Expulsive Suprachoroidal Hemorrhage
Expulsive suprachoroidal hemorrhage, a rare but serious condition, generally occurs intraoperatively in eyes with hypotony. The hemorrhage usually presents as a sudden increase in IOP accompanied by acute onset of pain and the following:
darkening of the red reflex
expulsion of the lens, vitreous, and bright red blood
The instant any suprachoroidal effusion or hemorrhage is recognized, the surgeon must close the incision with sutures or digital pressure. Prolapsed vitreous is excised and uveal tissue reposited, if possible. After the wound is securely closed, the surgeon may consider posterior sclerotomies to allow the escape of suprachoroidal blood to decompress the globe, enable repositioning of prolapsed intraocular tissue, and facilitate permanent closure of the cataract incision. Drainage of suprachoroidal blood may be achieved by performing sclerotomies in 1 or more quadrants, 5–7 mm posterior to the limbus (Video 10-9). Sclerotomies for choroidal hemorrhage are also discussed in BCSC Section 12, Retina and Vitreous. Elevated IOP serves both to stop bleeding and to expel suprachoroidal blood. Once there is optimal clearance of blood from the suprachoroidal space, the sclerotomies may be left open to allow further drainage postoperatively. It may be necessary to repeat the drainage procedure 7 days or more after an expulsive hemorrhage in cases of residual suprachoroidal blood that threatens ocular integrity or vision. These procedures may lower dangerously elevated IOPs and restore appropriate anatomical relationships within the eye, but they carry some risk that bleeding will recur.
Drainage of suprachoroidal hemorrhage. Courtesy of Christina Weng, MD.
If the incision can be closed without posterior sclerotomies, more rapid tamponade of the bleeding vessel can be achieved. Most surgeons would then terminate the operation and observe the patient for 7–14 days to allow clotting and liquefaction of the hemorrhage, while managing elevated IOP medically. Referral to a vitreoretinal surgeon for management and subsequent drainage of choroidal hemorrhage may be considered. It is important to inform the patient of the guarded prognosis for restoration of vision.
Excerpted from BCSC 2020-2021 series: Section 11 - Lens and Cataract. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.