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Study of acute intraoperative suprachoroidal hemorrhage
Study of acute intraoperative suprachoroidal hemorrhage Paul N. Arnold, M.D.
Acute intraoperative suprachoroidal hemorrhage or effusion (AISH) is one of the most distressing complications that can occur at the time of cataract extraction and intraocular lens (IOL) implantation. This process occurs along a continuum. I believe that AISH can present clinically as a perception of positive pressure within the eye or that it can lead to expulsive hemorrhage. Linguistic accuracy requires that this event be called an AISH rather than an "expulsive hemorrhage" unless blood is actually expulsed from the eye (or other intraocular contents propelled by blood) . The diagnosis of AISH covers the more common, difficult-but-controlled suprachoroidal hemorrhage as well as the expulsive hemorrhage. The goal of managing the AISH is to prevent an expulsive hemorrhage. I viewed most of the present cases as being potential, or incipient, expulsive hemorrhages .
Intraocular pressure (lOP) is dramatically altered by the opening into the eye and the suprachoroidal space is also altered. Secondary factors affecting the vasculature of the eye are the arterial blood pressure, retro-orbital venous pressure, the regional anesthetic block, the vasoactive preoperative dilating drops, and the pressure applied to the orbit preoperatively. In the presence of a stable vascular state, this lOP alteration does not produce an untoward event, while a compromised vascular status may result in a suprachoroidal hemorrhage or effusion. Davison 1 has provided an extensive review of AISH in the extracapsular age. His article is highly recommended for background on the subject and for the excellent discussion of the anatomy and physiology of AISH. His surgical management of each case was varied, although he concluded by recommending that surgery be postponed and
Presented, in part, at the Symposium on Cataract, IOL and Refractive Surgery, San Diego, April 1992. Reprint requests to Paul N. Arnold, M.D., 1265 East Primrose Street, Springfield, Missouri 65804.
J CATARACT REFRACT SURG-VOL 18, SEPTEMBER
1992
489
completed the next day "if it appears the surgery cannot be safely completed." Prior to beginning this study, his was the recommendation I followed. This paper presents a three-year prospective study in which I looked at the clinical nature of AISH and the response to one method of management. MATERIALS AND METHODS I prospectively studied 2,523 cataract surgical cases over the past three years. I looked for patients in whom a "significant" suprachoroidal event had occurred. I arbitrarily excluded the "positive pressure" cases from this particular study, even though I believe they constitute the benign end of this continuum . I tried to make a distinction between patients with positive pressure and those in whom the positive pressure was so great that the surgery was temporarily postponed or completed with difficulty. In the latter patients, if this rapid increase in lOP was unrelenting and followed by iris prolapse, and all other mitigating factors were ruled out, they were considered to have an AISH. This diagnosis was confirmed and documented by indirect ophthalmoscopy or B-scan ultrasonography within 24 hours of surgery. I performed all the surgery and administered all peribulbar anesthetic blocks on the patients being reported. I used the single injection peribulbar technique with a 25-gauge sharp needle. 2 Four to 6 cc of local anesthetic without epinephrine was delivered in all cases. The Honan balloon was applied for three to eight minutes prior to preparing the eye for surgery. Phacoemulsification was performed in the posterior chamber using a "one-handed" technique. 3 Since I believe that fluctuating lOP may incite a suprachoroidal hemorrhage or effusion, my technique minimized these occurrences as much as possible. I hypothesized that limiting the range of dynamic lOP fluctuation would minimize the anatomic distortion of the ocular vasculature. Based on this supposition, it would be logical to conclude that phacoemulsification would decrease the incidence of AISH more than a more open system of extracapsular cataract extraction (ECCE) . This particular phacoemulsification method seeks to maintain as watertight an anterior chamber as possible. Viscoelastics were used in all cases during the capsulectomy and the IOL insertion. Planned extracapsular surgery was performed by nucleus expression in appropriate situations. 490
Surgical Management of AISH Management of AISH consisted of immediate closure of the incision. There was no attempt to perform a sclerostomy and drain the AISH either intraoperatively or postoperatively. As in most other types of bleeding, creating a tamponade is the preferred treatment. An expulsive hemorrhage is the result of several events, beginning with a choroidal effusion. Progressive distortion of the uveal anatomy results in a worsening of the condition. If the wound is tamponaded, this external pressure counteracts the intravascular pressure to maintain the uveal anatomy. If a suprachoroidal hemorrhage is secondary to the tangential shearing forces caused by an effusion, the tamponade may prevent the actual hemorrhage. Elevation of the lOP is essential in creating the tamponade . After closing the incision, usually with 8-0 nylon, I applied Q-tip pressure over the incision. If the eye did not adequately soften after ten minutes of this treatment, I placed a Honan balloon on the eye until the eye became more manageable. "Manageable" is defined as being able to work within the anterior chamber without undo risk to the capsule or corneal endothelium. After the Honan balloon, set at 50 mm Hg, was placed on the eye, the lOP was checked every ten to 15 minutes to observe a reduction in overall ocular pressure. The infusion bottle was elevated to help counterbalance the increased uveal pressure. Two ampules of mannitol and 500 mg of acetazolamide were administered intravenously. These agents may help decrease the lOP in the immediate postoperative period. Once the tamponade effected coagulation and surgery was completed, the lOP (raised by this space-occupying lesion-the suprachoroidal hemorrhage) had to be reduced. Viscoelastics were introduced, although nothing stayed in the anterior chamber very well. I used a posterior scleral shelved incision which discouraged iris prolapse to some extent. Topical and systemic ocular hypotensives were used postoperatively until a normal lOP was obtained. I was able to resume intraocular surgery in all cases within ten to 60 minutes of the AISH. None of them was easy to complete. However, with great care, all the operations were successfully completed. I believe it is desirable to complete the surgery during the timeframe provided by the regional block. There is a certain psychological stress inflicted on the patient and his or her family by any delay. Once the capsulectomy has been performed, there is significant ocular morbidity involved in delaying the comple-
JCATARACfREFRACTSURG-VOL 18, SEPTEMBER 1992
tion of cataract extraction. 4 Since surgery the following day or week is not substantially easier in these difficult cases in my experience, there is little or nothing to be gained by delay (e.g., waiting one week as opposed to one hour) and much to lose.
Table 2. Post-AISH corrected visual acuity. Visual Acuity
Number (Percentage)
=0;20/20
6 (40) 14 (93)
=0;20/40
;::20/200
RESULTS
* Had pre-existent AMD
During the three years of this study, 15 of2,523 patients experienced an AISH. This represented 0.6% of the cataract surgery population. No patient had an AISH in the second eye. All patients had had surgery on the fellow eye or had it sometime afterward. Ninety-six percent of the surgical procedures (2,423) were performed by phacoemulsification. Eleven of these cases, 0.5%, experienced an AISH. Four percent of the surgical procedures (100) were performed by ECCE by nucleus expression. Four of these cases, 4.0%, experienced an AISH. Preoperative characteristics and postoperative visual acuity of the patients who experienced an AISH are shown in Tables 1 and 2. Three of the 15 AISH patients, 20%, had glaucoma preoperatively compared to 14 % of the general cataract surgery population. One AISH patient developed ghost cell glaucoma secondary to a vitreous hemorrhage. None of the general cataract surgery group developed glaucoma postoperatively. Intraocular pressure increased at varying times during the procedures. Three of the 15 AISH incidents occurred during the capsulectomy, three occurred during phacoemulsification or after expression of the lens nucleus, one occurred during
1 * (7)
irrigation and aspiration of the cortical material, four occurred after cataract extraction at the time of IOL insertion, and four occurred after the IOL had been placed during wound closure (Figure 1). Systemic hypertension was noted in eight of the 15 AISH patients (53%). Two of the 15 patients (13%) had diabetes mellitus. The average axial length of the eyes with AISH was 23.0 mm; the average length of the entire cataract surgery group was 23.1 mm. Two of the AISH patients (13%) were on warfarin sodium (Coumadin®) at the time of cataract surgery-one for further stroke prophylaxis and one for significant coronary artery disease. Both these patients also had primary open angle glaucoma and hypertension. Less than 1 % of the entire cataract surgery group was on coumadin. Final visual acuity of 20/20 or better was achieved by six of the 15 AISH patients (40%). An acuity of 20/40 or better was achieved by 14 (93%); one patient with age-related macular degeneration had an acuity of less than 20/200. All 15 AISH patients had induced with-the-rule astigmatism in the early postoperative period. Six of the 15 patients, 40%, developed a relative
Table 1. Operative and preoperative characteristics. AISH Patients Number of patients Average age Average axial length Percentage having ECCEl
General Cataract Surgery Patients
15 79 23.0 mm 4/15,27%
2,523 76 23.1 mm 100/2,523, 4%
Percentage having PE2
11/15,73%
2,423/2,523, 96%
Preoperative glaucoma
3/15,20%
14%
Hypertension
8/15,53% 2/15,13% 2/15, 13%
Diabetes mellitus On Coumadin at surgery
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(1) extracapsular cataract extraction (2) phacoemulsification
43% 20% <1%
[0
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z
Fig. 1.
(Arnold) Time at which AISH occurred in phacoemulsification and ECCE patients. #1 occurred during capsulectomy; #2, after nucleus expression; #3, during irrigation/aspiration; #4, during IOL insertion; #5, after IOL insertion.
J CATARACT REFRACT SURG-VOL 18, SEPTEMBER 1992
491
afferent pupillary defect (RAPD) after the AISH. DISCUSSION The 0.6% AISH incidence in my cataract surgery population is comparable to the 0.9% reported by Davison. l Seven of his 25 AISH patients (28.0%) required surgery on another day, whereas surgery was completed within an hour of the AISH in the 15 patients reported in the present series. All my patients were outpatients. The particular management technique may have prevented an expulsive hemorrhage from occurring in any of these 15 eyes. I think the preponderance of AISH in the ECCE group in this series reflects the more advanced age-related pathological processes in these eyes. The average age of the AISH group was 79 years. The average for the entire cataract surgery group was 76 years. The more advanced nature of the cataracts in the AISH group suggests a greater agerelated tissue pathology in the AISH group. This finding is consistent with a more fragile choroidal vasculature and an increased scleral rigidity. Glaucoma has been cited as a predisposing risk factor for suprachoroidal hemorrhage. 5 Bukelman and coauthors 6 found that glaucoma was more prevalent in their AISH patients than in their general cataract surgical group. Seven percent of their glaucomatous eyes had a "limited choroidal hemorrhage," while this occurred in only 1.5% of their other patients. Speaker et al. 7 performed a casecontrol study of risk factors for "suprachoroidal expulsive hemorrhage" and found glaucoma and increased lOP to be significant risk factors. There has been some controversy about the contribution of systemic hypertension to the incidence of AISH. Ruderman 5 reports that 59% of his elderly patients had systemic hypertension. Davison l reported only 28% in his series. Speaker et aI.7 did not find hypertension to be a significant risk factor. Systemic hypertension was noted in 8 of 15 patients of our AISH group (53%). A sampling from our general cataract surgery population had a hypertension prevalence of 43%. During surgery, blood pressures did not exceed 200/100 mm Hg in the AISH group. Such elevated blood pressure levels are not uncommon in this patient population in general. The slight preponderance of hypertension in the AISH group is of questionable significance. Only 2 of the 15 (13%) had diabetes mellitus. This is in contrast to approximately 20% of a sampling of our general cataract population who had some form of glucose intolerance. There is no exceptional difference here. The average axial length of the eyes with AISH was similar to that of the eyes in the entire cataract 492
surgery group. There does not appear to be an obvious anatomical predisposition in the AISH eyes. Although axial myopia is thought to be a risk factor for AISH, 7 neither the present series nor the cases reviewed by Davison showed this to be the case. Perhaps the most significant finding when comparing the AISH patients with their cataract surgical cohort was use of Coumadin in hypertensives with glaucoma. The occurrence of AISH in two patients with primary open angle glaucoma and hypertension who were on Coumadin reflects a generalized vascular senescence and fragility. None of the patients who experienced an AISH was on aspirin at the time of surgery. Approximately 3% of our general cataract surgery population continued aspirin through their operative period. There are patients in whom the discontinuation of anticoagulation is contraindicated. I usually leave this decision to the internist. My 5 mm scleral incision, one-handed phacoemulsification technique is not altered in the patient on anticoagulation therapy. The final, corrected visual acuity in the patients with an AISH was remarkably good. All 15 cases were closed with tightly tied interrupted 8-0 nylon sutures. All of the patients had induced with-therule astigmatism in the early postoperative period. These sutures were selectively cut to reduce astigmatism. Their six-month postoperative refractions did not show greater astigmatic deviation than my usual cataract patient cohort. Development of a relative afferent pupillary defect (RAPD) after AISH is an indication that nerve fiber damage occurred during the period of elevated lOP. We observed an RAPD in 6 of 15 patients (40%). Some of these patients with a RAPD had 20/20 Snellen visual acuity. This simply indicates that some nerve fiber damage had occurred in spite of maintaining excellent Snellen visual acuity. As we know from acute angle closure glaucoma, even a short-lived, extremely high lOP can lead to diffuse or focal nerve fiber damage. Most of the patients in the AISH group in the present study had at least 24 hours of elevated lOP in spite of therapy. I attribute the development of axonal damage in these eyes to the prolonged period of elevated lOP subsequent to the AISH. Although the incidence of 40% may seem high, even a small 0.3 log unit defect can be detected and is reported as an RAPD.8 Relative afferent pupillary defects have not been prospectively studied or reported in the previous series of patients with AISH.
J CATARACT REFRACT SURG-VOL 18, SEPTEMBER 1992
The AISH raises lOP. The Q-tip tamponade raises it further and could be criticized as endangering the optic nerve and retinal circulation. Hayreh and Weingeist 9 have shown that time is the critical element in central retinal artery occlusion. Retinal ischemia is tolerated for 90 to 100 minutes with good recovery of visual evoked responses and retinal morphology; beyond this, irreparable damage occurs. They state, "the retinal tolerance time to acute ischaemia is almost identical whether the ischaemia is produced by clamping the central retinal artery alone or by raising the intraocular pressure to above the level of the arterial blood pressure (with arrest of both the retinal and choroidal circulations)." In examining the AISH cases, I observed that in the planned extracapsular cases the lOP increase occurred during the first half of the operationmost commonly, right after nucleus expression; in the phacoemulsification cases it tended to occur after the cataract had been completely removed from the eye-that is, during IOL insertion or wound closure. This probably reflects the improved intraocular stability during phacoemulsification in a closed system compared to the early instability oflarge incision cataract surgery. In one illustrative case in which the AISH occurred during the capsulectomy, the 2.5 mm incision was closed with one suture and the Honan balloon was placed back on the eye. After approximately one hour, the case was completed without further complication. A posterior chamber lens was implanted in all but one of these patients. The one anterior chamber lens was placed in the eye of the one patient with a large opening in the posterior capsule. Anterior vitrectomy was also required in this patient, the only one in this AISH series. Bryant 4 has had great success waiting four to 17 weeks before concluding his proposed surgical plan by performing a secondary lens implantation. He does attempt to remove all the cortex before concluding the primary surgery. Davison l recommends waiting until the next day to finish surgery if primary implantation appears too risky. All my cases were completed in the same day, usually within an hour. All were primary lens implantations. One patient required a secondary operation consisting of anterior chamber washout and posterior vitrectomy for the treatment of ghost cell glaucoma. She developed a vitreous hemorrhage which did not clear after several weeks. I could see the red cells transform to erythroclasts floating in the vitreous and anterior chamber. There had been no tear in the posterior capsule during surgery, which led me to believe there must have been a zonulysis that was not clinically evident. This was followed
by medically uncontrolled lOP elevation. Her posterior vitrectomy was successful and she obtained 20/30 visual acuity postoperatively. She required no ocular hypotensive medication after her vitrectomy. The patients were treated postoperatively with topical beta blockers and systemic carbonic anhydrase inhibitors until a normal lOP was obtained. This occurred within 48 hours in all except the patient who had ghost cell glaucoma. If one considers positive pressure to present as a convexity of the posterior capsule during the irrigation/aspiration phase of cortical extraction unrelated to poor inflow or excessive outflow, 3.3% of patients (83 of 2,523) experienced positive pressure during the three-year study. I have chosen to exclude those cases from this particular AISH study because either the case was completed without serious difficulty or no suprachoroidal hemorrhage or effusion was found by indirect ophthalmoscopy or B-scan ultrasonography. If this number of "positive pressure" cases is added to the 0.6% of AISH patients, one could say that about 4.0% of this cataract surgical population exhibited some type of elevated suprachoroidal pressure during cataract surgery-96% of cases were done by phacoemulsification and 4% of cases were performed by nucleus expression planned ECCE. CONCLUSION I prospectively studied 2,523 patients having cataract/IOL implantation surgery over the previous three years. I was specifically studying patients who experienced an AISH. Fifteen patients met the criteria for inclusion in this study, an incidence of 0.6%. The identified risk factors for AISH were senescent eyes with very brunescent cataracts in patients with some systemic vascular disease, often requiring Coumadin, having ECCE (rather than phacoemulsification). Myopia and aspirin were not found to increase the risk. I believe that the risk factors are characterized by their common relationship to a generalized vascular pathology. The acute event was uniformly treated by immediate closure of the incision, external pressure on the eye (Q-tips pressed on the closed incision) to tamponade the hemorrhage or effusion, and pharmacological agents to decrease the postoperative lOP. Surgery was completed in all patients after a delay of ten minutes to one hour. A final visual acuity of 20/40 or better was achieved in over 90% of these patients. None of the eyes was lost to an expulsive hemorrhage.
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REFERENCES 1. Davison JA. Acute intraoperative suprachoroidal hemorrhage in extracapsular cataract surgery. J Cataract Refract Surg 1986; 12:606-622 2. Arnold PN. A prospective study of a single injection peribulbar technique. J Cataract Refract Surg 1991; 18:157-161 3. Arnold PN. One-handed method of posterior chamber phacoemulsification. J Cataract Refract Surg 1990; 16: 646-648 4. Bryant WR. Secondary intraocular lens implantation in eyes that experienced suprachoroidal hemorrhage during primary cataract surgery. J Cataract Refract Surg 1989; 15:629-634 5. Ruderman JM, Harbin TS Jr, Campbell DG. Postop-
494
6. 7.
8.
9.
erative suprachoroidal hemorrhage following filtration procedures. Arch Ophthalmol1986; 104:201-205 Bukelman A, Hoffman P, Oliver M. Limited choroidal hemorrhage associated with extracapsular cataract extraction. Arch Ophthalmol1987; 105:338-341 Speaker MG, Guerriero PN, Met JA, et al. A casecontrol study of risk factors for intraoperative suprachoroidal expulsive hemorrhage. Ophthalmology 1991; 98:202-210 Thompson HS. Putting a number on the relative afferent pupillary defect. In: Thompson HS, Daroff R, FrisEm L, et aI, eds. Topics in Neuro-Ophthalmology. Baltimore, Williams & Wilkins, 1979; 157-158 Hayreh SS, Weingeist TA. Experimental occlusion of the central artery of the retina. IV: Retinal tolerance time to acute ischaemia. Br J Ophthalmol 1980; 64: 818-825
J CATARACT REFRACT SURG-VOL 18, SEPTEMBER 1992
Acute intraoperative suprachoroidal hemorrhage or effusion (AISH) is one of the most distressing complications that can occur at the time of cataract extraction and intraocular lens (IOL) implantation. This process occurs along a continuum. I believe that AISH can present clinically as a perception of positive pressure within the eye or that it can lead to expulsive hemorrhage. Linguistic accuracy requires that this event be called an AISH rather than an "expulsive hemorrhage" unless blood is actually expulsed from the eye (or other intraocular contents propelled by blood) . The diagnosis of AISH covers the more common, difficult-but-controlled suprachoroidal hemorrhage as well as the expulsive hemorrhage. The goal of managing the AISH is to prevent an expulsive hemorrhage. I viewed most of the present cases as being potential, or incipient, expulsive hemorrhages .
Intraocular pressure (lOP) is dramatically altered by the opening into the eye and the suprachoroidal space is also altered. Secondary factors affecting the vasculature of the eye are the arterial blood pressure, retro-orbital venous pressure, the regional anesthetic block, the vasoactive preoperative dilating drops, and the pressure applied to the orbit preoperatively. In the presence of a stable vascular state, this lOP alteration does not produce an untoward event, while a compromised vascular status may result in a suprachoroidal hemorrhage or effusion. Davison 1 has provided an extensive review of AISH in the extracapsular age. His article is highly recommended for background on the subject and for the excellent discussion of the anatomy and physiology of AISH. His surgical management of each case was varied, although he concluded by recommending that surgery be postponed and
Presented, in part, at the Symposium on Cataract, IOL and Refractive Surgery, San Diego, April 1992. Reprint requests to Paul N. Arnold, M.D., 1265 East Primrose Street, Springfield, Missouri 65804.
J CATARACT REFRACT SURG-VOL 18, SEPTEMBER
1992
489
completed the next day "if it appears the surgery cannot be safely completed." Prior to beginning this study, his was the recommendation I followed. This paper presents a three-year prospective study in which I looked at the clinical nature of AISH and the response to one method of management. MATERIALS AND METHODS I prospectively studied 2,523 cataract surgical cases over the past three years. I looked for patients in whom a "significant" suprachoroidal event had occurred. I arbitrarily excluded the "positive pressure" cases from this particular study, even though I believe they constitute the benign end of this continuum . I tried to make a distinction between patients with positive pressure and those in whom the positive pressure was so great that the surgery was temporarily postponed or completed with difficulty. In the latter patients, if this rapid increase in lOP was unrelenting and followed by iris prolapse, and all other mitigating factors were ruled out, they were considered to have an AISH. This diagnosis was confirmed and documented by indirect ophthalmoscopy or B-scan ultrasonography within 24 hours of surgery. I performed all the surgery and administered all peribulbar anesthetic blocks on the patients being reported. I used the single injection peribulbar technique with a 25-gauge sharp needle. 2 Four to 6 cc of local anesthetic without epinephrine was delivered in all cases. The Honan balloon was applied for three to eight minutes prior to preparing the eye for surgery. Phacoemulsification was performed in the posterior chamber using a "one-handed" technique. 3 Since I believe that fluctuating lOP may incite a suprachoroidal hemorrhage or effusion, my technique minimized these occurrences as much as possible. I hypothesized that limiting the range of dynamic lOP fluctuation would minimize the anatomic distortion of the ocular vasculature. Based on this supposition, it would be logical to conclude that phacoemulsification would decrease the incidence of AISH more than a more open system of extracapsular cataract extraction (ECCE) . This particular phacoemulsification method seeks to maintain as watertight an anterior chamber as possible. Viscoelastics were used in all cases during the capsulectomy and the IOL insertion. Planned extracapsular surgery was performed by nucleus expression in appropriate situations. 490
Surgical Management of AISH Management of AISH consisted of immediate closure of the incision. There was no attempt to perform a sclerostomy and drain the AISH either intraoperatively or postoperatively. As in most other types of bleeding, creating a tamponade is the preferred treatment. An expulsive hemorrhage is the result of several events, beginning with a choroidal effusion. Progressive distortion of the uveal anatomy results in a worsening of the condition. If the wound is tamponaded, this external pressure counteracts the intravascular pressure to maintain the uveal anatomy. If a suprachoroidal hemorrhage is secondary to the tangential shearing forces caused by an effusion, the tamponade may prevent the actual hemorrhage. Elevation of the lOP is essential in creating the tamponade . After closing the incision, usually with 8-0 nylon, I applied Q-tip pressure over the incision. If the eye did not adequately soften after ten minutes of this treatment, I placed a Honan balloon on the eye until the eye became more manageable. "Manageable" is defined as being able to work within the anterior chamber without undo risk to the capsule or corneal endothelium. After the Honan balloon, set at 50 mm Hg, was placed on the eye, the lOP was checked every ten to 15 minutes to observe a reduction in overall ocular pressure. The infusion bottle was elevated to help counterbalance the increased uveal pressure. Two ampules of mannitol and 500 mg of acetazolamide were administered intravenously. These agents may help decrease the lOP in the immediate postoperative period. Once the tamponade effected coagulation and surgery was completed, the lOP (raised by this space-occupying lesion-the suprachoroidal hemorrhage) had to be reduced. Viscoelastics were introduced, although nothing stayed in the anterior chamber very well. I used a posterior scleral shelved incision which discouraged iris prolapse to some extent. Topical and systemic ocular hypotensives were used postoperatively until a normal lOP was obtained. I was able to resume intraocular surgery in all cases within ten to 60 minutes of the AISH. None of them was easy to complete. However, with great care, all the operations were successfully completed. I believe it is desirable to complete the surgery during the timeframe provided by the regional block. There is a certain psychological stress inflicted on the patient and his or her family by any delay. Once the capsulectomy has been performed, there is significant ocular morbidity involved in delaying the comple-
JCATARACfREFRACTSURG-VOL 18, SEPTEMBER 1992
tion of cataract extraction. 4 Since surgery the following day or week is not substantially easier in these difficult cases in my experience, there is little or nothing to be gained by delay (e.g., waiting one week as opposed to one hour) and much to lose.
Table 2. Post-AISH corrected visual acuity. Visual Acuity
Number (Percentage)
=0;20/20
6 (40) 14 (93)
=0;20/40
;::20/200
RESULTS
* Had pre-existent AMD
During the three years of this study, 15 of2,523 patients experienced an AISH. This represented 0.6% of the cataract surgery population. No patient had an AISH in the second eye. All patients had had surgery on the fellow eye or had it sometime afterward. Ninety-six percent of the surgical procedures (2,423) were performed by phacoemulsification. Eleven of these cases, 0.5%, experienced an AISH. Four percent of the surgical procedures (100) were performed by ECCE by nucleus expression. Four of these cases, 4.0%, experienced an AISH. Preoperative characteristics and postoperative visual acuity of the patients who experienced an AISH are shown in Tables 1 and 2. Three of the 15 AISH patients, 20%, had glaucoma preoperatively compared to 14 % of the general cataract surgery population. One AISH patient developed ghost cell glaucoma secondary to a vitreous hemorrhage. None of the general cataract surgery group developed glaucoma postoperatively. Intraocular pressure increased at varying times during the procedures. Three of the 15 AISH incidents occurred during the capsulectomy, three occurred during phacoemulsification or after expression of the lens nucleus, one occurred during
1 * (7)
irrigation and aspiration of the cortical material, four occurred after cataract extraction at the time of IOL insertion, and four occurred after the IOL had been placed during wound closure (Figure 1). Systemic hypertension was noted in eight of the 15 AISH patients (53%). Two of the 15 patients (13%) had diabetes mellitus. The average axial length of the eyes with AISH was 23.0 mm; the average length of the entire cataract surgery group was 23.1 mm. Two of the AISH patients (13%) were on warfarin sodium (Coumadin®) at the time of cataract surgery-one for further stroke prophylaxis and one for significant coronary artery disease. Both these patients also had primary open angle glaucoma and hypertension. Less than 1 % of the entire cataract surgery group was on coumadin. Final visual acuity of 20/20 or better was achieved by six of the 15 AISH patients (40%). An acuity of 20/40 or better was achieved by 14 (93%); one patient with age-related macular degeneration had an acuity of less than 20/200. All 15 AISH patients had induced with-the-rule astigmatism in the early postoperative period. Six of the 15 patients, 40%, developed a relative
Table 1. Operative and preoperative characteristics. AISH Patients Number of patients Average age Average axial length Percentage having ECCEl
General Cataract Surgery Patients
15 79 23.0 mm 4/15,27%
2,523 76 23.1 mm 100/2,523, 4%
Percentage having PE2
11/15,73%
2,423/2,523, 96%
Preoperative glaucoma
3/15,20%
14%
Hypertension
8/15,53% 2/15,13% 2/15, 13%
Diabetes mellitus On Coumadin at surgery
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(1) extracapsular cataract extraction (2) phacoemulsification
43% 20% <1%
[0
~
:::>
z
Fig. 1.
(Arnold) Time at which AISH occurred in phacoemulsification and ECCE patients. #1 occurred during capsulectomy; #2, after nucleus expression; #3, during irrigation/aspiration; #4, during IOL insertion; #5, after IOL insertion.
J CATARACT REFRACT SURG-VOL 18, SEPTEMBER 1992
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afferent pupillary defect (RAPD) after the AISH. DISCUSSION The 0.6% AISH incidence in my cataract surgery population is comparable to the 0.9% reported by Davison. l Seven of his 25 AISH patients (28.0%) required surgery on another day, whereas surgery was completed within an hour of the AISH in the 15 patients reported in the present series. All my patients were outpatients. The particular management technique may have prevented an expulsive hemorrhage from occurring in any of these 15 eyes. I think the preponderance of AISH in the ECCE group in this series reflects the more advanced age-related pathological processes in these eyes. The average age of the AISH group was 79 years. The average for the entire cataract surgery group was 76 years. The more advanced nature of the cataracts in the AISH group suggests a greater agerelated tissue pathology in the AISH group. This finding is consistent with a more fragile choroidal vasculature and an increased scleral rigidity. Glaucoma has been cited as a predisposing risk factor for suprachoroidal hemorrhage. 5 Bukelman and coauthors 6 found that glaucoma was more prevalent in their AISH patients than in their general cataract surgical group. Seven percent of their glaucomatous eyes had a "limited choroidal hemorrhage," while this occurred in only 1.5% of their other patients. Speaker et al. 7 performed a casecontrol study of risk factors for "suprachoroidal expulsive hemorrhage" and found glaucoma and increased lOP to be significant risk factors. There has been some controversy about the contribution of systemic hypertension to the incidence of AISH. Ruderman 5 reports that 59% of his elderly patients had systemic hypertension. Davison l reported only 28% in his series. Speaker et aI.7 did not find hypertension to be a significant risk factor. Systemic hypertension was noted in 8 of 15 patients of our AISH group (53%). A sampling from our general cataract surgery population had a hypertension prevalence of 43%. During surgery, blood pressures did not exceed 200/100 mm Hg in the AISH group. Such elevated blood pressure levels are not uncommon in this patient population in general. The slight preponderance of hypertension in the AISH group is of questionable significance. Only 2 of the 15 (13%) had diabetes mellitus. This is in contrast to approximately 20% of a sampling of our general cataract population who had some form of glucose intolerance. There is no exceptional difference here. The average axial length of the eyes with AISH was similar to that of the eyes in the entire cataract 492
surgery group. There does not appear to be an obvious anatomical predisposition in the AISH eyes. Although axial myopia is thought to be a risk factor for AISH, 7 neither the present series nor the cases reviewed by Davison showed this to be the case. Perhaps the most significant finding when comparing the AISH patients with their cataract surgical cohort was use of Coumadin in hypertensives with glaucoma. The occurrence of AISH in two patients with primary open angle glaucoma and hypertension who were on Coumadin reflects a generalized vascular senescence and fragility. None of the patients who experienced an AISH was on aspirin at the time of surgery. Approximately 3% of our general cataract surgery population continued aspirin through their operative period. There are patients in whom the discontinuation of anticoagulation is contraindicated. I usually leave this decision to the internist. My 5 mm scleral incision, one-handed phacoemulsification technique is not altered in the patient on anticoagulation therapy. The final, corrected visual acuity in the patients with an AISH was remarkably good. All 15 cases were closed with tightly tied interrupted 8-0 nylon sutures. All of the patients had induced with-therule astigmatism in the early postoperative period. These sutures were selectively cut to reduce astigmatism. Their six-month postoperative refractions did not show greater astigmatic deviation than my usual cataract patient cohort. Development of a relative afferent pupillary defect (RAPD) after AISH is an indication that nerve fiber damage occurred during the period of elevated lOP. We observed an RAPD in 6 of 15 patients (40%). Some of these patients with a RAPD had 20/20 Snellen visual acuity. This simply indicates that some nerve fiber damage had occurred in spite of maintaining excellent Snellen visual acuity. As we know from acute angle closure glaucoma, even a short-lived, extremely high lOP can lead to diffuse or focal nerve fiber damage. Most of the patients in the AISH group in the present study had at least 24 hours of elevated lOP in spite of therapy. I attribute the development of axonal damage in these eyes to the prolonged period of elevated lOP subsequent to the AISH. Although the incidence of 40% may seem high, even a small 0.3 log unit defect can be detected and is reported as an RAPD.8 Relative afferent pupillary defects have not been prospectively studied or reported in the previous series of patients with AISH.
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The AISH raises lOP. The Q-tip tamponade raises it further and could be criticized as endangering the optic nerve and retinal circulation. Hayreh and Weingeist 9 have shown that time is the critical element in central retinal artery occlusion. Retinal ischemia is tolerated for 90 to 100 minutes with good recovery of visual evoked responses and retinal morphology; beyond this, irreparable damage occurs. They state, "the retinal tolerance time to acute ischaemia is almost identical whether the ischaemia is produced by clamping the central retinal artery alone or by raising the intraocular pressure to above the level of the arterial blood pressure (with arrest of both the retinal and choroidal circulations)." In examining the AISH cases, I observed that in the planned extracapsular cases the lOP increase occurred during the first half of the operationmost commonly, right after nucleus expression; in the phacoemulsification cases it tended to occur after the cataract had been completely removed from the eye-that is, during IOL insertion or wound closure. This probably reflects the improved intraocular stability during phacoemulsification in a closed system compared to the early instability oflarge incision cataract surgery. In one illustrative case in which the AISH occurred during the capsulectomy, the 2.5 mm incision was closed with one suture and the Honan balloon was placed back on the eye. After approximately one hour, the case was completed without further complication. A posterior chamber lens was implanted in all but one of these patients. The one anterior chamber lens was placed in the eye of the one patient with a large opening in the posterior capsule. Anterior vitrectomy was also required in this patient, the only one in this AISH series. Bryant 4 has had great success waiting four to 17 weeks before concluding his proposed surgical plan by performing a secondary lens implantation. He does attempt to remove all the cortex before concluding the primary surgery. Davison l recommends waiting until the next day to finish surgery if primary implantation appears too risky. All my cases were completed in the same day, usually within an hour. All were primary lens implantations. One patient required a secondary operation consisting of anterior chamber washout and posterior vitrectomy for the treatment of ghost cell glaucoma. She developed a vitreous hemorrhage which did not clear after several weeks. I could see the red cells transform to erythroclasts floating in the vitreous and anterior chamber. There had been no tear in the posterior capsule during surgery, which led me to believe there must have been a zonulysis that was not clinically evident. This was followed
by medically uncontrolled lOP elevation. Her posterior vitrectomy was successful and she obtained 20/30 visual acuity postoperatively. She required no ocular hypotensive medication after her vitrectomy. The patients were treated postoperatively with topical beta blockers and systemic carbonic anhydrase inhibitors until a normal lOP was obtained. This occurred within 48 hours in all except the patient who had ghost cell glaucoma. If one considers positive pressure to present as a convexity of the posterior capsule during the irrigation/aspiration phase of cortical extraction unrelated to poor inflow or excessive outflow, 3.3% of patients (83 of 2,523) experienced positive pressure during the three-year study. I have chosen to exclude those cases from this particular AISH study because either the case was completed without serious difficulty or no suprachoroidal hemorrhage or effusion was found by indirect ophthalmoscopy or B-scan ultrasonography. If this number of "positive pressure" cases is added to the 0.6% of AISH patients, one could say that about 4.0% of this cataract surgical population exhibited some type of elevated suprachoroidal pressure during cataract surgery-96% of cases were done by phacoemulsification and 4% of cases were performed by nucleus expression planned ECCE. CONCLUSION I prospectively studied 2,523 patients having cataract/IOL implantation surgery over the previous three years. I was specifically studying patients who experienced an AISH. Fifteen patients met the criteria for inclusion in this study, an incidence of 0.6%. The identified risk factors for AISH were senescent eyes with very brunescent cataracts in patients with some systemic vascular disease, often requiring Coumadin, having ECCE (rather than phacoemulsification). Myopia and aspirin were not found to increase the risk. I believe that the risk factors are characterized by their common relationship to a generalized vascular pathology. The acute event was uniformly treated by immediate closure of the incision, external pressure on the eye (Q-tips pressed on the closed incision) to tamponade the hemorrhage or effusion, and pharmacological agents to decrease the postoperative lOP. Surgery was completed in all patients after a delay of ten minutes to one hour. A final visual acuity of 20/40 or better was achieved in over 90% of these patients. None of the eyes was lost to an expulsive hemorrhage.
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REFERENCES 1. Davison JA. Acute intraoperative suprachoroidal hemorrhage in extracapsular cataract surgery. J Cataract Refract Surg 1986; 12:606-622 2. Arnold PN. A prospective study of a single injection peribulbar technique. J Cataract Refract Surg 1991; 18:157-161 3. Arnold PN. One-handed method of posterior chamber phacoemulsification. J Cataract Refract Surg 1990; 16: 646-648 4. Bryant WR. Secondary intraocular lens implantation in eyes that experienced suprachoroidal hemorrhage during primary cataract surgery. J Cataract Refract Surg 1989; 15:629-634 5. Ruderman JM, Harbin TS Jr, Campbell DG. Postop-
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erative suprachoroidal hemorrhage following filtration procedures. Arch Ophthalmol1986; 104:201-205 Bukelman A, Hoffman P, Oliver M. Limited choroidal hemorrhage associated with extracapsular cataract extraction. Arch Ophthalmol1987; 105:338-341 Speaker MG, Guerriero PN, Met JA, et al. A casecontrol study of risk factors for intraoperative suprachoroidal expulsive hemorrhage. Ophthalmology 1991; 98:202-210 Thompson HS. Putting a number on the relative afferent pupillary defect. In: Thompson HS, Daroff R, FrisEm L, et aI, eds. Topics in Neuro-Ophthalmology. Baltimore, Williams & Wilkins, 1979; 157-158 Hayreh SS, Weingeist TA. Experimental occlusion of the central artery of the retina. IV: Retinal tolerance time to acute ischaemia. Br J Ophthalmol 1980; 64: 818-825
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