Suprachoroidal Hemorrhage

Suprachoroidal hemorrhage (SCH) refers to the accumulation of blood in the suprachoroidal space, a relatively uncommon but significant complication that can occur spontaneously, during ophthalmic surgery, or as a consequence of ocular trauma. If left undiagnosed and untreated, SCH can lead to severe vision loss or even blindness. Therefore, it is crucial for ophthalmologists to have a thorough understanding of this complication, taking proactive measures to prevent it during surgery and being knowledgeable about effective management strategies for patients with SCH. This review article aimed to provide a comprehensive overview of SCH, covering its risk factors, diagnostic approaches, and the best practices for its management. By enhancing awareness and knowledge in this area, we can improve patient outcomes and minimize the impact of SCH in ophthalmic practice.

[Spontaneous choroidal hemorrhage associated with novel oral anticoagulants: A report of two cases and literature review]

New direct oral anticoagulants (DOAC) have been approved for treatment and prevention of some thromboembolic diseases: acute and chronic phase of thromboembolic disease, deep venous thrombosis prophylaxis in orthopedic surgery and prevention of stroke in patients with atrial fibrillation. These molecules are an alternative to heparins and vitamin K antagonists. Among these, rivaroxaban (Xarelto^®, Bayer Schering Pharma) is a direct factor Xa inhibitor, and dabigatran etexilate (Pradaxa^®, Boehringer Ingelheim) is a direct free thrombin inhibitor. These molecules are almost the ideal anticoagulant: oral administration, few drug and food interactions, wide therapeutic target, and especially no lab monitoring. However, their use remains associated with hemorrhagic complications such as gastrointestinal, intracranial or urinary hemorrhages. We describe two clinical cases of spontaneous choroidal hemorrhage in patients treated with direct oral anticoagulants (rivaroxaban and dabigatran etexilate) for atrial fibrillation. These cases show that an ocular hemorrhagic risk exists with these drugs. Patients treated with DOAC should have the therapeutic dose adjusted based on creatinine clearance. Special monitoring should be performed in patients with age-related macular degeneration or with hypertension even though meta-analysis shows that the risk of intraocular bleeding is reduced by 22% compared with warfarin.

Muscle Relaxants as a Risk Factor for Vis-à-tergo During Penetrating Keratoplasty: A Prospective Interventional Study

INTRODUCTION

This study aimed to investigate the influence of three muscle relaxants on intraocular pressure (IOP), ocular pulse amplitude (OPA), and vis-à-tergo (VAT) in patients undergoing penetrating keratoplasty (PKP) under general anesthesia.

METHODS

Ninety-five patients undergoing PKP were included in this prospective single-center interventional study. IOP and OPA were measured with a dynamic contour tonometer before and 5 min after onset of general anesthesia. Mivacurium (n = 30), atracurium (n = 35), and rocuronium (n = 30) were administered as nondepolarizing muscle relaxants. VAT was assessed 15 min after surgery had begun.

RESULTS

When mivacurium was used, IOP decreased by 2.2 mmHg [standard deviation (SD) ±2.2 mmHg; p < 0.001]. Atracurium decreased the IOP by an average of 5.8 mmHg (SD ±1.8 mmHg; p < 0.001) and rocuronium caused an IOP reduction of 7.2 mmHg (SD ±2 mmHg; p < 0.001). The relative IOP decrease was 12% with mivacurium, 29% with atracurium, and 37% with rocuronium (p < 0.001). OPA decreased by 0.6 mmHg with mivacurium (SD ±0.6 mmHg; 26%; p < 0.001), 1.3 mmHg with atracurium (SD ±1.3 mmHg; 40%; p < 0.001), and 1.2 mmHg with rocuronium (SD ±0.7 mmHg; 42%; p < 0.001). The relative OPA decrease was 26% with mivacurium, 40% with atracurium, and 42% with rocuronium (p < 0.001). VAT occurred in 36% of cases. Mivacurium was used in 77% of these cases, atracurium in 26%, and rocuronium in 6.6% (p < 0.001).

CONCLUSIONS

Mivacurium is associated with a higher risk of VAT during PKP. Therefore, atracurium or rocuronium may minimize complications in ocular surgery with large incisions.

Three cases of suprachoroidal hemorrhage associated with chest compression or asphyxiation and detected using postmortem computed tomography

We report 3 cases of suprachoroidal hemorrhage (SCH) found to be triggered by increased intrathoracic pressure and detected using postmortem computed tomography (PMCT). Case 1 was a man aged in his 50s who was found dead at a landslide site. The autopsy showed clogging of the upper respiratory tract with soil debris from the landslide. The cause of death was determined to be asphyxia. PMCT showed SCH in both eyes, which was believed to be caused by chest compression or choking on the soil debris from the landslide. Case 2 was a woman aged in her 60s who was found dead in the sea. The autopsy revealed injuries primarily to her chest. We concluded that the cause of death was drowning. PMCT showed SCH in her right eye that was believed to be caused by chest compression. Case 3 was a woman aged in her 80s who was buried in a snowdrift and potentially died from hypothermia. PMCT showed SCH in both eyes, which was considered to be from an increase in intrathoracic pressure that might have been caused by the burial in the snow. Histological findings showed serous retinal detachment associated with retinal pigment epithelium damage due to SCH, which indicated that she was alive for several hours after the onset of SCH. The increase in intrathoracic pressure caused by dyspnea or chest compression was considered responsible for the onset of SCH in all of the present cases. PMCT might assist with the differential diagnosis of traumatic asphyxiation by SCH.