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Grand Rounds

Grand Rounds . Alejandro Leon, MD PGY-4 Vanderbilt Eye Institute August 24, 2007. Clinical presentation. Painful loss of vision left eye. 58 year old male. Blunt trauma to left eye 3 days ago. Mild discomfort and blurred vision. No flashes, no floaters. Morning day of presentation:

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Grand Rounds

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  1. Grand Rounds Alejandro Leon, MD PGY-4 Vanderbilt Eye Institute August 24, 2007

  2. Clinical presentation Painful loss of vision left eye. • 58 year old male. • Blunt trauma to left eye 3 days ago. • Mild discomfort and blurred vision. • No flashes, no floaters. • Morning day of presentation: • Intense pain in left eye. • “My vision is now black”.

  3. Previous history • PMH: Chronic sinusitis, s/p lumbar spinal fusion, HTN, hyperlipidemia. • FHx: No glaucoma. • SH: self employed truck driver. Denies smoking and alcohol use. • Allergies: NKDA. • Medications: BP medication, cholesterol pill, Travatan qHS OS.

  4. Physical exam • VA cc: OD: 20/40- OS: LP temporally. • Motility: Full OU. • CVF: Full OD, OS unable. • IOP: OD: 9 OS: 3. • External: unremarkable. • Pupils: +rAPD OS. • SLE: OD: 2+ NSC.

  5. Differential diagnosis • Choroidal effusion. • Suprachoroidal hemorrhage. • Rhegmatogenous retinal detachment. • Melanoma or metastatic tumor of choroid or ciliary body.

  6. Other exam findings. • DFE: • OD: WNL with 0.4 c/d • OS: No view. • Anything else you want to test?

  7. B-scan

  8. Diagnosis • Traumatic dehiscence of clear corneal wound. • Appositional suprachoroidal hemorrhage.

  9. Suprachoroidal Hemorrhage

  10. Suprachoroidal hemorrhage (SCH) • Defined as • Accumulation of blood between the choroid and the sclera. • Suprachoroidal space is an almost virtual space. (10 microliters) • One of the most dreaded complications. Could result in total loss of vision and phthisis.

  11. Suprachoroidal hemorrhage (SCH) • Limited suprachoroidal hemorrhage. • Massive suprachoroidal hemorrhage. • Appositional (“kissing”). • Expulsive.

  12. Pathophysiology Fragile vessels is exposed to • Sudden compression and decompression events. • Fluctuation in intraocular fluid dynamics and pressure. • Hypotony may lead to suprachoroidal effusion and cause tension on the vessels.

  13. Pathophysiology • Intact posterior capsule may tamponade against such intense intraocular decompression during surgery.

  14. Ocular manifestations • Decreased vision. • Pain. • Shallow anterior chamber with mild cells and flare. • Smooth, bullous, orange-brown elevation of the retina and choroid.

  15. Fundus findings

  16. Fundus findings

  17. Echography • B-scan • smooth, thick, dome-shaped membrane • Little, if any, after movement on kinetic evaluation. • Fresh blood clots. • high-reflective, solid-appearing mass, with irregular internal structure and irregular shape. • Serial ultrasonography for liquefaction of hemorrhage. • low-reflective mobile opacities replacing clot.

  18. Treatment Delayed nonexpulsive limited choroidal hemorrhage • Conservative. • Generally good prognosis. • Usually resolves spontaneously within 1–2 months. • Use of cycloplegics and topical corticosteroids.

  19. Treatment Delayed, nonexpulsive massive choroidal hemorrhage • Systemic corticosteroids (controversial). • Posterior sclerotomy to release suprachoroidal blood.

  20. Treatment Intraoperative massive choroidal hemorrhage • Tamponade. • Rapid wound closure to prevent: • Expulsion or loss of the intraocular contents. • Incarceration of vitreous or retina in the surgical wound.

  21. Treatment Secondary Management • Relieve vitreous or retinal incarceration. (to decrease risk of RD). • Drainage of choroidal hemorrhage ideally is conducted after liquefaction of the suprachoroidal hemorrhage (serial echography).

  22. Drainage of choroidal hemorrhage

  23. Choroidal hemorrhage in trauma • Intraocular structural damage. • High likelihood of retinal detachment and associated proliferative vitreoretinopathy. • B-scan choroidal hemorrhage tend to be more diffuse and less elevated.

  24. Wound Dehiscence in Pseudophakia

  25. Cataract wound dehiscence post trauma. • 11 patients • None small incision (no phacoemulsification) • Falling was the most frequent. • 3 days to 1 year after surgery. • 10/11 not wearing protective eyewear. • 6/11 had 20/40 or better vision. • 5/11 had 20/200 to LP vision. Johns KJ, et.al., Am J Ophthalmol. 1989. 108:535-39

  26. Small incision trauma dehiscence

  27. SCH with wound dehiscence • Report 3 previously aphakic eyes. • Traumatic dehiscence wound. • Massive SCH, uveal prolapse and retinal detachment. • Initial visual acuity was LP in all patients. • Drained when decrease of SCH seen in B-scan (average 14 days). • SCH drainage with PPV and silicone oil. • Final visual acuities varied from 20/70 to 1/200. • Good anatomical result. • Liggett PE, et al. Retina. 1990; 10 Suppl 1:S59-64.

  28. Back to our patient • Surgical wound closure. • Oral prednisone. • Atropine, Vigamox, and PF. • Followed every week with B-scan. • 2 weeks after event choroids without apposition but no signs of liquefaction. • 3 1/2 weeks later drained surgically.

  29. Back to our patient • Best visual acuity after procedure: • 2/200 “E” • Required tube shunt placement for IOP control.

  30. Take home points • Cataract wounds can dehisce even years after surgery with trauma. • Management of suprachoroidal hemorrhage include: • Recognize. • Tamponade and closure of eye. • Consider systemic steroids. • Drain when signs of liquefaction in B-scan.

  31. References. • Hurvitz LM. Late clear corneal wound failure after trivial trauma. J Cataract Refract Surg 1999; 25:283-284. • Routsis P. Late traumatic wound dehiscence after phacoemulsification. J Cataract Refract Surg 2000; 26:1092-1093. • Navon SE, Expulsive iridodialysis: an isolated injury after phacoemulsification. J Cataract Refract Surg 1997; 23:805-807. • Blomquist PH, Expulsion of an intraocular lens through a clear corneal wound. J Cataract Refract Surg 2003; 29:592-594. • Walker NJ, Foster A, Apel AJG. Traumatic expulsive iridodialysis after small-incision sutureless cataract surgery. J Cataract Refract Surg 2004; 30:2223-2224. • Liggett PE, Mani N, Green RE, Cano M, Ryan SJ, et al. Management of traumatic rupture of the globe in aphakic patients. Retina. 1990; 10 Suppl 1:S59-64. • Kuhn F, Morris R, Mester V. Choroidal detachment and expulsive choroidal hemorrhage. Ophthalmol Clin North Am. 2001 Dec;14(4):639-50. • Scott IU, Flynn HW, Schiffman J, Smiddy WE, Ehlies F. Visual acuity outcomes among patients with appositional suprachoroidal hemorrhage. Ophthalmology 1997; 104:2029-2046. • Meier P, Wiedemann, P. Massive suprachoroidal hemorrhage: secondary treatment and outcome. Graefe’s Arch Clin Exp Ophthalmol 2000. 238:28-32. • Kapusta MA, Lopez PF. Choroidal hemorrhage. Yanoff: Ophthalmology. 2nd Edition. Chapter 138. 2004 Mosby Inc. • Johns KJ, Sheils P, Parrish CM, Elliott JH, O’Day DM. Traumatic wound dehiscence in pseudophakia. Am J Ophthalmol 1989. 108:535-539.

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