Why patience is key for suprachoroidal hemorrhages and detachments

August 17, 2016

Surgery might not be the go-to option for suprachoroidal hemorrhages and detachments–they may resolve on their own. But when needed, a less invasive procedure can produce a quality outcome.

Take-home: Surgery might not be the go-to option for suprachoroidal hemorrhages and detachments­­–they may resolve on their own. But when needed, a less invasive procedure can produce a quality outcome.

Reviewed by John W. Kitchens, MD

Dr. KitchensLexington, KY–Suprachoroidal hemorrhages and detachments can be managed effectively without surgery, but when surgery is necessary, delaying surgery by 1 week might be all the hemorrhages need to liquefy.

“There are four key points for managing suprachoroidal hemorrhages and suprachoroidal detachments,” according to John Kitchens, MD, who is in private practice in Lexington, KY. He suggested that surgeons use conservative management.

Medical therapy also is key to successfully managing these patients in terms of comfort and improving outcomes. Timing is everything, especially when surgery is needed.

“Timing of the surgical intervention is critical with a wait time of 3 weeks, instead of 2 weeks, to ensure that the hemorrhage has had a chance to liquefy,” Dr. Kitchens said.

Finally, when surgery is unavoidable, a less-invasive surgical approach is an option.

Dr. Kitchens pointed out that careful management is pivotal with these cases. The outcomes may or may not be successful based on the treatment decisions made in the clinic, specifically surgery or observation.

Watchful waiting

Dr. Kitchens described the case of a patient who presented with an appositional choroidal hemorrhage 2 weeks after an intraocular lens exchange was performed. The OCT images showed that the hemorrhage was beginning to resolve and progress in that direction was seen at weeks 5 and 9. Nine months later, with just observation and medical therapy, the choroidal hemorrhage resolved.

However, in such cases, Dr. Kitchens noted it is important for surgeons to understand that despite resolution of the hemorrhage, abnormalities are possible. In this patient, at 18 months, persistent disc hyperfluorescence and choroidal vascular abnormalities were present. He also explained that postoperative cystoid macular edema can occur frequently and requires management.

Medical options

This course of action has important considerations. “Gabapentin (Neurotin, Pfizer) is a critical medication for these patients who can have a great deal of neuropathic pain,” he said.

The usual dose is 300 mg 3 times daily, which can be increased to 900 mg 3 times daily as needed. While the drug successfully decreases the pain level, the side effects of the drug include dizziness, fatigue, and drowsiness, Dr. Kitchens cautioned.

Prednisone is another option, with 40 mg prescribed daily and tapered over 2 to 3 weeks. “Patients taking prednisone have improved pain control during the time it takes to resolve their serous and hemorrhagic choroidals,” Dr. Kitchens said.

Less might be more

If a less invasive technique or a surgery is required, Dr. Kitchens pointed out that several means of sparing the conjunctiva are available. Dr. Kitchens favors treating these patients with guarded, 26-gauge needle drainage. He places a 270 sleeve around a 26-gauge, 3/8-inch needle and then hooks it up to an extrusion line.

Healon is injected into the anterior chamber to avoid hypotony, and the overfiltering flap is sutured if needed. Dr. Kitchens likes to put an illuminated infusing chandelier in the vitreous cavity when possible to get infusion directly into the vitreous cavity. He does this at the 6 o’clock position because that is typically the position of the lowest choroidal.

With the 26-gauge needle attached to aspiration, Dr. Kitchen retreats 10 mm back and always temporally to the site at which the needle is inserted. He continues insertion until only 2 to 3 mm of the tip of the needle is exposed. Gentle, slow, controlled aspiration then successful drains the serous choroidal almost completely.

“This procedure also can work to drain serious hemorrhagic choroidals.” Dr. Kitchen noted. “However, this may not work with a liquefied hemorrhagic choroidal.”

If drainage is not successful with a liquefied choroidal, the next step can be implemented–the use of valved cannulas. Dr. Kitchens demonstrated this in a monocular patient with appositional hemorrhagic choroidals. He used the older polyamide cannulas that have no valves. He advised trimming them to about 2 mm in length.

With newer valved cannulas, the process of draining the choroidals can be accomplished in a more controlled manner. Dr. Kitchens opens the valve and allows the hemorrhage to exit. The newer valved cannulas are positioned as described previously and inserted at an angle. In most cases, he said the choroidal is most elevated at this point and easy to engage if it is appositional.

In the case outlined here, Dr. Kitchens said he drained the hemorrhage directly using a non-valved cannula. When using a valved cannula, forceps are placed in to open the cannula and the infusion pushes the hemorrhage out.

In the event the hemorrhagic choroidal is partially liquefied or there is incomplete drainage, the vitrector is inserted into the valved cannula and vitrectomize the hemorrhagic clots, which opens the cannula for further drainage. Upon removal of the cannula, more hemorrhage is pumped out and the hemorrhage resolves.

Using the procedure with a vitrectomy

Dr. Kitchens also uses this procedure with a 23- or 25-gauge pars plana vitrectomy. “A vitrectomy is essential because there will be peripheral areas of abnormality, especially peripheral tears, that must be treated,” he said, adding that he often will inject a 30% sulfur hexafluoride expanding gas bubble into the vitreous cavity after the vitrectomy is completed.

In the case discussed, the choroidal was almost drained. “I am often surprised that the macula is spared in many of these cases and the patients can regain good visual acuity,” Dr. Kitchens said. This monocular patient had light perception vision before surgery that improved to 20/80 afterwards.

Be patient

“Conservative management often is successful,” Dr. Kitchens concluded. “Don’t give up on these patients after just a few weeks.

“Medical therapy can work for these patients; don’t be afraid to wait a bit longer to ensure that the choroidal has liquefied,” he added. “Consider some less invasive surgical techniques to spare the conjunctiva for the glaucoma specialists.”

 

John W. Kitchens, MD

E: jkitchens@gmail.com

This article was adapted from a presentation that Dr. Kitchens delivered at the 2015 American Academy of Ophthalmology meeting. Dr. Kitchens has no financial interest in this subject matter.