Suprachoroidal haemorrhage during pars plana vitrectomy with intraocular foreign body extraction

Author: Sergio Matas Granados (Spain)

Co-authors: Amparo Toro Fernández, Juan De Las Morenas Iglesias

Purpose

To report an unusual occurrence of an intraoperative acute suprachoroidal haemorrhage during a small-gauge pars plana vitrectomy (PPV) with intraocular foreign body (IOFB) extraction.

Setting/Venue

A 32 year old male with ocular trauma was programmed for an IOFB extraction. We were forced to stop the surgery because of an airway obstruction during the general anaesthesia without time to close the sclerotomies, resulting in a suprachoroidal haemorrhage.

Methods

We review the case of a male with IOFB scheduled for PPV with foreign body removal. General anaesthesia was induced with laryngeal mask. Initially the surgery proceeded without complications. Firstly, we performed a pars plana lensectomy. We proceeded with 23-gauge PPV, inducing a posterior vitreous detachment and removing the IOFB successfully through an enlarged sclerotomy. We were applying endolaser under air when suddenly we were forced to stop the surgery without time to close the sclerotomies. The anaesthesiologist indicated that there was a severe problem with the airway and the patient had to be awakened from the anaesthesia. The extubation of the patient caused a severe Valsalva phenomenon causing a 360 degrees suprachoroidal haemorrhage. This situation was managed by placing the infusion line in the anterior chamber, introducing perfluorocarbon liquid in vitreous cavity with the purpose of flattening the choroidal detachment, applying peripheral photocoagulation in order to cover any retinal tear, and silicone oil tamponade through the anterior chamber.

Results

After two weeks of follow-up, checking the intraocular pressure and ultrasound control of posterior pole, we scheduled a new intervention. The patient had a complete hyphema so we had to wash it out. We extracted silicone oil and checked the state of the fundus under local anaesthesia. We observed that the retina was attached and the suprachoroidal haemorrhage had been reabsorbed spontaneously. At present, the visual acuity of the patient is 0.1 and he is waiting for a secondary intraocular lens implant in sulcus.

Conlusions

Suprachoroidal haemorrhage induced by Valsalva phenomenon during PPV under general anaesthesia may cause dramatic sight-threatening visual damage. Small gauge vitrectomy with valved cannulas may allow better control of the intraocular pressure in a closed system although it is not always possible under certain circumstances as in this case with IOFB extraction. In our case, both severe hypotony and increased central venous pressure generated by the Valsalva phenomenon, seem to be responsible for the rupture of the vessels and the suprachoroidal haemorrhage. We suspect that this rupture could have been caused either by a sudden increase in the transmural pressure gradient or by a choroidal effusion that stretched and tore these choroidal vessels. Local anaesthesia could be more appropriate in these cases in order to avoid a suprachoroidal haemorrhage.

Financial Disclosure

NONE