SCH

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Information about SCH
Health & Medicine

Published on October 16, 2008

Author: ophthalmologyweb

Source: slideshare.net

Grand Rounds: October 3, 2007 86 yo CF 9 days s/p complete BVI OS c/o 2 days of HA, severe pain OS and in neck by Ali Bright Discussant: Dr. Brian Francis

86 yo CF 9 days s/p complete BVI OS CC : 2 days of HA, severe pain OS and in neck Ocular History : POAG OU s/p 2 trabeculectomies OS K edema 2nd to PBK OS K scar OS Blebitis OS Vitreous tap Intravitreal Abx injection Ocular Meds : Lotemax QID OS, Quixin QID OS, Xalatan once daily OU

CC : 2 days of HA, severe pain OS and in neck

Ocular History : POAG OU

s/p 2 trabeculectomies OS

K edema 2nd to PBK OS

K scar OS

Blebitis OS

Vitreous tap Intravitreal Abx injection

Ocular Meds : Lotemax QID OS, Quixin QID OS, Xalatan once daily OU

PMH : HTN, hypothyroid, arthritis Other Surgical History : pituitary adenoma removed Hip replacement hysterectomy Other Meds : Diltiazem, lisinopril, levothyroxine, glucosamine-chondroitin sulfate, multivitamin, Vit B Complex, Vit C, Calcium, fish oil, lecithin SH : occ wine, denies smoking and illicit drugs Relevant Family History : Mother – glaucoma Allergies : sulfa (pruritis) 86 yo CF 9 days s/p complete BVI OS

PMH : HTN, hypothyroid, arthritis

Other Surgical History : pituitary adenoma removed

Hip replacement

hysterectomy

Other Meds : Diltiazem, lisinopril, levothyroxine, glucosamine-chondroitin sulfate, multivitamin, Vit B Complex, Vit C, Calcium, fish oil, lecithin

SH : occ wine, denies smoking and illicit drugs

Relevant Family History : Mother – glaucoma

Allergies : sulfa (pruritis)

Ocular Exam Pain : 10/10! OS VA (cc): OD 20/30 PH to 20/25 OS HM TP : 15, 23 @ 11:10 a.m. Motility, CVF, Pupils : not recorded External Exam : WNL Conj : OS Baerveldt site superotemp, no bleb K : OS diffuse corneal edema with bullae AC : shallow OS Fundus : no view OS

Pain : 10/10! OS

VA (cc): OD 20/30 PH to 20/25

OS HM

TP : 15, 23 @ 11:10 a.m.

Motility, CVF, Pupils : not recorded

External Exam : WNL

Conj : OS Baerveldt site superotemp, no bleb

K : OS diffuse corneal edema with bullae

AC : shallow OS

Fundus : no view OS

Differential Diagnosis Choroidal effusion Retinal detachment (rhegmatogenous, tractional, exudative) Suprachoroidal hemorrhage Melanoma or metastatic tumor of the choroid or ciliary body

Choroidal effusion

Retinal detachment (rhegmatogenous, tractional, exudative)

Suprachoroidal hemorrhage

Melanoma or metastatic tumor of the choroid or ciliary body

B-Scan OS

Differential Diagnosis Choroidal melanoma A- and B-scan Choroidal melanoma collar button Kissing choroidal serous effusions Exudative Retinal Detachment Tractional RD Rhegmatogenous RD

Choroidal melanoma

A- and B-scan

A-Scan Representative

Plan cyclopegics, analgesics, topical steroids, follow with serial echography

cyclopegics, analgesics, topical steroids, follow with serial echography

B-Scan OS Plan : retina service consulted; shunt and scleral graft revision with suprachoroidal hemorrhage drainage

Plan : retina service consulted; shunt and scleral graft revision with suprachoroidal hemorrhage drainage

 

Suprachoroidal Hemorrhage Intro Accumulation of blood between the choroid and the sclera Normally the suprachoroidal space is an almost virtual space (10 µL) Etiology: spontaneous, intraop, 2 nd to intraocular surgery , trauma, or in association with intraocular vascular anomalies Limited SCH: suprachoroidal “hematoma” Massive SCH: expulsion or apposition Feared complication of all ocular surgeries Can result in total loss of vision and phthisis

Accumulation of blood between the choroid and the sclera

Normally the suprachoroidal space is an almost virtual space (10 µL)

Etiology: spontaneous, intraop, 2 nd to intraocular surgery , trauma, or in association with intraocular vascular anomalies

Limited SCH: suprachoroidal “hematoma”

Massive SCH: expulsion or apposition

Feared complication of all ocular surgeries

Can result in total loss of vision and phthisis

Arterial Supply to the Choroid

Venous Drainage from Choroid

Causes of SCH Impeding vortex vein outflow e.g. retrobulbar hemorrhage, retrobulbar anesthesia, pressure during surgery, scleral buckle Fluctuation in intraocular fluid dynamics and pressure E.g. sudden compression and decompression events Hypotony leads to choriocapillary effusion, stretching of suprachoroidal space, then tension on and rupture of posterior ciliary vessels (esp long) E.g. decompression hypotony

Impeding vortex vein outflow

e.g. retrobulbar hemorrhage, retrobulbar anesthesia, pressure during surgery, scleral buckle

Fluctuation in intraocular fluid dynamics and pressure

E.g. sudden compression and decompression events

Hypotony

leads to choriocapillary effusion, stretching of suprachoroidal space, then tension on and rupture of posterior ciliary vessels (esp long)

E.g. decompression hypotony

Surgery Associated with SCH (Chu and Green meta-analysis, 1999) Surgery Type % expulsive SCH (# patients) % delayed SCH (#patients) CE/IOL Placement 0.05-0.2% (~100,000) 0.06-0.81% (~6000) Corneal 0.087-1.08% (945) Glaucoma 0.15% (1329) 1.6-6.1% (~10,000) Vitreoretinal 0.41-1.0% (3710)

Risk Factors Systemic : advanced age, arteriosclerosis, DM HTN, anticoagulation, ischemic heart disease Ocular : previous laser photocoagulation, ocular surgery (esp PPV), aphakia, glaucoma , uveitis, high myopia , recent trauma Intraoperative : high IOP, high myopia, open-sky procedures, Valsalva maneuvers, intraoperative tachycardia, sudden drop in IOP, vitreous loss, bucking Post-op : after scleral buckle with vitrectomy, postoperative trauma, ocular hypotony, Valsalva, TPA administration

Systemic : advanced age, arteriosclerosis, DM HTN, anticoagulation, ischemic heart disease

Ocular : previous laser photocoagulation, ocular surgery (esp PPV), aphakia, glaucoma , uveitis, high myopia , recent trauma

Intraoperative : high IOP, high myopia, open-sky procedures, Valsalva maneuvers, intraoperative tachycardia, sudden drop in IOP, vitreous loss, bucking

Post-op : after scleral buckle with vitrectomy, postoperative trauma, ocular hypotony, Valsalva, TPA administration

Intraoperative Signs and Symptoms sudden onset of severe intraoperative pain excessive iris movement or prolapse forward movement of lens and vitreous body darkening/loss of red reflex excessive bleeding of conjunctiva and episclera vitreous hemorrhage tachycardia retinal detachment choroidal elevation protruding into operative field expulsion of intraocular contents

sudden onset of severe intraoperative pain

excessive iris movement or prolapse

forward movement of lens and vitreous body

darkening/loss of red reflex

excessive bleeding of conjunctiva and episclera

vitreous hemorrhage

tachycardia

retinal detachment

choroidal elevation protruding into operative field

expulsion of intraocular contents

SCH Signs

Management of Delayed SCH Limited choroidal hemorrhage usually resolves spontaneously in 1–2 months without damage conservative: cycloplegics and topical corticosteroids reduce over-filtration and hypotony Delayed, massive choroidal hemorrhage systemic corticosteroids + observe with serial ultrasonography or surgery 7-14 days post-hemorrhage

Limited choroidal hemorrhage

usually resolves spontaneously in 1–2 months without damage

conservative: cycloplegics and topical corticosteroids

reduce over-filtration and hypotony

Delayed, massive choroidal hemorrhage

systemic corticosteroids + observe with serial ultrasonography or

surgery 7-14 days post-hemorrhage

SEROUS CHOROIDAL DETACHMENT HEMORRHAGIC CHOROIDAL DETACHMENT Low IOP High IOP Transilluminates No transillumination Usually no pain Almost always painful despite analgesia Usually pre-equatorial may be more voluminous posterior to equator Resolution usually within 3 weeks Liquefies 6-26 days; resorbs ~4 weeks-several months Resolves without change in visual acuity Usually results in vision loss

When to Operate on SCH Lens-cornea touch Kissing choroidals (controversial) Massive choroidal hemorrhage with severe pain Persistently elevated intraocular pressure Persistently flat AC SCH under macula   Extension of hemorrhage into the subretinal space or vitreous cavity Significant vitreous incarceration Retinal incarceration Preferably after liquefaction of clots

Lens-cornea touch

Kissing choroidals (controversial)

Massive choroidal hemorrhage with severe pain

Persistently elevated intraocular pressure

Persistently flat AC

SCH under macula  

Extension of hemorrhage into the subretinal space or vitreous cavity

Significant vitreous incarceration

Retinal incarceration

Preferably after liquefaction of clots

Management of Intraoperative Massive Choroidal Hemorrhage Tamponade bleeding vessel with direct digital pressure on open wounds and rapid wound closure Prevent loss of intaocular contents and incarceration Reform anterior chamber e.g. with viscoelastic After PK, consider temporary keratoprosthesis Posterior sclerotomy intraop only if necessary to allow for wound closure Reduces tamponading effect of sealing the eye and may result in larger SCH Post-op: control IOP, inflammation and pain

Tamponade bleeding vessel with direct digital pressure on open wounds and rapid wound closure

Prevent loss of intaocular contents and incarceration

Reform anterior chamber e.g. with viscoelastic

After PK, consider temporary keratoprosthesis

Posterior sclerotomy intraop only if necessary to allow for wound closure

Reduces tamponading effect of sealing the eye and may result in larger SCH

Post-op: control IOP, inflammation and pain

Vitreoretinal Surgical Approach For SCH + RD, vitreoretinal traction, vitreous hemorrhage, and/or dislocated lens fragments sequence of surgical maneuvers is extremely important PP approach may damage anterior retina Perfluorocarbons can aid in flattening choroid and retina Long-acting intraocular gas or silicone oil may allow earlier visual rehabilitation and provide long-term tamponade

For SCH + RD, vitreoretinal traction, vitreous hemorrhage, and/or dislocated lens fragments

sequence of surgical maneuvers is extremely important

PP approach may damage anterior retina

Perfluorocarbons can aid in flattening choroid and retina

Long-acting intraocular gas or silicone oil may allow earlier visual rehabilitation and provide long-term tamponade

Controversy Over Management of Kissing Choroidals Perform surgery on all kissing choroidals (Berrocal and Reynolds) Observe unless apposition remained >2 weeks out from SCH occurrence (Scott et al) Operate if SCH involves >2 quadrants posterior to equator, or has kissing choroidals or SCH extending into macula (Meier and Wiedemann) Case-by-case approach (Chu et al)

Perform surgery on all kissing choroidals (Berrocal and Reynolds)

Observe unless apposition remained >2 weeks out from SCH occurrence (Scott et al)

Operate if SCH involves >2 quadrants posterior to equator, or has kissing choroidals or SCH extending into macula (Meier and Wiedemann)

Case-by-case approach (Chu et al)

Other Controversial Surgical Issues Most surgeons leave sclerotomies open Some suture them closed (Meier and Wiedemann) Favor surgical intervention after delayed SCH (Cannon et al, Abrams et al, Lakhanpal et al, Gressel et al, and Frenkel and Shin) After delayed SCH: observation + medical management = surgical intervention (Scott et al and Chu et al) Re-operate early after expulsive intraoperative SCH (Welch et al) No benefit of a second surgery in 9/9 patients following intraop expulsive SCH (Scott et al)

Most surgeons leave sclerotomies open

Some suture them closed (Meier and Wiedemann)

Favor surgical intervention after delayed SCH (Cannon et al, Abrams et al, Lakhanpal et al, Gressel et al, and Frenkel and Shin)

After delayed SCH: observation + medical management = surgical intervention (Scott et al and Chu et al)

Re-operate early after expulsive intraoperative SCH (Welch et al)

No benefit of a second surgery in 9/9 patients following intraop expulsive SCH (Scott et al)

Post-op Course VA: OS – HM TA: OS – 5 mmHg Assessment: hypotony, SCH resolving, serous retinal detachment likely involving macula

VA: OS – HM

TA: OS – 5 mmHg

Assessment: hypotony, SCH resolving, serous retinal detachment likely involving macula

Course and Outcome Good prognosis more likely in: Delayed, limited hemorrhage, especially > 7 days after inciting surgery SCH resulting from cataract surgery Higher visual acuity just after SCH Poor prognosis more likely if: Retinal detachment Hemorrhage in all 4 quadrants Extension into posterior pole Vitreous and/or retinal incarceration Low visual acuity just after SCH

Good prognosis more likely in:

Delayed, limited hemorrhage, especially > 7 days after inciting surgery

SCH resulting from cataract surgery

Higher visual acuity just after SCH

Poor prognosis more likely if:

Retinal detachment

Hemorrhage in all 4 quadrants

Extension into posterior pole

Vitreous and/or retinal incarceration

Low visual acuity just after SCH

Review Etiology, signs and symptoms, risk factors, and incidence of SCH B-scan is a useful diagnostic tool Follow patient with serial echography When to operate vs. manage conservatively How to handle limited, massive intraoperative, and delayed SCH Prognosis

Etiology, signs and symptoms, risk factors, and incidence of SCH

B-scan is a useful diagnostic tool

Follow patient with serial echography

When to operate vs. manage conservatively

How to handle limited, massive intraoperative, and delayed SCH

Prognosis

Acknowledgements Dr. Brian Francis Dr. Sheila Mahdaviani Dr. Vikas Chopra Dr. Amani Fawzi Lida Asatryan

Dr. Brian Francis

Dr. Sheila Mahdaviani

Dr. Vikas Chopra

Dr. Amani Fawzi

Lida Asatryan

Resources “ B-Scan Imaging With 10 MHz Probe.” http://www.ophthalmicultrasonography.com/Opt.htm Chu TG, Green RL. “ Suprachoroidal hemorrhage” . Surv Ophthalmol. 1999;43:471-486. Eye Text. http:// www.eyetext.net/images/thumbnails.php?page =16&sectionID=&PHPSESSID=4fcc71a83eaef46e34b.html Feretis E, Mourtzoukos S, Mangouritsas G, Kabanarou SA, Inoba K, Xirou T. “ Secondary management and outcome of massive suprachoroidal hemorrhage”. Eur J Ophthalmol . 2006 Nov-Dec;16(6):835-40. Healey PR, Herndon L, Smiddy W. Management of suprachoroidal hemorrhage. J Glaucoma . 2007 Sep;16(6):577-9. Jordan, Jens F. MD; Engels, ... Gunter K. MD. “ A Novel Approach to Suprachoroidal Drainage for the Surgical Treatment of Intractable Glaucoma”. Journal of Glaucoma . 15(3):200-205, June 2006. Meier, P. and Wiedemann, P . “ Massive suprachoroidal hemorrhage secondary treatment and outcome”. Graefes Arch Clin Exp Ophthalmol. 238 (2000), pp. 28–32. Moshfeghi, D., Kim, B., Kaiser, P., Sears, J., Scott, D., Smith. “Appositional Suprachoroidal Hemorrhage: A Case-Control Study”. Am J of Opthalmology . 2004, Dec ;138:959-63. “ OTI-Scan 3D - 3D B & Scan - Ophthalmic Ultrasound B-Scan Images.” Ophthalmic Technologies Inc. www.oti-canada.com/b3dimagesB.htm Sharma YR, Gaur A, Azad RV. Suprachoroidal haemorrhage. Secondary management. Indian J Ophthalmol 2001;49:191-2. Vrabec, T. “Exudative retinal detachment in Behçet's disease” . Arch Ophthalmol . 2001;119:1383- 1386. Wang LC, Yang CM, Yang CH, Huang JS, Ho TC, Lin CP, Chen MS. “Clinical characteristics and visual outcome of non-traumatic suprachoroidal haemorrhage in Taiwan”. Acta Ophthalmol . 2008 Jul 8. WuDunn D., Ryser D., Cantor LB. “Surgical drainage of choroidal effusions following glaucoma surgery”. J Glaucoma . 2005 Apr;14(2):103-8. Yanoff et al. Ophthalmology, 2nd Ed. St. Louis, MO: Mosby, 2004.

“ B-Scan Imaging With 10 MHz Probe.” http://www.ophthalmicultrasonography.com/Opt.htm

Chu TG, Green RL. “ Suprachoroidal hemorrhage” . Surv Ophthalmol. 1999;43:471-486.

Eye Text. http:// www.eyetext.net/images/thumbnails.php?page =16&sectionID=&PHPSESSID=4fcc71a83eaef46e34b.html

Feretis E, Mourtzoukos S, Mangouritsas G, Kabanarou SA, Inoba K, Xirou T.

“ Secondary management and outcome of massive suprachoroidal hemorrhage”.

Eur J Ophthalmol . 2006 Nov-Dec;16(6):835-40.

Healey PR, Herndon L, Smiddy W. Management of suprachoroidal hemorrhage.

J Glaucoma . 2007 Sep;16(6):577-9.

Jordan, Jens F. MD; Engels, ... Gunter K. MD. “ A Novel Approach to Suprachoroidal Drainage for the Surgical Treatment of Intractable Glaucoma”. Journal of Glaucoma . 15(3):200-205, June 2006.

Meier, P. and Wiedemann, P . “ Massive suprachoroidal hemorrhage secondary treatment and outcome”. Graefes Arch Clin Exp Ophthalmol. 238 (2000), pp. 28–32.

Moshfeghi, D., Kim, B., Kaiser, P., Sears, J., Scott, D., Smith. “Appositional Suprachoroidal Hemorrhage: A Case-Control Study”. Am J of Opthalmology . 2004, Dec ;138:959-63.

“ OTI-Scan 3D - 3D B & Scan - Ophthalmic Ultrasound B-Scan Images.” Ophthalmic Technologies Inc.

www.oti-canada.com/b3dimagesB.htm

Sharma YR, Gaur A, Azad RV. Suprachoroidal haemorrhage. Secondary management. Indian J Ophthalmol 2001;49:191-2.

Vrabec, T. “Exudative retinal detachment in Behçet's disease” . Arch Ophthalmol . 2001;119:1383- 1386.

Wang LC, Yang CM, Yang CH, Huang JS, Ho TC, Lin CP, Chen MS. “Clinical characteristics and visual outcome of non-traumatic suprachoroidal haemorrhage in Taiwan”. Acta Ophthalmol . 2008 Jul 8.

WuDunn D., Ryser D., Cantor LB. “Surgical drainage of choroidal effusions following glaucoma surgery”. J Glaucoma . 2005 Apr;14(2):103-8.

Yanoff et al. Ophthalmology, 2nd Ed. St. Louis, MO: Mosby, 2004.

Acknowledgements Dr. Brian Francis Dr. Sheila Mahdaviani Dr. Vikas Chopra Dr. Amani Fawzi Lida Asatryan

Dr. Brian Francis

Dr. Sheila Mahdaviani

Dr. Vikas Chopra

Dr. Amani Fawzi

Lida Asatryan

Surgical Technique

Which of the following is not a risk factor for suprachoroidal hemorrhage? Hypertension Diabetes Aphakia Glaucoma Inflammation A: Inflammation

Hypertension

Diabetes

Aphakia

Glaucoma

Inflammation

A: Inflammation

Which Is Not a Clear Indication for Surgically Draining a SCH? If the lens and cornea are touching Persistent elevation of intraocular pressure Suprachoroidal hemorrhage + serous retinal detachment Persistently shallow AC Vitreous incarceration Answer: SCH + serous retinal detachment

If the lens and cornea are touching

Persistent elevation of intraocular pressure

Suprachoroidal hemorrhage + serous retinal detachment

Persistently shallow AC

Vitreous incarceration

Answer: SCH + serous retinal detachment

Which of these blood vessels do not supply the choroid? A. Short posterior ciliary arteries B. Long posterior ciliary arteries C. Anterior ciliary arteries D. Central retinal artery E. A and D F. All of the above supply the choroid Answer: E

A. Short posterior ciliary arteries

B. Long posterior ciliary arteries

C. Anterior ciliary arteries

D. Central retinal artery

E. A and D

F. All of the above supply the choroid

Answer: E

When is the best time to operate for SCH? Within a few days of the hemorrhage 7-14 days 14-21 4-5 weeks After 2 months Answer 7-14 days

Within a few days of the hemorrhage

7-14 days

14-21

4-5 weeks

After 2 months

Answer 7-14 days

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