Delayed Suprachoroidal Haemorrhage - Article Example

Delayed Suprachoroidal Haemorrhage following Cyclodiode Laser Therapy Cyclodiode laser utilizing 810 nm wavelength has emerged as an effectivetool in the treatment of severe cases of glaucoma which are resistant to other conservative or surgical therapeutic options (Sabri 1999). It burns the ciliary body, reduces production of the aqueous humor, and reduces intraocular pressures even in refractory disease. It is superior to the traditional cryotherapy probe, achieving the same reduction in pressure with fewer side effects. However multiple applications may be needed because this treatment is reserved for the most difficult cases (Bloom 1997). It is highly successful in providing pain relief in painful blind hypertensive glaucomatous eyes (Martin 2001). It is also useful to bring down intra ocular pressures in pregnancy where use of topical ocular hypotensive agents are contraindicated (Wertheim 2002). A longer follow up by Walland and Mark (2000) has suggested that cyclophotocoagulation is a convenient and useful therapy in the control of IOP in end-stage glaucoma. Like any other laser surgery, cyclodiode therapy also has side effects, but the complications are minimal when compared to other forms of treatment (Bloom 1997). Mild complications include iritis and other inflammations of the eye which can last several weeks. This can be of concern because multiple applications may be needed for a patient (Bloom 1997). Rarely, severe complications like phthisis bulbi (Sabri 1999), panophthalmitis (Sii 2007), sympathetic ophthalmia, malignant glaucoma (Fankhauser, 2004), necrotizing scleritis (Sudha 2006), choroidal detachment and retinal detachment (Autrata 2003) can also occur. Sabri and Vernon have reported a case of scleral perforation following diode surgery (Sabri 1999) while Tay and others (2006) have described about supra choroidal haemorrhage (late complication). In neovascular glaucoma, response of intra ocular pressure to the laser therapy is highly variable and hence circumferential treatments in neovascular eyes should be avoided (Walland, 2000). Suprachoroidal haemorrhage (SCH) is a catastrophic complication of intraocular surgery. The bleeding is usually due to the rupture of the long posterior ciliary artery (Wolter 1982). It can cause immediate loss of vision or loss of the eye (Sharma, YR, 2003). It has been associated with cataract surgery, penetrating keratoplasty, glaucoma procedures, vitreoretinal surgery (Tay 2006) and secondary lens implantation (Reynolds 1993). The haemorrhage can occur during surgery (intra-operative) or post-operative (delayed). Intraoperative SCH can cause massive bleeding, resulting in the expulsion of intraocular contents. Postoperative SCH does not result in expulsion of contents. In cyclodiode laser surgery, the incidence of SCH has not much being reported. Tay and others (2006) reported the first occurrence of delayed SCH following cyclodiode laser treatment in 2006. They reported that the patient had some risk factors like older age, glaucoma, aphakia and a previous episode of hypotony following cyclodiode laser surgery in the contralateral eye, which probably predisposed him to SCH. It is important to know about the risk factors for SCH because it is a devastating complication of surgery leading to vision or total eye loss if not treated immediately and appropriately. Other risk factors which can predispose to SCH are hypertension, diabetes mellitus, myopia, pseudophakia, intraoperative hypertension with excessive drop in IOP, ocular inflammation (Tay 2006), taking at least one cardiovascular medication, elevated preoperative intraocular pressure, the lack of orbital compression, posterior capsule rupture before SCH, elective extracapsular cataract extraction, and phacoemulsification conversion (Ling, 2004). Since glaucoma itself is a risk factor for SCH and diode surgery is mainly done in refractory glaucoma cases, a high index of suspicion should be kept expecting SCH as a complication. When SCH occurs intraoperatively, early recognition and immediate rapid closure of the wound is important to preserve vision. Intraocular contents that have prolapsed should be reposited as quickly as possible and, if this is not possible, the eye can be softened by performing posterior sclerotomy. In delayed SCH, vitreo-retinal intervention may be necessary (Sharma 2001). The extent and location of a SCH and vitreoretinal status can be determined by postoperative B-scan ultrasonography. Liquefaction of blood in the suprachoroidal space can be seen echographically and it usually occurs between 7 and 14 days (Sharma 2001). In most cases of limited suprachoroidal hemorrhage without any initial retinal detachment, the visual prognosis is usually good and does not usually require secondary surgical intervention (Reynolds 1993). What doses of therapy lead to SCH and other complications is not known as yet. Vernon and others (2006) tried to achieve a standard protocol while using diode therapy for adult glaucoma. Though they did not arrive at any protocol consensus, they agreed upon the fact that using minimum cycloablation per sitting reduced the incidence of serious complications. It is believed that hypotony leads to choroidal effusion, which then stretches and tears the short or long posterior ciliary arteries causing SCH (Tay 2006). Hence aiming doses which do not cause much hypotony or sudden fall in pressures might help preventing SCH. In 2007, Sii and others reported the benefits of sequential titrated cyclodiode laser treatment, especially in those eyes with high risk for hypotony. History of hypotony post-cyclodiode laser treatment to the same or fellow eye, history of multiple ocular surgery, buphthalmos, high myopia, aphakia, uveitic eyes and connective tissue disease affecting eyes are at high risk for developing severe blinding complications. They used a minimal power of 1500mW and 1500ms in their surgeries. The dose was titrated down by 250mW in case of an audible “pop”. In case of high risk eyes and single eyes, they suggested initially starting with one quadrant, leaving the other 3 quadrants untreated. These remaining quadrants were later treated in subsequent sittings. This sequential approach is said to bring down the intra-ocular pressures slowly and prevent hypotony. It is worth considering this kind of approach because, in diseased conditions, the sclera is much thinner than normal and hence may require smaller doses to achieve ciliary photocoagulation (Sii 2007). Also, debris particles at the tip of the instrument enhance laser delivery. So single-use probes also may help in decreasing complications (Sii 2007). Though cyclodiode laser is an excellent tool for treating advanced and complicated glaucoma, severe blinding complications like suprachoroidal haemorrhage may arise following treatment. These can be minimized by identifying predisposing factors and high risk conditions, using minimal dose in sequential sittings, aiming at slow fall of intra-ocular pressure and recognizing haemorrhage at the earliest and intervening appropriately. References Autrat, R., Lokaj, M., Ehoek, J. 2003. Trans-scleral diode laser photocoagulation in children with refractory glaucoma- long term outcomes. Scripta Medica (BRNO), 76 (2), pp. 67–78. Bloom, P.A., Tsai, J.C., and Sharma, K. 1997. Cyclodiode trans-scleral diode laser cyclophotocoagulation in the treatment of advanced refractory glaucoma. Ophthalmology, 104, pp.1508-1520. Fankhauser, F., Kwasniewska, S., and Van der Zypen, E. 2004. 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