Outcomes in Patients with Suprachoroidal Hemorrhage After Anterior Segment Surgery

Introduction

Suprachoroidal hemorrhage (SCH) occurs when blood from the short or long ciliary arteries accumulates in the potential space between the choroid and sclera. It is usually precipitated by intraocular surgery or trauma. Mechanistically, SCH is theorized to occur in the setting of hypotony or sudden decrease in intraocular pressure (IOP), which leads to choroidal effusion, stretching of ciliary arteries, and then rupture of an artery with hemorrhage into the suprachoroidal space. Patients may present with symptoms of sudden onset severe pain, nausea, vomiting, and decreased vision, as well as signs of anterior chamber shallowing with elevated IOP. Onset may be delayed after surgery, and atypical presentations, such as SCH mimicking a choroidal mass, have been reported.^1,2

The incidence of SCH differs depending on the type of ocular surgery. Glaucoma surgery has the highest incidence of SCH, ranging from 0.15 to 6.1%.³ The incidence of SCH secondary to cataract surgery has decreased to 0.03–0.06% with the adoption of phacoemulsification techniques, presumably due to better maintenance of intraoperative IOP.⁴ Risk factors for the development of SCH include advanced age, anticoagulation, uncontrolled hypertension, atherosclerotic disease, diabetes, history of glaucoma, hypotony, high myopia, aphakia, previous intraocular surgery/trauma, elevated perioperative IOP, Valsalva maneuvers, and prolonged surgical time.^3,5–19

SCH can be classified in several ways: by etiology, extent of hemorrhage (ie in terms of quadrants), or by degree of elevation. Appositional or “kissing” SCH occurs when the degree of elevation of two opposing sides is so great that it causes inner retinal touch (Figure 1). Ultrasonography is helpful in identifying and defining the features of SCH; there is typically a dome-shaped elevation of the choroid filled with hyperechoic material, which becomes hypoechoic over time as the blood clot liquifies. Ultrasonography can thus also aid in determining the need for and optimal timing of surgical drainage (Figure 1A and B).

Figure 1 Representative B-scan ultrasonography of (A) non-appositional suprachoroidal hemorrhage managed with observation where visual acuity at last follow-up was 20/200, and (B) appositional suprachoroidal hemorrhage managed with delayed drainage. External photograph (C) showing appositional suprachoroidal hemorrhage visible through the pupil.

There have been many advances in vitreoretinal surgical technology. However, whether these advances have improved outcomes after suprachoroidal hemorrhage remains unclear. This study seeks to investigate visual acuity (VA) outcomes in patients with SCH after anterior segment surgery.

Materials and Methods

The institutional review board of the University of Miami approved the study protocol, and the study was conducted in accordance with the Declarations of Helsinki. This study involved the retrospective review of medical records and did not have prospective contact with potential study subjects prior to acquisition of the requested data. As a result, the University of Miami approved a waiver of consent in accordance with US Code of Federal Regulations guidelines. The study design was a retrospective case series of patients with suprachoroidal hemorrhage occurring after anterior segment surgery. SCH after trauma, PPV, or retinal detachment (RD) surgery were not included. Diagnosis of suprachoroidal hemorrhage was made clinically and followed by confirmation on B-scan ultrasonography. Images were individually reviewed by the physicians. Serous choroidals were ruled out by analysis of the B-scan images. Measured preoperative variables included age, sex, hypertension, anticoagulation status, lens status, surgery type causing SCH, presenting VA, presenting intraocular pressure (with hypotony defined as IOP <8mmHg), concurrent pathology on presentation (including flat anterior chamber, vitreous hemorrhage, retinal detachment), and duration of apposition. Intraoperative variables included management of SCH (observation, delayed drainage, or delayed vitrectomy (PPV)), while post-operative variables included VA and IOP on follow-up. Observation was defined as treatment limited to non-surgical interventions. Delayed drainage and PPV were not defined by a given number of days, but rather by the surgeon’s decision to observe/monitor with serial ultrasonography, and then to intervene surgically once there was evidence of liquefaction of the clot. Management decisions were surgeon preference and did not follow a prospective protocol. The following logMAR assignments were utilized: counting fingers = 2.0, hand motion = 2.3, light perception = 2.6, and no light perception = 3. VA and IOP “at last follow-up” were determined only from patients with greater than 3 months of follow-up (101 and 94 patients, respectively). Student’s t-test and Wilcoxon-Mann–Whitney u-test were used for parametric and non-parametric data, respectively. Spearman’s rank order correlation was used for continuous data. Patients and the public were not involved in the design, conduct, reporting, or dissemination plans of this research.

Results

The current study included 112 eyes from 112 patients diagnosed with SCH after cataract, corneal, or glaucoma surgery between January 1, 2014 and October 31, 2020. The mean patient age was 79.9 years, and 51 (46%) patients were female (Table 1). Regarding systemic factors, 85 (76%) patients were hypertensive, 30 (26.8%) were diabetic, and 42 (38%) were taking anticoagulant medications. The majority of patients were pseudophakic (n=85, 76%).

Table 1 Clinical Characteristics in Patients with SCH Associated with Anterior Segment Surgery (n=112)

The mean presenting VA was hand motion (HM) (logMAR 2.15, SD 0.703) and ranged from 20/70 to NLP (Table 1). The mean presenting IOP was 19.2 (SD 14.9). There were 76 cases of non-appositional SCH and 36 cases of appositional SCH. The mean presenting visual acuity for patients with non-appositional SCH was 2.03 logMAR (SD 0.78) versus 2.39 logMAR (SD 0.43) for appositional SCH.

Presenting features included relative afferent pupillary defect (rAPD) (n=8, 7%), hypotony (n=43, 44%), vitreous hemorrhage (n=32, 31%), and concurrent or delayed retinal detachment (n=30, 29%) (Table 2). SCH after glaucoma surgery accounted for 59 (53%) of cases, while SCH after cataract surgery accounted for 37 (33%) of cases. The remainder of cases occurred after non-traumatic corneal perforation or other corneal surgery (ie penetrating keratoplasty). SCH occurred intraoperatively (n=38, 35%) versus post-operatively (n=70, 65%).

Table 2 Clinical Features of SCH Associated with Anterior Segment Surgery

Management decisions were made by the individual physician, but observation was usually selected when SCH involved <2 quadrants or vision was NLP on presentation. Additionally, at this institution, timing of surgical intervention was usually based on echographic findings of clot lysis, which generally occurred 10 to 14 days after onset of hemorrhage. In cases of non-appositional SCH, 46 (61%) patients were observed (mean final VA 0.92, SD 0.88), 14 (18%) underwent delayed drainage (mean final VA 1.66, SD 1.08), and 16 (21%) underwent PPV (mean final VA 1.66, SD 0.92) (Table 3). In cases of appositional SCH, 12 (33%) patients were observed (mean final VA 1.78, SD 1.16), 15 (42%) underwent delayed drainage (mean final VA 1.951, SD 0.73), and 13 (36%) underwent PPV (mean final VA 1.89, SD 0.73). A significant number of patients with appositional SCH were treated with combined delayed drainage and PPV (n=7). Therefore, comparison of visual outcome between the interventions would not be meaningful. A representative surgical video showing delayed drainage by the scleral cutdown method is shown in the Supplementary video.

Table 3 Management as Selected by Treating Physician and VA Outcome

Mean VA at last follow-up was better in non-appositional versus appositional SCH (1.20 logMAR (SD 0.97) vs 1.86 logMAR (SD 0.89), respectively (p=0.002)) (Figure 2). Overall, 47 (42%) patients had final VA of 20/200 or better, and 64 (58%) had a VA ≤ 20/200, including 6 (5%) with counting fingers, 11 (10%) with hand motions, 19 (17%) with light perception (LP), and 11 (10%) with no light perception (NLP). Patients who were observed had the best mean final VA (logMAR 1.21, SD 1.03, p=0.0017), while those with delayed drainage (logMAR 1.87, SD 0.90) or delayed PPV with or without scleral buckle (logMAR 1.73, SD 0.84) had worse outcomes. Within each intervention type, appositional SCH (p=0.04) and duration of apposition >7 days (p=0.002) were associated with worse outcomes only in the observation group.

Figure 2 Visual acuity at last follow-up in non-appositional vs appositional suprachoroidal hemorrhage. The percentage of patients in each visual acuity group is shown.

Discussion

The current study reports the largest series of suprachoroidal hemorrhage and demonstrates that despite advances in ocular surgery, outcomes after SCH generally remain poor. Several previously identified factors were associated with poorer VA outcome: APD, retinal detachment, appositional SCH, and duration of apposition >7 days.²⁰ In the current study, duration of apposition >7 days was associated with poorer VA outcome only in cases that were managed by observation. This suggests that surgical intervention to relieve retinal apposition may be considered in eyes with appositional SCH if there is at least light perception vision. Appositional SCH may be associated with poorer visual outcome for multiple reasons, including greater degree of choroidal detachment, greater volume of suprachoroidal blood, and higher intraocular pressures. Furthermore, retina-to-retina adhesions have been reported in cases of appositional SCH and are generally considered an indicator of poor prognosis.^21,22

Prior retrospective studies at this institution also included traumatic SCH, or only assessed appositional SCH, and are therefore not directly comparable to the current study.^20,23 With these caveats in mind, however, the cohort in this study did demonstrate superior visual outcomes. Scott et al, studied only appositional SCH, reporting that 29% with appositional SCH achieved a VA better than counting fingers,²⁰ while 60% of patients in the current study had this outcome. In the study by Reynolds et al, which included traumatic SCH, 24% (25/106) of patients achieved a final VA of 20/200 or better,²³ while 38% (43/112) of patients in the current study had this outcome. In contrast to these prior studies, a higher proportion of patients in the current study were observed (52.8% vs 21.6% in Scott et al vs 46.2% in Reynolds et al). Future studies with comparable cohorts are needed to assess for changes in management outcomes.

More recent retrospective studies performed at other institutions reported differences in their cohort composition, but had comparable findings to the current study.²⁴ Qureshi et al performed a retrospective analysis of 20 patients who underwent drainage with or without vitrectomy for SCH.²⁴ The most common cause of SCH within their cohort was phacoemulsification (35%, 7/20), and the series included 2 cases of traumatic SCH. External drainage alone was performed in 55% (11/20), while 45% (9/20) had combined PPV and drainage. Of patients who underwent external drainage, 72% (8/11) achieved a vision of 20/200 or greater, and 9% (1/11) became NLP, as compared to patients who underwent PPV with external drainage, where only 11% (1/9) of patients achieved a vision of 20/200 or greater. Consistent with the current study, those patients undergoing PPV tended to have poorer outcomes, likely due to the increased complexity of these cases.

The current study is notable for its focus on SCH after anterior segment surgery. Traumatic SCH is highly variable in both its etiology and severity of presentation, and thus should represent a distinct entity.³ Limitations of the study include its retrospective nature, relatively small number of patients, single center focus, and management selected by physician preference.

Conclusion

SCH remains a severe potential complication of intraocular surgery and has a guarded visual prognosis. In eyes with non-appositional SCH, observation remains a reasonable management strategy. However, in eyes with appositional SCH, management remains more challenging and surgical intervention may be indicated.