Management of Suprachoroidal Hemorrhage during Phacoemulsification: A Comprehensive Review

Abstract

Suprachoroidal hemorrhage (SCH) is a rare and sight-threatening complication of various intraocular surgeries, including cataract surgery. Although the rate of SCH complicating cataract surgery has decreased in the era of phacoemulsification, most likely due to smaller self-sealing incisions and modern equipment, it remains a challenging complication to manage. The aim of this review is to summarize the current evidence of the pathophysiology and management of SCH complicating phaco surgery. A literature review was performed using the PubMed database searching for diagnosis, therapy, and management of SCH during phacoemulsification. The evidence available on the optimal management of this condition is low, and there is no consensus so far. An early diagnosis is thought to be essential to avoid progression to the devastating stage of expulsion of intraocular contents (expulsive hemorrhage). Sudden intraoperative anterior chamber shallowing, red reflex loss, and a significant increase in intraocular pressure are highly suspicious for this severe complication. A fundus examination and ocular ultrasound are crucial to confirm the diagnosis and, if it is confirmed, stabilize the globe immediately. The initial therapeutic approach includes aggressive topical and systemic medication focused on controlling ocular inflammation and intraocular pressure, whereas the timing and the indications of surgical intervention remain controversial.

Suprachoroidal Hemorrhage

“…The main pathogenetic mechanism is said to be IOP fluctuations, particularly hypotony. There is development of a high trans-arterial pressure gradient due to sudden hypotony which can lead to rupture of the short or long posterior ciliary artery which causes bleeding in the suprachoroidal space [4, 8]. It can also lead to development of choroidal effusion as the decreased IOP is unable to compensate for the choroidal vessel pressure and leakage.…”

“…Phacoemulsification involves 1–3 mm corneal self-sealing wounds and a closed irrigation-aspiration (I-A) system which has been shown to reduce the incidence of severe hypotony. As a result, cataract surgery by phacoemulsification decreases the risk of SCH and avoids the expansion of SCH to an ECH [8], but sudden IOP fluctuations in poorly constructed wounds can lead to SCH [8]. SCH has also been reported in femtosecond laser-assisted phacoemulsification secondary to multiple attempts at docking leading to sudden hypotony [62].…”

“…Elevated episcleral vessel pressure in the carotid cavernous fistula, cataract maturity, posterior capsular rupture, vitreous loss, and recent COVID-19 infection may increase the risk of SCH during operation. There is no confirmation to recommend that anticoagulation is a risk factor for acute SCH in cataract surgeries [8, 40, 63]. Increased retro-orbital pressure after local anesthetic block can cause compression of the vortex veins, leading to impendence of flow, choroidal stasis, and subsequent hemorrhage [8].…”

“…There is no confirmation to recommend that anticoagulation is a risk factor for acute SCH in cataract surgeries [8, 40, 63]. Increased retro-orbital pressure after local anesthetic block can cause compression of the vortex veins, leading to impendence of flow, choroidal stasis, and subsequent hemorrhage [8].…”

“…The most significant risk factor is hypotony or the sudden IOP drop in or after surgery [5], leading to choroidal effusion, stretching, and rupture of ciliary arteries [7]. Stretching of ciliary nerves leads to severe ocular pain [8]. SCH has also been reported following ocular trauma or spontaneously in individuals with specific ocular or systemic risk factors [2, 9].…”