Fig. 60.1 Ultrasonography following a suprachoroidal hemorrhage. Kissing choroidals accompanied by an RD. Draining the blood is a necessary step in treating the eye, but intravitreal surgery is also needed (see the text for more details), although from this image it is impossible to determine whether what appears to be an RD is indeed a detachment (or an incomplete PVD)

60.1.2 Timing of Surgery

There is a window within which it is inadvisable to operate: once the blood is clotted, it is difficult or impossible to remove it. The intervention thus has to be either immediate3 or delayed until the blood liquefies, which typically takes ~10 days. Ultrasonography is helpful in determining whether liquefaction has indeed occurred.

If the blood is clotted but it must nevertheless be removed, a large scleral opening is necessary and the probe is used to shave the clot.4

60.2Surgical Technique

•Determine the highest point of elevation preoperatively.5

•Place an infusion; never attempt to drain without continually pressurizing the globe.

3On the operating table when the bleeding is recognized.

4This is a rather dangerous maneuver because the choroid is right underneath the clot.

5Ultrasonography, if direct visualization is impossible.

–If the suprachoroidal blood is posterior to the ora serrata or the cannula can be visualized, the standard pars plana location is recommended; in all other cases use an AC maintainer.

–AC infusion is also possible in phakic eyes: the fluid will find its way posteriorly through the zonules (see Sect. 17.1). Keep in mind, though, that the lens will be pushed a little more posterior relative to its normal position.

•Do a peritomy in the quadrant where the choroidal detachment is the highest. Consider placing retraction sutures (see Sect. 54.4.2.1) underneath the adjacent muscles.

•With a blade, make a radial cut in the sclera as posterior as possible (see

Fig. 60.2a).

–The incision should be at least 2 mm long.

•Use a diathermy needle or, less preferably, a blade, to open the choroid.

–Use a tooth forceps to gape the wound. Chocolate-colored fluid should drain (see Fig. 60.2b).

Fig. 60.2 The technique of draining a suprachoroidal hemorrhage. (a) A radial incision is made in the sclera. An anterior chamber maintainer is visible inferiorly. (b) Chocolate-colored suprachoroidal blood is being drained. The scleral incision is gaped with forceps. The incision is small enough not to require suturing

•Use a scleral depressor or a muscle hook to indent the sclera at some distance from the incision and roll the instrument toward the incision to press more blood toward it.

•Repeat the procedure in additional quadrants as required.

•If VH or RD is present, perform a subtotal or total vitrectomy.

–If an AC maintainer has been used before, switch to the standard pars plana infusion as soon as the cannula can be visualized (see Sect. 21.6).

–If the infusion is through the pars plana, air (if the suprachoroidal blood is more posterior) or PFCL (if the suprachoroidal blood is more anterior) can be used.

–The specific maneuvers in the vitreous cavity are determined by the intraocular pathology.

Q&A

QWhat to do if kissing choroidals are present and there is retina-to-retina touch?

AOnce the vitreous has been removed in front of the detached retina, find some space and insert a blunt spatula between the two retinal crescents. Slowly maneuver the spatula into the area of contact and try to separate them. If the adhesion is not yet too strong, separation will succeed; once true adhesion has formed, this will not work, and retinectomy may have to be performed. The prognosis is extremely poor.

•Internally draining the suprachoroidal blood that proved too posterior to allow external removal is an appealing idea. The challenge is that this requires a retinotomy as well as a choriodotomy. The latter is elastic, and it will shrink if diathermy is used to open it; if diathermy is not used, there is a risk of additional bleeding.