Grand Rounds
Alejandro Leon, MD
PGY-4
Vanderbilt Eye Institute
August 24, 2007
Clinical presentation
Painful loss of vision left eye.
 58 year old male.
 Blunt trauma to left eye 3 days ago.
 Mild discomfort and blurred vision.
 No flashes, no floaters.
 Morning day of presentation:
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Intense pain in left eye.
“My vision is now black”.
Previous history
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PMH: Chronic sinusitis, s/p lumbar spinal
fusion, HTN, hyperlipidemia.
FHx: No glaucoma.
SH: self employed truck driver. Denies
smoking and alcohol use.
Allergies: NKDA.
Medications: BP medication, cholesterol pill,
Travatan qHS OS.
Physical exam
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VA cc: OD: 20/40OS: LP temporally.
Motility: Full OU.
CVF: Full OD, OS unable.
IOP: OD: 9 OS: 3.
External: unremarkable.
Pupils: +rAPD OS.
SLE: OD: 2+ NSC.
Differential diagnosis
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Choroidal effusion.
Suprachoroidal hemorrhage.
Rhegmatogenous retinal detachment.
Melanoma or metastatic tumor of choroid or
ciliary body.
Other exam findings.
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DFE:
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OD: WNL with 0.4 c/d
OS: No view.
Anything else you want to test?
B-scan
Diagnosis
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Traumatic dehiscence of clear corneal wound.
Appositional suprachoroidal hemorrhage.
Suprachoroidal Hemorrhage
Suprachoroidal hemorrhage (SCH)
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Defined as
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Accumulation of blood
between the choroid and the
sclera.
Suprachoroidal space is an
almost virtual space.
(10 microliters)
One of the most dreaded
complications. Could result
in total loss of vision and
phthisis.
Suprachoroidal hemorrhage (SCH)
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Limited suprachoroidal hemorrhage.
Massive suprachoroidal hemorrhage.
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Appositional (“kissing”).
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Expulsive.
Pathophysiology
Fragile vessels is exposed to
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Sudden compression and decompression events.
Fluctuation in intraocular fluid dynamics and
pressure.
Hypotony may lead to suprachoroidal
effusion and cause tension on the vessels.
Pathophysiology
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Intact posterior capsule may tamponade
against such intense intraocular
decompression during surgery.
Ocular manifestations
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Decreased vision.
Pain.
Shallow anterior chamber with mild cells and
flare.
Smooth, bullous, orange-brown elevation of
the retina and choroid.
Fundus findings
Anterior
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to the equator
Extends in an annular fashion
Postequatorial
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unilobulated or multilobulated.
Fundus findings
Anterior
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to the equator
Extends in an annular fashion
Postequatorial
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unilobulated or multilobulated.
Echography
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B-scan
 smooth, thick, dome-shaped membrane
 Little, if any, after movement on kinetic evaluation.
Fresh blood clots.
 high-reflective, solid-appearing mass, with irregular
internal structure and irregular shape.
Serial ultrasonography for liquefaction of hemorrhage.
 low-reflective mobile opacities replacing clot.
Treatment
Delayed nonexpulsive limited choroidal
hemorrhage
 Conservative.
 Generally good prognosis.
 Usually resolves spontaneously within 1–2
months.
 Use of cycloplegics and topical
corticosteroids.
Treatment
Delayed, nonexpulsive massive choroidal
hemorrhage
 Systemic corticosteroids (controversial).
 Posterior sclerotomy to release
suprachoroidal blood.
Treatment
Intraoperative massive choroidal hemorrhage
 Tamponade.
 Rapid wound closure to prevent:
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Expulsion or loss of the intraocular contents.
Incarceration of vitreous or retina in the surgical
wound.
Treatment
Secondary Management
 Relieve vitreous or retinal incarceration. (to
decrease risk of RD).
 Drainage of choroidal hemorrhage ideally is
conducted after liquefaction of the
suprachoroidal hemorrhage (serial
echography).
Drainage of choroidal hemorrhage
Choroidal hemorrhage in trauma
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Intraocular structural damage.
High likelihood of retinal detachment and
associated proliferative vitreoretinopathy.
B-scan choroidal hemorrhage tend to be more
diffuse and less elevated.
Wound Dehiscence in
Pseudophakia
Cataract wound dehiscence post trauma.
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11 patients
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None small incision (no phacoemulsification)
Falling was the most frequent.
3 days to 1 year after surgery.
10/11 not wearing protective eyewear.
6/11 had 20/40 or better vision.
5/11 had 20/200 to LP vision.
Johns KJ, et.al., Am J Ophthalmol. 1989. 108:535-39
Small incision trauma dehiscence
Age
(years)
Surgery to
trauma
Event
Wound
Associated
injury
72
3 years
Fell
Clear cornea
Iris prolapse
92
3.5 years
Fell
Scleral tunnel
Extrusion of
IOL.
68
4 months
Fell
Clear cornea
Expulsive
iridodialysis
91
5 years
8 months
Fell
Clear cornea
Expulsion IOL
and iris
84
10 weeks
Fell
Clear cornea
Expulsive
iridodialysis
SCH with wound dehiscence
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Report 3 previously aphakic eyes.
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Traumatic dehiscence wound.
Massive SCH, uveal prolapse and retinal detachment.
Initial visual acuity was LP in all patients.
Drained when decrease of SCH seen in B-scan
(average 14 days).
SCH drainage with PPV and silicone oil.
Final visual acuities varied from 20/70 to 1/200.
Good anatomical result.
Liggett
PE, et al. Retina. 1990; 10 Suppl 1:S59-64.
Back to our patient
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Surgical wound closure.
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Oral prednisone.
Atropine, Vigamox, and PF.
Followed every week with B-scan.
2 weeks after event choroids without
apposition but no signs of liquefaction.
3 1/2 weeks later drained surgically.
Back to our patient
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Best visual acuity after procedure:
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2/200 “E”
Required tube shunt placement for IOP control.
Take home points
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Cataract wounds can dehisce even years
after surgery with trauma.
Management of suprachoroidal hemorrhage
include:
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Recognize.
Tamponade and closure of eye.
Consider systemic steroids.
Drain when signs of liquefaction in B-scan.
References.
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Hurvitz LM. Late clear corneal wound failure after trivial trauma. J Cataract Refract Surg 1999;
25:283-284.
Routsis P. Late traumatic wound dehiscence after phacoemulsification. J Cataract Refract Surg
2000; 26:1092-1093.
Navon SE, Expulsive iridodialysis: an isolated injury after phacoemulsification. J Cataract Refract
Surg 1997; 23:805-807.
Blomquist PH, Expulsion of an intraocular lens through a clear corneal wound. J Cataract Refract
Surg 2003; 29:592-594.
Walker NJ, Foster A, Apel AJG. Traumatic expulsive iridodialysis after small-incision sutureless
cataract surgery. J Cataract Refract Surg 2004; 30:2223-2224.
Liggett PE, Mani N, Green RE, Cano M, Ryan SJ, et al. Management of traumatic rupture of the
globe in aphakic patients. Retina. 1990; 10 Suppl 1:S59-64.
Kuhn F, Morris R, Mester V. Choroidal detachment and expulsive choroidal hemorrhage.
Ophthalmol Clin North Am. 2001 Dec;14(4):639-50.
Scott IU, Flynn HW, Schiffman J, Smiddy WE, Ehlies F. Visual acuity outcomes among patients
with appositional suprachoroidal hemorrhage. Ophthalmology 1997; 104:2029-2046.
Meier P, Wiedemann, P. Massive suprachoroidal hemorrhage: secondary treatment and outcome.
Graefe’s Arch Clin Exp Ophthalmol 2000. 238:28-32.
Kapusta MA, Lopez PF. Choroidal hemorrhage. Yanoff: Ophthalmology. 2nd Edition. Chapter 138.
2004 Mosby Inc.
Johns KJ, Sheils P, Parrish CM, Elliott JH, O’Day DM. Traumatic wound dehiscence in
pseudophakia. Am J Ophthalmol 1989. 108:535-539.