Severe Polypoidal Choroidal Vasculopathy as a Harbinger of Spontaneous Suprachoroidal Hemorrhage

Purpose: To report a rare case of spontaneous suprachoroidal hemorrhage in polypoidal choroidal vasculopathy (PCV) and propose a possible pathophysiologic cascade with associated clinical warning signs. Methods: A single observational case was reviewed. Results: A 66-year-old man with PCV developed sequential massive submacular hemorrhage, breakthrough vitreous hemorrhage, non-appositional choroidal elevation, and ultimately appositional suprachoroidal hemorrhage with angle closure and ocular hypertension. Despite treatment with posterior sub-Tenon triamcinolone and conservative management, the final visual outcome was no light perception. Conclusions: Spontaneous suprachoroidal hemorrhage in PCV is an extremely rare but devastating event. Based on the patient's stepwise clinical progression over several follow-up visits, we propose a sentinel cascade involving severe choroidal and vortex vein congestion culminating in blowout hemorrhage into the suprachoroidal space. Recognition of red-flag features may aid in early identification and closer surveillance of high-risk cases.