Clinicopathological study on suprachoroidal and supraciliary hemorrhage during enucleation

PURPOSE: To investigate the pathogenesis of suprachoroidal and supraciliary hemorrhage that might have been induced during enucleation. METHODS: A histopathological examination of 392 enucleated eyeballs was carried out and 8 eyeballs with suprachoroidal and supraciliary hemorrhage were selected for further clinicopathological examination. RESULTS: Among 14 eyeballs with severe acute intraocular inflammation, 7 eyeballs with suprachoroidal and supraciliary hemorrhage were found and one other such eyeball was seen among 53 with neovascular glaucoma. Among these 8, there was one case of prolapse of intraocular tissue with severe hemorrhage into the suprachoroidal and supraciliary spaces; 4 cases of severe hemorrhage into the suprachoroidal and supraciliary spaces without prolapse of intraocular tissue; and 3 cases of mild hemorrhage into the suprachoroidal or supraciliary spaces. CONCLUSIONS: In the eyeballs with severe acute intraocular inflammation, intraocular pressure was elevated and the blood vessels were weakened by inflammatory cell infiltration. During enucleation external forces affected the blood vessel wall of the ciliary arteries and vortex veins, and the breakdown of vessel walls might have been the cause of the suprachoroidal and supraciliary hemorrhage.     

Spontaneous suprachoroidal hemorrhage secondary to thrombolysis for the treatment of myocardial infarction

Suprachoroidal haemorrhage occurs most commonly as an intraoperative or a postoperative complication of ocular surgery. Spontaneous suprachoroidal haemorrhage is rare. Herein a case is described of spontaneous suprachoroidal haemorrhage in a patient who received recombinant tissue plasminogen activator for the treatment of a myocardial infarction. Systemic thrombolysis may induce spontaneous suprachoroidal haemorrhage. Prompt diagnosis and treatment can improve the likelihood of a favourable visual outcome. To the authors' knowledge, there have been only three previous reports in the literature of spontaneous suprachoroidal haemorrhage secondary to thrombolysis.     

Use of perfluoroperhydrophenanthrene in the management of suprachoroidal hemorrhages.

BACKGROUND: Suprachoroidal hemorrhage may cause the expulsion of intraocular contents. Generally, cases of nonexpulsive suprachoroidal hemorrhage have a better outcome than their expulsive counterparts. Those cases with massive nonexpulsive suprachoroidal hemorrhage do better with treatment than without. Treatment modalities have included suprachoroidal hemorrhage drainage with or without intraocular volume reformation, and vitrectomy. METHODS: The authors used the liquid perfluorocarbon perfluoroperhydrophenanthrene in the treatment of three patients with nonexpulsive suprachoroidal hemorrhage. The perfluorocarbon was injected into the vitreous cavity while the suprachoroidal blood was drained through anterior sclerotomies. RESULTS: With 5 months of follow-up, complete resolution of the suprachoroidal blood was noted in all patients. All three patients had attached retinas, and postoperative visual acuities were improved over preoperative visual acuities. CONCLUSION: Perfluoroperhydrophenanthrene and other perfluorocarbon liquids may be beneficial in the treatment of certain cases of nonexpulsive suprachoroidal hemorrhages.     

A novel approach to suprachoroidal drainage for the surgical treatment of intractable glaucoma

PURPOSE: In glaucoma surgery, scarring of the artificial fistula is the limiting factor for long-term control of intraocular pressure (IOP). Several devices and surgical techniques have been developed for artificial aqueous humor drainage in intractable glaucoma. The authors describe a novel surgical technique that uses a silicone tube as a shunt for aqueous flow from the anterior chamber to the suprachoroidal space. PATIENTS AND METHODS: Thirty-one eyes of 31 patients with uncontrollable refractory glaucoma were included in this prospective consecutive case-control study. Each eye had undergone an average of 3.5+/-1.9 previous interventions for glaucoma. The baseline IOP was 44.25+/-8.7 mm Hg despite maximum therapy. As in trabeculectomy, a limbus-based scleral flap was prepared. The suprachoroidal space was accessed via a deep posterior scleral flap. The silicone tube was inserted as an intrascleral connection from the anterior chamber to the suprachoroidal space. Cyclodialysis was avoided by this surgical approach. Success was defined as a lowering of IOP to below 21 mm Hg without the need for further medication or intervention. RESULTS: The mean functional shunt survival was 55.9+/-45.6 weeks. IOP was reduced to 12.9+/-5.2 mm Hg in 70% of all eyes after 30 weeks postoperatively. After 52 weeks, 60% of the eyes could be classified as representing success, and 76 weeks after surgery, 40% of the eyes still showed controlled IOP. In none of the eyes were severe postoperative hypotony or suprachoroidal bleeding observed. No localized or general inflammation or infection was seen in connection with the silicon tube. Two patients needed anterior chamber lavage because of bleeding. In 2 patients the tube had to be removed because of corneal endothelial contact. Shunt failure of the tube was caused in some cases by connective tissue formation at the posterior lumen of the tube. CONCLUSION: This novel surgical approach and the placement of the silicone tube described here have several advantages. Its intrascleral course minimizes the risk of conjunctival erosion and associated infections. No cyclodialysis is performed. Connection to the suprachoroidal space exploits the resorptive capability of the choroid. It guarantees drainage but also provides a natural counterpressure, avoiding severe postoperative hypotony. The suprachoroidal shunt presented here achieves good follow-up results in terms of IOP control. No serious complications have been observed. This new method promises to be an effective surgical technique and presents a new therapeutic option in intractable glaucoma. Fibroblast reaction obstructing the posterior lumen, seemed to be the only factor limiting drainage. Further studies and experiments will be needed to elucidate the exact physiologic mechanisms underlying the draining, the capacity and duration of the draining effect, and the histologic background of suprachoroidal scarring.     

Suprachoroid hemorrhage without the connection to the surgical procedure

The aim of our report is to present 2 cases of patients with suprachoroidal hemorrhage (SH). Suprachoroidal hemorrhage occur relatively infrequently and in our cases are not associated with the surgery or postoperative period. The first case was a patient with suprachoroidal hemorrhage following spontaneous corneal penetration after corneal ulcer. The second case was a patient with a suprachoroidal hemorrhage after severe contusion of the eye globe. The most important is rapid diagnosis of disease, differentiation from other eye diseases and initiation of therapy. We discuss clinical symptomatology, diagnostic and treatment of suprachoroidal hemorrhage.     

Hydrostatic pressure of the suprachoroidal space

The hydrostatic pressure of the suprachoroidal space was measured in 18 cynomolgus monkey eyes by one of two methods: (1) direct cannulation, or (2) silicone sponge implantation. The intraocular pressure (IOP) and suprachoroidal pressure were monitored simultaneously with the IOP being held at various levels between 5 and 60 mm Hg. In eyes with direct cannulation, at an IOP of 15 mm Hg, the pressure in the anterior suprachoroidal (supraciliary) space was 0.8 +/- 0.2 mm Hg (n = 6, mean +/- SE) below the IOP, but the posterior suprachoroidal pressure was 3.7 +/- 0.4 mm Hg (n = 8) below the IOP. The suprachoroidal pressure in eyes with silicone sponge implant was 4.7 +/- 0.6 (n = 7) mm Hg below the IOP. A change in IOP produced a corresponding change in the supraciliary space pressure. However, the pressure difference between the anterior chamber and the posterior suprachoroidal space increased at higher IOP. This pressure differential is the driving force for uveoscleral outflow.     

Use of novel devices for control of intraocular pressure

This brief review in honor of Douglas Johnson, MD describes the rationales and initial clinical outcomes in studies to date on Trabectome^®, Glaukos iStent™, iScience (canaloplasty), and Solx (suprachoroidal shunt), all newly developed surgical technologies for treatment of open-angle glaucomas. These new approaches to angle surgery have been demonstrated in preliminary case series to safely lower IOP in the mid-teens with far fewer complications than expected with trabeculectomy and without anti-fibrotics. Trabectome and iStent are relatively non-invasive, aim to improve access of aqueous to collector channels and do not preclude subsequent standard surgery. Canaloplasty, modified from viscocanalostomy, is thought to improve trans-trabecular flow. Solx potentially offers an adjustable aqueous outflow into the suprachoroidal space.     

Serous supraciliochoroidal effusion after trabeculotomy <Emphasis Type="Italic">ab externo</Emphasis>

A 20-year-old man underwent uneventful trabeculotomy ab externo for open-angle glaucoma. One week postoperatively, ultrasound biomicroscopy (UBM) revealed annular serous ciliochoroidal effusion and communicating fluid pass between the suprachoroidal space and excisted trabecular meshwork. Four months after surgery, intraocular pressure was well controlled without medication. The UBM revealed suprachoroidal effusive space and no fluid pass. Suprachroidal effusion should be considered a possible complication after trabeculotomy ab externo. The authors have stated that they do not have a significant financial interest or other relationship with any product manufacturer or provider of services discussed in this article.     

Choroidal vascular permeability in visually regulated eye growth

The choroidal thickness fluctuates both diurnally and in response to changes in visual input. The fluctuations may represent a physiologic means of aligning the retinal photoreceptors with the focal position of distant images during the emmetropization process. To evaluate the basis for choroidal thickness changes, we studied the sources of the extravascular fluid in the chick choroid in two visually-regulated ocular growth conditions: accelerated ocular growth in goggle-induced form-deprivation myopia and ocular growth retardation in the recovery from myopia after goggle removal. Two week old chicks, controls, myopic and those recovering from myopia, received fluorescein dextran (MW = 140,000) as a tracer. It was given by intravenous injection to identify a potential vascular pathway and by intracameral injection to identify a potential pathway from the anterior chamber to the suprachoroidal space. Using a microscopically positioned needle, clear fluid was aspirated from the suprachoroidal space of the enucleated chick eye; this fluid presumably corresponds to the contents of the lacunae, prominent lymphatic-like structures of the chick choroid. Plasma, aqueous humor and suprachoroidal fluid were sampled 1 hr after injection and assayed for both protein content and the tracer dye. Sulfated glycosaminoglycans were assayed in the suprachoroidal fluid, choroid and sclera under each experimental condition. In control chicks, aqueous humor and suprachoroidal fluid protein concentrations were about 0.8 and 9% of plasma levels respectively. Aqueous humor protein concentration was unaltered in myopic or recovering eyes. Suprachoroidal fluid protein concentration in myopic eyes fell dramatically to 1.5% of plasma levels (P < 0.001). In contrast, recovery from myopia led to a marked increase in suprachoroidal fluid protein level to 30% of that in plasma (P < 0.001). None of the procedures affected suprachoroidal fluid protein in the contralateral control eyes. In all three groups of chicks, fluorescein dextran distribution in the suprachoroidal fluid at 1 hr after intravenous injection tracked protein levels, with reduced levels in myopic eyes and elevated levels in recovering eyes. After intracameral injection, suprachoroidal fluid dextran levels were higher in injected eyes of control chicks (P < 0.01) and in recovering eyes (P < 0.001) but lower in myopic eyes (P < 0.01), compared to the levels in the respective contralateral non-injected eyes in each group. Sulfated glycosaminoglycan levels were at the limits of detection in the suprachoroidal fluid under all conditions and, on a whole choroid basis, were unaltered in the choroid in either myopia or recovery. Suprachoroidal fluid is lymph-like in nature and largely derives from plasma. Sulfated glycosaminoglycan levels do not seem to regulate the fluid content of the choroid in either myopia or recovery. Instead, the changes in protein and marker dye levels in myopic and recovering eyes suggest markedly altered choroidal circulatory dynamics and capillary permeability in both conditions.     

Suprachoroidal hemorrhage during pars plana vitrectomy

Suprachoroidal hemorrhage is an uncommon but serious complication of pars plana vitrectomy that can be associated with a guarded visual prognosis. Risk factors for development of suprachoroidal hemorrhage during pars plana vitrectomy include high myopia, history of previous retinal detachment surgery, rhegmatogenous retinal detachment, use of cryotherapy, scleral buckling at the time of pars plana vitrectomy, external drainage of the subretinal fluid, intraoperative systemic hypertension, and bucking during general anesthesia. In eyes with suprachoroidal hemorrhage during pars plana vitrectomy, the final visual and anatomic outcomes may be compromised by persistent retinal detachment, secondary glaucoma, and ocular hypotony. In most cases, intraoperative drainage of suprachoroidal hemorrhage is not associated with a better outcome. The prognosis is more favorable if the suprachoroidal hemorrhage is localized and does not extend in to the posterior pole.     

Management of Delayed Suprachoroidal Hemorrhage after Glaucoma Surgery

ABSTRACT

Purpose: To review the most current treatment recommendations and outcomes for delayed suprachoroidal hemorrhages. Methods: Article review of management and outcomes of suprachoroidal hemorrhages, with emphasis on delayed suprachoroidal hemorrhages in the setting of glaucoma surgery. Conclusion: Time of drainage of suprachoroidal hemorrhages remains controversial. Earlier drainage should be considered with high intraocular pressure, expulsion of intraocular content, or retinal detachment. In clinically stable eyes with suprachoroidal hemorrhage, recommendations range from observation to immediate drainage. Clot lysis occurs at roughly 14 days.     

暴发性脉络膜上腔出血的研究进展

暴发性脉络膜上腔出血（expulsive suprachoroidal hemorrhage,ESCH）是内眼手术少见的最严重并发症之一,可累及睫状体、玻璃体、视网膜,可致视力完全丧失。其发病机制尚不清楚,但与脉络膜组织成分及血供相关。既往研究表明,ESCH最重要的诱发因素之一是眼压突然下降,多出现于白内障、青光眼、玻璃体切除手术的术中及术后。眼部B超可诊断ESCH,并且可观察脉络膜上腔凝血液化的程度,这有助于明确手术时机。手术是ESCH最重要的治疗方式,早期行脉络膜上腔引流手术可挽救残存视力,但不同引流方式的效果存在争议。术前重视危险因素管理,术中谨慎操作,及时发现并有效处理可避免ESCH的严重后果。（国际眼科纵览,2022, 46：522-527）     

The evaluation of incidence of massive suprachoroidal hemorrhage n the material of the Department of Ophthalmology,Medical Academy in Bialystok from 1990 to 2000

PURPOSE: Massive suprachoroidal hemorrhage is a well-known, possibly serious complication of many surgical procedures, including cataract extraction, glaucoma-filtering procedures, penetrating keratoplasty, retinal detachment surgery and pars plana vitrectomy. The aim of our study is evaluation of the incidence of massive suprachoroidal hemorrhage among patients operated in Department of Ophthalmology, Medical Academy in Bia?ystok from 1990 to 2000. MATERIAL AND METHODS: From 1990 to 2000, 6225 intraocular operations, including 5541 cataract extractions, 195 glaucoma-filtering surgeries, 438 retinal detachment surgeries and 51 multiprocedure surgeries were performed. The criteria for diagnosis were the intraoperative signs of suprachoroidal hemorrhage (shallowing of the anterior chamber, increasing of the intraocular pressure, iris prolapse, expulsion of the lens and vitreous, retinal and choroidal elevation and loss of the red reflex) and postoperative ultrasonic examination. RESULTS: 18 eyes were identified with massive suprachoroidal hemorrhage, including 16 eyes during cataract extraction and 2 eyes during filtering procedures. The incidence of suprachoroidal hemorrhage for all intraoperative surgeries was 0.29%. It occurred in 0.28% of cataract surgeries and 1.02% of glaucoma filtering procedures. There were no incidence of suprachoroidal hemorrhage during retinal detachment surgeries. CONCLUSION: A massive suprachoroidal hemorrhage is a relatively rare complication of intraocular operations. Most frequently it is associated with glaucoma filtering surgery.     

Hemorragia supracoroidea diferida después de queratoplastia endotelial automatizada con pelado de la membrana de Descemet (DSAEK)

This study, a case series of 2 patients and a literature review, aims to describe the second and third known cases of delayed suprachoroidal hemorrhage after Descemet stripping automated endothelial keratoplasty (DSAEK). The suprachoroidal hemorrhage is defined as the presence of blood in the suprachoroidal space; final visual acuity is rarely greater than 0.1 (decimal scale). Both cases presented had known risk factors: high myopia, previous ocular surgeries, arterial hypertension, and being under anticoagulant therapy. The diagnosis of delayed suprachoroidal hemorrhage was made at the 24-hour follow-up visit, as they recalled a sudden and tremendous acute pain hours after surgery. Both cases were drained through a scleral approach.Delayed suprachoroidal hemorrhage is a rare but devastating consequence that can occur after DSAEK. Awareness of the most critical risk factors allows for early identification, which is of paramount importance for the prognosis of these patients.     

Suprachoroidal seton implantation in refractory glaucoma: a novel surgical technique

PURPOSE: To describe a new surgical technique in which aqueous humor is diverted from the anterior chamber to the suprachoroidal space for the augmentation of uveoscleral outflow in the management of refractory glaucoma. METHODS: Four painful-blind eyes of four consecutive patients were included in the study. Mean age of patients was 54.7+/- 9.2 years. Preoperative diagnosis was neovascular glaucoma complicating diabetic retinopathy in three cases and chronic angle-closure glaucoma in one case. Mean preoperative intraocular pressure of the patients receiving two medications was 58.5 +/- 9.2 mm Hg. A modified Krupin eye valve with disk was implanted into the suprachoroidal space. The anterior tube part of the Seton device was placed into the anterior chamber through the long scleral tunnel for draining the aqueous humor from the anterior chamber to the suprachoroidal space. RESULTS: The placement of modified Krupin eye valve with disk to the suprachoroidal space was achieved in all cases. While mean preoperative intraocular pressure was 58.5 +/- 9.2 mm Hg, it was 14.2 +/- 4.7 mm Hg at postoperative one week. It was 13.5 +/- 4.6 mm Hg and 15 +/- 4.9 mm Hg at one and three months respectively. At the last follow-up visit, mean intraocular pressure was 17.25 +/- 5.37 mm Hg ranging from 12 to 24 mm Hg. Choroidal detachment was developed in one case and regressed in six weeks. Rubeosis irides regressed at third month in three cases. None of the eyes developed suprachoroidal hemorrhage, retinal detachment, or phthisis bulbi. CONCLUSION: The drainage of aqueous humor from the anterior chamber to the suprachoroidal space with the implantation of the glaucoma Seton device is effective in lowering intraocular pressure in refractory glaucoma.     

兔眼脉络膜上腔出血模型建立及自然转归的研究

目的建立兔眼脉络膜上腔出血（SCH）模型,观察其自然转归。方法经隧道式巩膜全层切口注入兔眼脉络膜上腔自体抗凝血建立SCH模型,并行检眼镜、B型超声及组织病理学观察。结果术后实验组兔眼均出现了SCH。术后1h视网膜及脉络膜呈明显红色隆起,边界清楚,出血范围为8～10个视盘直径;术后1d出血范围扩大、隆起度降低,术后3d出血开始吸收,术后7d大部分吸收,术后14d基本吸收,术后21d完全吸收。术后1～3d脉络膜上腔炎性细胞浸润,术后7d脉络膜上腔血液部分溶血,术后14d完全溶血,光感受器层发生空泡变性,睫状体萎缩。结论经隧道式巩膜全层切口注入兔眼脉络膜上腔自体抗凝血建立SCH模型的方法简单实用、安全可靠、重复性较好,为视网膜受损及相关治疗提供依据。     

Hemorragia supracoroidea espontánea bilateral en un paciente en tratamiento con heparina de bajo peso molecular

We present the case of an 81-year-old woman who developed a bilateral spontaneous suprachoroidal hemorrhage while under treatment with sodium enoxaparin. Temporal suspension of anticoagulant therapy led to an improvement of the choroidal hemorrhage. After three months follow-up, there was a complete reabsorption of the choroidal detachments, but there was a persistent vitreous hemorrhage in the right eye, which had been more severely affected. Pars plana vitrectomy with air tamponade was successfully performed in the right eye. Vision improved to 20/50 in the right eye and 20/20 in the left eye.Suprachoroidal hemorrhage is a rare condition with a poor visual prognosis. Reports on the development of suprachoroidal hemorrhage in patients with no predisposing ocular conditions are scarce, and in none were both eyes affected. The case reported herein is, to the best of our knowledge, the first case of bilateral, simultaneous suprachoroidal hemorrhage without predisposing ocular factors due to treatment with anticoagulants, with a favourable visual outcome.     

Delayed massive suprachoroidal hemorrhage after retinal detachment surgery: case report

Massive suprachoroidal hemorrhage may occur at surgery, early postoperatively or may be delayed. The authors describe a case of 79-year-old woman, who developed a massive suprachoroidal hemorrhage in 72 hours after retinal detachment surgery. In our case, the main reason of suprachoroidal hemorrhage development was postoperative hypotony and occurrence of a lot of factors such hypertension, diabetes, high myopia, pseudophakia, which predispose to hemorrhage. This case is very rare but interesting because of its multifocal pathogenetical mechanism.     

Delayed suprachoroidal hemorrhage after needle revision of trabeculectomy bleb in a patient with hairy cell leukemia

PURPOSE: To report a rare complication, delayed suprachoroidal hemorrhage, of needle revision of a nonfunctioning trabeculectomy bleb in a patient with previously undetected hairy cell leukemia. DESIGN: Interventional case report. METHODS; An 89-year-old man presented with massive delayed suprachoroidal hemorrhage after needle revision of a trabeculectomy bleb. RESULTS: Routine investigations before choriodal drainage showed a low platelet count. Anterior chamber washout and choroidal drainage were done after intravenous platelet infusions. Subsequently, the diagnosis of hairy cell leukemia was made by the hematologist. CONCLUSIONS: Delayed suprachoroidal hemorrhage is a rare but devastating complication of needle revision of trabeculectomy blebs and should be borne in mind while performing this seemingly trivial outpatient procedure.     

脉络膜上腔给药治疗兔眼穿通伤

目的 比较脉络膜上腔给药与全身给药治疗眼穿通伤的疗效。方法 16只日本大耳白兔制成双眼穿通伤模型,分为 经脉络膜上腔给药与全身给药两组,经处理后行视网膜脱离及玻璃体浑浊评级、眼底造影及组织病理研究。结果 脉络膜上 腔给药组抑制炎症和增殖反应的效果优于全身给药组。结论 脉络膜上腔给药安全有效,可作为一种新的穿通伤治疗手段。