Spontaneous suprachoroidal hemorrhage associated with age-related macular degeneration and anticoagulation therapy

Spontaneous suprachoroidal haemorrhage: clinical features, visual outcomes and prognosis factors

BACKGROUND

To describe clinical features, risk factors and outcomes of patients with diagnosis of rare spontaneous suprachoroidal haemorrhage (SSCH) over a 20-year period from a tertiary eye unit.

METHODS

Retrospective, observational case-series of patients with SSCH, defined as SCH without a known cause at diagnosis. Variables analysed included age, gender, ethnicity, systemic and ocular comorbidities, systemic medication, initial and final best corrected visual acuity (BCVA), clinical features, management and follow-up.

RESULTS

Total of 11 eyes of 11 patients were identified. Median age was 70 years (SD 25.9). Most patients were female (82%) and white British. Median follow-up period was 2.2 years. Hypertension was the most frequently associated underlying systemic disease (45%) and 36% were on anti-coagulant or anti-platelet therapy. High myopia was observed in 36% of cases. Presenting BCVA of 1.00 logMAR or better was a positive predictor of final BCVA. No significant improvement in the initial versus final BCVA was found in patients who underwent surgery versus those who remained under observation.

CONCLUSION

Patients over 60 years-old with hypertension, anticoagulant treatment, high myopia, and pseudophakia were common. Visual outcomes were poor, surgical intervention had limited impact. Good initial BCVA predicted better final acuity while extensive SSCH correlated with poorer visual results. Despite the study's limitations, this series offers valuable insights into visual prognosis and prognostic factors.

Hidden Kiss: A Rare Case of Spontaneous Suprachoroidal Hemorrhage Masquerading as Vitreous Hemorrhage Causing Secondary Angle-Closure Glaucoma

Suprachoroidal hemorrhage (SCH) is an uncommon sight-threatening pathology, most often encountered intraoperatively. However, spontaneous presentation of SCH is even rarer. We report the case of a 69-year-old diabetic patient with spontaneous SCH (SSCH) in her left eye masquerading as a vitreous hemorrhage. She developed treatment-resistant secondary angle-closure glaucoma. She was referred to the vitreoretinal team for intraocular exploration to identify the source of the hemorrhage. Pars plana vitrectomy identified extensive SCH intraoperatively. As far as the authors are aware, this is the first case in which the patient had such severe SSCH that the characteristic kissing choroidal sign was not visualized on repeated examinations and multimodal imaging. All initial evidence pointed towards a diagnosis of vitreous hemorrhage. This case demonstrates that if a patient has angle-closure glaucoma and persistently raised intra-ocular pressure that is treatment-resistant, then SCH is an important differential diagnosis to consider. Clinicians need to be aware of the risk factors of SCH, and early recognition with a timely intervention of SCH is important to optimize visual outcomes.

Massive Spontaneous Suprachoroidal Hemorrhage in a Patient With Type 1 Chronic Myeloid Leukemia and Lymphoplasmacytic Lymphoma: Case Report and Review of the Literature

Purpose:

This work reports a rare case of spontaneous suprachoroidal hemorrhage (SSCH) and summarizes the literature on its treatment options and outcomes.

Methods:

A case report and comprehensive literature review are presented on the medical and surgical management of SSCH on PubMed from 1998 to 2021.

Results:

The literature search revealed 58 studies, 33 of which included 52 eyes of 47 patients. Surgical treatment typically consisted of choroidal drainage with posterior sclerotomies combined with pars plana vitrectomy and silicone oil placement. Medical therapy involved intraocular pressure control with laser peripheral iridotomy and topical, oral, and intravenous medication.

Conclusions:

In cases of SSCH, conservative management and a prompt workup should be initiated to identify the cause before proceeding with surgery. If the initial workup does not reveal a cause, medical and surgical treatments are both viable and the decision is at the discretion of the treating physician.

Bilateral spontaneous suprachoroidal hemorrhage in a patient taking a low-molecular-weight-heparin

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.

Bilateral spontaneous suprachoroidal hemorrhage in a patient taking a low-molecular-weight heparin

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.

Spontaneous suprachoroidal hemorrhage in a high myopia patient with rhegmatogenous retinal detachment: a case report and literature review

Purpose: To report a rare case of spontaneous suprachoroidal hemorrhage (SSCH) in a high myopia patient with rhegmatogenous retinal detachment (RRD) and successful treatment.Methods: We present a case of SSCH that occurred in a 73 woman with high myopia with RRD and discuss the results of a systemic review of the literature published from 1999 to 2017.Results: Phacoemulsification without intraocular lens implantation and vitrectomy combined with silicone oil injection was performed and retinal detachment and choroidal detachment were reattached after oil removed. In the literature review, we found that among a total of 36 patients (37 eyes), acute secondary glaucoma was a complication in 70.3% (26 eyes) of the cases, and over half of the cases (24 eyes, 64.9%) were treated with surgery. Eighteen cases (50%) were characterized by systemic hypertension and 21 cases (58.3%) had abnormal hemostasis. Age-related macular degeneration (ARMD) was the most common (12 eyes, 32.4%) ocular disease and was followed by glaucoma (7 cases, 18.9%). Visual acuity was classified as hand motion (HM) or worse in 25 eyes (out of 34 eyes, 73.5%) at initial presentation and in 25 eyes (out of 36 eyes, 69.4%) upon final examination. Nine cases experienced significant visual improvement, including six that underwent vitrectomy.Conclusion: Advanced age, systemic anticoagulation, and hypertension are strong risk factors. RRD associated with massive SSCH is an extremely rare event. Vitrectomy and choroidal blood drainage can effectively remove suprachoroidal hemorrhage (SCH) and promote retinal reattachment in these eyes. However, the final visual prognosis usually remains poor.

SPONTANEOUS SUPRACHOROIDAL HEMORRHAGE ASSOCIATED WITH IATROGENIC COAGULOPATHY

PURPOSE

To present a case of spontaneous suprachoroidal hemorrhage in a patient on anticoagulation.

METHODS

Single case report.

RESULTS

A 68-year-old woman with a history of hypertension, atherosclerosis, and heart failure presented with massive spontaneous suprachoroidal hemorrhage in the left eye. She had no known ophthalmic pathology. She was taking warfarin and she had a high international normalization ratio. Despite medical and surgical therapy, there was no improvement and vision deteriorated to no light perception.

CONCLUSION

Spontaneous expulsive suprachoroidal hemorrhage is a rare entity. Advanced age, systemic anticoagulation, and hypertension are strong risk factors. It is important to monitor international normalization ratio in warfarinized patients; particularly, uncontrolled high levels may cause spontaneous suprachoroidal hemorrhage in the absence of predisposing ocular pathology.

Spontaneous suprachoroidal hemorrhage: Case report and review of the literature

We present the clinical course, management, and final outcome of spontaneous suprachoroidal hemorrhage (SSCH) in an age-related macular degeneration (AMD) patient—a 64-year-old male receiving antiplatelet therapy who developed SSCH during the Valsalva maneuver. In addition to our case study, we discuss the results of a systemic review of the literature and reference lists of retrieved studies published from January 2001 to December 2013. Among a total of 31 patients (32 eyes), acute secondary glaucoma was a complication in 87.5% of the cases, and over half of the cases (20 eyes, 62.5%) received surgery. Twenty cases (64.5%) were characterized by systemic hypertension (HTN), followed by cardiovascular or cerebral vascular disease in 17 cases (54.8%). The Valsalva maneuver was performed in five cases (16.1%) prior to the episode. Twenty-three cases (74.2%) had abnormal hemostasis, including use of anticoagulants or thrombolytic agents (18 cases), chronic renal failure (CRF, 5 cases), and blood dyscrasia (3 cases). AMD was the most common (17 eyes of 16 patients, 53.1%) ocular disease. Visual acuity was classified as hand motion (HM) or worse in 20 eyes (of 28 eyes, 71.4%) at initial presentation and in 24 eyes (of 30 eyes, 80%) upon final examination. Anticoagulated patients with AMD should be informed of the risk of intraocular hemorrhage. Medical therapy usually fails in the treatment of glaucoma. Surgical intervention provides an option for the purpose of pain relief. Even so, the final visual prognosis is usually poor.

Spontaneous hyphema and pupillary block in a patient with a left ventricular assist device

The left ventricular assist device (LVAD) has been a standard of care for the management of patients with advanced heart failure since the 1990s. An increased risk of spontaneous bleeding related to the device has been noted, ranging from minor epistaxis to major thoracic and mediastinal hemorrhages. To our knowledge, intraocular hemorrhage has not been previously reported. We report a 72-year-old patient with an LVAD who subsequently developed a spontaneous intraocular hemorrhage that manifested as hyphema, pupillary block, and acute intraocular pressure elevation.

Rhegmatogenous retinal detachment associated with massive spontaneous suprachoroidal hemorrhage and prognosis of pars plana vitrectomy

AIM

To describe the clinical characters of rhegmatogenous retinal detachment (RRD) associated with massive spontaneous suprachoroidal hemorrhage (SSCH). To evaluate optimal timing and prognosis of pars plana vitrectomy.

METHODS

A retrospective review of 6 cases (6 eyes) of RRD and massive SSCH among 3772 cases of RRD was conducted. All of 6 patients were treated with twenty-gauge vitrectomy, suprachoroidal blood drainage, phacoemulsification (PHACO) or lensectomy and silicon oil tamponade. The clinical characters, intraoperative findings and treatment outcomes were reported.

RESULTS

In the 6 affected eyes of 6 patients (3 men and 3 women; mean age, 53.83y; range 34-61y), preoperative visual acuity ranged from faint light perception (LP) to counting finger (CF). The average interventional duration from visual decreased to surgery was 12.8 d (range 9-15d). All eyes were associated with high myopia and the mean ocular length was 30.32 mm (range 28.14-32.32 mm). Choroidal hemorrhage were successfully drained in the operation of all 6 eyes. Intraoperative findings showed there were multiple retinal breaks in all 6 eyes and in 4 eyes breaks were along supratemporal and/or infratemporal retinal vascular arcade, especially in the edge of chorioretinal atrophy areas. These patients were followed up from 6 to 34mo (Mean, 23.5mo). The best-corrected visual acuity after surgery varied from CF to 20/100, with improvement in 5 eyes (83.33%) and no change in 1 eye (16.67%). Ocular hypertension ocurred in 1 eye (16.67%), which was successfully treated by silicon oil removal combined with trabeculectomy. In 4 eyes, tractional retinal detachment caused by proliferative vitreoretinopathy (PVR) appeared and a secondary surgery of pre-retinal membrane peeling and silicon oil retained were performed. In 4 eyes, silicon oil cannot be removed. The initial and final reattachment rates were 33.33% and 66.67%, respectively.

CONCLUSION

RRD associated with massive SSCH is an extremely rare event. The most common risk factor is long axial length. Vitrectomy and choroidal blood drainage can effectively remove suprachoroidal hemorrhage and promote retinal reattachment in these eyes. However, silicon oil could not be removed in most eyes and final visual acuities are generally poor.

Postoperative suprachoroidal hemorrhage in a glaucoma patient on low molecular weight heparin

Suprachoroidal hemorrhage is a complication associated with intraocular surgery that can occur both intraoperatively and postoperatively. Several intraoperative or postoperative risk factors have been indentified. The use of low-molecular weight heparin (LMWH) is considered one of the risk factors in surgical cases (ocular or non ocular) and non-surgical cases. Here we present a case of suprachoroidal hemorrhage in a glaucoma patient that occurred after preoperative prophylactic LMWH for deep venous thrombosis. The use of LMWH has been reported to cause suprachoroidal hemorrhage even in patients without any risk factors. The use of LMWH continues to increase, hence it is important to be aware of the possibility of suprachoroidal hemorrhage and to determine the risk/benefit ratio, especially in patients with other risk factors.