Management of suprachoroidal hemorrhage during cataract surgery

Abstract

A 61-year-old patient with end-stage liver cirrhosis was admitted for cataract surgery with corrected distance visual acuities (CDVAs) of 0.3, in both eyes. His international correction ratio (INR) for blood coagulation was 2.1 without any anticoagulants, and general anesthesia was contraindicated. He was deemed inoperable for liver transplantation. Two weeks after uneventful phacoemulsification in his right eye under topical anesthesia, he underwent phacoemulsification for the cataract in the left eye. However, during surgery, extensive zonular dialysis was noted and the surgery proceeded with extracapsular cataract extraction and anterior vitrectomy, during which a rapid suprachoroidal hemorrhage (SCH) was noted. The incisions were then rapidly sutured. Intravenous 150 cc of 18% mannitol and 2 mg midazolam and sublingual 5 drops of nifedipine were given, and he was placed in the slightly reverse-trendelenburg position. Following suturation of the incision, the globe was left aphakic, slightly hypertonic with no loss of vitreous through the incisions. The postoperative treatment regimen of topical prednisolone and moxifloxacin eye drops of each per hour, cyclopentolate three times a day, and peroral prednisolone 40 mg was commenced. Despite no retinal reflex on the first day and no light perception for 2 weeks, transscleral SCH evacuation with limited pars plana vitrectomy was performed in the postoperative third week. Despite recurrent hemorrhage and intravitreal inflammatory bands, choroidal detachments regressed slowly with the improvement of CDVA up to 0.6 with aphakic contact lens correction at 3 months. The patient passed away due to complications of liver cirrhosis at 6 months.

Management of Suprachoroidal Hemorrhage during Phacoemulsification: A Comprehensive Review

“…However, the latter is supposed to be extremely rare using phacoemulsification [ 2 , 5 , 6 , 7 , 10 ]. Indeed, phacoemulsification with small corneal self-sealing incisions between 1 mm and 3 mm, a closed irrigation-aspiration (I/A) system, and faster postoperative wound healing minimize the risk of severe ocular hypotony and prevent the prolapse of intraocular contents [ 2 , 4 , 8 , 12 , 13 , 14 , 15 ]. For this reason, cataract surgery by phacoemulsification does not only decrease the risk of SCH, but prevents the extension of SCH to an EH if it occurs [ 2 , 8 , 14 ].…”

“…Sudden anterior chamber shallowing (ACS) during surgery (especially at the stage of nucleus removal, I/A, or IOL insertion), along with red reflex loss, IOP increase, and pain are highly suspicious for ASCH [ 8 , 12 ]. Other warning signs include prolapse of the iris that cannot be repositioned, rupture of the posterior capsule with vitreous loss, and the spontaneous dislocation of the intraocular lens into the anterior chamber [ 5 , 13 , 24 ]. The loss of the red reflex with progressing black shadows observed under the operating microscope is quite specific to ASCH and might be the only sign in vitrectomized eyes in which the aqueous substance contained within the vitreous cavity may escape through the zonule fibers, resulting in the absence of other typical signs of SCH development [ 24 ].…”

“…As cataract surgery is widely accepted as an elective procedure, several authors have suggested that adopting certain preventive measures that may be performed before, during, or after surgery could avoid the occurrence of SCH [ 1 , 5 , 13 ].…”

“…First of all, patients recommended for cataract surgery, especially when considered to be high-risk cases, should be thoroughly evaluated in advance, paying particular attention to both systemic and ocular risk factors for SCH [ 1 , 5 , 13 ]. In this regard, a comprehensive examination should be undertaken, looking for cardiovascular disease, liver failure, coagulation abnormalities, and the use of cardiovascular medication [ 5 ].…”

“…Moreover, although not specifically addressed in the literature of phacoemulsification-related SCH, risk factors identified for glaucoma and vitrectomy-related SCH such as anticoagulant therapies should be taken into consideration as well. The bleeding risk should be assessed before the surgery through a complete blood count and coagulation panels; blood values with an emphasis on INR levels should be studied and stabilized before the procedure [ 1 , 13 ]. Finally, ocular risk factors, including high myopia and a history of glaucoma or IOP increase, should be documented and treated accordingly [ 1 , 5 ].…”