Metela I. Lukavu1,2 and Kangwa I. M. Muma1,3
1Department of Ophthalmology, School of Medicine and Clinical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia
2Eye Unit, Ndola Teaching Hospital, Ndola, Zambia
3University teaching Hospitals-Eye Hospital, Lusaka, Zambia
Ndola Teaching Hospital’s eye unit had a rare but vision threatening intraocular surgery complication in a male patient aged 62 years. The patient developed suprachoroidal haemorrhage of the Left Eye (LE) intraoperatively. It was his second eye for cataract surgery as he had previously been operated on the right eye for cataract. He had no systemic illness or ocular disease and was not on any medication. The patient ended up with an evisceration of the LE.
Suprachoroidal haemorrhage (SCH) is a rare but potentially devastating vision threatening complication of intraocular surgery [1,2]. It occurs due to rapture of the long and short posterior ciliary arteries [1,2] which leads to accumulation of blood within the potential space between the choroid and sclera. When it occurs, an attempt can be made to control it. If successful, the guarded prognosis can be reasonably improved and the patient can have useful vision and the globe saved [3,4,7]. In most cases the, vision is lost completely and can end up with evisceration.
The incidence of SCH tends to vary depending on the country, region and continent. It is estimated that the incidence of SCH in cataract surgery is currently 0.03% with new techniques compared to older techniques which was at 0.8%. Majority of SCH (50%) occurs after nucleus expression [8, 9, 10].
Risk factors of SCH include advanced age, cardiovascular conditions, peripheral vascular disease and certain medications such as anticoagulants, antiplatelet agents and cardiovascular drugs. Others include high myopia, Aphakia, Glaucoma, raised intraocular pressure pre-operatively and previous intraocular surgery, for example, Penetrating Keratoplasty (PK) or vitrectomy [3-10]. SCH can also be as a result of type of anaesthesia employed with retrobulbar anaesthesia having the greatest risk were as with general anaesthesia the risk for SCH is minimal.
Surgically the risk for SCH increases in case of posterior capsule rapture with vitreous loss, conversion from phacoemulsification to Extra Capsular Cataract Extraction (ECCE) and longer duration of intraocular surgery. Furthermore, post-operative risk factors include hypotony and valsalva manoeuvres (coughing and straining) [3-10].
A 62-year-old male patient presented to the Ndola Teaching Hospital (NTH) eye clinic for cataract surgery in the second eye which was the LE. The first cataract surgery in the RE was successful with good visual outcome (visual acuity, 6/12). The patient had no abnormalities elicited from his past medical history as well as his previous surgery and the rest of the examinations were normal except for the visual acuity of the left eye which was Hand Motion (HM). The basic tests such as blood sugar and Ultrasound were normal. Patient had no systemic disease. Routine pre-operative medications were given. Local anaesthesia was administered through a retrobulbar injection of lignocaine 2% with adrenaline. While on the operating table, the patient suddenly developed Suprachoroidal Haemorrhage (SCH) intraoperatively. The occurrence of this complication was so rapid that there was no chance to perform the necessary manoeuvres to save the eye. There was rapid extrusion of all intraocular contents which lead to evisceration of the eye.
Ndola Teaching Hospital eye unit had this rare and devastating experienced of SCH. The incidence happened so rapidly that the eye could not be salvaged by the necessary manoeuvres that would have saved the eye and possibly retain useful vision. The majority of patients encountering this complication recover with useful vision and the minority end up with blindness or complete loss of the eye [3, 4, 5]. Only a small proportion of patients completely lose the eye through evisceration such as reported by Sharma et al.,1997, in India where out of 6971 intraocular surgeries done between 1988 and 1994, only 12 developed SCH demonstrating that SCH was extremely rare at a prevalence of 0.17% and only three (0.04%) cases could end up with evisceration . At NTH, of the thousands of intraocular surgeries that have been performed over years, this was the first encounter. This confirms the findings of Sharma et al. .
Intraoperative SCH is defined as a sudden haemorrhagic swelling of the choroid which develops at the time of surgery. It is associated with expulsion of some or all of the intraocular contents. This is what happened in the case under study. Various studies have focused on identifying patients at risk and reduction of risk factors help to reduce the incidence [3-10]. Proper intraoperative and postoperative surgical management may be critical in saving the eye and having a good visual outcome [6,7]. Some eyes can recover from SCH with useful vision. Spaeth et al.,2007, have concluded from their study that occurrence of SCH does not in itself lead to poor outcome. The prognostic factors also include vitreous haemorrhage and retinal break or detachment . The NTH patient did not have risk factors, but presented the most rapid and devastating progression of SCH.
In cases where there are risk factors, it is vital to have a high index of suspicion for expulsive SCH. Where SCH is suspected intraoperatively, immediate rapid closure of the wound is important especially when SCH progression is not so rapid. Where there is a chance to control or stop the SCH, prolapsed intraocular contents should be reposited as quickly as possible whilst maintaining the anatomical integrity of the eye. If this is not possible, the eye can be softened by performing posterior sclerotomy. In the case under discussion the progression of SCH was so rapid that there was no room to control or stop it and it was not possible to achieve wound closure. Sclerotomy was also not possible to perform. All the eye viscera rapidly spontaneously extravasated and the eye ended up in evisceration.
Suprachoroidal haemorrhage though rare can be devastating. The course of suprachoroidal haemorrhage can be unpredictable and can lead to dramatic loss of vision. Prompt recognition and appropriate management may limit its consequences and provide a reasonable visual outcome.
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