Use of PPV (23G) in a 55-year-old patient with high myopia 23 days after phacoemulsification complicated by suprachoroidal hemorrhage

A 55-year-old woman presented to the Ophthalmology Outpatient Clinic of the Prof. K. Gibinski University Clinical Center of the Silesian Medical University in Katowice, Poland, with SCH and hemorrhagic OS retinal detachment, which developed during cataract phacoemulsification surgery with high degenerative myopia. During admission, a B-projection ultrasound was performed, which showed massive formations of separated choroid forming a “kissing choroidal sign” and dense echoes of extravasated blood in the choroidal space (Fig. 1).

Figure 1.

B-projection ultrasound image of the OS, massive formations of the separated choroid, the so-called “kissing choroidal sign”

VA before surgery was at 0.001, and IOP was 20 mmHg. The patient had a history of 2-fold cerebrovascular incidents in 2009 and 2013 and type 2 diabetes mellitus since 2021 treated with oral medications; the patient is permanently taking Acidum acetylsalicylicum in a daily dose of 150 mg. After analyzing the local condition and performing additional tests, the patient was qualified for a PPV procedure (23 G).

The patient was anesthetized by performing a periocular injection (2% lignocaine solution and 0.5% bupivacaine solution in a 1:1 ratio). Based on the ultrasound image in the B projection of the left eyeball, an infusion was placed at the site of the uveal membrane that adhered to the sclera. The remaining trocars were placed at the typical site. Central and peripheral PPV was performed. The eye was then filled with PFCL. An external lateral transconjunctival incision was made, 8mm from the corneal stroma with a calibrated knife (20G). An 8/0 absorbable suture was placed over the wound, and the sclerotomy was unsealed by splitting its edges. The IOP was gradually increased, periodically up to 60 mmHg; the eyeball was massaged; and the blood was evacuated from the suprachoroidal space. Decompression was performed to an extent sufficient to expose the macular area. After checking that the retina was adherent and the choroidal blisters had decreased, direct replacement of the PFCL with silicone oil was performed (Fig. 2).

Figure 2.

PPV (23G) OS with mAndo iridotomy, partial evacuation of subretinal and subretinal blood, retinal endolaser, PFCL removal and silicone oil endotamponade

At follow-up 7 days after the PPV procedure, the VA OS was at 0.06, and the IOP was 14 mmHg. During the next follow-ups 1 and 3 months after the PPV procedure, there was a significant improvement in the VA value at 0.1 and 0.7, respectively (Fig. 3). The IOP value remained stable at 14 mmHg during the subsequent follow-ups. 3 months after the procedure, a color fundus photo of the OS was taken that showed the reconstructed anatomical structure of the retina (Fig. 4). Postoperative ocular biometry was 31.44mm for the right eye (OD) and 33.18mm for the OS. Postoperative refraction was −1.75/−1.0 ax 12 for the OS, and refraction for the OD was −3.0/−0.5 ax 137. Optical coherence tomography (OCT) imaging performed 5 months after surgery showed a significant degree of retinal thinning with preservation of the layered structure (Fig. 5).

Figure 3.

Line graph of visual acuity versus time since surgery

Figure 4.

Color photograph of the fundus of the OD and SL; in the OS, the endotamponade with silicone oil is visible, as well as the applied retina in all quadrants

Figure 5.

Optical coherence tomography study of the OS 5 months after the PPV procedure

Limitations of our work are a limited sample size, a follow-up of 5 months, and a lack of differentiation in the timing of conducting the surgical procedure.

The existing literature shows no clear consensus on the optimal timing for decompressive surgery in cases of SCH [7]. Some experts recommend waiting 10–14 days for the clot to liquefy, as this allows for effective evacuation after the suprascleral blood undergoes hemolysis [8,9]. Subsequent research suggests that surgical intervention should occur within 14 days of SCH onset for the best outcomes [9,10,11]. Delaying surgery beyond this period has been linked to poorer visual results for patients [11].

Allowing the hemorrhage to resolve naturally can lead to retinal detachment in cases of vitreous entrapment, potentially resulting in suboptimal visual acuity. In severe cases of hemorrhage, if surgery is delayed, the risk of eyeball atrophy or loss increases. Early surgical intervention can offer the best chance of preserving useful vision [10,12]. However, some studies indicate that performing surgery too soon, within 3 days of the complication, may not be effective. For instance, an attempt to evacuate the blood within this timeframe failed, as reported by Qureshi, Jalil, Sousa et al. [7].

Surgical intervention in the patient we described occurred after 23 days and was fully successful. Similar results were obtained by the authors Quershi, Jalil, Sousa et al. performing blood drainage in two patients 20 and 22 days after SCH, respectively, obtaining satisfactory anatomical and functional results [7].

Myopia is considered a risk factor for SCH during cataract surgery due to the increased axial length, which leads to greater fragility of the choroidal vessels, making them narrower and more stretched. Doppler ultrasonography of these altered vessels reveals reduced blood flow [13]. In cases of high myopia, Laplace’s law has been applied to the corneal-scleral coating. Larger eyes and/or thinner layers of corneo-scleral tissue will exhibit greater wall stress. In addition, the tension increases in proportion to the intraocular pressure. It follows that the same value of pressure exerts much greater pressure on the walls of the eyeball and vessels in large eyes. When the myopic eye is opened and the pressure in the eyeball reaches atmospheric pressure, the weak and stretched ciliary vessels lose support due to the large pressure drop in their surroundings and easily rupture. In addition, the reduced stiffness of the thin and flaccid sclera with its tendency to collapse intraoperatively is an additional factor responsible for the higher incidence of SCH [9,10,14,15,16]. The length of the eyeball of the patient we described was 33.18 mm, thus demonstrating significant wall tension, increased vascular fragility and thus a significant risk of bleeding.

According to the authors Meier and Wiedemann, posterior access vitrectomies should be performed in a situation where the hemorrhage involves the macula, which may cause damage to the photoreceptors of the fovea due to toxicity or hypoxia caused by SCH or two quadrants behind the equator without its involvement [9,10,17]. According to Quershi, Jalil, Sousa et al. and Reynolds, Haimovici, Flynn et al. surgical intervention should also be undertaken when SCH co-occurs with a complication, such as vitreous hemorrhage or entrapment or when the “kissing choroidal sign” occurs [7,18].

The patient we described had a complicated SCH, which consisted of a hemorrhagic retinal detachment with macular involvement and the presence of a “kissing choroidal sign” on B projection ultrasound. The above factors led to the decision to extend the procedure of draining blood from the choroidal space to include vitrectomy from a posterior access. Such a procedure was also described by the authors Quershi, Jalil, Sousa et al. [8]. On the other hand, the significant extent of bleeding into the choroidal space may have been caused by the patient’s intake of Acidum acetylsalicylicum in a daily dose of 150 mg [19].