Suprachoroidal hemorrhage may occur during or after any form of intraocular surgery, particularly glaucoma surgery, in which large variations in IOP are commonplace. By definition, such hemorrhages accumulate in the supraciliary and suprachoroidal space, a potential space between the sclera and uvea that is modified by uveal adhesions and entries of vessels. Hemorrhages may be limited or massive and involve 1–4 quadrants. When retinal surfaces touch one another, dictated by scleral spur and the entries of the short posterior ciliary vessels and nerves, the choroidal hemorrhage is termed appositional, or “kissing.” These hemorrhages may be further classified as nonexpulsive or expulsive; the expulsive type involves extrusion of intraocular contents. Reported risk factors for suprachoroidal hemorrhage include
arteriosclerotic cardiovascular disease
Sturge-Weber–associated choroidal hemangiomas
Transient hypotony is a common feature of all incisional ocular surgery; in a small percentage of patients, it may be associated with suprachoroidal hemorrhage from rupture of the long or short posterior ciliary arteries.
Surgical management strategies are controversial. Most studies recommend immediate closure of ocular surgical incisions and removal of vitreous incarceration in the wound, if possible; the primary goal is to prevent or limit expulsion. Successful intraoperative drainage of a suprachoroidal hemorrhage is rare, however, because the blood coagulates rapidly. Most surgeons recommend observation of suprachoroidal hemorrhages for 7–14 days to allow some degree of liquefaction of the hemorrhage. Determining the timing of secondary surgical intervention is aided by B-scan ultrasound, through evaluation of echographic features of clot liquefaction. Indications for surgical drainage include recalcitrant pain, increased IOP, retinal detachment, and appositional choroidal detachments associated with ciliary body rotation and angle closure. Furthermore, prolonged IOP elevation in the presence of an anterior chamber hemorrhage (hyphema) increases the risk of corneal blood staining and is an indication for surgical intervention.
In surgical management of suprachoroidal hemorrhage, an anterior chamber infusion line is placed to maintain IOP (Video 20-7, Fig 20-11). A full-thickness sclerotomy is then placed subjacent to the site of maximum accumulation of blood. After the suprachoroidal blood drains, pars plana vitrectomy may be performed. Appositional and closed-funnel suprachoroidal hemorrhage, prolonged elevation of IOP, and retinal detachment all portend a poor visual prognosis.
Drainage of suprachoroidal hemorrhage.
Courtesy of Koen A. van Overdam, MD.
Scott IU, Flynn HW Jr, Schiffman J, Smiddy WE, Murray TG, Ehlies F. Visual acuity outcomes among patients with appositional suprachoroidal hemorrhage. Ophthalmology. 1997;104(12):2039–2046.
Excerpted from BCSC 2020-2021 series: Section 10 - Glaucoma. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.