive spontaneous suprachoroidal hemorrhage. CASE REPORT: The first case was a 73-year-old male with uncontrolled hypertension, who presented with left vision loss, only able to perceive light, with very high intraocular pressure (IOP) and blood pressure (BP), 68 mmHg and 196/106 mmHg, respectively. Ocular examination showed a limited fundus view, and the B-scan revealed near kissing suprachoroidal hemorrhage. The second case was a 59-year-old male, post valve replacement surgery on life-long warfarin, who presented with hand movement vision and IOP of 47 mmHg. The B-scan showed massive submacular and suprachoroidal hemorrhage with therapeutic range International Normalized Ratio (INR). CONCLUSION: Suprachoroidal hemorrhage is one of the rare complications that can be seen in any ocular surgery. However, spontaneous suprachoroidal hemorrhage is a rarer disease. Most of the reported cases are associated with underlying medical conditions. Thus prevention is crucial. This involves ophthalmologists, physicians and general practitioners in managing this group of patients with associated risk factors, for better recognition of this devastating ocular complication in which early detection may reduce ocular morbidity.

Spontaneous Expulsive Suprachoroidal Hemorrhage.

BACKGROUND: Spontaneous Expulsive Suprachoroidal Hemorrhage (SESCH) is an extremely rare phenomenon that leads to atraumatic spontaneous globe rupture. Only a handful of SESCH cases have been reported worldwide, primarily in developing countries. Risk factors associated with SESCH include uncontrolled hypertension, previous eye surgery, glaucoma, atherosclerosis, advanced age, and corneal damage. CASE REPORT: We report a case of expulsive suprachoroidal hemorrhage in a ninety-seven-year-old female. The patient presented to the emergency department with painful bleeding from her right eye. She denied any trauma or injury to the eye. She denied any use of anticoagulation. Physical examination showed a right ocular hematoma with mild active bleeding. She had exophthalmos and proptosis with extrusion of the ocular structures. A computed tomography scan of the orbits demonstrated right globe rupture with diffuse hemorrhage. Ophthalmology was consulted, and the patient subsequently had an evisceration of her right eye. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Spontaneous expulsive choroidal hemorrhage is exceedingly rare. SESCH predominantly affects diseased eyes in the elderly. Early recognition of impending globe rupture in patients who present with suprachoroidal hemorrhage is necessary and requires prompt ophthalmology consultation. Emergency physicians must be aware that an atraumatic open globe can occur and requires immediate evaluation by an ophthalmologist and emergent repair in the operating suite.

Delayed Suprachoroidal Hemorrhage After Xen45 Gel Stent.

PRCIS: In patients with significant preoperative comorbidities, prolonged activity restrictions beyond 2 weeks after Xen45 surgery may mitigate the risks of delayed SCH. PURPOSE: To report the first case to date of delayed suprachoroidal hemorrhage (SCH) not associated with hypotony 2 weeks after the placement of the Xen45 gel stent. CASE SUMMARY: An 84-year-old white man with significant cardiovascular comorbidities underwent uneventful ab externo implantation of a Xen45 gel stent for asymmetric progression of severe primary open angle glaucoma. The patient had a reduction in intraocular pressure by 11 mm Hg on postoperative day 1 and maintained preoperative visual acuity. The intraocular pressure remained stable at 8 mm Hg on multiple postoperative visits until the patient developed a SCH at postoperative week 2 immediately after a light session of physical therapy. The patient was treated medically with topical cycloplegic, steroid, and aqueous suppressants. He maintained preoperative visual acuity throughout the postoperative course and had resolving SCH without the need for surgical intervention. CONCLUSIONS: This is the first report of a delayed presentation of SCH in the absence of hypotony after ab externo implantation of the Xen45 device. The possibility of this vision-threatening complication should be considered as part of the risk assessment and included in the consent process for the gel stent. In patients with significant preoperative comorbidities, prolonged activity restrictions beyond 2 weeks after Xen45 surgery may mitigate the risks of delayed SCH.

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. Online Video Link: https://youtu.be/UnCH-lWGzwU.

Valsalva-Induced Spontaneous Suprachoroidal Hemorrhage: A Case Report and Review of the Literature.

We report a rare case of spontaneous suprachoroidal hemorrhage and present a systematic review of the literature using PubMed/Medline databases. Patients that developed a spontaneous suprachoroidal hemorrhage with a history of previous intraocular surgery were excluded. An 82-year-old male patient with no known ocular pathologies or surgical history was referred with acute ocular pain and decreased vision in the right eye (BCVA: 0.6 with hyperopic correction) following a Valsalva maneuver. General history included chronic heart failure and coronary artery disease, treated with anticoagulant and antihypertensive drugs. Dilated fundus examination revealed a posterior red-brown choroidal mass, with a thickness of 1.5 mm on B-scan ultrasonography. The lesion was not visible on fluorescein or indocyanine green angiography and was located under the choroid on B-scan optical coherence tomography. The diagnosis of a spontaneous suprachoroidal hemorrhage was evoked, and the patient was observed. Five months later, BCVA was 1.0 uncorrected, with a normal-appearing fundus. In a literature review, eight cases of spontaneous suprachoroidal hemorrhage following an episode of increased intrathoracic pressure were identified, including our patient. M/F ratio was 1 : 1, with a median age of 66.5 years. All cases presented systemic pathologies. All cases presented with a unilateral suprachoroidal hemorrhage. Only 2/8 patients had ocular comorbidities. Complications requiring treatment were noted in 4/8 cases, including 2 cases that resulted in the loss of the vision following an acute angle-closure glaucoma. Spontaneous resolution of the hemorrhage was observed in the other 4 patients. In 6/8 cases, vision recovered over a mean period of 10 weeks. In conclusion, spontaneous suprachoroidal hemorrhage following a Valsalva maneuver in eyes with no history of ocular surgery or trauma is rare, and has been associated with advanced age, cardiovascular disease and asthma. In severe cases (2/8) the eye was lost, while most cases (6/8) recovered, presenting a good visual outcome.

Volcano explosion in the eye: Expulsive choroidal haemorrhage.

BACKGROUND: This video shows the dreaded complication of expulsive suprachoroidal haemorrhage in a penetrating keratoplasty . It teaches the various measures that help in preventing and managing the challenge peri-operatively. PURPOSE: This video is intended to sensitize the corneal surgeons about this rare complication using real-time surgical video and prepare them to face this challenge by demonstrating the preventive and mitigating strategies. SYNOPSIS: A patient who was suitably taken up for an autokeratoplasty had expulsive choroidal haemorrhage in the non-seeing eye. This complication was managed using glycerin-preserved donor corneal button. Further, the video discusses various pre-operative and intra-operative optimizations to avoid such a complication and mitigate the damage caused by it, should it ever happen during a surgery. HIGHLIGHTS: Expulsive choroidal haemorrhage can be a traumatizing event and one must be mentally prepared to manage it. Pre-operative high-risk factors should always be managed and intra-operative maneuvers performed to prevent the complication, as shown in the video. VIDEO LINK: https://youtu.be/s_ImBugPELw.

Clinical characteristics and mortality rates for suprachoroidal hemorrhage: seven-year experience at a tertiary eye center.

PURPOSE: To investigate comorbidities and medications associated with acute (ASCH) and delayed (DSCH) suprachoroidal hemorrhage (SCH), and to explore visual outcomes and mortality following SCH. METHODS: Retrospective review of SCH cases diagnosed at a tertiary center between 2013 and 2019. Demographics, history, surgery type, visual acuity, intraocular pressure (IOP), and mortality data were reviewed. RESULTS: Fifty eyes of 50 patients experienced SCH related to surgery: 15 (30%) ASCH and 35 (70%) DSCH. Glaucoma surgery was the most common preceding surgery, and SCH was more likely to be delayed in glaucoma surgery relative to other surgeries (p = 0.001). The proportions of patients on anticoagulant, antiplatelet, or NSAID medications were 30% (n = 15), 52% (n = 26), and 12% (n = 6), respectively. The mean preoperative IOP was 25.0 ± 10.2 mmHg. The mean final best corrected visual acuity did not significantly differ between DSCH and ASCH (logMAR 1.92 vs. 2.36; p = 0.39). After controlling for pre-drainage visual acuity, final visual acuity was not statistically significantly different between eyes that were drained versus those that were not drained (p = 0.06). Of all 50 patients, the mortality rate was 12% with a mean time to mortality after SCH of 754 ± 564 days for those who died. CONCLUSION: DSCH was more common than ASCH, with glaucoma surgery being the most common procedure to result in SCH. Visual outcomes and mortality rate were comparable between ASCH and DSCH. Further research is needed regarding the role of surgical drainage on improving visual outcomes in eyes with SCH.

Choroidal hemorrhage, preplaced sutures, and host-over-donor keratoplasty.

An old and currently seldom used technique, true preplaced sutures, is described in a case that was high risk for choroidal hemorrhage (CH). A penetrating keratoplasty technique, termed graft-over-host technique, was used allowing the surgeon to expeditiously close the eye in the event of CH. After partial-thickness trephination, true preplaced sutures through the corneal host tissue were passed. After complete trephination, the corneal donor graft was placed under the host and sutured in a controlled fashion. The preplaced sutures had been drawn immediately, giving a broad secure cover, allowing controlled permanent suturing of the graft while selectively removing the preplaced sutures. When CH occurs, the preplaced sutures allow the surgeon to quickly close the eye securely.

Modified posterior drainage of post-operative suprachoroidal hemorrhage.

PURPOSE: To study the anatomical and functional outcomes of trans-conjunctival 23G or 25G cannula-guided modified posterior passive drainage of post-operative suprachoroidal hemorrhage (SCH). METHODS: A retrospective study was done on 15 eyes in the last nine years. Vitrectomy with perfluorocarbon liquid injection to push SCH from inside along with 23G or 25G cannula-guided passive drainage of SCH was performed by making multiple sutureless posterior sclerotomies at 10-15 mm behind the limbus. Postoperatively, best corrected visual acuity (BCVA), intraocular pressure (IOP), and posterior segment findings were compared from pre-operative findings. RESULTS: Mean age at presentation was 64.93 ± 7.62 years. Complete resolution of SCH with attached retina was achieved in 60% (9/15) of cases. Mean pre-operative BCVA of Log MAR 2.82 ± 0.21 improved to mean post-operative BCVA Log MAR 1.04 ± 0.53 (P < 0.001). Mean pre-operative IOP of 27.87 ± 8.67 mmHg improved significantly to post-operative IOP of 10.2 ± 5.16 mmHg (P < 0.001). Silicone oil removal was possible in 11/15 (73.33%) cases. CONCLUSION: Posterior passive drainage of post-operative SCH by multiple sclerotomies using 23G or 25G cannulas can salvage these eyes with both anatomical and functional recovery.

Experimental Laboratory Modeling of Choroidal Vasculature: A Study of the Dynamics of Intraoperative Choroidal Hemorrhage during Pars Plana Vitrectomy

Objectives: Choroidal hemorrhages (CH) result from rupture of choroidal vessels leading to extravasation of blood into the suprachoroidal space. In this study, we aimed to understand the hemodynamics of CH by developing a purpose-built scale model of the choroidal vasculature and calculating stress levels in the model under different conditions. Materials and Methods: We modeled the choroidal vasculature using a rubber tube 10 cm in length and 1 cm in diameter that was wrapped with conductive thread to enable the measurement of stress at the walls of the tube. Stress levels across the tube were continuously measured under different systemic intravascular blood pressure levels (IVP), intraocular pressure (IOP) levels, and distortion. Results: Stress values across the choroidal vessel model correlated negatively with IOP and positively with IVP and distortion. All correlations were statistically significant (p<0.05) and were stronger when the model was filled with expansile tamponade compared to non-expansile tamponades. Distortion showed the strongest correlation in terms of increasing stress across the model, while IVP showed stronger correlation compared to IOP. Raising IOP to counteract the stress in the model was effective when the stress in the model was secondary to increased IVP, but this approach was not effective when the stress in the model was caused by distortion. Conclusion: Excessive distortion of the globe during surgical maneuvers could be the primary reason for the rarely observed intraoperative CH. Non-expansile ocular tamponade provides better support for the vascular bed against CH and should be the recommended choice of tamponade in patients with existing CH. Increasing IOP excessively is of limited effect in preventing CH in vessels that are under stress as a result of distorting surgical maneuvers.

Suprachoroidal hemorrhage due to Valsalva maneuver, importance of enhanced depth imaging optical coherence tomography in differential diagnosis.

We describe a case report of a spontaneous suprachoroidal hemorrhage, in which the enhanced depth imaging optical coherence tomography (OCT-EDI) is extremely useful in establish the differential diagnosis with a choroidal tumor. A 70 year-old woman was referred with a central scotoma after a Valsalva maneuver. In the posterior pole we observed a grey bilobed subretinal mass with the appearance of a choroidal tumor. OCT-EDI revealed an optically dark region with a scalloped anterior tumor contour and subretinal fluid, the choroicapillaris appeared to be intact and displaced anteriorly. The diagnosis was a suprachoroidal hemorrhage and it resolved in 12 weeks. Spontaneous suprachoroidal hemorrhage is a rare condition and it can resemble choroidal tumor. OCT-EDI is a very valuable tool in the differentiation of hemorrhage from tumors.

Surgical Management of Choroidal Diseases. / Chirurgisches Management bei Erkrankungen der Aderhaut.

Accumulation of serous fluid in the suprachoroidal space, known as uveal effusion, and choroidal or suprachoroidal haemorrhage (SCH) following rupture of ciliary blood vessels are considered rare, but serious, events with extremely poor functional prognosis. As a result, uveal effusion, and expulsive suprachoroidal haemorrhage in particular, continue to be considered as more or less fatal complications. However, clinical experience demonstrates that both clinical entities can be managed by conservative as well as surgical strategies, depending on their severity and localisation, with sometimes surprisingly favourable visual outcome. In addition to prognostic factors, timely recognition and prompt, if possible preventive, acute care, as well as carefully considered timing of adequate surgical measures taking advantage of the specific characteristics of the choroidal tissue, are crucial to treatment success. Along with technical advances in the field of vitreoretinal surgery, numerous variants of therapeutic approaches to the treatment of choroidal effusion and suprachoroidal haemorrhage have been proposed to date. This review presents some of the most important surgical techniques and strategies in the field.

Suprachoroidal hemorrhage associated with pars plana vitrectomy.

PURPOSE: To analyze the characteristics, related risk factors, and prognosis of suprachoroidal hemorrhage (SCH) associated with pars plana vitrectomy (PPV). METHODS: Cases of SCH associated with PPV excluding trauma were retrospectively analyzed in Beijing Tongren Hospital between January 2010 and June 2020. The data collected included general data, myopia status, axial length, state of the crystalline lens, SCH onset time, range, treatment method, visual prognosis, and methods of operation and anesthesia. Patients were divided into those with SCH related to the first PPV (Group 1), and SCH related to second intraocular surgery in the vitrectomized eye (Group 2). Patients were also classified by the SCH onset time into either the expulsive suprachoroidal hemorrhage group (ESCH) and the delayed suprachoroidal hemorrhage group (DSCH). The general data, related risk factors, and the visual prognosis of SCH in the different groups were analyzed. RESULTS: SCH associated with PPV was studied in 28 cases with an incidence of 0.06 %; 16 males and 12 females. The mean age of the patients was (53.51 ± 10.21) years old, the mean follow-up time was (24.94 ± 14.60) days, and the mean axial length was (28.21 ± 3.14) mm. Of these cases, 21 were classified as high myopia, 25 as aphakia/ pseudophakic, and 7 as focal hemorrhage. Silicone oil removal occurred in 12 cases (43 %). Patients in Group 2 were younger than Group 1 (P = 0.005). In terms of treatment and prognosis, 5 eyes were simply closely observed, 4 were given single suprachoroidal drainage, 15 were given suprachoroidal drainage combined with silicone tamponade, 2 underwent anterior chamber puncture, and 2 gave up treatment. A follow-up vision: NLP ~ 20/30; among them, 2 eyes with NLP (7.14 %), 6 of ≥ 20/200 (21.43 %). The final outcomes presented a significantly positive correlation with baseline vision but no significant correlation with age or axial length. CONCLUSIONS: SCH has a higher incidence rate after a second intraocular surgery in a vitrectomized eye which is associated with the lack of vitreous support and easier fluctuation of intraocular pressure. SCH associated with PPV is more localized and has a relatively good prognosis; high myopia and aphakic/ pseudophakic eyes are risk factors. Active treatment can effectively improve visual prognosis. TRIAL REGISTRATION: Retrospective case series study, not applicable.