Risk factors of massive suprachoroidal hemorrhage during extracapsular cataract extraction surgery

Intraocular pressure changes before and after a femtosecond laser procedure for cataract surgery

This study aimed to evaluate the changes in intraocular pressure (IOP) before and after femtosecond laser capsulorhexis and lens fragmentation for cataract surgery. We measured the IOP before, immediately, 30 min, and 1 h after the laser procedure in 47 eyes of 47 patients who underwent the femtosecond laser procedure. The mean IOP was 17.51 ± 3.28 mmHg, 30.23 ± 6.70 mmHg, 17.96 ± 3.75 mmHg, and 21.77 ± 5.88 mmHg before, immediately after, 30 min after, and 1 h after the laser procedure, respectively. The mean IOP significantly increased immediately (adjusted P < 0.001) and 1 h (adjusted P = 0.001) after the laser procedure compared with the pre-laser IOP. The mean IOP at 30 min after the laser procedure was significantly lower than that immediately after the procedure (adjusted P < 0.001). However, the IOP 1 h after the laser procedure became higher than that 30 min after the laser procedure. Additionally, the IOP 1 h after the laser procedure was positively correlated with the baseline IOP and negatively correlated with the axial length. In conclusion, this study demonstrated that cataract surgery should be commenced within 30 min after the femtosecond laser procedure to ensure a safe cataract surgery that reduces the risk of increased intraocular pressure.

Cataracts

94 million people are blind or visually impaired globally, and cataract is the most common cause of blindness worldwide. However, most cases of blindness are avoidable. Cataract is associated with decreased quality of life and reduced life expectancy. Most cases of cataract occur after birth and share ageing and oxidative stress as primary causes, although several non-modifiable and modifiable risk factors can accelerate cataract formation. In most patients, phacoemulsification with intraocular lens implantation is the preferred treatment and is highly cost-effective. There has been an increase in the use of comprehensive cataract surgical services, including diagnoses, treatment referrals, and rehabilitation. However, global inequity in surgical service quality is still a limitation. Implementation of preoperative risk assessment, risk reduction strategies, and new surgical technologies have made cataract surgery possible at an earlier stage of cataract severity with the expectation of good refractive outcomes. The main challenge is making the service that is currently available to some patients accessible to all by use of universal health coverage.

Clinical characteristics and mortality rates for suprachoroidal hemorrhage: seven-year experience at a tertiary eye center

PURPOSE

To investigate comorbidities and medications associated with acute (ASCH) and delayed (DSCH) suprachoroidal hemorrhage (SCH), and to explore visual outcomes and mortality following SCH.

METHODS

Retrospective review of SCH cases diagnosed at a tertiary center between 2013 and 2019. Demographics, history, surgery type, visual acuity, intraocular pressure (IOP), and mortality data were reviewed.

RESULTS

Fifty eyes of 50 patients experienced SCH related to surgery: 15 (30%) ASCH and 35 (70%) DSCH. Glaucoma surgery was the most common preceding surgery, and SCH was more likely to be delayed in glaucoma surgery relative to other surgeries (p = 0.001). The proportions of patients on anticoagulant, antiplatelet, or NSAID medications were 30% (n = 15), 52% (n = 26), and 12% (n = 6), respectively. The mean preoperative IOP was 25.0 ± 10.2 mmHg. The mean final best corrected visual acuity did not significantly differ between DSCH and ASCH (logMAR 1.92 vs. 2.36; p = 0.39). After controlling for pre-drainage visual acuity, final visual acuity was not statistically significantly different between eyes that were drained versus those that were not drained (p = 0.06). Of all 50 patients, the mortality rate was 12% with a mean time to mortality after SCH of 754 ± 564 days for those who died.

CONCLUSION

DSCH was more common than ASCH, with glaucoma surgery being the most common procedure to result in SCH. Visual outcomes and mortality rate were comparable between ASCH and DSCH. Further research is needed regarding the role of surgical drainage on improving visual outcomes in eyes with SCH.

Surgical Management of Choroidal Diseases

Accumulation of serous fluid in the suprachoroidal space, known as uveal effusion, and choroidal or suprachoroidal haemorrhage (SCH) following rupture of ciliary blood vessels are considered rare, but serious, events with extremely poor functional prognosis. As a result, uveal effusion, and expulsive suprachoroidal haemorrhage in particular, continue to be considered as more or less fatal complications. However, clinical experience demonstrates that both clinical entities can be managed by conservative as well as surgical strategies, depending on their severity and localisation, with sometimes surprisingly favourable visual outcome. In addition to prognostic factors, timely recognition and prompt, if possible preventive, acute care, as well as carefully considered timing of adequate surgical measures taking advantage of the specific characteristics of the choroidal tissue, are crucial to treatment success. Along with technical advances in the field of vitreoretinal surgery, numerous variants of therapeutic approaches to the treatment of choroidal effusion and suprachoroidal haemorrhage have been proposed to date. This review presents some of the most important surgical techniques and strategies in the field.

Outcomes of suprachoroidal haemorrhage drainage with and without vitrectomy: a 10-year study

PURPOSE

The management of suprachoroidal haemorrhage (SCH) remains a challenge. We aimed to analyse and discuss the safety and efficacy outcomes of SCH drainage surgery over a 10-year period in one of the largest tertiary centres in the UK.

METHODS

Retrospective observational study of consecutive patients who underwent SCH drainage in Manchester Royal Eye Hospital over a 10-year period (from 2008 to 2018). Safety and efficacy were assessed by analysing surgery-related complications and functional and anatomical success. Outcomes of those who underwent external drainage alone versus combined drainage and vitrectomy were compared.

RESULTS

Twenty consecutive patients with a mean age of 70 ± 19 years were studied. Age over 70 years, hypertension, cardiovascular disease, and glaucoma were the most common risk factors for SCH. Eleven patients underwent external drainage alone and nine patients had combined vitrectomy and drainage. Overall, mean pre-operative BCVA improved from 2.22 ± 0.26 logMAR (20/3319 Snellen) to 1.42 ± 1.02 LogMAR (20/526 Snellen) at last follow-up visit (p = 0.002). Severe hypotony occurred in 4 patients. Overall anatomical and functional success rates were both 75%.

CONCLUSIONS

Drainage of SCH with or without vitrectomy is a valuable approach in the management of extensive SCH, a condition generally associated with poor prognosis.

Efficacy of Three Different Prophylactic Treatments for Postoperative Nausea and Vomiting after Vitrectomy: A Randomized Clinical Trial

Postoperative nausea and vomiting (PONV) after vitreoretinal surgery may potentially be associated with severe complications, such as suprachoroidal hemorrhage. The purpose of the present multicenter clinical trial (NCT02386059) was to assess the efficacy of three different prophylactic treatments for PONV after vitrectomy under local anesthesia. Patients undergoing primary vitrectomy were randomized to the control arm or to one of the treatment arms (4 mg ondansetron, 4 mg dexamethasone, combination of the two drugs). The primary outcome measure was the proportion of complete response (no nausea, no vomiting, no retching, and no use of antiemetic rescue medication) during 24 h after vitrectomy. Secondary outcomes included the severity standardized score of PONV, postoperative pain standardized score, and rate of ocular and non-ocular adverse events. Baseline demographics of the 1287 patients were comparable between the four arms. The combined therapy group showed a statistically significant lower incidence of PONV compared to the placebo and monotherapy (p < 0.001). PONV severity was also reduced in the combination group compared to the others (p < 0.001). Postoperative pain scores and adverse events were comparable among the four groups. Combined therapy with dexamethasone and ondansetron was the most effective treatment for reducing the incidence and severity of PONV in patients undergoing vitrectomy under local anesthesia.

Sub-Tenon’s urokinase injection-assisted vitrectomy in early treatment of suprachoroidal hemorrhage: Four cases report

BACKGROUND

Suprachoroidal hemorrhage (SCH) is a rare but potentially catastrophic ocular event. Surgery for SCH is often challenging because of the difficulty in resolving the retinal and choroidal detachment. Here, we describe a novel surgical technique in which urokinase is administered by sub-Tenon’s injection to target an organized clot in SCH prior to drainage.

CASE SUMMARY

A consecutive case series of four eyes with serous and hemorrhagic choroidal detachments secondary to cataract surgery or trauma was documented to evaluate the feasibility of using a sub-Tenon’s urokinase injection-assisted 23-gauge and 20-gauge incision to drain choroidal detachments. Urokinase (2000 IU) was given by sub-Tenon’s injection one day before surgery for clot liquefaction. A 23-gauge infusion line was placed in the anterior chamber. A 20-gauge incision was created in the suprachoroidal space 3.5 mm from the limbus. After drainage, pars plana vitrectomy was performed because of concomitant pathology that demanded this additional procedure. Visual acuity, ocular findings, the timing of surgical interventions, surgical procedures, and outcomes were retrospectively reviewed in four patients. Postoperative follow-up of the patients ranged from 6 to 24 mo (mean, 13 mo). After the treatment, all patients achieved excellent anatomical recovery.

CONCLUSION

Sub-Tenon’s urokinase injection-assisted vitrectomy makes clot liquefaction happen in the early treatment stage, resulting in marked stability during the procedure.

Delayed Suprachoroidal Hemorrhage After Pars Plana Vitrectomy: Five-Year Results of a Retrospective Multicenter Cohort Study

PURPOSE

To determine the incidence, risk factors, and outcomes of delayed suprachoroidal hemorrhage after vitrectomy.

DESIGN

Retrospective multicenter cohort study.

METHODS

All consecutive patients who underwent primary vitrectomy, from January 2009 to December 2014, at 4 tertiary vitreoretinal centers in Italy were enrolled. Patient demographics and systemic, ophthalmic, operative, and postoperative data from all centers were extracted from the electronic record system using standardized data collection forms. All eyes that developed delayed suprachoroidal hemorrhage within 48 hours of the end of the vitrectomy were identified as the delayed suprachoroidal hemorrhage group; all other eyes that underwent vitrectomy in the same period, without delayed suprachoroidal hemorrhage, were considered the control group.

RESULTS

From a total of 4852 vitrectomy procedures, 39 cases of delayed suprachoroidal hemorrhage (0.8%) were identified. Multivariable logistic regression showed that significant risk factors for developing delayed suprachoroidal hemorrhage included advancing age (odds ratio [OR], 2.22; P < .001), longer axial length (OR, 2.57; P < .001), presence of rhegmatogenous retinal detachment (OR, 3.27; P = .005), extensive intraoperative photocoagulation (OR, 4.94; P < .001), and emesis postoperatively (OR, 24.39; P < .001). Decision-tree analysis showed that the stronger predictors of delayed suprachoroidal hemorrhage were emesis postoperatively (P < .001) and extensive intraoperative photocoagulation (P < .001). After a mean follow-up of 27 ± 8 months, the best-corrected visual acuity decreased from 1.3 preoperatively to 1.6 logarithm of minimal angle of resolution at last follow-up (P < .001).

CONCLUSIONS

Delayed suprachoroidal hemorrhage occurs in 0.8% of vitrectomized eyes. The main risk factors are postoperative emesis and intraoperative extensive photocoagulation.

Massive suprachoroidal hemorrhage: Surgical management and outcome

Objective: To describe options for vitreoretinal surgery in the management of massive suprachoroidal hemorrhage (SCH).

Methods: Visual acuity (VA), ocular findings, timing of surgical intervention, surgical procedures, and outcomes of four patients diagnosed with massive SCH and admitted to the University Eye Clinic Essen were reviewed retrospectively.

Results: Four eyes of four patients (mean age, 82 years; range, 74–89 years) were studied. In three cases the occurrence of SCH was related to cataract surgery and occurred intra- or postoperatively. One patient developed spontaneous SCH of unclear origin. Three patients had a history of arterial hypertension; one eye had high myopia, two patients suffered from cardiovascular diseases, and two patients had glaucoma. Postoperative follow up of the patients ranged from 5 to 29.5 months (mean, 19.6 months). Transscleral drainage of SCH was in all cases combined with pars plana vitrectomy, use of heavy liquids (perfluorodecalin) and silicone oil tamponade. The mean time interval from hemorrhage to surgical intervention was 16.5 days (range 5–29 days). Preoperative VA of all eyes was light perception. Two patients achieved a final postoperative visual acuity of 20/20 and 20/320, respectively, one patient improved to hand motion, and one patient resulted in no light perception.

Conclusions: Surgical interventions including transscleral drainage of SCH, vitrectomy, and silicone oil tamponade are valuable options in the management of massive SCH to save the eye and possibly improve the otherwise extreme poor prognosis.

Anti-vascular endothelial growth factor with or without pneumatic displacement for submacular hemorrhage

PURPOSE

To compare the treatment outcomes of a combination of pneumatic displacement and intravitreal anti-vascular endothelial growth factor, and anti-vascular endothelial growth factor monotherapy for submacular hemorrhage resulting from exudative age-related macular degeneration.

DESIGN

Retrospective, comparative, interventional case series.

METHODS

Forty eyes treated with a combination therapy and 42 eyes treated with monotherapy for submacular hemorrhage resulting from exudative age-related macular degeneration with no significant difference in baseline central foveal thickness were compared. Central foveal thickness and best-corrected visual acuity (BCVA) at baseline, 1, 3, and 6 months after initial treatment were measured and compared between the 2 groups after adjustment of baseline central foveal thickness.

RESULTS

Central foveal thickness (P < .0001) and BCVA (combination, P < .0001; monotherapy, P = .022) were improved after both treatments. Combination therapy showed more rapid improvement of central foveal thickness (P = .009) and BCVA (P = .007) within 1 month than monotherapy, but there was no difference at 6 months (P = .385 and P = .303, respectively). In eyes with subretinal hemorrhage thicker than 450 μm, visual outcome at 6 months was better in the combination therapy group than in the monotherapy group (P = .021), whereas BCVA showed no significant difference between groups in eyes with subretinal hemorrhage less than 450 μm (P = .930).

CONCLUSIONS

Both treatments are useful options for submacular hemorrhage resulting from exudative age-related macular degeneration. Combination therapy may yield a better treatment outcome than monotherapy in eyes with thick subretinal hemorrhage. Nevertheless, the potential for adverse events resulting from pneumatic displacement should be considered.

Three cases of suprachoroidal hemorrhage associated with chest compression or asphyxiation and detected using postmortem computed tomography

We report 3 cases of suprachoroidal hemorrhage (SCH) found to be triggered by increased intrathoracic pressure and detected using postmortem computed tomography (PMCT). Case 1 was a man aged in his 50s who was found dead at a landslide site. The autopsy showed clogging of the upper respiratory tract with soil debris from the landslide. The cause of death was determined to be asphyxia. PMCT showed SCH in both eyes, which was believed to be caused by chest compression or choking on the soil debris from the landslide. Case 2 was a woman aged in her 60s who was found dead in the sea. The autopsy revealed injuries primarily to her chest. We concluded that the cause of death was drowning. PMCT showed SCH in her right eye that was believed to be caused by chest compression. Case 3 was a woman aged in her 80s who was buried in a snowdrift and potentially died from hypothermia. PMCT showed SCH in both eyes, which was considered to be from an increase in intrathoracic pressure that might have been caused by the burial in the snow. Histological findings showed serous retinal detachment associated with retinal pigment epithelium damage due to SCH, which indicated that she was alive for several hours after the onset of SCH. The increase in intrathoracic pressure caused by dyspnea or chest compression was considered responsible for the onset of SCH in all of the present cases. PMCT might assist with the differential diagnosis of traumatic asphyxiation by SCH.

Suprachoroidal hemorrhage in pars plana vitrectomy: risk factors and outcomes over 10 years

PURPOSE

To investigate the rate and risk factors of developing suprachoroidal hemorrhage (SCH) after pars plana vitrectomy (PPV) and the outcomes as a result.

DESIGN

Retrospective, comparative consecutive series.

PARTICIPANTS

A total of 5459 patients who underwent pars plana vitrectomies over 10 years in 3 surgical centers.

METHODS

All patient demographic, medical, and ophthalmic data and operative information from 3 vitreoretinal centers were entered prospectively into an electronic medical record. Univariate analysis was undertaken, comparing risk factors between cases (SCH) and controls. Multivariable logistic regression was performed to test for independence between the risk factors (P < 0.2 in univariate analysis) and SCH.

MAIN OUTCOME MEASURES

Risk factors for developing SCH. Visual outcome and development of complications.

RESULTS

A total of 5459 PPVs were undertaken for a wide range of indications. Fifty-six cases of PPV were complicated by SCH (1.03%). Multivariable logistic regression showed that significant risk factors for developing this included advancing age, (mean age, 69 years in cases and 60 years in controls; odds ratio [OR], 1.04; P = 0.001), male sex (76.8% of cases and 58.7% of controls; OR, 2.38; P = 0.008), presence of rhegmatogenous retinal detachment (RRD) (80.3% of cases and 52.5% of controls; OR, 5.92; P < 0.0001), presence of a dropped lens fragment (10.7% of cases and 4.5% of controls; OR, 6.94; P = 0.002), and the use of antiplatelet or anticoagulant drugs (33.9% of cases and 17.7% of controls; OR, 2.29; P = 0.007). Suprachoroidal hemorrhage was more common with increasing quadrants of RRD. The significant operative risk factor was application of an explant (25% of cases and 4.07% of controls; OR, 5.63; P < 0.0001). Phthisis (7.1% of cases and 0.9% of controls; P = 0.002, Fisher exact test) and glaucoma (14.3% of cases and 7.2% of controls; P = 0.044, chi-square test) were more common in cases than in controls.

CONCLUSIONS

The risk factors for developing intraoperative SCH during PPV are male sex, advancing age, RRD, a scleral explant, a dropped lens fragment, and the use of aspirin or warfarin. Patients with this complication have a greater risk of developing ocular hypertension requiring treatment and phthisis.

Serious adverse events after cataract surgery

PURPOSE OF REVIEW

Over the past several decades, there have been many advances in the equipment, instrumentation and techniques of performing cataract surgery. This review will address the impact of these advances on the safety profile of cataract surgery.

RECENT FINDINGS

Recent studies have demonstrated a decline in the risk of serious postoperative adverse events (endophthalmitis, suprachoroidal hemorrhage, retinal detachment) following cataract surgery. Factors that increase the risk of serious complications from cataract surgery include patient-related factors (male sex, concomitant diabetic retinopathy, same day cataract surgery combined with another intraocular surgery, tamsulosin use) and surgeon-related factors (low surgical volume, limited experience, operating on patients who are most prone to adverse events).

SUMMARY

Cataract surgery continues to be a very well tolerated surgical procedure with few patients experiencing serious sight-threatening adverse events. Studies in the literature have helped surgeons identify patients who are at high risk for surgical complications and develop strategies to limit surgical complications when operating on these patients. As multifocal intraocular lenses, femtosecond laser technology, and other surgical innovations continue to gain popularity, it will be interesting in the coming years to determine whether there will be a continued reduction in complications of cataract surgery.