Suprachoroidal hemorrhage management centers on minimalist techniques
Suprachorodial hemorrhage can be managed effectively with a conservative approach, but if surgical intervention becomes necessary, timing is critical for optimizing the outcome and minimally invasive techniques can be considered, said John W. Kitchens, MD.
Suprachorodial hemorrhage can be managed effectively with a conservative approach, but if surgical intervention becomes necessary, timing is critical for optimizing the outcome and minimally invasive techniques can be considered, said John W. Kitchens, MD.
“To allow for complete drainage through surgery, it is ideal to wait until the suprachoroidal hemorrhage is maximally ‘liquified,’ ” said Dr. Kitchens. “If it develops as an intraoperative complication, don’t attempt drainage immediately because the blood will coagulate very quickly and it is possible to do more harm than good.”
Dr. Kitchen pointed out that surgeons should wait two to three weeks for the choroidal to resolve itself before attempting drainage. In the meantime, he recommended the use of medical therapy, which is key for success.
Dr. Kitchens is in private practice, Retina Associates of Kentucky, Lexington, and voluntary faculty, Department of Ophthalmology, University of Kentucky, Lexington.
Medical management
The regimen for medical management of suprachoroidal hemorrhage should include gabapentin and prednisone. Gabapentin controls neuropathic pain and is administered at a dose of 300 mg three times daily initially with titration up to 900 mg three times daily as needed. Prednisone is started at a dose of 40 mg daily that is tapered over two to three weeks.
“Combining these two medications with atropine and topical anti-inflammatory medications will keep patients comfortable and give them the best chance for resolution of the suprachoroidal hemorrhage with medical management,” Dr. Kitchens said.
If surgery becomes necessary for drainage, it can be done with a traditional scleral-cutdown approach or with a minimally invasive transconjunctival technique that causes less trauma to the conjunctiva. The technique also allows for total control of the drainage along with direct visualization that will permit maximal drainage.
“Because the transconjunctival technique is less traumatic to the conjunctiva, it is particularly advantageous in cases of suprachoroidal hemorrhage related to glaucoma-filtering surgery,” Dr. Kitchens added.
How technique is performed
The transconjunctival technique is performed using a 26-gauge, 3/8-inch needle covered with a 270 scleral buckling sleeve for needle guarding, preventing inadvertent penetration beyond the suprachoroidal space. The sleeve is attached to the extrusion line for aspiration, and this set-up enables transition to vitrectomy after completing the drainage step.
The infusion is placed in an anterior position, typically 1 mm to 2 mm posterior to the surgical limbus and inferiorly where the choroidal height is lowest.
“The choroidal tends to be highest temporally, and so I go about 10 mm posteriorly to penetrate with the guarded needle,” Dr. Kitchens explained. “Then, I aspirate slowly and carefully. Because this is a closed system, it provides a very controlled resolution.”
With aspiration, drainage occurs temporally, where the needle was inserted, and nasally. The needle is removed when the flattening choroidal comes close to the tip, leaving some residual. Then the case is finished with pars plana vitrectomy.
“It is important to follow up with a vitrectomy because there can be areas of traction peripherally,” Dr. Kitchens said.
The same technique can also be performed using a 25-gauge cannula system, preferably with a valved steel cannula. Use of a valved cannula affords internal visualization and better control over release of the suprachoroidal hemorrhage, Dr. Kitchens said.
John W. Kitchens, MD
This article is based on a presentation given by Dr. Kitchens at the Retina Subspecialty Day held prior to the 2016 American Academy of Ophthalmology meeting. Dr. Kitchens has no relevant financial interest to disclose.
