[Choroidal effusion and expulsive hemorrhage in penetrating interventions--lesson from 26 patients]

The aim of this study was, to analyze in cases of choroidal effusion and expulsive hemorrhage the surgical procedures and to derive recommendations to handle the expulsive event properly and adapted to the phase of the surgical procedure.

We report on 25 patients (27 eyes), 17 women and 8 male, who suffered from choroidal effusion and/or expulsive hemorrhage during or following surgery, in which the eye was opened. The age at the time of the event was between 52 and 90 years (median 80). 21 times the complication arrived during cataract surgery (age 57-90 years (median 81), five times during or following fistulating glaucoma surgery (age 55-84 years (median 63) and once during corneal transplant surgery (age 52 years).

Old age (50% of the patients > or = 81 years old), local anesthesia (except in one case), then arterial hypertension, coronary heart disease, myocardial infarction are accompanying characteristics in patients with this event. Choroidal effusion and expulsive hemorrhage can usually be managed, if wound closure is always possible and the necessary counterpressure can be applied. This is the case with a step incision and with at least three preplaced strong silk "safety" sutures (7.0 silk). With this technique all our own patients could be managed, but the characteristic of the six patients who were referred to us was, that no safety sutures had been placed. Three cases developed choroidal effusion following filtering procedures in glaucomatous eyes. After revision at the 10th to 15th day following expulsive hemorrhage with evacuation of the suprachoroidal hemorrhage, restoration of the anterior segment and of the vitreous cavity, in three of five desperate patients useful function from hand movement to 0.6 could be reached. Echography is used to determine the time the coagula are liquified and the moment to evacuate the hemorrhage. This is between 10 to 15 days.

Basically any expulsive event has to be managed by creating counterpressure. This means working in a closed system as long as possible. As long as not a tunnel incision is made, respectively when an expression technique with a large incision is used, together with a step incision at least three strong silk 7.0 "safety" sutures have to be preplaced, to allow a secure closure of the wound in any moment during surgery. If an expulsive event is the cause of protrusion of vitreous, vitrectomy is wrong because this lowers intraocular pressure. Urgent is the closure of the wound, even if vitreous and iris become squeezed into the wound. A sclerotomy is indicated only, if the wound can't be closed. Even if the expulsive hemorrhage leads first to amaurosis, evacuation of the hemorrhage together with revision of the anterior segment, vitrectomy and refilling may bring back some useful visual function. The surgical technique for revision, but also for measures in the different phases of cataract surgery are described in detail.