Author: Serkan Ozen (Turkey)
Co-authors: Hasan Burhanettin Kaptı
Purpose
We aimed to perform etiologic analysis by presenting the development of suprachoroidal hemorrhage while applying the surgical approach consisting of dislocated intraocular lens extraction and scleral fixation intraocular lens implantation in an eye that had previously undergone vitrectomy. We tried to determine the preoperative and intraoperative risks. We also presented the drainage of suprachoroidal hemorrhage from a trocar in addition to the conventional scleral incision method.
Setting/Venue
72-year-old male patient with a medical history of irregular antihypertensive, anticoagulant and antidepressant use was admitted to our clinic with the complaint of sudden atraumatic vision loss in his right eye.The patient had undergone 2 vitrectomies (without cerclage) in 2004 for recurrent retinal detachment under silicone oil in another center.The silicone was then removed without any complications.On examination, the pupil was fixed and mid-dilated, the intraocular single-piece lens with its capsular support was dislocated and moving on stabile retina.There were nondetached retinal folds near ora-serrata, suggesting a suspicion of previously performed retinectomy or retinotomy.The rest of ocular exam was normal.
Methods
Dislocated iol removement with using decalin in a vitrectomy set up and scleral fixation iol implantation was planned. Interestingly, one of the haptics of the lens was captured in the angle area on the day of the operation, as the dropped iol was mobile. This situation gave us the advantage of holding the lens without using a decaline during the operation. Under local anesthesia, a 23G infusion trocar was inserted at 7 o'clock, at this stage one of the IOL haptics was at the angle.A straightened rycroft was entered through the infusion trocar and luxated iol was pushed upwards from posterior to the anterior chamber. The IOL was taken out through the enlarged corneal incision. While preparing the scleral lens with PC9 suture, the trocar was removed, and sclera was closed.Tonus was provided by giving viscoelastic and scleral fixation iol was implanted with PC9 passing from 2 and 7 o'clock area.While attempting to centralize the lens, loss of retinal reflex was observed, the lens was removed immediately.Viscoelastic was given from the corneal incision for preventing bulging of choroid.Unfortunately,the injected viscoelastic refluxed from corneal incision.Primary closure of the cornea was rapidly made, as it was observed that there was expulsive bleeding.
Results
He was closely monitored with topical steroids, antibiotics and antiglaucomatous drops. He received oral steroids in decreasing posology for 10 days.In severe IOP crises, IV mannitol was given. Daily follow-up of choroidal hematoma was done by USG. Kissing choroidal appearance did not regress, but it was seen that the brightness in the ultrasonographic density of the hematoma started to decrease showing signs of clot liquefaction. According to USG follow-up on the postoperative 14th day, the kissing choroid continued and IOP control deteriorated and the patient was re-operated.After placing infusion in the anterior chamber, suprachoroidal bleeding was drained from 4 and 10 o'clock with an oblique trocar at a distance of 8MM to the limbus with scleral entry and drainage. Afterwards, the retina and choroid normalized within 2 weeks, but the IOP was hypotonic with values in the range of 4-7 mmhg in monthly follow-up.
Conlusions
Suprachoroidal (Expulsive) hemorrhage is a devastating and dramatic process for the surgeon and the patient. When the clues of this devastating complication are analyzed based on this case and other experiences in the literature; it should be kept in mind that the risk of suprachoroidal bleeding may develop in the following situations and the retinal reflex should be controlled during surgery as a precaution:1- In cases with previous retinal surgery including silicone injection and removal procedures; 2- In cases with impaired posterior capsule integrity; 3- In cases with intraocular lens dislocation and aphakia; 4- In elderly patients receiving hypertensive and anticoagulant therapy; 5- In cases with prolonged combined surgical procedures who were under local anesthesia (Retro-bulbar). Performing the procedure under general anesthesia in stressful patients who are straining, coughing; paying attention to intraoperative hypotonia; avoiding rough, high-moment pushing-pulling actions in contact with the eye are also important issues that can reduce the likelihood of this insidious complication.
Financial Disclosure
NONE
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