Expulsive supra choroidal hemorrhage during silicone oil removal…..By Dr Hamid Aryaei tabar MD KUMS
Major COMlications of so removal • Re RD (25 %) • Hypotony (16%) • SCH(1%)
Why we remove so • K
Causes of so removel • Ant segment complications (esp in aphakic eyes ) • Post segment complications related to SO • RE-RD • SO emulsifications
Techniques for SO REMOVAL • Three port approach (active aspiration by pump vs manual aspiration ) • Limbal approach(two port )…(corneal damage, lack of opportunity to check the status of the retina) • Minimally invasive system (23G, 3-port)…use active aspiration with silicone soft canula (most up to date technique ) • Heavy oil removal (by 23 G 3-port system vs tubeless siphoning)
Risk factors • OCULAR • SYSTEMIC • INTRA – OPERATIVE(iop fluctuations , Valsalva maneuvers, rise of Blood pressure )
Risk factors • Athero sclerosis • Older ages • Multiple operation • Anticoagulant use &coagulation defects • Hx of sch in the operated eye or contralateral eye • High myopia • Trauma Hx • DM • HTN • Aphakia • Pseudophakia
Risks related to techniques • Sedation or with local anesthesia • Broad post buckling • 360 degrees cerclage • Cryotheraphy • SRFD(external ) • Prolong surgery • Slippage of infusion cannula into the suprachoroidal space
Pathogenesis • Hypotony ,,,low iop with high choroidal vascular pressure • Fragility of choroidal vessels( old age ,athero sclerosis , HTN , DM , axial myopia , glaucoma) • Obstruction of the vortex veins by SB • Direct damage of choroidal vessels (by needle during SRFD), when suturing the sclera during SB • CRYO (early removal of cryo probe while the choroid is still frozen ), cryo fracture • Mechanism of progression(shearing of more traversing vessels by a local hemorrhage )
Consequences of sch • Secondary retinal degeneration leading to retinal break and RD • Subretinal hemorrhage which causes photoreceptor damage • Vitreous hemorrhage • Glaucoma • Persistent ocular hypotony
Clinical findings • Sudden rise of iop • Shallowing of AC • Loss of red reflex • Dark brown convexity in the retinal periphery & visualization of oraseratta or pars plana • Bleeding into the subretinal space or vitreous cavity • Signs of prolapse ( vitrous or intraocular contents) • ECHO – B shows extention and concomitant RD( can shows liquefaction)
How to prevent • Control BP & HTN (brfore and during surgery) systolic BP below 150 • Patients using antocoagulantsuch as warfarin ,,,keep INR levels 2-3 • Stop antiplatelet medications if possible • Controll inflammation before surgery ( frequent steroids , ST sterois , ….) • Good glaucoma control before surgery • If SCH occurred during previous surgery find the cause and solve it if possible • Avoid iop fluctuation • Avoid hypotonia (intra and post operative)
Preventing sch • Cheque position of infusion canula . Prevent possible pulling by intra operative maneuvers • avoid sudden reduction of iop( prefer automated constant iop control ). • Apply external pressure during SRFD • Inject intra ocular injection of air or BSS if large SRFD • Avoid removing cryo probe before it thaws • avoid excess pressure over globe in eyes with friable sclera • Make sure of tight closure of sclerotomies at end of operation(do siedle test with flourscein in special cases) • After removing lid speculum look for hypotony • Avoid Valsalva maneuvrs during GA (prefer laryngeal masks) • In eyes with pre existing sch at the end of surgery prefer liquis rather than Air/Gas because of compresability
how to solve it • Cheque infusion line for blockage & that the infusion bag is full • Place another infusion line from a new sclerotomy and close the main line if cannula tip cannot be seen • Increase infusion pressure
How to solve it (post operatively) • Depends on site and extent of sch & associated complications • Macula not involved &no other complication …….OBSERVE • Large SCH & or RD , VH , vitreous incarceration do surgery • Surgery include drainage & VR surgery
VITREO RETINAL SURGERY FOR SCH • 1-2 WEEKS post event • Do ECHO-B and look for liquefaction(kinetic exam ) • Drainage can be achieved by sclerotomies if not , do radial sclerotomies at the dependent part of the quadrant involved by SCH • TPA,s injection may help for early liquefaction and surgery( inject 40.000IU INTO CLOT &wait for 15-25 min • Use long cannula • Use PFC
Nadarajah technique for sch drainage for massive sch & apposed retina) • 180 peritomy (iinferior) • 2 full thichness triangular scleral flap 3*3*3 mm at equator (inf-nasal & inf-temporal ) • Faps not sutured but cong sutured • 0.3 Ml of C3F8 injected intra vitreal • Early intervention
Diffrentiall diagnosis • Aphakic Pupillary Block • Choroidal Melanoma • Exudative Retinal Detachment • Malignant Glaucoma • Postoperative Retinal Detachment • Pseudophakic Pupillary Block • Tractional Retinal Detachment
Imaging Studies See the list below: • B-scan ultrasonography can aid in differentiating between serum and blood collected under or within the choroid (shown in the image below). B-scan ultrasonography is also helpful to delimit and stage the extent of the detachment when media are not clear. can ultrasonography examination of choroidal detachment. Fluid appears to be serum on one side (upper) and blood on the other side (below). Retina-to-retina contact, or kissing choroidal detachment, is present.
Medical Care • topical corticosteroids, • cycloplegics, • mydriatics • . Oral steroids • When the IOP is high, which can occur with hemorrhagic choroidal detachments, IOP-lowering drugs can be used. Osmotics and aqueous suppressants are recommended. • Parasympathomimetics are contraindicated.
Surgical Care • If choroidal detachment persists longer than 1 week after the underlying cause has been identified and addressed, drainage of the suprachoroidal fluid should be considered • . The 7-day limit is an indication only; individualized assessment is key. • If an improvement is suspected, waiting longer and closely monitoring the patient may be warranted. • Immediate action is indicated when lens-cornea touch or IOL-cornea touch exists. This condition causes endothelial corneal damage and acceleration of lens opacities.
Surgical care • If the AC remains flat after the cause has been identified and addressed, injection of viscoelastics into the AC should be considered. • If lens-cornea touch or IOL-cornea touch exists, the AC reformation should be performed immediately, at the slit lamp if possible, while waiting to assess the need for suprachoroidal fluid drainage.
Sch drainage suprachoroidal space. After the posterior sclerostomies are ated.
Surgery for sch • The AC reformation at the slit lamp is best performed through a paracentesis tract in the peripheral cornea; paracentesis tracts usually are made at the time of cataract or glaucoma surgery. • If not present, a paracentesis should be made with extreme care because the eye is likely to be soft and sore with a peripherally flat chamber; otherwise, inadvertent iris and lens damage may result. Performing a small full-thickness corneal incision with a sharp 15° knife is safer. • A cooperative patient is mandatory if the procedure is to be performed safely at the slit lamp. • The AC reformation procedure requires preparation with topical anesthesia, povidone-iodine preparation, and assistants to hold the lids and head of the patient.
technique for suprachoroidal fluid drainage • With paracentesis in the peripheral cornea. , balanced salt solution (BSS) is injected to fill the AC • . The paracentesis site made at the time of surgery can be used. • Preoperatively, the sectors where the most fluid is accumulated should be identified by ophthalmoscopy or B-scan ultrasonography. • Beginning with the sector where the detachment is largest, posterior sclerostomy is performed at 4-5 mm from the limbus. • Circumferential cuts are made, producing an incision of about 2 mm in length. This is shown in the illustration in the next slide
As soon as the suprachoroidal space is reached, the fluid drains. Serous detachments drain clear yellow fluid. Hemorrhagic detachments drain dark red fluid, often particulated with blood clots, shown in the image below. Gentle poking with a blunt instrument a few millimeters around the sclerostomy helps drainage when spontaneous flow slows down. i
Schdrainage • after one quadrant is drained, the AC is filled again with BSS, and the second quadrant receives a posterior sclerostomy in the same fashion. This procedure can be repeated for all 4 quadrants. • At the end, especially in highly myopic eyes without a lens, SF6 gas can be left in the vitreous cavity to tamponade. No agreement exists regarding the closure of sclerostomies, which some surgeons elect to leave unsutured to allow for more drainage.
prognosis • Variable ,,,depends on location and severity of condition & presence of associated conditions • When not involve the macula sisual outcome is acceptable • Massive sch ….. Severe v.loss • NLP in 12-57 % despite multiple intervention • Massive cases 86 % NLP
POOR VISUAL AND ANATOMIC OUTCOME • Initial RD • Long duration of retinal apposition • Vitreous incarceration into the wound • 360 – degree SCH • Involvement of post pole • Secondary glaucoma • hypotony
Thank you for your attention معبد اناهیتا کنگاور کرمانشاه Dy : DR Hamid Aryaei TabarMDKUMS 9th Iranian vitreo retinal congress