Acute Intraoperative Suprachoroidal Hemorrhage

standard approach for phacoemulsification and intraocular lens implantation. In a prospective study, 2 the scleral tunnel incision sutured with absorbable interrupted sutures produced only an average of 0.34 diopter of induced astigmatism after all sutures had absorbed. It is interesting that neither Dr. Masket nor any ofthe other authors who have written about the scleral tunnel incision acknowledge the origin of the incision. It is also interesting that, in addition to various suggested modifications of the shape of the scleral tunnel incision, the trend is to a sutureless scleral tunnel incision. The rationale for the sutureless scleral tunnel incision is not clear. Not suturing the incision does not reduce the amount of induced astigmatism; it leaves the patient with the possibility of a ruptured wound (S.P. Thornton, M.D., "Total Iris Dehiscence Following IOL Implant," Ocular Surgery News, August 1, 1992), and the possibility of endophthalmitis. 3,4,5

randomized, and controlled study. Nevertheless, the 1992 ASCRS survey 1 indicated that 35% of respondent members are using a sutureless method. Poorly constructed wounds that demonstrate leakage at surgery or hypotony in the early postoperative period potentiate infection and should be sutured to create a proper seal. Sutures may be eliminated only when the incision is appropriately constructed to guarantee a hermetic seal. In my study that was cited by Dr. Girard, no benefit was gained from suturing and I reported that mean preoperative and one day postoperative intraocular pressures were statistically indistinguishable for patients with sutured and un sutured incisions; no cases were noted to have hypotony or leakage. Given those circumstances, I believe that a self-sealing internal corneal valve in combination with a reduced dimension sclero-corneal tunnel incision allows sutureless surgery to be safe and effective.

Louis J. Girard, M.D.

REFERENCES

Houston, Texas REFERENCES 1. Girard LJ, Hofmann RF. Scleral tunnel to prevent in-

2. 3. 4. 5.

duced astigmatism. In: Emery JM, Jacobson AC, eds, Current Concepts in Cataract Surgery; Proceedings of the Eighth Biennial Cataract Surgical Congress. Norwalk, CT, Appleton-Century-Crofts, 1984; 101-102 Girard LJ, Hofmann RF. Scleral tunnel to prevent induced astigmatism. Am J Ophthalmol 1984; 97:450-456 Stonecipher KG, Parmley VC, Jensen H, Rowsey 11. Infectious endophthalmitis following sutureless cataract surgery. Arch Ophthalmol1991; 109:1562-1563 Miller KM, Glasgow BJ. Bacterial endophthalmitis following sutureless cataract surgery. Arch Ophthalmol 1993; 111:377-379 Nelson DB, Donnenfeld ED, Perry HD. Sterile endophthalmitis after sutureless cataract surgery. Ophthalmology 1992; 99:1655-1657

Samuel Masket, M.D., replies: Dr. Girard correctly indicates that the scleral tunnel ("pocket") method has become the standard for small incision cataract surgery. While clear corneal incisions are increasing in popularity, 54 % of respondents to the 1992 ASCRS member survey indicated a preference for the incision to be placed 2 mm posterior to the limbus. 1 However, the origin of the scleral tunnel method is generally attributed to Richard Kratz. In a 1980 publication,2 the combination of a scleral tunnel incision with keratometrically controlled running suture tension was reported. Colvard, lead author of the publication, credits the origin of the method to Kratz (personal communication, 1983). Indeed, Kratz has been cited in numerous reports from many authors, including me, in reference to the scleral tunnel method. The question regarding safety and efficacy of selfsealing incisions is difficult to answer without a large,

1. Learning DV. Practice styles and preferences of ASCRS members-1992 survey. J Cataract Refract Surg 1993; 19:600-606 2. Colvard DM, Kratz RP, Mazzocco TR, Davidson B. Clinical evaluation of the Terry surgical keratometer. Am Intra-Ocular Implant Soc J 1980; 6:249-251

Acute Intraoperative Suprachoroidal Hemorrhage To the Editor: James Davison has contributed another useful insight to the anterior segment surgeon in his paper "Acute Intraoperative Suprachoroidal Hemorrhage in Capsular Bag Phacoemulsification."l Dr. Davison reported that with his capsular bag phacoemulsification technique, his incidence of AISH has decreased from 0.9% to 0.06%. I would like to expand on several of his points. My AISH study of2,523 consecutive eyes operated on between 1988 and 1990 (published in this journal although not cited in his paper) showed an AISH incidence of 0.6%, closer to his initial finding. 2 I emphasized that I used a posterior chamber, in-the-bag phacoemulsification technique in 96% of these patients expressly to decrease intracameral pressure fluctuations. 3 I have also noticed a decreasing incidence of AISH in my patient population as I have moved to an ever more watertight incision. I do not use a paracentesis for a second instrument, and I use a 2.5 mm keratome to accommodate insertion of the phaco tip in a snug fashion. I believe this leads to "improved containment," as Dr. Davison mentions. This will decrease the intraocular pressure fluctuations and, therefore, decrease the shear mechanism at work in the suprachoroidal space during cataract surgery. I also presented a method of surgical management of

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the 15 cases of AISH that is in accord with his newer management in the two cases reported. I have recommended simply applying direct pressure to the incision with a Q-tip. This transmits pressure to the suprachoroidal space and tamponades the suprachoroidal effusion or hemorrhage. This maneuver is perhaps distinct from what Dr. Davison describes as "massage," which I fear would cause more shear. This direct pressure is maintained for five to 15 minutes until the intraocular pressure is stabilized. Surgery can then be completed. Dr. Davison expresses concern about the "health of the retinal vasculature." This is an essential concern. As I pointed out in my paper, Hayreh and Weingeist4 have shown experimentally that occlusion of the central retinal artery does not lead to irreversible axonal damage if present for fewer than 90 minutes. Paul N. Arnold, M.D. Springfield, Missouri

REFERENCES 1. Davison JA. Acute intraoperative suprachoroidal hemorrhage in capsular bag phacoemulsification. J Cataract Refract Surg 1993; 19:534-537 2. Arnold PN. Study of acute intraoperative suprachoroidal hemorrhage. J Cataract Refract Surg 1992; 18:489-494 3. Arnold PN. One handed, posterior chamber phacoemulsification. J Cataract Refract Surg 1990; 18:157-161 4. Hayreh SS, Weingeist T A. Experimental occlusion of the central artery of the retina. IV: Retinal tolerance time to acute ischaemia. Br J Ophthalmol 1980; 64:818-825

James A. Davison, M.D., replies: I would like to congratulate Dr. Arnold for his fine paper on acute intraoperative suprachoroidal hemorrhage. We have had similar experiences and share most viewpoints. Had his paper been published earlier, I would not have felt the need to report my own experiences and recommendations with capsular bag phacoemulsification. I finished my manuscript and submitted it in March 1992. I was on record in my 1986 paper as recommending next-day completion of surgery but because of the contrast of my more recent experience, I felt obligated to update to same-day, same-operating-session completion and point out the improvements offered by capsular bag phacoemulsification through the selfsealing wound. The final revision of this manuscript was accepted by the Journal in September 1992, coincident with the publication of Dr. Arnold's paper in the September issue. Drs. Hans and Thierry Wilbrandt have recently published a paper on transducer-measured intraocular pressure fluctuations during various phacoemulsification strategies, which I did not have the opportunity to cite. 1 I highly recommend it as well as Dr. Arnold's to all ophthalmologists. Dr. Arnold and I seem to differ in one of our recommendations. While neither of us endorses intraoperative vitreous taps or drainage of suprachoroidal blood, I 814

would attempt intraoperative pars plana vitrectomy and drainage of suprachoroidal hemorrhage or effusion in a situation where retinal blood flow appeared to be completely obstructed for more than a few minutes. Hayreh and Weingeist's research was conducted on healthy monkeys, not cataract-age humans who commonly have fragile circulations and aged tissue. Fortunately this disasterous circulatory dynamic remains a hypothetical situation in my experience. James A. Davison, M.D. Marshalltown, Iowa

REFERENCE I. Wilbrandt HR, Wilbrandt TH. Evaluation of intraocular pressure fluctuations with differing phacoemulsification approaches. J Cataract Refract Surg 1993; 19:223-231

General Anesthesia and AISH To the Editor: I read with interest Dr. Davison's article describing two cases of acute intraoperative suprachoroidal hemorrhage (AISH) using modern phacoemulsification techniques. I have handled one case of AISH while performing in-the-bag phacoemulsification. After a short pause for ocular compression and a dilated funduscopic examination, I was able to conclude the case uneventfully. While making the procedure more difficult, this complication did not preclude successful completion of the case. In case number two, Dr. Davison described a patient who had also experienced AISH in her other eye. In light of the fact that this patient suffered the same complication when the other eye was operated on (presumably both were done under local anesthesia), would he now recommend doing the second eye under general anesthesia? The previously reported incidence of AISH in other operative situations is lower in patients who have had surgery using general anesthesia. While the incidence of AISH is so low that the benefit/risk ratio for routine use of general anesthesia is generally not favorable, it might be prudent to use it when a patient has experienced this complication in the first eye. Randy J. Epstein, M.D. Chicago, Illinois

James A. Davison, M.D., replies: I would like to thank Randy Epstein for his letter. He is correct; there is evidence of a lower incidence of expulsive choroidal hemorrhage with the use of general anesthesia during penetrating keratoplasty. Intraocular venous congestion from increased resistance in episcleral venous outflow caused by retrobulbar injection has been suspected as a risk factor for development of expUlsive hemorrhage early in the operation. 1,2 For local

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