gh.naderian, m.d.. supra choroidal hemorrhage cystoid macular edema retinal detachment
TRANSCRIPT
GH.Naderian , M.D.
Supra choroidal hemorrhage
Cystoid macular edema
Retinal detachment
Supra choroidal hemorrhage Intraoprative Delayed post operative
More common in patients with glaucoma
Incidence of supra choroidal H. following modern cataract surgery is reported to be between 0.03% and 0.06%
The incidence of this complication following glaucoma surgery is reported to be 1.6% to 2%
Source of hemorrhage : One of the short or long posterior
ciliary arteries
Acute intraoperative expulsive hemorrhage there is most likely a rupture of a necrotic or weakened vessels wall associated with hypotony during the procedure
Predisposing conditions: Advanced aged Hypertension Arteriosclerosis Blood
dyscrasias Anticoagulatio
n Glaucoma High myopia Hypotony
Trauma Uveitis Suprachoroidal
H. in fellow eye IOP Valsalva Prolonged
hypotony ( wound leakage)
Inadequate local anesthesia
Intraoperative supra choroidal hemorrhage :
Iris prolapse Shallowing of AC Vitreous prolapse Graping of the incision Firmness of the globe Striae in the cornea Change in the red reflex *sudden pain *
The first priority following recognition of a possible intraoperative suprachoroidal H. is secure closure of the incision
Delayed supra choroidal H. This type of H. usually occurs
between the third to fifth postoperative day and in most cases is preceded by hypotony and the development of ciliochoroidal serous effusions
The patient will generally have a history of sudden onset of eye pain , often with nausea , vomiting , decreased vision , headache , tearing and possible lid swelling or chemosis
At times the patient may be awakened from sleep with these symptoms
On examination
IOP ( may be ) Shallowing of the AC ( often) Vitreous prolapsed Loss of the red reflex
If the supra choroidal H. is large , the choroidal detachments may be visible on slit lamp examination behind the lens
The presence of blood in the vitreous or the AC should be noted
If there has been break through bleeding to beneath or through the retina , the prognosis for recovery of vision is diminished
Initial treatment
Analgesics Control of IOP Cycloplegics Topical and oral steroids
The diagnosis of a suprachoroidal H. is usually made based on the clinical presentation and ophthalmic examination
The use of ultrasonography may aid in the diagnosis , especially when there is media opacification or blood present
Complete clot lysis will generally require 5 to 14 days , although this time may be variable in different individuals
Several factors may influence the decision to consider drainage of a supra choroidal effusion
It is well established that most suprachoroidal H. will eventually clear spontaneously
It also appears that the final visual outcome may be similar whether early drainage is performed or the hemorrhage is allowed to resolve on its own
Indication of drainage
Massive kissing effusion Intractable pain Persistent or recurrent flat AC Prolapse of intraocular contents Suspicion of RD Vit. H Retained lens fragments
Cystoid Macula Edema
Irvine – Gass syndrome =CME following cataract surgery
Risk factors
Post capsular rupture Vitreous loss and incarceration Anterior chamber and secondary
IOL Diabetes History of CME in other eye Uveitis
Peak incidence is at 6-10 weeks
Spontaneous resolution occurring clinically in approximately 95% of uncomplicated cases usually within 6 months
CME diagnosed by clinical exam , FA & OCT
Treatment
Correction of the underlying cases Systemic carbonic anhydrase
inhibitors Topical & systemic Indometacine Steriods ( topical , oral ,
subtenon) IVB & IVT Parsplana vitrectomy
Retinal detachment
The incidence of retinal detachment following cataract surgery is approximately 1%
When cataract surgery is accompanied by vitreous loss, the incidence of RD increase to 5% or more
Another risk factor for pseudophakic RD is YAG capsulotomy
In one reported study the performances of YAG laser capsulatomy doubled the incidence of RD
Flashing and floatering are important
What to do for this problem ?
1- Complete fundus examination before surgery
2- Any predisposing pathology must be treated
3- Decreased any manipulation during surgery
4- Any complication retinal surgeon examination