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  1. 1. Grand Rounds: October 3, 2007 86 yo CF 9 days s/p complete BVI OS c/o 2 days of HA, severe pain OS and in neck by Ali Bright Discussant: Dr. Brian Francis
  2. 2. 86 yo CF 9 days s/p complete BVI OS <ul><li>CC : 2 days of HA, severe pain OS and in neck </li></ul><ul><li>Ocular History : POAG OU </li></ul><ul><li>s/p 2 trabeculectomies OS </li></ul><ul><li>K edema 2nd to PBK OS </li></ul><ul><li>K scar OS </li></ul><ul><li> Blebitis OS </li></ul><ul><li> Vitreous tap Intravitreal Abx injection </li></ul><ul><li>Ocular Meds : Lotemax QID OS, Quixin QID OS, Xalatan once daily OU </li></ul>
  3. 3. <ul><li>PMH : HTN, hypothyroid, arthritis </li></ul><ul><li>Other Surgical History : pituitary adenoma removed </li></ul><ul><li> Hip replacement </li></ul><ul><li> hysterectomy </li></ul><ul><li>Other Meds : Diltiazem, lisinopril, levothyroxine, glucosamine-chondroitin sulfate, multivitamin, Vit B Complex, Vit C, Calcium, fish oil, lecithin </li></ul><ul><li>SH : occ wine, denies smoking and illicit drugs </li></ul><ul><li>Relevant Family History : Mother – glaucoma </li></ul><ul><li>Allergies : sulfa (pruritis) </li></ul>86 yo CF 9 days s/p complete BVI OS
  4. 4. Ocular Exam <ul><li>Pain : 10/10! OS </li></ul><ul><li>VA (cc): OD 20/30 PH to 20/25 </li></ul><ul><li> OS HM </li></ul><ul><li>TP : 15, 23 @ 11:10 a.m. </li></ul><ul><li>Motility, CVF, Pupils : not recorded </li></ul><ul><li>External Exam : WNL </li></ul><ul><li>Conj : OS Baerveldt site superotemp, no bleb </li></ul><ul><li>K : OS diffuse corneal edema with bullae </li></ul><ul><li>AC : shallow OS </li></ul><ul><li>Fundus : no view OS </li></ul>
  5. 5. Differential Diagnosis <ul><li>Choroidal effusion </li></ul><ul><li>Retinal detachment (rhegmatogenous, tractional, exudative) </li></ul><ul><li>Suprachoroidal hemorrhage </li></ul><ul><li>Melanoma or metastatic tumor of the choroid or ciliary body </li></ul>
  6. 6. B-Scan OS
  7. 7. Differential Diagnosis <ul><li>Choroidal melanoma </li></ul><ul><li>A- and B-scan </li></ul>Choroidal melanoma collar button Kissing choroidal serous effusions Exudative Retinal Detachment Tractional RD Rhegmatogenous RD
  8. 8. A-Scan Representative
  9. 9. Plan <ul><li>cyclopegics, analgesics, topical steroids, follow with serial echography </li></ul>
  10. 10. B-Scan OS <ul><li>Plan : retina service consulted; shunt and scleral graft revision with suprachoroidal hemorrhage drainage </li></ul>
  11. 12. Suprachoroidal Hemorrhage Intro <ul><li>Accumulation of blood between the choroid and the sclera </li></ul><ul><li>Normally the suprachoroidal space is an almost virtual space (10 µL) </li></ul><ul><li>Etiology: spontaneous, intraop, 2 nd to intraocular surgery , trauma, or in association with intraocular vascular anomalies </li></ul><ul><li>Limited SCH: suprachoroidal “hematoma” </li></ul><ul><li>Massive SCH: expulsion or apposition </li></ul><ul><li>Feared complication of all ocular surgeries </li></ul><ul><li>Can result in total loss of vision and phthisis </li></ul>
  12. 13. Arterial Supply to the Choroid
  13. 14. Venous Drainage from Choroid
  14. 15. Causes of SCH <ul><li>Impeding vortex vein outflow </li></ul><ul><ul><li>e.g. retrobulbar hemorrhage, retrobulbar anesthesia, pressure during surgery, scleral buckle </li></ul></ul><ul><li>Fluctuation in intraocular fluid dynamics and pressure </li></ul><ul><ul><li>E.g. sudden compression and decompression events </li></ul></ul><ul><li>Hypotony </li></ul><ul><ul><li>leads to choriocapillary effusion, stretching of suprachoroidal space, then tension on and rupture of posterior ciliary vessels (esp long) </li></ul></ul><ul><ul><li>E.g. decompression hypotony </li></ul></ul>
  15. 16. Surgery Associated with SCH (Chu and Green meta-analysis, 1999) Surgery Type % expulsive SCH (# patients) % delayed SCH (#patients) CE/IOL Placement 0.05-0.2% (~100,000) 0.06-0.81% (~6000) Corneal 0.087-1.08% (945) Glaucoma 0.15% (1329) 1.6-6.1% (~10,000) Vitreoretinal 0.41-1.0% (3710)
  16. 17. Risk Factors <ul><li>Systemic : advanced age, arteriosclerosis, DM HTN, anticoagulation, ischemic heart disease </li></ul><ul><li>Ocular : previous laser photocoagulation, ocular surgery (esp PPV), aphakia, glaucoma , uveitis, high myopia , recent trauma </li></ul><ul><li>Intraoperative : high IOP, high myopia, open-sky procedures, Valsalva maneuvers, intraoperative tachycardia, sudden drop in IOP, vitreous loss, bucking </li></ul><ul><li>Post-op : after scleral buckle with vitrectomy, postoperative trauma, ocular hypotony, Valsalva, TPA administration </li></ul>
  17. 18. Intraoperative Signs and Symptoms <ul><li>sudden onset of severe intraoperative pain </li></ul><ul><li>excessive iris movement or prolapse </li></ul><ul><li>forward movement of lens and vitreous body </li></ul><ul><li>darkening/loss of red reflex </li></ul><ul><li>excessive bleeding of conjunctiva and episclera </li></ul><ul><li>vitreous hemorrhage </li></ul><ul><li>tachycardia </li></ul><ul><li>retinal detachment </li></ul><ul><li>choroidal elevation protruding into operative field </li></ul><ul><li>expulsion of intraocular contents </li></ul>
  18. 19. SCH Signs
  19. 20. Management of Delayed SCH <ul><li>Limited choroidal hemorrhage </li></ul><ul><ul><li>usually resolves spontaneously in 1–2 months without damage </li></ul></ul><ul><ul><li>conservative: cycloplegics and topical corticosteroids </li></ul></ul><ul><ul><li>reduce over-filtration and hypotony </li></ul></ul><ul><li>Delayed, massive choroidal hemorrhage </li></ul><ul><ul><li>systemic corticosteroids + observe with serial ultrasonography or </li></ul></ul><ul><ul><li>surgery 7-14 days post-hemorrhage </li></ul></ul>
  20. 21. SEROUS CHOROIDAL DETACHMENT HEMORRHAGIC CHOROIDAL DETACHMENT Low IOP High IOP Transilluminates No transillumination Usually no pain Almost always painful despite analgesia Usually pre-equatorial may be more voluminous posterior to equator Resolution usually within 3 weeks Liquefies 6-26 days; resorbs ~4 weeks-several months Resolves without change in visual acuity Usually results in vision loss
  21. 22. When to Operate on SCH <ul><li>Lens-cornea touch </li></ul><ul><li>Kissing choroidals (controversial) </li></ul><ul><li>Massive choroidal hemorrhage with severe pain </li></ul><ul><li>Persistently elevated intraocular pressure </li></ul><ul><li>Persistently flat AC </li></ul><ul><li>SCH under macula   </li></ul><ul><li>Extension of hemorrhage into the subretinal space or vitreous cavity </li></ul><ul><li>Significant vitreous incarceration </li></ul><ul><li>Retinal incarceration </li></ul><ul><li>Preferably after liquefaction of clots </li></ul>
  22. 23. Management of Intraoperative Massive Choroidal Hemorrhage <ul><li>Tamponade bleeding vessel with direct digital pressure on open wounds and rapid wound closure </li></ul><ul><ul><li>Prevent loss of intaocular contents and incarceration </li></ul></ul><ul><li>Reform anterior chamber e.g. with viscoelastic </li></ul><ul><li>After PK, consider temporary keratoprosthesis </li></ul><ul><li>Posterior sclerotomy intraop only if necessary to allow for wound closure </li></ul><ul><ul><li>Reduces tamponading effect of sealing the eye and may result in larger SCH </li></ul></ul><ul><li>Post-op: control IOP, inflammation and pain </li></ul>
  23. 24. Vitreoretinal Surgical Approach <ul><li>For SCH + RD, vitreoretinal traction, vitreous hemorrhage, and/or dislocated lens fragments </li></ul><ul><li>sequence of surgical maneuvers is extremely important </li></ul><ul><ul><li>PP approach may damage anterior retina </li></ul></ul><ul><li>Perfluorocarbons can aid in flattening choroid and retina </li></ul><ul><li>Long-acting intraocular gas or silicone oil may allow earlier visual rehabilitation and provide long-term tamponade </li></ul>
  24. 25. Controversy Over Management of Kissing Choroidals <ul><li>Perform surgery on all kissing choroidals (Berrocal and Reynolds) </li></ul><ul><li>Observe unless apposition remained >2 weeks out from SCH occurrence (Scott et al) </li></ul><ul><li>Operate if SCH involves >2 quadrants posterior to equator, or has kissing choroidals or SCH extending into macula (Meier and Wiedemann) </li></ul><ul><li>Case-by-case approach (Chu et al) </li></ul>
  25. 26. Other Controversial Surgical Issues <ul><li>Most surgeons leave sclerotomies open </li></ul><ul><li>Some suture them closed (Meier and Wiedemann) </li></ul><ul><li>Favor surgical intervention after delayed SCH (Cannon et al, Abrams et al, Lakhanpal et al, Gressel et al, and Frenkel and Shin) </li></ul><ul><li>After delayed SCH: observation + medical management = surgical intervention (Scott et al and Chu et al) </li></ul><ul><li>Re-operate early after expulsive intraoperative SCH (Welch et al) </li></ul><ul><li>No benefit of a second surgery in 9/9 patients following intraop expulsive SCH (Scott et al) </li></ul>
  26. 27. Post-op Course <ul><li>VA: OS – HM </li></ul><ul><li>TA: OS – 5 mmHg </li></ul><ul><li>Assessment: hypotony, SCH resolving, serous retinal detachment likely involving macula </li></ul>
  27. 28. Course and Outcome <ul><li>Good prognosis more likely in: </li></ul><ul><ul><li>Delayed, limited hemorrhage, especially > 7 days after inciting surgery </li></ul></ul><ul><ul><li>SCH resulting from cataract surgery </li></ul></ul><ul><ul><li>Higher visual acuity just after SCH </li></ul></ul><ul><li>Poor prognosis more likely if: </li></ul><ul><ul><li>Retinal detachment </li></ul></ul><ul><ul><li>Hemorrhage in all 4 quadrants </li></ul></ul><ul><ul><li>Extension into posterior pole </li></ul></ul><ul><ul><li>Vitreous and/or retinal incarceration </li></ul></ul><ul><ul><li>Low visual acuity just after SCH </li></ul></ul>
  28. 29. Review <ul><li>Etiology, signs and symptoms, risk factors, and incidence of SCH </li></ul><ul><li>B-scan is a useful diagnostic tool </li></ul><ul><ul><li>Follow patient with serial echography </li></ul></ul><ul><li>When to operate vs. manage conservatively </li></ul><ul><li>How to handle limited, massive intraoperative, and delayed SCH </li></ul><ul><li>Prognosis </li></ul>
  29. 30. Acknowledgements <ul><li>Dr. Brian Francis </li></ul><ul><li>Dr. Sheila Mahdaviani </li></ul><ul><li>Dr. Vikas Chopra </li></ul><ul><li>Dr. Amani Fawzi </li></ul><ul><li>Lida Asatryan </li></ul>
  30. 31. Resources <ul><li>“ B-Scan Imaging With 10 MHz Probe.” </li></ul><ul><li>Chu TG, Green RL. “ Suprachoroidal hemorrhage” . Surv Ophthalmol. 1999;43:471-486. </li></ul><ul><li>Eye Text. http:// =16&sectionID=&PHPSESSID=4fcc71a83eaef46e34b.html </li></ul><ul><li>Feretis E, Mourtzoukos S, Mangouritsas G, Kabanarou SA, Inoba K, Xirou T. </li></ul><ul><li>“ Secondary management and outcome of massive suprachoroidal hemorrhage”. </li></ul><ul><li>Eur J Ophthalmol . 2006 Nov-Dec;16(6):835-40. </li></ul><ul><li>Healey PR, Herndon L, Smiddy W. Management of suprachoroidal hemorrhage. </li></ul><ul><li>J Glaucoma . 2007 Sep;16(6):577-9. </li></ul><ul><li>Jordan, Jens F. MD; Engels, ... Gunter K. MD. “ A Novel Approach to Suprachoroidal Drainage for the Surgical Treatment of Intractable Glaucoma”. Journal of Glaucoma . 15(3):200-205, June 2006. </li></ul><ul><li>Meier, P. and Wiedemann, P . “ Massive suprachoroidal hemorrhage secondary treatment and outcome”. Graefes Arch Clin Exp Ophthalmol. 238 (2000), pp. 28–32. </li></ul><ul><li>Moshfeghi, D., Kim, B., Kaiser, P., Sears, J., Scott, D., Smith. “Appositional Suprachoroidal Hemorrhage: A Case-Control Study”. Am J of Opthalmology . 2004, Dec ;138:959-63. </li></ul><ul><li>“ OTI-Scan 3D - 3D B & Scan - Ophthalmic Ultrasound B-Scan Images.” Ophthalmic Technologies Inc. </li></ul><ul><li> </li></ul><ul><li>Sharma YR, Gaur A, Azad RV. Suprachoroidal haemorrhage. Secondary management. Indian J Ophthalmol 2001;49:191-2. </li></ul><ul><li>Vrabec, T. “Exudative retinal detachment in Behçet's disease” . Arch Ophthalmol . 2001;119:1383- 1386. </li></ul><ul><li>Wang LC, Yang CM, Yang CH, Huang JS, Ho TC, Lin CP, Chen MS. “Clinical characteristics and visual outcome of non-traumatic suprachoroidal haemorrhage in Taiwan”. Acta Ophthalmol . 2008 Jul 8. </li></ul><ul><li>WuDunn D., Ryser D., Cantor LB. “Surgical drainage of choroidal effusions following glaucoma surgery”. J Glaucoma . 2005 Apr;14(2):103-8. </li></ul><ul><li>Yanoff et al. Ophthalmology, 2nd Ed. St. Louis, MO: Mosby, 2004. </li></ul>
  31. 32. Acknowledgements <ul><li>Dr. Brian Francis </li></ul><ul><li>Dr. Sheila Mahdaviani </li></ul><ul><li>Dr. Vikas Chopra </li></ul><ul><li>Dr. Amani Fawzi </li></ul><ul><li>Lida Asatryan </li></ul>
  32. 33. Surgical Technique
  33. 34. Which of the following is not a risk factor for suprachoroidal hemorrhage? <ul><li>Hypertension </li></ul><ul><li>Diabetes </li></ul><ul><li>Aphakia </li></ul><ul><li>Glaucoma </li></ul><ul><li>Inflammation </li></ul><ul><li>A: Inflammation </li></ul>
  34. 35. Which Is Not a Clear Indication for Surgically Draining a SCH? <ul><li>If the lens and cornea are touching </li></ul><ul><li>Persistent elevation of intraocular pressure </li></ul><ul><li>Suprachoroidal hemorrhage + serous retinal detachment </li></ul><ul><li>Persistently shallow AC </li></ul><ul><li>Vitreous incarceration </li></ul><ul><li>Answer: SCH + serous retinal detachment </li></ul>
  35. 36. Which of these blood vessels do not supply the choroid? <ul><li>A. Short posterior ciliary arteries </li></ul><ul><li>B. Long posterior ciliary arteries </li></ul><ul><li>C. Anterior ciliary arteries </li></ul><ul><li>D. Central retinal artery </li></ul><ul><li>E. A and D </li></ul><ul><li>F. All of the above supply the choroid </li></ul><ul><li>Answer: E </li></ul>
  36. 37. When is the best time to operate for SCH? <ul><li>Within a few days of the hemorrhage </li></ul><ul><li>7-14 days </li></ul><ul><li>14-21 </li></ul><ul><li>4-5 weeks </li></ul><ul><li>After 2 months </li></ul><ul><li>Answer 7-14 days </li></ul>