Delayed Suprachoroidal Haemorrhage - Assignment Example

Delayed Suprachoroidal Haemorrhage Following Glaucoma Surgery: An Evidence-Based Review Introduction: The suprachoroidal space, normally, is a dead space where choroid stays closely apposed to the sclera. Blood may accumulate in this space as a delayed complication following glaucoma surgery displacing choroid from its normal position. This is called delayed suprachoroidal haemorrhage, and this is a rare complication of glaucoma surgery (Gressel, M. G., Parrish, R. K., 2nd, and Heuer, D. K., 1984(1)). The bleeding occurs from ruptured choroidal vessels as a delayed consequence after trabecular surgery for correction of galucoma. All forms of detachment of the choroid have almost similar presentation, the only difference lies in the time of presentation (Cheema, R.A., Choong, Y.F., and Algawi, K.D., 2003(2)). Incidence: This complication particularly happens following filtration procedures for glaucoma surgery, the prototype of which is trabeculectomy where a guarded partial- thickness filtering mechanism is established by excising a block of limbal tissue beneath a lamellar scleral flap. This scleral flap is designed to provide resistance and limit excessive flow of aqueous humor (Ariano, M.L. and Ball, S.F., 1987(3)). Although this flap is meant for reducing complications, such as, flat chamber, haemorrhagic choroidal effusion, and hypotony, yet in about 2.9% cases, this procedure is attended with delayed suprachoroidal haemorrhage. Since there are different methods for performing a filtration procedure, subdivided into groups, the incidence is about 1.5% in trabeculectomy without antimetabolites, 2.4% in trabeculectomy with antimetabolites, 2.8% in valved tube shunt implantation, and 7.1% in nonvalved tube shunt implantations, indicating there is an increased incidence of delayed suprachoroidal haemorrhage after tube shunts for glaucoma surgery in comparison to simple trabeculectomy (Tuli, S.S., WuDunn, D., Ciulla, T.A., and Cantor, L.B., 2001(4)). Risk Factors: There are several risk factors identified for delayed suprachoroidal haemorrhage following glaucoma surgery. These are white race; anticoagulation; drugs that alter coagulation profile, such as, aspirin; severe postoperative hypotony; and aphakia or anterior chamber intraocular lens. Few other predisposing factors have been identified. These are old age, diffuse arteriosclerosis, glaucoma itself, suprachoroidal haemorrhage in the fellow eye, and a very short axial length or high myopia. However, the most significant causal factors has been identified to be postoperative hypotony. This may result from sudden inordinate decompression of the eye on the face of glaucoma, particularly when the surgery is initiated when the intraocular pressure has yet not been stabilised (Howe, L.J. and Bloom, P., 1999(5)). Mechanism: The exact mechanism that triggers such complication is unknown. Since the bleeding occurs due to rupture of the choroidal blood vessels, an increase in the transmural pressures of the choroidal vascular arcade that can be precipitated by elevated blood pressure, low intraocular pressure, or combination of both may be the probable causal mechanism. Once blood accumulates in this space, mainly created by the accumulated blood itself, there is almost no way that it gets reabsorbed unless the underlying cause of hypotony is treated. There is associated breakdown of blood-aqueous barrier across the pigmented epithelium. Thus, this blood settles beneath the retina in the posterior segment of the eye. This reduces the visual acuity since this precipitates a retinal detachment (Berke, S.J., Bellows, A.R., and Shingleton, B.J., 1987(6)). Prognosis: Fortunately, delayed suprachoroidal hemorrhages following glaucoma surgery may go unnoticed in most of the cases as they are more subtle, anterior, and shallow. The most significant complication out of untreated suprachoroidal haemorrhage is loss of useful vision in about 40% of cases. On the other end of the spectrum, however, there may be complications, such as, progression of lens opacity in a phakic eye. Cyclitic papillary membranes may develop. When the chamber is flat, corneal endothelial damage and peripheral anterior synechiae may develop. As mentioned earlier, since this involves choroidal and retinal detachments, this may as well result in maculopathy and globe pthisis. Overall prognosis is worse (Costa, V.P., Smith, M., and Spaeth, G.L., 1993(7)). Table of Studies Institution/ Place Sample Size Risk Factors Complications Prognosis Outcome Limitations University of Missouri-Kansas City School of Medicine, Department of Ophthalmology (Mardelli, P.G., Lederer, C.M., Murray, P.L., et al., 1996(8)). 62 Failed Filtration surgery And Anticoagulation Ocular hypotony Serous choroidal detachment Suprachroidal haemorrhage Bleb leak Iris blocking sclerostomy Hyphaema Corneal abrasion Good Mitomycin needle revision comparable to trabeculectomy with mitomycin Did not study methods to prevent delayed suprachoroidal haemorrhage The Western Eye Hospital, Marylebone Road, London (Howe, L.J. and Bloom, P., 1999 (9)). 3 Aphakia High myopia Large preoperative reduction in intraocular pressure Postoperative hypotony Systemic vascular disease Ischaemic heart disease Aspirin Rupture of necrotic ciliary arteries Immediate development of shallow Bleb Loss of visual acuity Relative afferent papillary defect Subconjunctival haemorrhage Total hyphema Gross hypotony Vitreous haemorrhage Haemorrhagic choroidal detachment Poor visual prognosis With conservative management, despite initial subjective improvement, the sight remained reduced at hand movement, persistent RAPD and a soft eye. Open funnel retinal detachment The sample size was less. This is a report. Moorfields Eye Hospital, London. (Canning, C.R., Lavin, M., McCartney, A.C., Hitchings, R.A., and Gregor, Z.J., 1989(10)). 432 Aphakia Vitrectomy Advanced age Haemorrhage occurred more often after anterior chamber tube drainage Eyes having previous lens extraction and vitrectomy have higher preoperative intraocular pressure and greater fall in pressure after vitrectomy Poor prognosis Not mentioned Relationship with other risk factors like advanced age, myopia, systemic hypertension, and high preoperative pressure were not demonstrated to be risk factors in contrast to other studies. Not mentioned (Abrams, G.W., Thomas, M.A., and Williams, G.A., 1986(11)). 8 Aphakia Sustained hypotonia Serous chroroidal detachment Scleral infolding Related to extent of haemorrhage Whether or not surgical drainage was performed In only one patient, rapid drainage led to recovery of visual acuity better than hand motions Could not study the effects in other 7 patients due to delayed care. Department of Ophthalmology, Calderdale and Huddersfield National Health Service Trust, Huddersfield Royal Infirmary, Lindley, Huddersfield, United Kingdom. (Syam, P.P., Hussain, B., and Anand, N., 2003(12)). 7 Aphakia Subluxated lens Aniridia Haemorrhagic choroidal detachment completely filled the posterior segment Visual acuity reduced to light perception only Good Rapid drainage with sclerotomy and simultaneous air insufflation with continuous-infusion air pump Vision restored to prefiltration acuity in 5 patients. One patient had decline to 20/100 Another patient declined to hand motions at 5 cm Detail of mechanism not explained. Small sample size Department of Ophthalmology, Indiana University, Indianapolis, Indiana, USA. (Tuli, S.S., WuDunn, D., Ciulla, T.A., and Cantor, L.B., 2001(13)). 2285/ 66 cases identified White race Anticoagulation Severe postoperative hypotony Aphakia Anterior chamber intraocular lens More often associated with shunt procedures than with trabeculectomy, most with nonvalved tube shunt implantation. Poor Visual outcome of patients with haemorrhage poor Caution should be exercised when operating on patients with known risk factors since with haemorrhage, there is decrease in the logarithm of the minimal angle of resolution visual acuity from 0.72 to 1.36 that was statistically significant compared with controls. Retrospective case-control study. Not mentioned (Frenkel, R. E. and Shin, D. H., 1986(14)). 2 along with 18 similar cases from literature Elderly patients Aphakic eyes Postoperative hypotony History of vitreous manipulation or complication General anaesthesia Increased venous pressure Use of 5-FU High myopia Following glaucoma surgery Good with timely intervention with drainage of the suprachoroidal haemorrhage and reformation of the anterior chamber, but without concomitant vitrectomy In both limited and massive delayed suprachoroidal haemorrhage, favourable visual outcome is not determined by the worst vision at the time of delayed suprachoroidal haemorrhage Too small sample size combined with retrospective data. Reference List 1. Gressel, M. G., Parrish, R. K., 2nd, and Heuer, D. K., (1984). Delayed Nonexpulsive Suprachoroidal Hemorrhage, Archives of Ophthalmology; 102: 1757. 2. Cheema, R.A., Choong, Y.F., and Algawi, K.D., (2003). Delayed Suprachoroidal Hemorrhage Following Viscocanalostomy. Ophthalmic Surgery Lasers Imaging; 34(3): pp. 209-211. 3. Ariano, M.L. and Ball, S.F., (1987). Delayed Nonexpulsive Suprachoroidal Hemorrhage After Trabeculectomy. Ophthalmic Surgery; 18(9): pp. 661-666. 4. Tuli, S.S., WuDunn, D., Ciulla, T.A., and Cantor, L.B., (2001). Delayed Suprachoroidal Hemorrhage After Galucoma Filtration Procedures. Ophthalmology; 8 (10): pp. 1808-1811. 5. Howe, L.J. and Bloom, P., (1999). Delayed Suprachoroidal Haemorrhage Following Trabeculectomy Bleb Needling. British Journal of Ophthalmology; 83: 753. 6. Berke, S.J., Bellows, A.R., and Shingleton, B.J., (1987). Chronic And Recurrent Choroidal Detachment After Glaucoma Filtering Surgery. Ophthalmology; 94(2): pp. 154-162. 7. Costa, V.P., Smith, M., and Spaeth, G.L., (1993). Loss Of Visual Acuity After Trabeculectomy. Ophthalmology; 100(5): pp. 599-612. 8. Mardelli, P.G., Lederer, C.M., Murray, P.L., et al., (1996). Slit-Lamp Needle Revision Of Failed Filtering Blebs Using Mitomycin C. Ophthalmology;103:1946-1955. 9. Howe, L.J. and Bloom, P., (1999). Delayed Suprachoroidal Haemorrhage Following Trabeculectomy Bleb Needling. British Journal of Ophthalmology; 83: 753. 10. Canning, C.R., Lavin, M., McCartney, A.C., Hitchings, R.A., and Gregor, Z.J., (1989). Delayed suprachoroidal haemorrhage after glaucoma operations. Eye; 3 ( Pt 3): pp. 327-331. 11. Abrams, G.W., Thomas, M.A., and Williams, G.A., (1986). Management of postoperative suprachoroidal hemorrhage with continuous-infusion air pump. Archives of Ophthalmology; 104(10): pp. 1455-1458. 12. Syam, P.P., Hussain, B., and Anand, N., (2003). Delayed suprachoroidal hemorrhage after needle revision of trabeculectomy bleb in a patient with hairy cell leukemia. American Journal of Ophthalmology; 136(6): 1155-1157 13. Tuli, S.S., WuDunn, D., Ciulla, T.A., and Cantor, L.B., (2001). Delayed Suprachoroidal Hemorrhage After Galucoma Filtration Procedures. Ophthalmology; 8 (10): pp. 1808-1811. 14. Frenkel, R. E. and Shin, D. H., (1986). Prevention And Management Of Delayed Suprachoroidal Hemorrhage After Filtration Surgery. Archives of Ophthalmology; 104: 1459. Read More