GH.Naderian , M.D.

Supra choroidal hemorrhage

Cystoid macular edema

Retinal detachment

Supra choroidal hemorrhage Intraoprative Delayed post operative

More common in patients with glaucoma

Incidence of supra choroidal H. following modern cataract surgery is reported to be between 0.03% and 0.06%

The incidence of this complication following glaucoma surgery is reported to be 1.6% to 2%

Source of hemorrhage : One of the short or long posterior

ciliary arteries

Acute intraoperative expulsive hemorrhage there is most likely a rupture of a necrotic or weakened vessels wall associated with hypotony during the procedure

Predisposing conditions: Advanced aged Hypertension Arteriosclerosis Blood

dyscrasias Anticoagulatio

n Glaucoma High myopia Hypotony

Trauma Uveitis Suprachoroidal

H. in fellow eye IOP Valsalva Prolonged

hypotony ( wound leakage)

Inadequate local anesthesia

Intraoperative supra choroidal hemorrhage :

Iris prolapse Shallowing of AC Vitreous prolapse Graping of the incision Firmness of the globe Striae in the cornea Change in the red reflex *sudden pain *

The first priority following recognition of a possible intraoperative suprachoroidal H. is secure closure of the incision

Delayed supra choroidal H. This type of H. usually occurs

between the third to fifth postoperative day and in most cases is preceded by hypotony and the development of ciliochoroidal serous effusions

The patient will generally have a history of sudden onset of eye pain , often with nausea , vomiting , decreased vision , headache , tearing and possible lid swelling or chemosis

At times the patient may be awakened from sleep with these symptoms

On examination

IOP ( may be ) Shallowing of the AC ( often) Vitreous prolapsed Loss of the red reflex

If the supra choroidal H. is large , the choroidal detachments may be visible on slit lamp examination behind the lens

The presence of blood in the vitreous or the AC should be noted

If there has been break through bleeding to beneath or through the retina , the prognosis for recovery of vision is diminished

Initial treatment

Analgesics Control of IOP Cycloplegics Topical and oral steroids

The diagnosis of a suprachoroidal H. is usually made based on the clinical presentation and ophthalmic examination

The use of ultrasonography may aid in the diagnosis , especially when there is media opacification or blood present

Complete clot lysis will generally require 5 to 14 days , although this time may be variable in different individuals

Several factors may influence the decision to consider drainage of a supra choroidal effusion

It is well established that most suprachoroidal H. will eventually clear spontaneously

It also appears that the final visual outcome may be similar whether early drainage is performed or the hemorrhage is allowed to resolve on its own

Indication of drainage

Massive kissing effusion Intractable pain Persistent or recurrent flat AC Prolapse of intraocular contents Suspicion of RD Vit. H Retained lens fragments

Cystoid Macula Edema

Irvine – Gass syndrome =CME following cataract surgery

Risk factors

Post capsular rupture Vitreous loss and incarceration Anterior chamber and secondary

IOL Diabetes History of CME in other eye Uveitis

Peak incidence is at 6-10 weeks

Spontaneous resolution occurring clinically in approximately 95% of uncomplicated cases usually within 6 months

CME diagnosed by clinical exam , FA & OCT

Treatment

Correction of the underlying cases Systemic carbonic anhydrase

inhibitors Topical & systemic Indometacine Steriods ( topical , oral ,

subtenon) IVB & IVT Parsplana vitrectomy

Retinal detachment

The incidence of retinal detachment following cataract surgery is approximately 1%

When cataract surgery is accompanied by vitreous loss, the incidence of RD increase to 5% or more

Another risk factor for pseudophakic RD is YAG capsulotomy

In one reported study the performances of YAG laser capsulatomy doubled the incidence of RD

Flashing and floatering are important

What to do for this problem ?

1- Complete fundus examination before surgery

2- Any predisposing pathology must be treated

3- Decreased any manipulation during surgery

4- Any complication retinal surgeon examination