Suprachoroidal hemorrhage (SH) is a devastating complication of intraocular surgery. While the incidence of SH following sutured scleral-fixated intraocular lens (SFIOL) is reported to be 3%, there are no reports following sutureless SFIOL surgery. SH can be intraoperative or postoperative, limited, or massive. In our institution, we performed 572 sutureless SFIOL surgeries in 2016–2017, of which we encountered SH in three cases. Here, we report these three cases of SH following an uneventful sutureless SFIOL surgery and postulate the possible mechanisms underlying it.
A 70-year-old male with an inferiorly subluxated capsular bag with intraocular lens (IOL) with pseudoexfoliation, underwent 25-gauge (G) pars plana vitrectomy (PPV) with IOL explantation and sutureless SFIOL as described by Scharioth et al. Partial-thickness scleral grooves were made using a 23G microvitreoretinal (MVR) knife at horizontal meridians, slightly above 3 o'clock and below 9 o'clock. A 25G intraocular forceps (Scharioth IOL scleral fixation forceps, 25G/0.5 mm, 1286 SFD, DORC International BV) was used to exteriorize and tuck the haptics into the grooves. On the first postoperative day (POD), ultrasound examination showed SH limited to nasal and temporal quadrants. The patient was given topical steroids and cycloplegics. SH resolved by 1 month.
A 49-year-old male presented with secondary angle-closure glaucoma following a traumatic anterior subluxation of the crystalline lens in the left eye, with intraocular pressure (IOP) of 48 mmHg. He underwent PPV with lensectomy after IOP control. Endolaser photocoagulation was done around the intraoperatively diagnosed dialysis with perfluoropropane (C3F8) tamponade. SFIOL was deferred. Six months later, he underwent uneventful sutureless SFIOL as described above. On the first POD, there were total hyphema and dispersed vitreous hemorrhage with limited SH in the nasal and temporal quadrants. SH resolved in a month with conservative treatment.
A 40-year-old male presented with poor vision in his right eye, post laser capsulotomy for posterior capsular opacification with extensive pitting of the IOL. He was scheduled for an IOL exchange, during which the capsular bag was inadvertently removed. He underwent 25G PPV with uneventful sutureless SFIOL. On the first POD, ultrasound examination revealed massive central appositional SH [Figure 1a]. Initial conservative management, followed by choroidal drainage, after noting clot lysis on ultrasonography, was done. One month postoperatively, SH had resolved completely, with a persistent retinal fold at macula [Figure 1b].
The baseline characteristics and follow-up details of all the three cases are summarized in Table 1. Patient consent was obtained for publication of the details.
SH is a rare but potentially blinding complication of intraocular surgeries. To the best of our knowledge, SH has never been reported in the setting of sutureless SFIOL before. In a previous case series of 109 eyes with scleral fixation of IOLs, with 59 eyes having sutureless SFIOL, we did not encounter any case of intraoperative or postoperative SH.[2,6] The predisposing factors include advanced age, myopia, history of hypertension, aphakia, and immediate postoperative hypotony.[3,7,8] The mechanisms underlying it include acute changes in IOP which are transmitted across the walls of the posterior ciliary vessels causing their rupture or direct damage to the ciliary vessels by sharp instruments.
Advanced age has been reported to increase the risk due to fragility of the choroidal vessels. Chandra et al. have shown a positive association between the use of anticoagulants and SH. Only one of our patients was elderly and the other two were middle aged. None of them were on anticoagulants. Myopia has been significantly associated with delayed SH.[7,8] Low scleral rigidity and choroidal vascular fragility are implicated in this association. In our series, all patients had normal axial lengths.
Immediate postoperative hypotony increases the risk of delayed SH, especially when the preoperative IOP is high. One patient in our series with posttraumatic glaucoma underwent a staged surgery after medical control of IOP. All our cases had low IOP on POD 1, which may have aggravated the SH as discussed further.
Two cases with limited SH recovered normal vision with conservative treatment. One patient had central appositional SH. Surgical drainage after clot lysis is evident is recommended for patients with central appositional choroidal configuration, associated retinal detachment, a persistent flat anterior chamber, or uncontrolled IOP. The visual outcomes in eyes with appositional hemorrhage are reported to be poor. Our patient had a fairly good outcome despite the hemorrhage being massive, with his vision not improving beyond 6/18 due to a retinal fold across the fovea.
A possible explanation lies in the fact that the long posterior ciliary arteries pierce the sclera (at 3 and 9 o'clock meridians) at the posterior pole itself and then run anteriorly between the sclera and the choroid to join the major arterial circle located at the root of the iris. The superficial ciliary branch continues forward to form the episcleral arterial circle. Most importantly, both these arterial plexuses encircle the globe posterior to the limbus. We postulate that direct trauma by the sharp MVR to the arterial circle due to an inadvertent deep scleral groove may have caused the SH. Both these factors of direct trauma to the ciliary vessels intraoperatively and reduced IOP in the immediate postoperative period contributed to SH. The risk of making a deeper groove is increased with a straight MVR blade. This is because the supraorbital ridge does not allow the shaft of the blade to be made parallel to the ocular surface while fashioning the tunnel [Figure 2a]. Further, the left-sided tunnel requires an awkward positioning of the surgeon's arm making the depth unpredictable. Using an instrument like a bent 24G needle, a bent MVR or an angled side port knife may facilitate a more controlled way of making grooves, and thereby reduce the risk of making a deeper groove [Figure 2b].
During sutureless SFIOL surgery, careful attention to the depth of the scleral grooves and avoiding immediate postoperative hypotony is recommended to avoid disastrous complications like SH.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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