Suprachoroidal hemorrhage during pars plana vitrectomy

Suprachoroidal Hemorrhage during Pars Plana Vitrectomy Risk Factors and Outcomes Homayoun Tabandeh, MS, FRCOphth,1,2 Paul M. Sullivan, MD, FRCOphth,1 Peter Smahliuk, FRCOphth,1 Harry W. Flynn, Jr., MD,2 Joyce Schiffman, MS2 Objective: Suprachoroidal hemorrhage (SCH) is an uncommon but serious complication of pars plana vitrectomy (PPV) that can be associated with a guarded visual prognosis. The purpose of this study is to document the risk factors and outcomes of this complication. Design: Case– control study of consecutive cases of intraoperative SCH occurring during PPV (n ⫽ 36) and controls of PPV uncomplicated by SCH (n ⫽ 116). Main Outcome Measures: Baseline systemic and ocular characteristics, intraoperative findings, surgical procedures, and final anatomic and visual outcomes were measured. Results: Significant risk factors for the development of SCH during PPV included high myopia (22% of cases vs. 5% of controls), history of retinal detachment (RD) surgery (61% vs. 22%), rhegmatogenous RD (97% vs. 60%), use of cryotherapy (75% vs. 33%), scleral buckling at the time of PPV (50% vs. 19%), external drainage of the subretinal fluid (22% vs. 2%), and intraoperative systemic hypertension. In the 34 SCH cases with 3 months’ or more follow-up, the final visual acuity was 20/200 or greater in 11 (32%), count fingers in 5 (15%), hand movement in 7 (21%), light perception in 7 (21%), and no light perception in 4 (12%). In the 106 controls with 3 months’ or more follow-up, the final visual acuity was 20/200 or greater in 79 (75%), count fingers in 20 (19%), hand movement in 5 (5%), light perception in 1 (1%), and no light perception in 1 (1%). In the eyes with SCH, 17 (50%) had persistent RD, 10 (33%) had secondary glaucoma develop, and 8 (24%) became hypotonic. The visual and anatomic outcomes of the SCH cases were significantly worse than those in the control group (P ⬍ 0.001). The visual outcome was more favorable if the SCH did not extend into the posterior pole (P ⫽ 0.002). Attempted intraoperative drainage of SCH was not associated with a better outcome. Conclusion: Risk factors for the development of intraoperative SCH during PPV are high myopia, previous RD surgery, rhegmatogenous RD, cryotherapy, scleral buckling, external drainage of subretinal fluid, and intraoperative systemic hypertension. Anatomic and visual outcomes are significantly worsened after this complication. Ophthalmology 1999;106:236 –242 Suprachoroidal hemorrhage (SCH) is an uncommon but serious complication of intraocular surgery. It can be associated with a variety of surgical procedures that involve marked fluctuations in the intraocular pressure (IOP). Suprachoroidal hemorrhage has been reported after cataract surgery,1–7 glaucoma filtration procedures,5,6,8 –12 keratoplasty,5,6,13,14 and retinal detachment (RD) surgery.5,6,15–20

Originally received: October 28, 1997. Revision accepted: August 24, 1998. Manuscript no. 97614. 1 Moorfields Eye Hospital, London, England. 2 Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami School of Medicine, Miami, Florida. Presented at the annual meeting of the American Academy of Ophthalmology, San Francisco, California, October 1997. Supported in part by the Department of Health and Human Services, Public Health Service Grant EY10900 and by the Anne Allerton and Kings Funds. Address correspondence to Homayoun Tabandeh, MS, FRCOphth, Department of Ophthalmology, College of Medicine, PO Box 100284, Gainesville, FL 32610-0284.

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Suprachoroidal hemorrhage can also occur in association with subretinal neovascular membrane, laser photocoagulation, blood clotting abnormalities, and Valsalva maneuvers.21–26 In a large series of SCH during intraocular surgery, Speaker et al5 reported an incidence of 0.16% during cataract surgery, increasing to 0.19% when intracapsular technique was used. In this report, SCH occurred in 0.15% of filtration procedures and 0.56% of penetrating keratoplasties. The incidence of SCH during vitreoretinal surgery was 0.41%. Reported risk factors for the development of SCH during intraocular procedures include elevated preoperative IOP, history of glaucoma,3,5,19,27 axial length greater than 25 mm,5,10,28 aphakia, and pseudophakia.10,19,29,30 Systemic risk factors for SCH include hypertension, atherosclerosis, diabetes, advanced age, and intraoperative tachycardia.3,5,9,19 General anesthesia has been implicated by some reports1,31 and not by others.5 Acute ocular hypotony is common during many intraocular surgeries and is believed to precipitate the development of SCH. Pars plana vitrec-

Tabandeh et al 䡠 Suprachoroidal Hemorrhage Associated with Pars Plana Vitrectomy Table 1. Preoperative Systemic Characteristics of Patients with Suprachoroidal Hemorrhage (SCH) and Controls

History of hypertension [no. (%)] Diabetes mellitus [no. (%)] Atherosclerotic vascular disease [no. (%)] Aspirin [no. (%)] Systolic BP ⱖ 180 mmHg [no. (%)] Preoperative mean BP (mmHg) [mean (SD)] Preoperative heart rate (bpm) [mean (SD)] Age (yrs) [mean (SD)]

SCH (n ⴝ 36)*

Control (n ⴝ 116)*

P

6 (17) 1 (3) 3 (8) 1 (3) 1 (3) 104 (12) 76 (9) 57 (16)

25 (22) 15 (13) 14 (12) 5 (4) 8 (7) 101 (15) 78 (10) 54 (18)

0.67† 0.16† 0.74† 1.00† 0.58† 0.32‡ 0.36‡ 0.41‡

BP ⫽ blood pressure; bpm ⫽ beats per minute. * In some patients, data were not available for some variables. N varies from 32 to 36 for cases and 111 to 116 for controls. † Chi-square test. ‡ t test.

tomy (PPV) differs from other intraocular surgical procedures in that the prolonged acute hypotony is not a predominant feature. However, it may be associated with marked IOP fluctuations as well as extensive globe distortion, stretching of the chorioscleral layers, and planned or inadvertent perforations of the choroid. It is therefore a possibility that a number of mechanisms, and therefore risk factors, may be involved in the development of SCH during PPV. The purpose of the current study was to investigate the risk factors and the visual and anatomic outcomes of intraoperative SCH during PPV.

Subjects and Methods Study cases (n ⫽ 36) with a diagnosis of intraoperative SCH occurring during PPV were identified by a computerized search of the Vitreoretinal Service database at Moorfields Eye Hospital and by a review of the operating room records spanning the period from 1986 to 1996. Suprachoroidal hemorrhage was defined as the occurrence of a dark choroidal bulge with or without intravitreous cavity hemorrhage during PPV, confirmed after surgery by ophthalmoscopy or ultrasonography. Study controls consisted of all patients (n ⫽ 116) who underwent PPV without intraoperative SCH during a representative month (March 1996). The patient records were reviewed and data were collected on age, general health, including preoperative presence of cardiovascular and respiratory diseases, blood dyscrasias, anticoagulant and antiplatelet therapy, ocular history, including high myopia (ⱖ8 diopters), clinically diagnosed glaucoma, lens status, and previous ocular surgical procedures. Preoperative diagnosis, Snellen visual acuity, IOP, systolic and diastolic blood pressures, and pulse rate were recorded. In patients with RD, type and number of breaks and extent of detachment were documented. Intraoperative factors studied were the type of surgical procedure, including cryotherapy and laser retinopexy, scleral buckling, external drainage of subretinal fluid and type of internal tamponade, type of anesthesia, blood pressure and pulse rate, extent and timing of the hemorrhage, and any known precipitating factors. Postoperative data included Snellen visual acuity, retinal status, IOP, secondary complications, and further surgical procedures. For the purpose of the study, the visual and anatomic outcomes were defined as the visual acuity and retinal reattachment status at the last follow-up visit between 3 months and 1 year after surgery.

Data were collected on standardized data collection forms and entered in a computerized database (FileMaker Pro 2.0; Claris Corporation, Santa Clara, CA). Statistical analysis was performed using SPSS for Windows Version 6.0 (SPSS Inc., Chicago, IL). The effects of dichotomous variables, such as history of diabetes and external drainage of subretinal fluid, on the development of SCH were analyzed using chi-square tests. The t tests were used to compare continuous variables, including age, IOP, and systemic blood pressure between cases and controls. To assess the influence of SCH on the visual outcome, visual acuity was ranked as an ordinal variable. Anatomic outcome was ranked as retina attached, localized traction RD, and RD involving the posterior pole. Visual acuity and anatomic outcomes then were analyzed using the chisquare test, the Mann–Whitney U test, or the Kruskal–Wallis test, as appropriate.

Results Preoperative systemic characteristics for cases and controls are presented in Table 1. No significant difference between cases and controls was observed in the number of patients with history of hypertension (P ⫽ 0.67), diabetes (P ⫽ 0.16), atherosclerotic vascular disease (P ⫽ 0.74), use of aspirin or other antiplatelet medications (P ⫽ 1.00), preoperative mean blood pressure (P ⫽ 0.32), preoperative heart rate (P ⫽ 0.36), or age (P ⫽ 0.41) (Table 1). In the cases with SCH, 22 (61%) eyes had previous RD surgery, including scleral buckling procedure only (16), PPV without scleral buckling procedure (2), and PPV with scleral buckling procedure (4). Eight patients had a preoperative visual acuity of 20/200 or greater, 9 had vision of count fingers, 12 had hand motion (HM), and 6 had light perception only. The preoperative vision was undetermined in one case. The primary indication for surgery was rhegmatogenous RD in 35 patients and combined tractional/rhegmatogenous RD in 1 patient. In patients without SCH, the most common indication for PPV was rhegmatogenous RD (69), followed by vitreous hemorrhage (12), macular hole (8), tractional RD (5), epiretinal membrane (5), combined tractional/ rhegmatogenous RD (4), retained lens fragments (4), and dislocated intraocular lens (3). The preoperative ocular characteristics of both groups are summarized in Table 2. There were significant differences between the two groups in the percent of patients with high myopia (P ⫽ 0.01), history of RD surgery (P ⬍ 0.001), and presence of rhegmatogenous RD (P ⬍ 0.001).

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Ophthalmology Volume 106, Number 2, February 1999 Table 2. Preoperative Ocular Characteristics of Patients with Suprachoroidal Hemorrhage (SCH) and Controls

Previous retinal detachment surgery [no. (%)] Rhegmatogenous retinal detachment [no. (%)] High myopia [no. (%)] PVR (grade ⱖ C1) [no. (%)] Previous nonretina intraocular surgery [no. (%)] Preoperative IOP (mmHg) [mean (SD)] History of clinically diagnosed glaucoma [no. (%)] History of trauma [no. (%)] Lens status [no. (%)] Phakic Aphakic Pseudophakic

SCH (n ⴝ 36)*

Control (n ⴝ 116)*

P

22 (61) 35 (97) 8 (22) 8 (23) 11 (31) 14.8 (6.7) 4 (11) 1 (3)

26 (22) 69 (60) 6 (5) 12 (10) 43 (37) 15.5 (7.1) 8 (7) 6 (5)

⬍0.001† ⬍0.001† 0.01† 0.11† 0.58† 0.63‡ 0.66† 0.87† 0.98§

24 (67) 5 (14) 7 (19)

79 (69) 10 (9) 26 (23)

PVR ⫽ proliferative vitreoretinopathy. * In some patients, data were not available for some variables. N varies from 35 to 36 for cases and 113 to 116 for controls. † Chi-square test. ‡ t test. § Chi-square test for phakic versus nonphakic (aphakic and pseudophakic).

The intraoperative characteristics are summarized in Table 3. All procedures were performed with the patient under general anesthesia. Patients with concurrent cryotherapy, scleral buckling, external transchoroidal drainage of subretinal fluid, and systemic hypertension during surgery were more likely to have SCH develop. In most patients, the SCH was noted during surgical periods involving marked fluctuations in the IOP (Table 4). The SCH was anterior to the equator in 6 eyes, extended posterior to the equator but not involving the macular region in 13 eyes, and involved the posterior pole in 12 eyes. Two eyes had an isolated posterior pole SCH, and in three eyes the extent of the hemorrhage remained undetermined. In ten eyes, an attempt was made to drain the blood from the suprachoroidal space through posterior sclerotomies. On the first postoperative day, 13 (39%) of 33 eyes with SCH had a hyphema. The mean postoperative IOP was 29.9

mmHg, including 18 (51%) of 35 eyes with a pressure of 30 mmHg or greater and 8 (23%) of 35 eyes with a pressure of 40 mmHg or greater. First postoperative day data were not available on the anterior chamber features in three cases and on IOP in one case. The visual acuity and anatomic outcomes for the SCH cases versus the controls are listed in Table 5. The cases had worse outcomes for visual acuity (P ⬍ 0.001) and for RD (P ⬍ 0.001). The SCH cases also suffered more secondary glaucoma (on glaucoma therapy or IOP ⱖ 30 mmHg) and ocular hypotony (IOP ⱕ 6 mmHg). The visual and anatomic outcomes were worse in the patients with more posterior extension of the SCH (Table 6). In the patients who underwent intraoperative drainage of the suprachoroidal blood, visual acuity outcome was worse than those who did not undergo drainage. However, there was a bias for draining cases with more severe SCH. Similarly, intraoperative drainage of SCH

Table 3. Intraoperative Characteristics of Patients with Suprachoroidal Hemorrhage (SCH) and Controls

Ocular [no. (%)] Use of cryotherapy Scleral buckling Type Segmental Encircling Radial Size Small Large Large encircling External drainage of SRF Systemic Intraoperative mean blood pressure (mmHg) [mean (SD)] Maximum systolic BP ⱖ 180 mmHg [no. (%)] Intraoperative heart rate (bpm) [mean (SD)]

SCH (n ⴝ 36)*

Control (n ⴝ 116)*

27 (75) 18 (50)

38 (33) 22 (19)

3 (17) 14 (78) 1 (5)

10 (45) 12 (55) 0

5 (29) 12 (71) 9 (50) 8 (22)

19 (86) 3 (14) 1 (4) 2 (2)

0.001†

108 (20) 5 (14) 81 (14)

94 (14) 0 81 (14)

⬍0.001‡ ⬍0.001† 0.98‡

BP ⫽ blood pressure; SRF ⫽ subretinal fluid; bpm ⫽ beats per minute. * In some patients, data were not available for some variables. N varies from 35 to 36 for cases and 109 to 115 for controls. † Chi-square test. ‡ t test.

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P ⬍0.001† 0.001†

Tabandeh et al 䡠 Suprachoroidal Hemorrhage Associated with Pars Plana Vitrectomy Table 4. Surgical Stage during Which Suprachoroidal Hemorrhage Was First Noted Stage

No.

Scleral buckle placement Fluid-SO exchange Fluid–air exchange Cryotherapy PPV External drainage Other* Undetermined

8 8 7 4 4 2 2 1

Total

36

SO ⫽ silicone oil; PPV ⫽ pars plana vitrectomy. * Membrane peel, sclerotomy closure.

did not affect the rate of retinal reattachment or development of secondary glaucoma or hypotony (Table 7).

Discussion The mechanisms leading to SCH remain uncertain. It is believed that the initial event is ocular hypotony, giving rise to an abnormal transluminal vascular pressure. In the setting of low IOP, the short or long posterior ciliary arterial branches may rupture, giving rise to severe hemorrhage.32–34 The extent of the SCH may be limited by the increase in choroidal and suprachoroidal space volume, by the subsequent rise in intraocular or tissue pressure, or by the increase in the extraluminal pressure. Clotting mechanisms may limit further bleeding. Pars plana vitrectomy differs from other intraocular surgical procedures in that the prolonged acute hypotony usu-

ally is not a predominant feature, although marked fluctuations in the IOP do occur. The procedure often involves extensive distortion of the globe during scleral buckling and planned or inadvertent perforations of the choroid. Obstruction of the vortex veins can result from scleral buckling and may be associated with SCH.35 Although PPV may share many risk factors for the development of SCH with other intraocular procedures, it appears that there are additional risk factors that apply to PPV. In a series of seven SCH cases complicating PPV, Lakhanpal et al17 described scleral buckling, fluid– gas exchange, and cryopexy as risk factors. In a case– control study of a series of 13 perioperative SCH cases, Piper et al19 identified advanced age, elevated preoperative IOP, RD, aphakia or pseudophakia, and scleral buckling as risk factors. Similarly, in a series of 12 cases of SCH associated with PPV, Sharma et al20 found myopia, aphakia or pseudophakia, rhegmatogenous RD, scleral buckling, and duration of surgery to be statistically significant risk factors. The current series identified the major risk factors as high myopia, previous RD surgery, presence of rhegmatogenous RD, encircling with broad scleral buckle, cryotherapy, external transchoroidal drainage of subretinal fluid, and intraoperative systemic hypertension (Table 8). Scleral buckling with a broad explant involves extensive globe distortion, increased likelihood of vortex vein damage, and inadvertent needle perforation, all of which can result in SCH. External drainage of subretinal fluid involves choroidotomy and therefore damage to the choroidal vasculature. Of note in the current series is the lack of significance for history of glaucoma, preoperative ocular hypertension, nonphakia, and intraoperative tachycardia as risk factors. This may be a reflection of relative contributions of different pathophysiologic mechanisms to the development of SCH during PPV procedures. Further studies involving larger samples may

Table 5. Visual and Anatomic Outcomes* after Pars Plana Vitrectomy for Cases and Controls SCH (n ⴝ 34) [no. (%)] Postoperative VA ⱖ20/60 20/80–20/200 CF HM LP NLP Retinal status Attached Localized TRD Detached Hypotony (IOP ⱕ 6 mmHg) Glaucoma†

Control (n ⴝ 106) [no. (%)]

P ⬍0.001‡

2 (6) 9 (26) 5 (15) 7 (21) 7 (21) 4 (12)

49 (46) 30 (28) 20 (19) 5 (5) 1 (1) 1 (1)

17 (50) 2 (6) 15 (44) 8 (24) 10/30 (33)

100 (94) 3 (3) 3 (3) 0 7/98 (7)

⬍0.001‡

⬍0.001§ ⬍0.001§

TRD ⫽ tractional retinal detachment; SCH ⫽ suprachoroidal hemorrhage; VA ⫽ visual acuity; CF ⫽ counting fingers; HM ⫽ hand motion; LP ⫽ light perception; NLP ⫽ no light perception; IOP ⫽ intraocular pressure. * Two cases and 10 controls with less than 3 months of follow-up were excluded from the outcome analysis. † Glaucoma defined as IOP ⱖ 30 mmHg and/or antiglaucoma therapy at the time of the last examination. Patients with preoperative glaucoma were excluded from the outcome analysis. ‡ Mann-Whitney U test. § Chi-square test.

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Ophthalmology Volume 106, Number 2, February 1999 Table 6. Visual and Anatomic Outcomes* of Suprachoroidal Hemorrhage (SCH) Cases by Extent†

Postoperative VA ⱖ20/60 20/80–20/200 CF HM LP NLP Retinal status Attached Localized TRD Detached Hypotony (IOP ⱕ 6 mmHg) Glaucoma‡

Group 1 (n ⴝ 5)

Group 2 (n ⴝ 12)

Group 3 (n ⴝ 12)

1 2 1 1 0 0

1 4 3 3 1 0

0 2 0 1 6 3

4 0 1 0 1/5

10 0 2 1 2/10

1 2 9 6 4/10

P 0.002§

0.001§

0.013㛳 0.39㛳

Group 1 ⫽ SCH anterior to the equator; Group 2 ⫽ SCH extending posterior to equator but not involving posterior pole; Group 3 ⫽ SCH extending to posterior pole. TRD ⫽ tractional retinal detachment. See Table 5 for other abbreviations. * Two patients with less than 3 months of follow-up were excluded from the outcome analysis. † Two eyes had an isolated localized posterior pole SCH, and in three eyes the extent of SCH remained undetermined. ‡ Glaucoma defined as IOP ⱖ 30 mmHg and/or antiglaucoma therapy at the time of the last examination. Patients with preoperative glaucoma were excluded from the outcome analysis. § Kruskal-Wallis test. 㛳 Mann-Whitney U test.

find some of the above factors contributing to SCH development. Visual outcome after SCH during intraocular surgery is influenced by the etiology and extent of the hemorrhage, the presence of concurrent RD, and possibly by its management.4 – 6,8,12,36 –38 In a series of 30 cases of massive SCH complicating cataract surgery, Welch et al4 found immedi-

Table 7. Visual and Anatomic Outcomes* of Suprachoroidal Hemorrhage (SCH) Cases by Attempted Intraoperative Drainage of SCH

Postoperative VA ⱖ20/60 20/80–20/200 CF HM LP NLP Retinal status Attached Localized TRD Detached Ocular hypotony Glaucoma†

Drain (n ⴝ 10)

No Drain (n ⴝ 24)

0 2 0 1 5 2

2 7 5 6 2 2

3 0 7 3 2/7

14 2 8 5 8/23

P 0.02‡

0.13‡

0.90§ 1.00§

See Table 5 for abbreviations. * Two patients with less than 3 months of follow-up were excluded from the outcome analysis. † Glaucoma defined as IOP ⱖ 30 mmHg and/or antiglaucoma therapy at the time of the last examination. Patients with preoperative glaucoma were excluded from the outcome analysis. ‡ Mann-Whitney U test. § Chi-square test.

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ate RD and vitreous incarceration to be predictors of poor prognosis. In the 28 patients with reported outcome, 43% recovered a vision of 20/200 or greater. Speaker et al5 reported a final visual acuity of 20/200 or greater in 29% and no light perception (NLP) in 32% of the cases. The visual outcome was found to be significantly better in patients who underwent extracapsular cataract surgery or phacoemulsification compared with that of other procedures. A final visual acuity of 20/400 or greater was achieved in 50% of eyes that underwent extracapsular cataract surgery compared with 7% of eyes that underwent other procedures. In the cases that occurred during vitreoretinal procedures, none had a final visual acuity of greater than 20/400. In a study of 106 cases of SCH, Reynolds et al6 found initial RD, indeterminate retinal status, and 360° SCH to be associated with poor visual outcome. In their series, a visual acuity of 20/200 or greater was achieved by 10% of eyes with initial RD compared with 43% of eyes without a detachment. Twenty percent of eyes with 360° SCH and 47% of eyes with SCH limited to two quadrants achieved a visual acuity of 20/200 or greater. Patients with SCH associated with cataract surgery had a better outcome than with other procedures. Chu and coworkers36 reported NLP in 22% and a visual acuity of 20/200 or greater in 17% of patients with massive choroidal hemorrhage. In a study of appositional choroidal hemorrhage secondary to a number of intraocular procedures and trauma, Scott and colleagues39 reported 29.4% of patients achieving either their preoperative visual acuity or a visual acuity of 20/200 or greater. Twenty-seven percent had NLP. Concurrent RD, poor visual acuity on presentation, presence of an afferent pupillary defect, and duration of retinal apposition were found to be predictors of poor outcome.

Tabandeh et al 䡠 Suprachoroidal Hemorrhage Associated with Pars Plana Vitrectomy Table 8. Possible Risk Factors for Development of Suprachoroidal Hemorrhage during Pars Plana Vitrectomy

High myopia Aphakia or pseudophakia Previous RD surgery Elevated preoperative IOP Rhegmatogenous RD Cryotherapy SBP at time of PPV External drainage of SRF Advanced age Intraoperative hypertension

Lakhanpal17 (n ⴝ 7)

Piper19 (n ⴝ 13)

Sharma20 (n ⴝ 12)

Current Series (n ⴝ 36)

⫹ ⫹ ⫹ NR NR ⫹ ⫹ NR NR NR

⫺ ⫹ ⫺ ⫹ ⫹ ⫺ ⫹ NR ⫹ ⫺

⫹ ⫹ ⫺ ⫺ ⫹ ⫺ ⫹ NR ⫺ ⫺

⫹ ⫺ ⫹ ⫺ ⫹ ⫹ ⫹ ⫹ ⫺ ⫹

PPV ⫽ pars plana vitrectomy; RD ⫽ rhegmatogenous retinal detachment; SBP ⫽ scleral buckle procedure; SRF ⫽ subretinal fluid; ⫹ ⫽ significant risk factor; ⫺ ⫽ not significant risk factor; NR ⫽ not reported.

Suprachoroidal hemorrhage can compromise visual outcome by a number of mechanisms, which include secondary retinal degeneration, associated retinal breaks and detachment, subretinal and vitreous hemorrhage, glaucoma, and ocular hypotony. In addition, SCH during PPV can further limit the visual prognosis by interfering with detachment surgery, resulting in failure to reattach the retina. Visual acuity outcomes in published series generally have been poor. Lakhanpal et al17 reported the outcome in a series of seven patients in whom massive SCH developed during PPV for complex RD. Visual results were found to be poor with six of the seven patients showing NLP and one remaining patient with a visual acuity of 20/400. Attempted intraoperative surgical drainage of the SCH did not appear to alter the outcome. In a case– control study of intraoperative and postoperative SCH associated with PPV involving 13 cases, Piper et al19 reported a visual acuity of 20/200 or greater in 46% of the cases and NLP in only one case, the visual outcome being influenced by the extent of the hemorrhage. In a series of 12 cases of SCH during PPV, Sharma et al20 reported a final visual acuity of 20/200 or greater in 33% and NLP in 25%. In summary, the final visual acuity was 20/200 or greater in 32% and NLP in 12% of the current series. Retinal reattachment was achieved in 50%. Suprachoroidal hemorrhage had an adverse effect on final visual acuity and retinal attachment, as shown by significantly worse outcomes in case study eyes compared to control PPV eyes uncomplicated by SCH. Both visual and anatomic outcomes were worse in cases in which the SCH extended to the posterior pole. Intraoperative drainage of the hemorrhage did not appear to confer a beneficial effect on the outcomes. Secondary glaucoma and ocular hypotony were other postoperative complications that further added to the ocular morbidity.

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