Further Outpatient Care
Monitor visual acuity, AC depth, IOP, and extension of the detachment.
After managing the underlying cause, a postoperative totally flat AC with corneal-lenticular touch should be managed surgically. A flat chamber with contact of the corneal endothelium with the lens or pseudophakos can lead to rapid corneal endothelial failure and decompensation, extensive anterior and posterior synechiae, and acceleration of cataract changes in phakic patients. It can also trigger aqueous misdirection.
Inpatient & Outpatient Medications
Prescribe topical steroids and cycloplegics. Oral steroids may be indicated.
Consider topical IOP-lowering agents, oral carbonic anhydrase inhibitors, and systemic osmotics in patients with significant IOP elevation.
Avoid anticoagulants or aspirin with suprachoroidal hemorrhage. [31]
Deterrence/Prevention
In open globe surgery, particularly glaucoma surgery, hypotony must be avoided by careful suturing techniques.
During surgery, take care not to suddenly decompress the globe; use a paracentesis tract to slowly deflate it.
Preoperative osmotics or carbonic anhydrase inhibitors can be used to decrease the IOP to a safe level before surgery.
Whether or not to discontinue aspirin or anticoagulants in preparation for glaucoma surgery is not yet clear. Some surgeons propose prophylactic scleral windows in patients with prior choroidal detachments or those with high episcleral venous pressure risks such as in Sturge-Weber.
During the postoperative period of any intraocular surgery, but especially after glaucoma surgery, increased venous pressure in the choroidal plexus may trigger choroidal hemorrhages. This risk can be increased in subjects under oral anticlotting treatment. Patients should be warned to avoid any effort likely to elicit a Valsalva effect, like lifting heavy objects, straining at stools, severe coughing.
Complications
Serous choroidal detachment or suprachoroidal hemorrhage can result in intraocular content expulsion, phthisis, retinal detachment, cataract formation, or intractable secondary glaucoma. [32]
Prognosis
The prognosis is guarded. In general, a correlation exists between the severity and extension of the detachment and the prognosis.
Preexisting eye conditions (eg, advanced glaucoma) influence the final functional outcome.
Even with treatment, loss of functional vision can occur in 10-80% of patients. [10]
In general, the prognosis for patients with choroidal hemorrhages is worse than for those with serous choroidal detachments, especially when choroidal hemorrhages are intraoperative, where severe functional damage is frequent.
Patient Education
During the postoperative period of any intraocular surgery, but especially after glaucoma surgery, increased venous pressure in the choroidal plexus may trigger choroidal hemorrhages. This risk can be increased in subjects under anticlotting or anticoagulation treatment. Patients should be warned to avoid any effort likely to elicit a Valsalva effect, like lifting heavy objects, straining at stools, severe coughing.
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Serous choroidal detachment. Two lobes (ie, superotemporal, supranasal) of fluid accumulation are visible. The choroidal folds seen at the posterior pole are due to concomitant hypotony.
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B-scan ultrasonography examination of choroidal detachment. Fluid appears to be serum on one side (upper) and blood on the other side (below). Retina-to-retina contact, or kissing choroidal detachment, is present.
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Kissing choroidal detachment. When the lobes of the detachment are sufficiently large, retina-to-retina contact occurs. If this is extended centrally, the clinical picture is described as kissing choroidals. The extension of the lobes of detachment/edema is important for the decision-making process regarding the clinical management.
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Postoperative suprachoroidal hemorrhage. In this buphthalmic aphakic eye, suprachoroidal hemorrhage resulted in vitreous hemorrhage, retinal detachment, and extrusion of retina and blood through the pupil into the anterior chamber.
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Drainage of suprachoroidal space. After the posterior sclerostomies are performed, gentle infusion in the anterior chamber through a paracentesis tract helps the globe to maintain a tone while the fluid exit from the suprachoroidal space is facilitated.
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Drainage of suprachoroidal space. The hemorrhagic fluid is darker than fresh blood. Mechanical gaping of the radial incisions facilitates the egress of fluid.
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Drainage of suprachoroidal hemorrhage. At least two quadrants, guided by B-scan images. Careful sclerostomies are performed at 4-5 mm from the limbus. The anterior chamber (AC) should be frequently reformed or a low-pressure AC infusion line should be placed. Gentle pressure on the surrounding sclera will help drainage. Serum is yellow and clear, blood is very dark red. Do not grab or pull from inside the sclerostomies. The technique is the same for drainage of serous choroidal detachment.
