Suprachoroidal hemorrhage

Suprachoroidal Hemorrhage Outcome of Surgical Management According to Hemorrhage Severity William J. Wirostko, MD, Dennis P. Han, MD, William F. Mieler, MD, Jose S. Pulido, MD, Thomas B. Connor, Jr., MD, Evelyn Kuhn, PhD Objective: To report the visual and anatomic outcome after surgical drainage of suprachoroidal hemorrhage according to hemorrhage severity. Design: A retrospective chart review. Participants: Forty-eight consecutive eyes undergoing surgical drainage of a suprachoroidal hemorrhage at The Medical College of Wisconsin were examined. Intervention: Demographic and clinical data were abstracted from patients’ medical records. Eyes were classified into four categories of increasing hemorrhage complexity: (1) nonappositional choroidal hemorrhage without vitreous or retinal incarceration in the wound (12 eyes); (2) centrally appositional choroidal hemorrhage without vitreous or retinal incarceration in the wound (17 eyes); (3) choroidal hemorrhage with associated vitreous incarceration in the wound (11 eyes); and (4) choroidal hemorrhage with associated retinal incarceration in the wound (8 eyes). Main Outcome Measures: Visual acuity, rate of persistent hypotony, and incidence of irreparable retinal detachment after surgical drainage for four classes of suprachoroidal hemorrhage were defined. Results: Overall, 11 (23%) of 48 eyes had no light perception (NLP) vision develop, 9 (19%) of 48 eyes had persistent postsurgical hypotony (intraocular pressure ⬍ 6), and 21 (64%) of 33 eyes with retinal detachment enjoyed successful retinal reattachment surgery. A definite trend toward an increased rate of NLP vision (P ⬍ 0.02), persistent hypotony (P ⬍ 0.05), and irreparable retinal detachment (P ⫽ 0.11) was observed with increasing suprachoroidal hemorrhage complexity. Eyes with retinal incarceration, compared to eyes without retinal incarceration, had an increased rate of NLP vision (63% vs. 15%; P ⬍ 0.01), persistent postsurgical hypotony (50% vs. 13%; P ⬍ 0.05), and irreparable retinal detachment (50% vs. 20%; P ⫽ 0.07). Conclusions: Eyes requiring surgical drainage of a suprachoroidal hemorrhage have a guarded prognosis, with a poorer outcome associated with increasing hemorrhage complexity. A classification system incorporating choroidal apposition, and vitreous and retinal incarceration in the wound, provides a format for reporting and assessing the efficacy of management strategies in this condition. Ophthalmology 1998;105:2271–2275 A suprachoroidal hemorrhage (SH) is a rare but potentially catastrophic ocular event. It occurs most frequently after ocular surgery or trauma and is capable of moving retinal surfaces into apposition and expelling intraocular contents out of the eye.1 Factors reported to predispose one to SH

Originally received: February 20, 1998. Revision accepted: June 24, 1998. Manuscript no. 98084. From The Eye Institute, Medical College of Wisconsin, Milwaukee, Wisconsin. Presented in part as a poster at the Association for Research in Vision and Ophthalmology annual meeting, Fort Lauderdale, Florida, May 1997; and at the American Academy of Ophthalmology annual meeting, San Francisco, California, October 1997. Supported in part by a Heed Ophthalmic Foundation Fellowship (WJW) and an unrestricted grant from Research to Prevent Blindness, Inc., New York, New York. No conflicting commercial interests exist. Address correspondence to Dennis P. Han, MD, The Eye Institute, 925 N. 87th St., Milwaukee, WI 53226.

include advanced age, glaucoma, increased axial length, systemic cardiovascular disease, nonphakic status, and a history of vitreous loss.2,3 Visual rehabilitation after SH often is limited, and many patients suffer severe vision loss.4,5 Surgical drainage of the SH has been advocated for patients with retinal detachment (RD), central choroidal apposition (CCA), retinal or vitreous incarceration in the wound, a persistent flat anterior chamber, extreme pain, uncontrolled elevated intraocular pressure, or the inability to reposit the intraocular contents.4 –10 Several clinical features that portend a poor visual outcome include a 360° SH,5 the presence of RD at presentation,5 and vitreous incarceration in the wound.11 Information regarding the visual prognosis after surgical drainage of SH is limited. Few large studies have been performed, and the collection of data is hampered by both its rare occurrence and the absence of adequate classification. In one of the largest series, Reynolds et al5 reported their experience with 41 eyes. Thirty-four percent obtained a final visual acuity of 20/200 or better. In 1988, Welch et

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Ophthalmology Volume 105, Number 12, December 1998 al4 reported similar results for 30 eyes. Most recently, Scott et al11 described the visual acuity outcome after surgical drainage for 26 eyes with appositional SH. The literature is less complete for information regarding the anatomic prognosis after SH drainage, including the risk of irreparable RD and persistent postdrainage hypotony (PPH). Data for these issues are restricted to older and smaller studies.4,6 –10 It is unclear whether the older studies still are representative of our current situation, given the recent advances in vitreoretinal surgery. We report the postoperative final visual acuity, incidence of PPH, rate of retinal reattachment, and etiology of poor final visual acuity for 48 eyes receiving surgical drainage of an SH. In addition, we evaluate the prognostic value of various SH risk factors and anatomic severity factors. We propose an SH classification system based on the presence or absence of CCA, vitreous incarceration in the wound (VI), and retinal incarceration in the wound (RI). We suggest such a system has merit for reporting and assessing the efficacy of SH management strategies.

Materials and Methods A retrospective consecutive review of 48 eyes undergoing SH drainage at the Medical College of Wisconsin from January 1, 1987, through January 1, 1997, was performed. Cases were identified through the surgical log book and included those receiving either primary or secondary SH drainage. No eyes with no light perception (NLP) vision were noted to have undergone surgery. Data were obtained from medical records. Patient information consisted of age, gender, circumstances of the SH, and presence of SH risk factors, including glaucoma, systemic cardiovascular disease, myopia, nonphakic status, and a history of vitreous loss. Clinical SH features included the preoperative vision, the preoperative intraocular pressure, the absence or presence of CCA, the presence of RD at presentation, the presence of vitreous hemorrhage, and the presence of VI or RI. Surgical management was reviewed. Outcome results at the time of last visit included visual acuity, intraocular pressure, presence of retinal attachment, and presence of silicone oil. Throughout the study, hypotony was defined as an intraocular pressure of less than 6 mmHg and severe vision loss as a drop in visual acuity to less than 5/200. Eyes were classified into four categories of increasing hemorrhage complexity according to the absence or presence of CCA,

Table 1. Potential Prognostic Factors Patient age Timing of SH development (intraoperative or delayed) Hemorrhage etiology (surgery or trauma) Preoperative vision Intraocular pressure (preoperative and immediate postoperative) Myopia Lens status Presence of retinal detachment at presentation Vitreous hemorrhage History of glaucoma History of cardiovascular disease History of previous vitrectomy surgery SH ⫽ suprachoroidal hemorrhage.

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Table 2. Etiologies for Suprachoroidal Hemorrhage (n ⫽ 48) Trauma (16 eyes) Glaucoma filtering procedure (7 eyes) Pars plana vitrectomy (7 eyes) Cataract extraction (5 eyes) Combined cataract extraction and trabeculectomy (4 eyes) Scleral buckle procedure (3 eyes) Penetrating keratoplasty (3 eyes) Infectious corneal perforation (2 eyes) Unknown (1 eye)

VI, or RI. These categories were established a priori because of their basis in clinically discernible findings, both preoperatively and intraoperatively. In addition, they describe a progression for increasing derangement of intraocular structures. The number of eyes in each category is as follows: I. SH without CCA, VI, or RI (12 eyes) II. SH with CCA but without VI or RI (17 eyes) III. SH with VI but without RI (with or without CCA) (11 eyes) IV. SH with RI (with or without VI and CCA) (8 eyes) The SH complexity was considered greater in the higher numbered categories. The Wilcoxon rank–sum test was used to test for an association between SH class and final visual acuity, PPH, and irreparable RD. Chi square analysis and multivariate analysis using logistic regression were used to search for an association between surgical outcome and potential prognostic factors. These factors are listed in Table 1. In some analyses, multiple regression was used in which the dependent variable was the rank of the final visual acuity.

Results Twenty-five (52%) of 48 patients were male and 23 (48%) of 48 patients were female. Median follow-up was 9 months (range, 0 – 60 months). Etiologies of SH are listed in Table 2. Twenty-nine (60%) of 48 patients had their SH associated with ocular surgery. Their median age was 73 years (range, 37– 86 years), and 24 (83%) of 29 were older than 60 years of age. Twenty-seven (93%) of 29 possessed at least 1 of the following additional risk factors: nonphakic status (90%; 26 of 29), a history of vitreous loss (69%; 20 of 29), systemic cardiovascular disease (57%; 17 of 29), glaucoma (55%; 16 of 29), or myopia (14%; 4 of 29). Twenty-six (90%) of 29 patients possessed 2 or more of the above risk factors. Thirteen (45%) of 29 patients incurred their SH intraoperatively, whereas 16 (55%) of 29 had their SH develop after surgery. Intraoperative SH occurred during cataract extraction (4 eyes), scleral buckle placement with pars plana vitrectomy (3 eyes), penetrating keratoplasty with cataract extraction (2 eyes), penetrating keratoplasty (1 eye), pars plana vitrectomy (1 eye), scleral buckle placement (1 eye), and combined cataract extraction with trabeculectomy (1 eye). Delayed SH developed after glaucoma-filtering surgery (7 eyes), combined cataract extraction and trabeculectomy (3 eyes), scleral buckle procedure (2 eyes), cataract extraction (1 eye), pars plana vitrectomy with scleral buckle placement (1 eye), pars plana vitrectomy (1 eye), and penetrating keratoplasty (1 eye). The remaining SH were produced either by trauma (33%; 16 of 48), infectious corneal perforation (4%; 2 of 48), or an unidentified factor (2%; 1 of 48). The median age for the traumatic group was

Wirostko et al 䡠 Suprachoroidal Hemorrhage: Outcome Table 3. Indications for Secondary Surgical Drainage (n ⫽ 45) Retinal detachment [73%(33/45)] Central choroidal apposition [53%(24/45)] Vitreous incarceration in the wound [24%(11/45)] Retinal incarceration in the wound [18%(8/45)] Persistent flat anterior chamber [7%(3/45)] Progressively decreasing vision [2%(1/45)]

39 years (range, 13–97 years). Traumatic injuries consisted of blunt ruptures (9 eyes), penetrating lacerations (5 eyes), and contusions (2 eyes). Surgical management of SH included either primary drainage alone (3 eyes), primary and secondary drainage (5 eyes), or secondary drainage alone (40 eyes). Primary drainage was performed through a posterior sclerostomy at the time of wound closure. Indications for primary drainage included a rapidly expanding intraoperative hemorrhage (62%; 5 of 8) or the inability to reposit intraocular contents (37%; 3 of 8). Only one eye achieved anatomic success with primary drainage alone (the two other eyes declined further intervention). Secondary drainage was performed through a posterior sclerotomy under a constantly maintained limbal fluid line infusion. This was attempted only after echography showed SH liquefaction. Median time from presentation until SH liquefaction (secondary drainage) was 14 days (range, 1–27 days). Indications for secondary intervention included associated RD (73%; 33 of 45), CCA (53%; 24 of 45), VI (24%; 11 of 45), RI (18%; 8 of 45), persistent flat anterior chamber (7%; 3 of 45), and progressive vision loss (2%; 1 of 45) (Table 3). Many eyes had multiple indications. All 33 RDs were diagnosed before SH liquefaction and repaired as soon as liquefaction allowed (median, 15 days; range, 1–27 days). The RDs were managed either by pars plana vitrectomy with scleral buckle placement (24 eyes), pars plana vitrectomy without scleral buckle (when a buckle was already present) (6 eyes), or pars plana vitrectomy with silicone oil tamponade and no scleral buckle (when large retinectomies were performed for retinal incarceration in the wound) (3 eyes). Initial vitreous replacements included perfluoropropane (20 eyes), sulfur hexafluoride (6 eyes), and silicone oil (5 eyes) (2 eyes received no vitreous substitute after the retinal detachment was deemed irreparable during surgery). Vitreous substitutes were chosen according to surgeon preference. Primary gas tamponade was successful in 16 (62%) of 26 cases, whereas primary silicone oil tamponade was successful in 3 (60%) of 5 eyes. Three (12%) of 26 eyes receiving gas initially required subsequent silicone oil injection. Secondary silicone oil injection was successful in two (66%) of these three eyes. Eighteen (38%) of all 48 eyes studied required more than 1 procedure. Indications for reoperation included recurrent RD (11 eyes), persisting or recurrent SH (4 eyes), and removal of silicone oil (3 eyes). The visual and anatomic outcomes are shown according to SH category in Figure 1. The percentage of eyes in classes I through IV that progressed to NLP vision was 17% (2 of 12), 12% (2 of 17), 18% (2 of 11), and 63% (5 of 8), respectively. Overall, 23% (11 of 48) of eyes had NLP vision develop. The percentage of eyes in classes I through IV that maintained 5/200 vision was 42% (5 of 12), 41% (7 of 17), 36% (4 of 11), and 12% (1 of 8), respectively. The prevalence of PPH in each category was 8% (1 of 12), 12% (2 of 17), 18% (2 of 11), and 50% (4 of 8), respectively. Overall, PPH developed in 19% (9 of 48) of eyes. One eye had PPH develop despite the presence of silicone oil, and two eyes remained hypotonus despite retinal reattachment. The prevalence of irreparable RD in each class was 16% (2 of 12), 18% (3 of 17), 27% (3 of 11), and 50% (4 of 8), respectively. In this study, the category of

Figure 1. Percent of eyes having no light perception vision (P ⬍ 0.02), persistent postsurgical hypotony (P ⬍ 0.05), and an irreparable retinal detachment (P ⫽ 0.11) develop according to suprachoroidal hemorrhage class.

irreparable RD included retinas that were considered not treatable at the time of preoperative assessment (2 eyes) and retinas that remained detached despite reattachment procedures (10 eyes). Of eyes presenting with an RD, the rates of retinal reattachment in each subgroup, respectively, were 78% (7 of 9), 62% (5 of 8), 62% (5 of 8), and 50% (4 of 8). Overall, retinal reattachment was obtained in 64% (21 of 33) of eyes. Etiologies for severe vision loss (⬍5/200) included irreparable RD (39%; 12 of 31), PPH (retina attached) (19%; 6 of 31), presumed retinal atrophy secondary to submacular SH or RD (16%; 5 of 31), glaucomatous optic atrophy (16%; 5 of 31), corneal opacification (6%; 2 of 31), and retinal vascular occlusion (3%; 1 of 31) (Table 4). Statistical analysis showed an association of SH class with both visual and anatomic outcome after SH drainage. The SH class was related to the risk of having NLP vision develop, with more NLP vision occurring in higher SH classes (P ⬍ 0.02, Wilcoxon rank– sum test). The SH class was related to the development of PPH, with more PPH occurring in the higher classes (P ⬍ 0.05, Wilcoxon rank–sum test). The SH class was loosely related to the development of irreparable RD, with more irreparable RD occurring in higher classes (P ⫽ 0.11, Wilcoxon rank–sum test). Multivariate analysis showed that SH class was related to final visual acuity (P ⬍ 0.02, Spearman rank correlation). Retinal incarceration was strongly associated with a poor prognosis (Fig 2). Sixty-three percent (5 of 8) of eyes with RI progressed to NLP vision compared to 15% (6 of 40) of eyes without RI (P ⬍ 0.01, chi square test). Fifty percent (4 of 8) of eyes with RI had PPH develop compared to 12.5% (5 of 40) of eyes without RI (P ⬍ 0.05, chi square test). Finally, 50% (4 of 8) of eyes with RI possessed an irreparable RD compared to 20% (8 of 40) of eyes without RI (P ⫽ 0.07, chi square test). The presence of RI increased an eye’s risk for having NLP vision develop by 11.7 times (P ⫽ 0.005, stepwise logistic regression). RD at presentation also was associated with vision loss. Eighty-two percent (27 of 33) of eyes presenting with an RD lost vision to less than 5/200 Table 4. Causes for Final Visual Acuity ⬍5/200 (n ⫽ 31) Irreparable retinal detachment [39%(12/31)] Hypotony (retina attached) [19%(6/31)] Presumed retinal atrophy (retina attached, no hypotony) [16%(5/31)] Glaucomatous optic atrophy [16%(5/31)] Corneal opacification [6%(2/31)] Retinal vascular occlusion [3%(1/31)]

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Ophthalmology Volume 105, Number 12, December 1998 compared to 27% (4 of 15) without an RD (P ⬍ 0.01, chi square test) (Fig 3). RD at presentation increased an eye’s risk for losing vision to less than 5/200 by 4.7 times (P ⫽ 0.02, stepwise logistic regression). Multivariate analysis identified no association with a poor prognosis for any of the other factors listed in Table 1. A significant association existed for traumatic SH and higher SH classes (P ⬍ 0.001, Wilcoxon rank–sum test). The percentages of traumatic SH in classes I through IV were 8% (1 of 12), 12% (2 of 17), 55% (6 of 11), and 88% (7 of 8), respectively. Despite this, no association between trauma and severe vision loss, PPH, or irreparable RD was observed.

Discussion Our data suggest that, currently, the visual prognosis for eyes undergoing surgical drainage of an SH remains poor. In this study, only 35% (17 of 48) of eyes maintained 5/200 visual acuity. The factors that we associated with a worse prognosis included RI (P ⬍ 0.01) and RD at presentation (P ⬍ 0.01). This observation is in agreement with that of previous studies.4,5,11 We could not identify prognostic information for any other factor listed in Table 1. We suspect that this was because of the limited size of our study. It may also be because of the inability of this study’s population to generate statistically effective cohorts for each factor since most eyes had many factors. In our patients, delayed secondary intervention using a constantly maintained limbal fluid line infusion was effective for draining SH. Ninety-one percent (41 of 45) of eyes undergoing such treatment did not require further drainage. In contrast, 88% (7 of 8) of eyes receiving primary drainage required additional SH drainage. We recognize the bias that most eyes receiving primary drainage have more severe SH. The retrospective nature of this study prevented us from identifying the ideal length of time between SH occurrence and secondary drainage. Retinal detachment remains a common and difficult problem with SH. In our study, RD was both the most frequent indication for SH drainage and the most common cause of severe vision loss. In addition, it was a significant risk factor for poor final visual acuity (P ⬍ 0.02). The most problematic RDs occurred in eyes with increased SH com-

Figure 2. Percent of eyes having no light perception vision (P ⬍ 0.01), persistent postsurgical hypotony (P ⬍ 0.05), and an irreparable retinal detachment (P ⫽ 0.07) develop according to the presence or absence of retinal incarceration.

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Figure 3. Percent of eyes having a final visual acuity worse than 5/200 develop according to the presence and absence of retinal detachment at presentation (P ⬍ 0.01).

plexity. For eyes presenting with an RD, the rate of retinal reattachment dropped from 78% (7 of 9) in class I to 50% (4 of 8) in class IV. This trend approached statistical significance (P ⫽ 0.11, Wilcoxon rank–sum test). Furthermore, the only eye showing adhesion of apposing retinal surfaces was in class IV. These findings are not surprising, given the greater anatomic disruption, inflammation, and release of proliferative vitreoretinopathy precursor cells associated with increased SH severity.12 Yet, despite a higher incidence of retinal detachment in class I compared to classes II and III, class I still had the greatest percentage of eyes recovering vision to 5/200 or greater. (We believe the higher incidence of RD in class I vs. classes II and III reflects inclusion bias rather than a predisposition for RD in that group.) We observed no deleterious effect on the rate of retinal reattachment from the use of perfluoropropane gas before silicone oil injection. Rates of retinal reattachment for primary silicone oil injection and secondary silicone oil after perfluoropropane gas were 60% (3 of 5) and 66% (2 of 3), respectively. We observed no significant increased rate of irreparable RD in eyes with CCA compared to eyes without CCA. This study suggests that the ability to reattach a retina in the presence of SH is improving. Our 50% (4 of 8) rate of retinal reattachment for eyes with RI is better than the 0% rate reported by Welch et al4 in 1988. We believe this improvement reflects advancements in the use of vitreous substitutes, including perfluoropropane and silicone oil.13,14 For eyes in this study with RI and retinal reattachment, silicone oil was used in 75% (3 of 4), and perfluoropropane was used in 25% (1 of 4). The nonrandomized nature and small number of eyes in this study preclude further vitreous substitute analysis. Hypotony is a significant problem after SH and appears to be more frequent in eyes with greater SH complexity. Its prevalence ranged from 8% in class I to 50% in class IV (P ⬍ 0.05, Wilcoxon rank–sum test). This association most likely reflects the greater incidence of irreparable RD in eyes with increased SH complexity. However, it also is possible that this trend reflects other factors, such as hemorrhagic necrosis of the ciliary body as described by Lakhanpal.15 Evidence for permanent ciliary body injury in our series includes PPH in three eyes that obtained retinal

Wirostko et al 䡠 Suprachoroidal Hemorrhage: Outcome reattachment, including one that contained silicone oil. Unfortunately, no histopathologic studies were performed. It is unclear whether the incidence of PPH after SH has decreased with the advances in vitreoretinal surgical technique. Historic data are scant, and, currently, many eyes continue to have PPH develop despite aggressive surgical intervention, including silicone oil injection. However, one patient in our series did have hypotony develop as well as a drop of vision from 20/400 to hand motions shortly after silicone oil removal 7 months after the SH. Similar cases have prompted Alexandridis6 to recommend prolonged retention of silicone oil in eyes with severe SH. One must always weigh the advantages of prolonged silicone oil retention against its disadvantages in these eyes. Our classification system is based on the absence or presence of CCA, VI, and RI. It shows value for predicting the visual and anatomic outcome after surgical drainage of SH. The rates of having NLP vision, PPH, and irreparable RD develop were all related to SH class using the Wilcoxon rank–sum test. The lack of statistical significance for other factors is probably related to the small number of eyes studied. Our system has merit in being simple and easy to use. It incorporates practical clinical signs that may be discerned in all cases of SH, including the absence or presence of CCA, VI, and RI. The observation that class I eyes had the best visual and anatomic outcome despite a higher prevalence of RD compared to class II and class III eyes discouraged us from using RD in our classification system. Nonetheless, RD was a significant risk factor for a poorer prognosis using both chi square testing and logistic regression. We suspect that this finding is due to more macular sparing in the lower classes. Unfortunately, in this study an accurate assessment of macular involvement from RD and SH was limited by the retrospective data. We suggest that macular sparing be analyzed in future studies. Notably, we observed a significant trend for more traumatic SH in the higher classes (P ⬍ 0.001, Wilcoxon rank–sum test). However, the small number of trauma eyes in this study precluded an assessment of trauma as an independent factor influencing visual prognosis. A major limitation of this study is its retrospective nature, which may allow selection bias to influence the baseline characteristics of the study population; patients with a worse prognosis may have been more inclined to defer surgery. Nonetheless, the policy at our institution remains to offer surgical intervention to all eyes with SH and light perception vision or better at presentation. Suprachoroidal hemorrhage is a serious event with many eyes suffering blindness despite surgical drainage and the use of advanced vitreoretinal surgical techniques. An analysis of vision-limiting factors and an accurate classification

system are essential for assessing and improving treatment. We believe our system of classification based on anatomic SH complexity has merit for classifying such eyes and creates a format for reporting treatment results. Multivariate analysis of a larger group of eyes should prove useful in refining such a system.

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