SUPRACHOROIDAL HEMORRHAGE

DURING PARS PLANA VITRECTOMY IN

TRAUMATIZED EYES
HAIFENG MEI, MD,* YIQIAO XING, MD,* ANHUAI YANG, MD,*
JING WANG, MD,* YA XU, MD,* ARND HEILIGENHAUS, PhD
Background: Suprachoroidal hemorrhage (SCH) is a rare but dangerous complication
of intraocular surgery. There are some risk factors for this devastating complication during
pars plana vitrectomy. In this case, we will report the intraoperative occurrence of SCH
during pars plana vitrectomy in traumatized eyes.
Methods: Retrospective analysis of SCH during pars plana vitrectomy in five eyes with
the history of blunt (n 1) or penetrating (n 4) trauma was made. Baseline systemic and
ocular characteristics, surgical procedures, time point of SCH, management of SCH, and
final visual outcomes were measured.
Results: One eye with associated myopia developed SCH during the time of producing
vitreous posterior detachment under ocular hypotony. In other two eyes, SCH developed
under ocular hypotony during fluid gas exchange. The remaining two eyes got SCH when
the depression of the area of pars plana occurred. Sclerotomy closure was performed
immediately once SCH occurred. Vitrectomy and posterior sclerotomy were then performed between 8 and 12 days later. After a median follow-up of 12 months (range: 320
months), final visual acuity was above 20/400 in four eyes, no light perception in one eye,
the best visual acuity was 20/60.
Conclusions: Ocular trauma is one of the vital risk factors for the development of
intraoperative SCH during pars plana vitrectomy. It is important to control effectively the
intraocular inflammation preoperatively and avoid abrupt ocular hypotony and pressure on
the area of pars plana intraoperatively to the limit.
RETINA 29:473 476, 2009

hypertension.1 Speaker et al reported the incidence of

SCH to be 0.41% for retinal and vitreous surgery.2
Although Piper et al estimated the incidence of SCH
during PPV to be 1.9%.3 Ocular trauma is a quite
common disease, which may eventually require to be
treated by PPV. The incidence of SCH during PPV in
traumatized eyes is obviously higher than that in other
diseases in our hospital. Herein, we report on five
traumatized eyes that developed SCH during PPV.

uprachoroidal hemorrhage (SCH) is an uncommon

but devastating complication of intraocular surgery.
Pars plana vitrectomy (PPV) is a commonly applied
technology for the treatment of diseases of retina and
vitreous. Various risk factors have been reported to be
associated with SCH during PPV, including myopia,
advanced age, inflammation, diabetes, and systemic
From the *Department of Ophthalmology, Renmin Hospital of
Wuhan University, Wuhan, Peoples Republic of China; and Department of Ophthalmology at St. Franziskus Hospital, University
of Duisburg-Essen, Muenster, Germany.
Reprint requests: Haifeng Mei, MD, Jiefang Road 238, Wuhan,
Hubei Province 430060, Peoples Republic of China; e-mail:
mhf021471@yahoo.com

Materials and Methods

In this observational case series, we reviewed the
records of patients with ocular trauma who underwent
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RETINA, THE JOURNAL OF RETINAL AND VITREOUS DISEASES

PPV and intraoperatively developed SCH. Data were

collected according to age, general health, preoperative diagnosis, preoperative visual acuity, the time
point of SCH occurring during PPV, management of
SCH both during surgery and postoperative period. Final
visual acuity and length of follow-up were recorded.
Results
Table 1 indicates the demographic characteristics of
the patients in this series. There are five traumatized
eyes occurring SCH during PPV from January 1999 to
November 2005, involving four men and one woman,
with a median age of 31 years (range: 12 43 years).
One eye was myopic, with an axial length of 27.4 mm,
while ocular trauma was blunt in this eye. Two patients had the history of penetrating trauma, vitreous
hemorrhage and traumatized cataract. Penetrating
trauma with retained foreign body was found in one
eye. Penetrating trauma with retina detachment was
presented in remaining eye. Primary closure had been
performed for all patients with penetrating trauma just
after trauma. The incisions in Case 2 and Case 3
extended to equator which is more than 7 mm from
limbus. Case 2 had dislocated intraocular lens. Rupture of lens and lens fragments dislocated into vitreous
cavity were found in Case 3, Case 4, and Case 5. The
etiology of trauma included soccer collision injury,
explosive injury of eye globe and iron wire or branch
trauma. Suprachoroidal hemorrhage was not found in
all patients preoperatively on B-scan ultrasound. All
of these patients underwent PPV between 2 and 31
days after ocular trauma, including lensectomy in four
eyes. Local anesthesia was used in all case.
Suprachoroidal hemorrhage occurred during the
time of producing posterior vitreous detachment with
high negative pressure in one eye with myopia. Two
eyes developed SCH in the time of acute ocular hypotony during fluid gas exchange. The other two eyes
developed SCH in the time of depression to the area of
pars plana to visualize the foreign body or remove the
retained lens fragment and secondary anterior proliferate vitreoretinopathy. Normally the extent of depression was 360 degree, including the position of sclera
laceration. The pressure of depression was moderate.
All of the patients experienced a sudden onset of
severe ocular pain, accompanying with headache, nausea, and vomiting. A sudden increase of the intraocular pressure (IOP) with firm of the globe, loss of the
red fundus reflex, and secondary shallowing of the
anterior chamber appeared immediately after the SCH
occurred. The intraoperative management consisted of
rapid suturing of all surgical incisions. Postoperative
management mainly included topical use of steroid

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and vancomycin. Examination by B-scan indicated

complete liquefaction, and kissing bullae of the SCH
before surgery.
Eventually, PPV in combination with posterior
sclerotomy was performed in all of the patients at a
median time of 10 days later (range: 8 12 days).
Drainage sclerotomy was created in the quadrant of
the involved SCH. Then continuously injecting a kind
of vitreous substitute into the globe was performed to
maintain IOP. The reestablishment of IOP facilitated
the egress of lyses blood through the drainage sclerotomy. After the SCH had been drained, the relatively
normal anatomic relationships could be reestablished.
A conventional three-point PPV configuration was
created. Eventually, internal tamponade with C3F8 or
silicone oil was performed.
After a median follow-up of 12 months (range:
320 months), final visual acuity was no light perception in 1 eye, 20/400 in 1 eye, 20/250 in 1 eye, 20/200
in 1 eye, 20/60 in 1 eye. Suprachoroidal hemorrhage
was absorbed gradually, all of the patients achieved
attached retina. The IOP was stable between 10 and 20
mmHg.
Discussion
Suprachoroidal hemorrhage is a rare but dangerous
complication of intraocular surgery that usually leads
to loss of visual acuity and phthisis. It has been
reported to occur during cataract surgery, penetrating
keratoplasty, glaucoma filtering procedures, scleral
buckling surgery, and PPV.4 7 As SCH is a rare event,
it is difficult to analyze the most critical risk factors.
The previous research reported that the incidence of
SCH during PPV varies from 0.17% to as high as
1.9%.8 The incidence of SCH during retina and vitreous surgery has been estimated to be 0.12% at our
hospital (unpublished observation). But for traumatized eyes, the incidence of SCH may be markedly
higher (1.8%, unpublished observation).
Risk factors for this devastating complication have
been identified at the presence of high myopia, advanced age, elevated preoperative IOP, history of
glaucoma, aphakia, systemic hypertension, and diabetes mellitus. Herein, we describe SCH in a series of
eyes that had been previously ocular trauma. However, the patients included differ from the previous
described risk factors in some respects. At first, the
patients herein were all in younger age with a median
age of 31 years (range: 12 43 years), they did not
have the history of systemic hypertension or diabetes.
Secondly, all the patients had a history of ocular
trauma, and PPV was usually performed a few days
after that trauma. Thirdly, apart from the single eye

43

26

32

41

12

Sex

OBT
VH
Myopia
OPT
VH
TC
OPT
VH
TC
OPT
TC
RD
OPT
TC
FBR

Preoperative
Diagnosis

31

Time Between
Trauma and
Surgery (Day)

Normal

Normal

Normal

Normal

Normal

General
Condition

PPV/lens

PPV/lens

PPV/lens

PPV/lens

PPV

Surgical
Procedure
High negative
pressure to
obtain PVD
Depression to
the place of
pars plana
IOP decreasing
suddenly
during fluid
gas exchange
IOP decreasing
suddenly
during fluid
gas exchange
Depression to
the place of
pars plana

Time Point of
SCH Occurring

11

10

12

PPV, post
sclerotomy
c3f8

PPV, post
sclerotomy
c3f8

PPV, post
sclerotomy
c3f8
PPV, post
sclerotomy
c3f8
PPV, post
sclerotomy
c3f8

Secondary
Surgery
Procedure

20/200

LP

LP

CF

CF

Initial
VA

20/60

NLP

20/250

20/200

20/400

Final
VA

16

20

13

Follow-Up
Month

F, female; M, male; OBT, ocular blunt trauma; VH, vitreous hemorrhage; PPV, pars plana vitrectomy; Lens, lensectomy; PVD, posterior vitreous detachment; CF, counting fingers;
OPT, ocular penetrating trauma; TC, traumatized cataract; LP, light perception; NLP, no light perception; RD, retinal detachment; FBR, foreign body retained.

Age

Case
No.

Time Between
SCH and
Secondary
Management
(Days)

Table 1. Suprachoroidal Hemorrhage in Traumatized Eyes During PPV-Demographics, Occurrence, Management, and Sequelae
SCH DURING PPV IN TRAUMATIZED EYES
MEI ET AL

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with myopia, the PPV was performed in combination

with lensectomy in the other four eyes. Finally, SCH
occurred uniformly in intraoperative phase of hypotony or compression the area of pars plana.
The mechanisms leading to SCH in such traumatized eyes remain uncertain. Commonly, there are still
some inflammatory reactions just after ocular trauma,
the choroidal vascular may also be congested and
dilated. In the case of lensectomy, the absence of the
lens and zonular support is believed to allow more
stretching and separation of the uvea from sclera during ciliochoroidal effusion. Micro trauma to the vessels might also be present. Also, acute ocular hypotony during PPV must be appears to be a major
precipitating factor9 that may result in a rupture of a
necrotic long or short posterior ciliary artery with
choroidal effusion.10 Decompression of the globe during PPV is another risk factor for the development of
SCH, as it may contribute to choroidal hyperemia and
facilitate the rupture of weakened arteries.11
The immediate recognition of SCH is critical for the
management of this harmful event. It is important to
suture all surgical incisions immediately. There is
evidence that a draining posterior sclerotomy during
the acute formation of SCH may result in a further
increase in the size of SCH, and that the removal of
clots may not be impossible.12 Many recent reports
have advocated the delaying the drainage of an SCH
for 7 to 14 days, as the clot lyses generally appears
approximately 10 to 15 days.1315 In this series, vitrectomy and posterior sclerotomy was performed at
the median time of 10 days (range: 8 12 days).
Visual acuity outcomes in the previously published
case series generally have been poor. Lakhanpal et al
reported that six out of the seven patients with SCH
that had developed during PPV finally had visual
acuity of no light perception.16 However, in this series,
a final visual acuity of 20/400 or greater is found in
four patients, the best visual acuity is even 20/60, and
only one patient has final visual acuity of no light
perception.
In summary, previous ocular trauma is a significant
risk factor for the development of SCH during PPV.
However, this disastrous complication may be
avoided by controlling preoperatively the intraocular inflammation effectively and preventing of acute
ocular hypotony and rapid decompression of globe
intraoperatively.

2009

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NUMBER 4

Key words: suprachoroidal hemorrhage, pars plana

vitrectomy, trauma.

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