Violating ‘taboos’ to treat a suprachoroidal hemorrhage

September 15, 2015

A group of surgeons were faced with a suprachoroidal hemorrhage following trauma, and decided to break the ‘rules’ when tackling the case, and came out with surprisingly good results.

Take-home message: A group of surgeons were faced with a suprachoroidal hemorrhage following trauma, and decided to break the ‘rules’ when tackling the case, and came out with surprisingly good results.

 

By Laird Harrison; Reviewed by Matteo Forlini, MD  

Ravenna, Italy-Operating only 7 days after trauma causing a suprachoroidal hemorrhage, surgeons at Domus Nova Hospital, Ravenna, Italy, were able to reconstruct the iris and cornea, as well as treat the hemorrhage and implant an IOL in a single procedure.

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The 4-hour procedure violated more than one traditional “taboo” about treating this type of injury, said Matteo Forlini, MD.

Dr. Forlini and his father (Cesare Folini, MD) collaborated in a presentation on a case study of the procedure. Not only did they operate sooner than is usually recommended, they only used 3 trocars-all in the pars plana-to achieve suprachoroidal hemorrhage drainage. Also contrary to textbook advice, they removed the cornea.

The particular circumstances of the patient in this case necessitated these unusual steps, Dr. Forlini said.

Breakdown of events prior to surgery

Five years after receiving a cornea transplant, the 56-year-old man was in bed watching television. When he pulled the covers up, the remote control flew into his eye and hit the cornea at the site of the suture.

“It was very unlucky,” said Dr. Forlini, adding they decided to operate quickly.

Next: Examining the procedure

 

“The usual procedure when you have a massive suprachoroidal hemorrhage is to wait at least 10 to 15 days before making the drainage because you need the blood clots to become fluid,” he explained. “But in this case, we started with drainage only after 7 days because our hypothesis was that . . . there was not only hemorrhagic detachment, but also effusion and exudation.”

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The procedure succeeded because the surgeons achieved complete drainage of the subchoroidal space by placing their trocars in the pars plana.

After this drainage, they decided to continue with microincision vitrectomy surgery (MIVS) because of a partial vitreous hemorrhage, vitreous incarceration and tractional retinal detachment.

Textbooks typically advise against removing the cornea in an eye with suprachoroidal hemorrhage for fear of causing hyptony or provoking more bleeding while the eye is underpressurized.

But, this patient’s cornea was opacified, there were large synechias and the vitreous was incarcerated.

They proceeded to remove the cornea using penetrating keratoplasty (PK), and to perform a complete vitrectomy and iris surgery.

Examining the procedure

They calculated that the anterior chamber infusion would be enough to maintain the intraocular pressure and avoid the use of a Flieringa ring.

In this “open-sky” approach, it was relatively easy to remove the incarcerated vitreous and repair the iris using perfluorocarbon liquids to stabilize the posterior pole, Dr. Forlini said.

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Next, they used a temporary keratoprosthesis (TKP) in apposition to continue the vitrectomy “closed eye.”

They removed the perfluorocarbon liquid bubble and used blue staining to remove the inner limiting membrane in order to prevent a potential secondary pucker. Then they reintroduced the perfluorocarbon bubble for an accurate peripheral vitrectomy using a bimanual technique.

At this juncture, they debated whether to insert a new cornea and immediately close the bulb, or continue on to a pupilloplasty.

Next: Seizing an oportunity

 

They decided on the latter approach, rebuilding the damaged and partially atrophic iris using 10-0 prolene sutures.

Finally, they seized the opportunity afforded by the open-sky approach to correct refraction with an IOL.

They used a retropupillary iris claw because the surgery is short, gentle pressure with a spatula is enough for stable fixation, and the retropupillary implant is safer and more aesthetically pleasing with no visible tilting.

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Even in a rebuilt iris, this kind of IOL is easily implanted. And the open-sky procedure allowed the surgeons to continue with the iris suturing after the IOL was implanted, until an adequate papillary opening was obtained.

“It’s much, much faster using the open-sky approach,” Dr. Forlini said. “The IOL implantation was only a couple of minutes.”

As a tamponade, they chose heavy silicone. They used triamcinolone in the anterior chamber to protect the corneal graft from inflammation.

Concluding thoughts

They concluded that acute hypotony was the major reason for the exudation and consequent massive suprachoroidal hemorrhage in this patient. The large opening at the weak point in the cornea allowed violent expulsion of the ocular content.

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Their experience convinced them that early secondary repair could be performed in 7 days or less with MIVS. And it showed that a “pole-to-pole” strategy, including removal of the cornea, allowed treatment of all the damage caused by the trauma.

Next: 'This is the way to treat cases like (this)'

 

In fact, open-sky vitrectomy allows better treatment of the anterior segment damages, despite the potential risks, thanks to intraocular infusion, they found.

“The patient’s vision is now good,” said Dr. Forlini, noting that the macula was never damaged.

The case was one of a half dozen they have completed in this way. “In our experience, this is the way to treat cases like that,” he said.

 

Matteo Forlini, MD

E:forlinic@forlinic.it

This article was adapted from a presentation by Drs. Folini at the 2015 meeting of the American Society of Retina Specialists. They did not indicate a financial interest in the subject matter.