- Holds globe anteriorly - Applies pressure on globe Surgeon: - Makes 3 sclerotomies - Inserts infusion cannula - Inserts vitrectomy probe - Removes blood clots Air pump Infusion light pipe Vitrectomy probe Sclerotomies Globe Assistant Surgeon RECOMMENDED SURGICAL TECHNIQUE (2)  Vitrectomy probe is used to remove any vitreous haemorrhage and to lyse any membranes or adhesions  An endolaser is used to seal any retinal breaks or

1. Scenario
 Lady in 70s on the ward
 History of heart disease and is on
anticoagulants
 Bilateral phacotrabeculectomies with MMC
and PCIOL for bilateral primary open angle
glaucoma (left eye was done 2 days ago)

2. Called in the middle of the
night because she has
develped sudden onset of
pain in left eye
What possible diagnoses run
through your mind? Are you going
to examine her?

3. My differential diagnosis
would include:
 Endophthalmitis/blebitis
 Uveitis
 Corneal surface problem
 Malignant glaucoma
 Iris bombe (pupil block)
 Raised IOP from other causes
 Delayed suprachoroidal haemorrhage
 Migraine
 Others

4. What diagnosis would you think if you saw
this? What does the picture show?

5. SUPRACHOROIDAL
HAEMORRHAGE
Nick Sargent

6. The most feared
intraoperative complication?
Every surgeon needs to be prepared for
it, to recognise it, and know what to do
the instant it happens.

7. a.k.a and abbreviations
 Suprachoroidal haemorrhage (SCH)
 Massive suprachoroidal haemorrhage
(MSCH)
 Expulsive choroidal haemorrhage
(ECH)

8. WHAT IS IT?
 Large bleed into the suprachoroidal
space which results in the extrusion of
intraocular contents from the eye or
apposition of retinal surfaces

9. Enucleated eye showing suprachoroidal and
vitreous haemorrhage following ocular
perforation
SCH

10. HISTOPATHOLOGY of
MASSIVE SCH
 Totally detached choroid and neural
retina
 Gaping wound
 May see a ruptured ciliary artery

11. Retina in the AC
and cornealscleral
incision
Hyphaema
AN EYE WITH THAT HAD INTRAOPERATIVE EXPULSIVE SCH

12. Histopathology of same eye.
Neuroretina is seen in the corneal wound.
Optic nerve
Surgical incision
Blood clot
Detached retina
Detached retina
Blood clot

13. Specimen of an eye that got SCH following
rupture of a corneal ulcer
SCH
Prolapsed lens
through cornea
Detached retina

14. CLASSIFICATION

15. SOME HAVE ATTEMPTED TO
PROVIDE A CLASSIFICATION
 Type 1 ECH : massive haemorrhage
with expulsion of retinal tissue
 Type 2 ECH : vitreous loss and an
abolished vitreous cavity
 Type 3 ECH : less extensive SCH with
a partially preserved vitreous cavity

16. What was the
classification again?

17. MORE SIMPLE
CLASSIFICATION
1) EXPULSIVE : spontaneous nucleus
expression with extrusion of ocular
contents
2) NON-EXPULSIVE : SCH without
loss of ocular contents

18. INCIDENCE OF SCH
(old studies)
 0.2% in cataract Sx
 0.3% in PK Sx
 0.7% with filtration surgery

19. PATHOGENESIS

20.  Exact cause of spontaneous SCH is not
known.
 Can get SCH after surgical instruments
impact on the choroid.
 Although suprachoroidal effusion and SCH
may precede the development of expulsive
haemorrhage, the relationship remains
unclear.

21.  Source of bleeding seems to be ruptured
long or short, posterior ciliary arteries.
Thought to occur at the sight where the
arteries make a right-angled turn crossing
the suprachoroidal space from its scleral
canal.

22.  One theory is that sudden hypotony
straightens the sclerotic vessel and causes
the rupture.

23.  Experiments on rabbits using
anticoagulants to precipitate SCH have
given another possible sequence of events:

24. Engorgement of the choriocapillaris
Suprachoroidal effusion occurring mainly
near the posterior pole
Stretching and tearing of choroidal vessels and
vessels at the ciliary body base
Massive extravasation of blood, primarily from the
torn vessels at the ciliary body base
Expulsion of blood and intraocular contents
through incision

25. CONTRIBUTING
PREOPERATIVE
PREDISPOSING FACTORS

26. SYSTEMIC
 Generalised arteriosclerosis
 Hypertension
 Diabetes mellitus
 Blood dyscrasias:
– Polycythaemia
– Haemophilia
– thrombocytopenia
 Anticoagulants
 Advanced age

27. MANAGEMENT OF PATIENTS UNDERGOING CATARACT SURGERY ON ORAL
ANTICOAGULANTS (N.Sargent, T.Keenan, 2008)
Expected to be uncomplicated phaco LA/GA
On admission:
•Full consent by resident with documentation in notes
•Check for phacodonesis and pupil dilates to >4mm
•Resident to check INR is in therapeutic range:
DVT prophylaxis 2.0 to 2.5
DVT or PE Rx 2.0 to 3
AF 2.0 to 3.0
Recurrent DVT or PE 3.0 to 4.0
Low risk prosthetic heart valves 2.0 to 3.0
High risk prosthetic heart valves 3.0 to 4.0
On listing for surgery: consultant or resident to give blood
form for INR to be performed within 48 hours of Sx
INR within therapeutic range?Yes No
Inform surgeon straight away by phone:
•Consider discharging and referring to treating
doctors
•Consider keeping in ward if INR too high whilst
reducing warfarin (e.g. if from Gaza)
•Consider surgery if INR below therapeutic
range and if LA
Proceed to surgery:
•Subtenon/topical LA
•Clear corneal incision

28. MANAGEMENT OF PATIENTS UNDERGOING CATARACT SURGERY ON ORAL
ANTICOAGULANTS (N.Sargent, T.Keenan, 2008)
ECCE or Phaco with high risk of needing to
convert to ECCE (e.g. phacodonesis with small
pupil and hard lens), trabeculectomy
•Inform consultant surgeon
straight away by phone.
•Consider keeping in ward if INR
too high whilst reducing warfarin
(e.g. if from Gaza)
Proceed to surgery:
•Subtenon/topical LA
•Clear corneal incision if
possible
Footnote *If therapeutic range for INR 3-4.0
(generally this is the case if fitted with an old-
fashioned Starr-Edwards ‘ball-and-cage’
prosthetic mitral valve)
•liase with anaesthetist.
•Consider stopping warfarin and as soon INR
below 3.0 commence heparin IV infusion.
•Stop IV heparin 2-3 hours before surgery.
On admission resident to check INR
INR less than 3.0 ?
(see footnote)
Yes No

29. OCULAR I
 Glaucoma (including high preop IOP and
history of 5-fluorouracil injections)
 Severe axial myopia
 Aphakia
 Previous vitrectomy

30. OCULAR II
 Previous multiple scleral buckling operations
 Dense brunescent nuclear sclerosis and
ECCE
 Large incision used with nucleus expression
extracapsular cataract extraction
 PK

31. CONTRIBUTING
INTRAOPERATIVE
FACTORS

32. OCULAR INTRAOPERATIVE
FACTORS I
 Retrobulbar anaesthesia (increased
resistance to venous outflow)
 Retrobulbar anaesthesia without
adrenaline
 Sudden decrease in intraocular pressure

33. OCULAR INTRAOPERATIVE
FACTORS II
 Vitreous loss
 Combining extracapsular extraction
with a trabeculectomy
 Capsular bag phaco versus iris plane
phaco (increased intraocular pressure
swings)

34. SYSTEMIC
 Valsalva manoeuvre
 Coughing
 Sudden rise in systemic BP
 Elevated intraoperative pulse >85 bpm
 General anaesthesia

35. POSTOPERATIVE
FACTORS
- Wound leak
- Ocular trauma
- Valsalva manoeuvre

36. PRESENTATION/
RECOGNITION

37. In an ECCE, typically occurs
after lens delivery
 Progressive AC shallowing
 Loss of red reflex
 Red mound appearing in vitreous
 Increased IOP
 Gaping of wound
 Iris prolapse that will not reposit

38. This is followed by
 Vitreous extrusion
 Loss of red reflex
 Appearance of a dark mound behind the
pupil
 Severe cases all intraocular contents maybe
extruded through the incision

39. Suprachoroidal haemorrhage during PK Sx
After expulsion of lens, retina and
choroid in front of a bright red
haemorrhage
BEFORE: corneal button removed

40. MANAGEMENT

41. When you think about
MANAGEMENT in exams, think
about dividing into:
1) Preventative (pre- and intraoperative)
measures
2) Intraoperative management
3) Post-operative management

42. PREVENTATIVE MEASURES
Can divide again into:
1) Pre-op
2) Intra-op
3) Post-op

43.  Checking INR levels if on anticoagulants. Avoid aspirin
and other anticoagulants where possible, except routine
phacos.
 Check BP, control systemic hypertension
 Cancel coughing patients or give cough suppressants
 Control excessively high IOP (consider diamox and
mannitol on day of surgery)
PREOPERATIVE MEASURES

44.  Use minimal pre-op G.Phenylephrine to avoid
systemic hypertension
 Do not give large volumes of anaesthesia
behind the globe
 Use adrenaline in lid blocks
PREOPERATIVE MEASURES

45. Do not stop NSAIDs for
cataract surgery
Royal College of Surgeons
guidelines

46.  BP and heart rate monitoring
 Avoid rapid decompression of globe
 Gentle manipulation, particularly with nuclear expression
 Careful with stay sutures
 Consider use of preplaced ‘safety sutures’ before
aspiration and irrigation during all extracapsular
extractions
INTRAOPERATIVE

47. POST-OPERATIVE
 Avoid eye trauma or eye pressure
 Avoid hypotony
 Avoid valsalva manoeuvres

48. INTRAOPERTIVE
MANAGEMENT OF SCH

49. RAPID CLOSURE OF
WOUND
 Even if vitreous and iris become squeezed into the
wound.
 Use multiple 8/0 or heavier sutures, even silk.
 Intermittent repositing of the uvea with an iris
spatula
 whilst waiting for suture to be loaded, close wound
with anything (clamp, forceps, finger)

50. DIRECT PRESSURE ON
GLOBE
 Tamponades the effusion or
haemorrhage, which allows coagulation

51. If an expulsive event is the cause
of protrusion of vitreous,
vitrectomy is wrong because this
lowers IOP

52. IOP LOWERING AGENTS
GIVEN STAT ON THE TABLE
 IV mannitol
 Carbonic anhydrase inhibitors
 Topical beta-blockers

53. POSTERIOR SCLEROTOMY
 Indications:
– if wound can’t be closed.
– Intraocular tissue extrudes in spite of wound closure
– IOP remains extremely elevated after 15 to 20 minutes
 The decision is delayed if the wound is successfully
closed without extrusion of tissue
 May, however, exacerbate bleeding and extrusion

54. POSTERIOR
SCLEROTOMY: METHOD
 Use either a blade or Elliot trephine
 5-7mm posterior to the limbus in the
same quadrant as the major
hemorrhagic bulge
 1.5mm in diameter

55. POSTERIOR
SCLEROTOMY: METHOD
 Haemorrhagic fluid is drained whilst
maintaining an elevated IOP (i.e. press on
globe) that serves to both stop the bleeding
and to extravasate suprachoroidal blood
 May wish to leave sclerotomies open to
allow further post-op drainage

56. IMMEDIATE POSTOPERATIVE
MANAGEMENT
 Intensive topical steroids
 Topical antibiotics
 Systemic steroids

57. SUBSEQUENT
MANAGEMENT

58. 1 day post-op following
expulsive haemorrhage

59. MANAGEMENT OPTIONS FOR
SUPRACHOROIDAL HAEMORRHAGE
 Observation
 Delayed secondary management:
– Drainage sclerotomy alone (to remove
SCH and re-establish normal IOP)
– Drainage sclerotomy combined with PPV
with or without scleral buckling

60. EVALUATION AND TIMING
OF SURGERY
 Between 7 and 14 days post-op, the blood
undergoes liquefaction allowing better
drainage of the haemorrhage as well as
allowing time for intraocular inflammation to
settle down.
 B-scan USS can help ascertain whether
complete clot lysis has occurred.

61. EVALUATION AND TIMING
OF SURGERY
 Wait 1-2 weeks before draining. Attempts to drain a
SCH before some degree of clot lysis has occurred are
usually unsuccessful
 Perform earlier if:
– Very high IOP
– Corneal lenticular touch
– Intractable ocular pain

62. MSCH with central retinal and choroidal
apposition. Dome shaped appearance.
Blood

63. MSCH with central retinal and choroidal
apposition. Dome shaped appearance.
Steeply rising , double peaked ,
wide spike
Lower reflective spikes representing
haemorrhage in suprachoroidal space

64. 2 days post SCH in another patient. Clot seen as
low-medium, irregular internal reflectivity)
Blood clot
Blood clot

65. PROGRESSION OF A CLOT TO LYSIS
24 hours. Central retinal
apposition. Arrows point to
large blood clot (irregular
reflectivity)
5 days . Blood clot is more
homogenous (echolucent)
2 weeks. Suprachoroidal space
filled with fine diffuse opacities
(mobile during dynamic
examination) indicative of clot
lysis. Low reflective reflectivity
of the liquified blood

66. Progression of another SCH
24 hours. Central retinal
apposition. Arrows point to
large blood clot (irregular
reflectivity)
2 weeks. Decreased
elevation of the choroidal
haemorrhage
5 weeks. Resorption of the
SCH. Small peripheral SCH.

67. VITRECTOMY: indications
 Indications for vitrectomy include:
 Vitreous or retinal incarcerated in the wound
 Vitreous haemorrhage
 Rhegmatogenous and/or tractional RD (also require
scleral buckling)
 Central choroidal incarceration
 Persistent flat AC

68. VITRECTOMY: Aims of Sx
 Remove vitreous haemorrhage
 Remove retained lens material
 Relieve vitreoretinal traction
 Reestablish the normal anatomic
configuration of the posterior
segment

69. RECOMMENDED SURGICAL
TECHNIQUE (1)
 1-3 sclerotomies placed either:
– 3-4mm posterior to the limbus
– At the equator into the suprachoroidal space
 Eye initially inflated 1st through a limbal wound,
then through a pars plana wound with either:
– Saline
– Sterile air
– PCFL (Perfluorocarbon liquids) which have the advantage
compressing suprachoroidal blood anteriorly, thereby
facilitating anterior drainage
 An iris spatula is used to release blood clots
through the scleroomy sites

70. Insufflation of phakic or aphakic)
eye with choroidal haemorrhage
 An infusion light pipe
connected to an air pump,
BSS syringe, or
perflurocarbon liquid. Use
constant infusion pressure.
 An iris spatula opens the
sclerostomy wound and
facilitates clot removal

71.  After the SCH has been drained, the normal
anatomic relationship can be reestablished.
 A 3 port PPV can be made
 Residual anterior vitreous can be removed
with vitrectomy
 Vitreous strands causing vitreoretinal
traction can be cut
RECOMMENDED SURGICAL
TECHNIQUE (2)

72.  If a rhegmatogenous RD is present, the
retinal break can be treated with retinopexy.
 If perfluorocarbon liquid used, then perform
either:
– fluid-fluid exchange with BSS
– Liquid-air exchange
RECOMMENDED SURGICAL
TECHNIQUE (3)

73.  In most cases a scleral buckle is performed
to:
– Help relieve residual vitreoretinal traction
– Support areas of retinal breaks
 May need a long-term internal tamponade
agent (gas or oil)
RECOMMENDED SURGICAL
TECHNIQUE (3)

74. SECONDARY IOL
 Can be considered

75. There are studies that have
suggested that not all cases
probably require surgical
drainage in order to obtain
comparable visual improvement
Chu TG, et al. Massive suprachoroidal haemorrhage
with central retinal vein apposition. A clinical and
echographic study. Archives of Ophth.109 (11): 1575-
81, 1991 Nov.

76. PROGNOSIS

77.  Visual outcome is often bad and can
result in total loss of sight.
 Useful vision can be salvaged in some
cases:
20% will attain a post-operative
vision of 6/12 or better

78.  Better prognosis with small incision
phaco compared with standard incision
ECCE
 Worse prognosis if vision is PL or
worse on 1st post-op day
 Possible additional sequelae:
– 2ry RD complicated by PVR
– Phthisis bulbi

79. CLINICAL FEATURES ASSOCIATED
WITH A POORER VISUAL
OUT|COME INCLUDE
 Initial or indeterminate RD
 360 degrees SCH
 Breakthrough bleeding into the
vitreous
 Subretinal haemorrhage

80. OUTCOME AFTER SURGICAL
DRAINAGE WITH VITRECTOMY
 Up to 50% reattachment rate of RD for eyes
with retinal incarceration
(W. Wirostko, et al, USA)
 Half of eyes achieve 6/60 vision or better
 Phthisis bulbi develops in 28% of eyes
(might be due to haemorrhagic necrosis of
the CB in some cases)

81. LIMITED INTRAOPERATIVE
CHOROIDAL HAEMORRHAGE
Choroidal haemorrhage limited to
an ocular quadrant

82.  Incidence:
– 2-5% in ICCE or ECCE
– Higher in filtration surgery
 Presents as positive posterior vitreous
pressure with bulging of the iris or
vitreous loss at the time of surgery
LIMITED INTRAOPERATIVE
CHOROIDAL HAEMORRHAGE

83.  See a dull reddish-brown elevation of
the retina
 The haemorrhage usually remains self-
limited, requiring no therapy, and the
prognosis for vision is good
LIMITED INTRAOPERATIVE
CHOROIDAL HAEMORRHAGE

84. Possible to get delayed
massive SCH

85.  Occurs more commonly than an
intraoperative haemorrhage (~2%)
 When cataract combined with
trabeculectomy.
 These cases may present with sudden
severe ocular pain 1-4 days post-op.
Delayed (postoperative)
SCH

86.  Usually preceded by a serous choroidal
detachment
 One possible source of pain: traction
on the long posterior ciliary nerves
Delayed (postoperative)
SCH

87. Delayed SCH
Retina in AC

88. 89 year old female who had complicated cataract
extraction+ACIOL+trabeculectomy.
2 days post-op, she awakened with severe eye pain
Forward displacement of
vitreous and retina
Flat AC

89. Large , darkly coloured dome-shaped elevations
arising from the peripheral retina extending
towards the optic nerve

90.  IOP may be raised from blockage of
the filtration sclerostomy or angle
closure from forward rotation of the
lens-iris diaphragm
 Ocular contents are not expulsed from
the eye unless wound rupture occurs
Delayed (postoperative)
SCH

91.  Drainage indicated when:
– Very high IOP
– Flat AC
– In some cases when the vitreous
cavity by haemorrhage
Surgery for Delayed
(postoperative) SCH

92.  The suprachoroidal space is entered via an
equatorial sclerotomy, and the AC is
simultaneously filled with air or a
viscoelastic during drainage
 If the haemorrhage occurs after filtration
surgery, the sclerotomy may have to be
sutured to facilitated drainage
Surgery for Delayed
(postoperative) SCH

93.  Between 50-75% of eyes maintain a VA similar to
that present prior to the filtration surgery
 If vitreous is incarcerated in the sclerotomy site, it
should be removed to reduce the risk of a post-
drainage RD
 Presence of breakthrough bleeding most often
requires:
– vitrectomy
– Scleral buckle
– Air/fluid exchange
Surgery for Delayed
(postoperative) SCH

94. INFUSION MISDIRECTION
SYNDROME (IMS) seen in
Phaco Sx
This can mimic SCH intraoperatively

95. INFUSION MISDIRECTION SYNDROME
 This happens when zonular defects, common in pseudoexfoliation,
permit infusion fluid to pass into the retrocapsular space
 It can also occur in situations where there is a peripheral opening in
the posterior capsule

96. INFUSION MISDIRECTION
SYNDROME
 This is a common cause of AC
shallowing
 It results in the anterior displacement
of the posterior capsule

97. INFUSION MISDIRECTION
SYNDROME RESEMBLING SCH
 When confronted with AC shallowing, the surgeon must stop
and think what the cause is
 If the media is clear, ophthalmoscopy will permit visualisation
of SCH
 If the media is not clear or if ophthalmoscopy is not
conclusive:
– stop the procedure and put patient in recovery
room
– re-examine in 1 hour
– if AC depth remains shallow, SCH is likely and a B-
scan will confirm the diagnosis. The procedure
must then be cancelled

98. INFUSION MISDIRECTION
SYNDROME RESEMBLING SCH
 If the AC depth has returned to normal, the
problem was IMS in which case can :
– The procedure can be completed by phaco using
low flow, low vacuum and low infusion bottle
height
– Or convert to ECCE
– Use a ‘dry’ cortex removal technique utilizing
infusion
 Instead of waiting an hour, you could consider
performing a limited pars plana vitrectomy with
simultaneous reformation of the AC by viscoelastic
injection

99. INFUSION MISDIRECTION
SYNDROME RESEMBLING SCH
 Also consider using a dispersive viscoelastic
(‘Viscoat’) into the entire periphery of the AC prior
to resuming phaco to:
– Push the peripheral iris posteriorly
– Reduce the possibility of recurrence of IMS by
impeding access of fusion to the zonular region
 IMS is probably much more common than a SCH

100. CONCLUSIONS

101. CONCLUSIONS
 Much feared and is often a devastating
and blinding condition
 Think about preventative measures
 Need quick recognition and quick
closure of the wound
 Vitreoretinal options available post-op
 Conditions such as IMS can mimic SCH

102. THE END