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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 2  |  Issue : 1  |  Page : 14

Spontaneous expulsive suprachoroidal hemorrhage


Department of Ophthalmology, Pontifical Catholic University of Campinas, Campinas, Brazil

Date of Submission10-Mar-2020
Date of Acceptance06-May-2020
Date of Web Publication24-Jun-2020

Correspondence Address:
Dr. Henrique Sampaio Ferreira
Av John Boyd Dunlop s/n -Jardim Ipaussurama, Postal Code: 13059-900, Campinas
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/PAJO.PAJO_11_20

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  Abstract 


The objective is to report a rare case about spontaneous expulsive choroidal hemorrhage in PUC Campinas Hospital. It is a retrospective case report. A 102-year-old patient with untreated glaucoma and recent corneal ulcer was admitted in the emergency room with completely spontaneous uveal and crystalline exposure and submitted to evisceration. This report discusses about this rare entity and the development in this particular patient in the city of Campinas, São Paulo state, Brazil.

Keywords: Corneal ulcer, evisceration, glaucoma, spontaneous expulsive choroidal hemorrhage


How to cite this article:
Ferreira HS, Patrus BP, Neves GL, Almeida Filipe PH, Sawatani CS, Andrade Sobrinho MV. Spontaneous expulsive suprachoroidal hemorrhage. Pan Am J Ophthalmol 2020;2:14

How to cite this URL:
Ferreira HS, Patrus BP, Neves GL, Almeida Filipe PH, Sawatani CS, Andrade Sobrinho MV. Spontaneous expulsive suprachoroidal hemorrhage. Pan Am J Ophthalmol [serial online] 2020 [cited 2020 Jul 2];2:14. Available from: http://www.thepajo.org/text.asp?2020/2/1/14/287688




  Introduction Top


Spontaneous suprachoroidal hemorrhage is a very rare entity that leads to a poor visual prognosis.[1]

Choroidal hemorrhage can be classified in expulsive and nonexpulsive. The first one presents by the expulsion of intraocular contents through corneal or scleral orifice. The second form the content remains inside the globe. Also can be classified in surgical type: that occurs during intraocular intervention, as opposed to spontaneous: that is a very rare event associated with corneal and scleral weakness, where the patient doesn't have a history of recent surgery or trauma.[2]

The pathophysiology of spontaneous expulsive hemorrhage is not well defined. Some authors argue that the mechanism of spontaneous expulsive hemorrhage is the same as surgery-related expulsive hemorrhage. Rapid and strong displacement of the retina and choroid occurs when there is a sudden decompression of the eye wall and causes ischemia in the posterior ciliary arteries in the region where they enter the eyeball.[2]

Pietruschka and Schill argue that hemorrhage in the posterior ciliary arteries causes the intraocular pressure increase that would be responsible for the corneal rupture in a previously weakened cornea and limbus.[3]

Pe'er et al. believe that an acute necrosis of the wall of the choroidal vessels is responsible for copious hemorrhage. And, that the initial event would be a breach of the corneal barrier.[4]

Spontaneous expulsive hemorrhage has multiple risk factors, the most important of which are advanced age, systemic arterial hypertension, atherosclerosis, diabetes, vascular diseases, glaucoma, corneal lesions, aphakia, pseudophakia, and intraocular tumors.[1],[5]

Objective

The aim of this study is to report a case of spontaneous expulsive choroidal hemorrhage in a 102-year-old female.


  Case Report Top


A 102-year-old female was taken to the emergency room by the family members after having spontaneous eye hemorrhage in the right eye [Figure 1]. The family members reported untreated glaucoma and denied previous surgery, use of anticoagulants, and trauma. They also reported that the patient had untreated corneal ulcer in the right eye for 10 days. In the first evaluation, visual acuity in the right eye had no light perception and the left eye was 20/200. During the inspection of the right eye, blood, uveal, and crystalline contents were completely expelled. [Figure 2]. Upon examination of the slit lamp, the left eye was calm, transparent cornea, and anterior chamber formed. There was no uptake of fluorescein in the cornea and no seidel. There was the presence of nuclear and posterior subcapsular cataract. Left eye tonometry: 46 mmHg. And, the left eye fundus was not possible due to opaque media.
Figure 1: Inspection of the patient's eye

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Figure 2: Presence of the lens intact for inspection

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Blood tests, including coagulogram, were normal and surgery was performed after the anesthesiology team evaluated.

The patient underwent evisceration of the right eye [Figure 3]. Surgical findings were perforated cornea, prolapse of the uveal content, and thin sclera. The culture of bacteria and fungi was negative. Intravenous cefazolin was prescribed for 72 h and ciprofloxacin 500 mg every 12 h for 7 days, antiglaucomatous drops were prescribed for the left eye, and the patient was discharged [Figure 4].
Figure 3: Protruding uveal content

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Figure 4: Evisceration

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  Discussion Top


According to Hsiao et al. in a meta-analysis study with 32 eyes, that suffered spontaneous suprachoroidal hemorrhage, the main associated systemic diseases were hypertension (20 cases, 64.5%), cardiovascular or cerebrovascular disease (17 cases, 54.8%), diabetes (7 cases, 22.6%), and atherosclerosis (6 cases, 19.4%). In 58.1% of cases, anticoagulants, antiplatelet, and thrombolytic agents were used. Five cases reported to have done the Valsalva maneuver prior to the episode.[1] Also, advanced ages such as 60 years and older are a major risk factor to developing this issue.[2]

Chai et al. in a literature review noticed that the main associated ocular diseases were age-related macular degeneration, glaucoma, and pseudophakia.[5] Besides those, Ophir et al. suggests that thinning of the eye wall, such as infectious corneal ulcer and corneal staphyloma are common associated ocular diseases.[2]

In cases of spontaneous expulsive hemorrhage without perforation of the globe, the main treatment is blood drainage through sclerotomy or vitrectomy. Perforated eyes the main resource is trying to close the globe and prevent the prolapse of the intraocular structures.

The prognosis of spontaneous expulsive hemorrhage is worse when compared to surgical expulsive hemorrhage since the most effective treatment of this pathology is to prevent extrusion of the uveal content, and this situation is only possible in the operating room. The patient with spontaneous expulsive hemorrhage, in most cases, arrives at the hospital with a protruding uveal content.


  Conclusion Top


Our impression of the case is that the physiopathology mechanism that could explain the event is the combination of the high intraocular pressure, due to untreated glaucoma, and the corneal ulcer causing a perforation, leading to a surge and necrosis of the posterior ciliary arteries.

Spontaneous expulsive hemorrhage is not a common entity; however, it has a poor visual prognosis. In this case, the patient had as risk factors: advanced age, untreated glaucoma, and corneal ulcer.

Most of the risk factors of this pathology are immutable; however, the treatment of glaucoma and intraocular pressure, in addition to the treatment of corneal ulcers, reduces the chances of intraocular inflammation and perforation of the globe.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hsiao SF, Shih MH, Huang FC. Spontaneous suprachoroidal hemorrhage: Case report and review of the literature. Taiwan J Ophthalmol 2016;6:36-41.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Ophir A, Pikkel J, Groisman G. Spontaneous expulsive suprachoroidal hemorrhage. Cornea 2001;20:893-6.  Back to cited text no. 2
    
3.
Pietruschka G, Schill H. Spontaneous Expulsive Choroidal Hemorrhage. Klin Monthly Ophthalmology 1964;145:167-74.  Back to cited text no. 3
    
4.
Pe'er J, Weiner A, Vidaurri L. Clinicopathologic report of spontaneous expulsive hemorrhage. Ann Ophthalmol 1987;19:139-41.  Back to cited text no. 4
    
5.
Chai F, Zeng L, Li C, Zhao X. Spontaneous suprachoroidal hemorrhage in a high myopia patient with rhegmatogenous retinal detachment: A case report and literature review. Biosci Rep 2019;39:1-8.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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