Expulsive Choroidal Effusion
20/80. At that time, the only hemorrhage
A Complication of Intraocular
Richard S. Ruiz, MD, Paul C. Salmonsen, MD
\s=b\ Massive serous choroidal effusion
may occur as an expulsive complication
of intraocular surgery. The pathophysiol-
ogy of expulsive hemorrhage involves rup-
ture of the short posterior ciliary arteries,
while that of effusion involves massive
exudation through the walls of the choroi-
dal vessels. Many of the predisposing fac-
tors may be shared including atheroscle-
rosis, hypertension, and sudden surgical
decompression. The treatment of both en-
tities is the same\p=m-\swiftclosure of the
wound, drainage of suprachoroidal blood
or effusion through a posterior sclerotomy
site, and injection of a physiologic solu-
tion into the anterior chamber to tampo-
nade the leaking vessels and restore nor-
mal intraocular anatomic relationships.
The visual prognosis following expulsive
choroidal effusion is much more favor-
able than that of expulsive hemorrhage.
(Arch Ophthalmol 94:69-70, 1976)
hemorrhage
Sudden
posterior ciliary
most familiar
from the short
arteries is the
expulsive complication
of intraocular surgery.1 There is an¬
other problem that may be equally
disastrous—massive serous choroidal
effusion.
REPORT OF CASES
Case 1.—A 72-year-old woman was ad¬
mitted for the extraction of a senile cata¬
ract in the left eye. Her general health was
good with the exception of arthritis that
had been continuously treated with predni¬
sone during the preceding two years. The
dose of the steroids was regulated by her
symptoms and averaged 20 mg/day.
The blood pressure was 170/100 mm Hg
and results of examination of the heart,
lungs, and abdomen were normal. Subcuta¬
neous ecchymoses, indicative of vascular
fragility, were evident on the hands, arms,
and legs. Results of external ocular exami¬
nation were normal. Best corrected visual
Submitted for publication July 31, 1974.
From the Program in Ophthalmology, the Uni-
versity of Texas Medical School at Houston.
Reprint requests to 1121 Hermann Profes-
sional Building, Houston, TX 77025 (Dr Ruiz).
Downloaded from www.archophthalmol.com on March 20, 2011
Surgery
acuity was 20/50 OD and 20/80-2 OS. The
corneas were clear, the anterior chambers
deep, and there were bilateral posterior
subcapsular cataracts. Intraocular ten¬
sions by applanation were 15 mm Hg OD
and 14 mm Hg OS.
The patient was brought to the oper¬
ating room for cataract extraction. Five ml
of 2% lidocaine with epinephrine and
1:5,000hyaluronidase was injected retrobul-
barly. Twelve milliliters of 2% lidocaine
and 1:5,000 hyaluronidase was used in a
modified Van Lint procedure for lid aki-
nesia. Lid retraction sutures were placed
in the upper and lower lids and a lateral
canthotomy was made. A limbus-based
flap and grooved limbal incision were
created. Two sutures were preplaced. Im¬
mediately following completion of the 180°
limbal incision into the anterior chamber,
the patient had a severe coughing episode,
which caused the lens and iris to bulge for¬
ward. The coughing subsided, but the lens
and iris were displaced too far anteriorly
to allow closure of the wound. It was as¬
sumed the zonules had ruptured, and the
decision was made to remove the lens. At
this point, coughing ensued again and the
lens as well as a massive amount of formed
vitreous were ejected from the eye. An an¬
terior vitrectomy was begun, but soon a
large choroidal detachment could be seen
nasally. The corneoscleral wound was
closed and the globe became firm. Since we
suspected an expulsive hemorrhage, three
posterior sclerotomies at the 8-o'clock posi¬
tion, the 9:30-o'clock position and the 10-
o'clock position were created 13 mm poste¬
rior to the limbus in an effort to drain the
blood from the eye. Surprisingly, only a
small amount of serosanguineous fluid was
obtained, even though the bare choroid
was exposed for 3 mm with each incision.
The choroid was perforated several times
in an effort to drain additional fluid, but to
no avail. The sclerotomies were left open
for continued drainage. All prolapsed iris
and vitreous were excised and the limbal
cataract incision tightly closed using 7-0
black silk sutures. During the immediate
postoperative period, large choroidal de¬
tachments were observed; however, no
hemorrhage was seen in the vitreous or on
the retina. Three weeks after surgery, the
retina and choroid had settled back in
place, and the corrected visual acuity was
observed was small, flame-shaped, and lo¬
cated nasal to the disc.
Six weeks postoperatively, the visual
acuity had improved to 20/50, but the ora
serrata was detached nasally and was un¬
der pronounced traction by the vitreous
base. As the tenting of the ora and the vit¬
reous traction appeared to be increasing,
cryopexy was carried out over the entire
nasal aspect of the sclera anterior to the
equator in an attempt to prevent the ret¬
ina from detaching. In spite of this, three
months later the retina detached nasally
and a scierai buckling operation was re¬
quired. The surgery was successful and the
corrected visual acuity is presently 20/30
+ 2.
Case 2.—A 72-year-old woman entered
the hospital for the extraction of a senile
cataract in the left eye. In 1971 an un¬
eventful intracapsular cataract extraction
had been performed on the right eye. The
blood pressure was 130/70 mm Hg, and re¬
sults of the general physical examination
were normal. Best corrected visual acuity
was 20/30 OD and ability to count fingers
at three feet OS. The external ocular ex¬
amination was negative, and slit-lamp
biomicroscopy confirmed the presence of a
dense nuclear sclerotic cataract in the left
eye. The intraocular tensions by applana¬
tion were 20 mm Hg OU.
The patient received 300 ml of 15% man-
nitol intravenously. She was brought to
the operating room, intubated, and given
halothane general anesthesia. Wire lid re¬
tractors were inserted and a lateral can-
thotomy was performed. A limbus-based
conjunctival flap and limbal groove were
created. The anterior chamber was entered
superiorly and the wound extended 90° to
the 3-o'clock position. Two corneoscleral
sutures were inserted at the 1-o'clock and
2-o'clock positions. The patient began
coughing and straining on the intubation
tube, and developed tachycardia and an in¬
verted wave by ECG. Iris prolapse oc¬
curred and the anterior chamber flattened.
The sutures were temporarily tied, and af¬
ter several minutes, the patient's condition
stabilized and the coughing subsided. The
eye seemed soft, and it was elected to con¬
tinue with extraction of the cataractous
lens. The wound was extended to the 9-
o'clock position and another corneoscleral
suture was placed at the 11-o'clock posi¬
tion. Iris prolapse increased and a periph¬
eral iridectomy was made at the 12-o'clock
position. The lens was delivered intracaps-
ularly with the cryophake, but it was fol¬
lowed by a copious amount of formed vit¬
reous. While an anterior vitrectomy was
being performed, the patient again
coughed, forcing more vitreous from the
eye. A large temporal choroidal detach¬
ment could be seen through the pupil. The
wound was closed and a sclerotomy created
at the 2:30-o'clock position 15 mm posterior
to the limbus. Serous fluid flowed out of the
sclerotomy from the suprachoroidal space.
More coughing developed, which caused
even more iris prolapse and vitreous loss.
The iris was reposited and the vitreous
cleaned from the wound site. Indirect oph¬
thalmoscopy demonstrated nasal, tempo¬
ral, and superior choroidal detachments
extending almost to the disc. No signs of
hemorrhage were evident. Closure of the
wound was completed and the sclerotomy
site was left open.
During the postoperative period, large
choroidal detachments were observed that
extended into the posterior pole. Treat¬
ment consisted of orally administered
prednisone, 40 mg daily, and topically ad¬
ministered prednisolone sodium phosphate,
1% four times daily, as well as cycloplegic
medication. The choroidal detachments
gradually diminished and eight weeks fol¬
lowing surgery they had completely sub¬
sided. Corrected visual acuity was 20/40
ten weeks postoperatively and has re¬
mained at this level. The patient's recovery
has been complicated by intermittent ele¬
vations of intraocular pressure due to an¬
terior synechiae. These pressure variations
have responded satisfactorily to pilocar¬
pine and carbonic anhydrase inhibitors.
COMMENT
The endothelial cells of the retinal
capillaries are firmly bound together
by desmosomes, making the vessel
walls impermeable to the escape of
large particles. In striking contrast is
the endothelium of the choroidal ves¬
sels whose cells are loosely adherent
and normally allow the passage of
large molecules of high molecular
weight.2(p292)
The transmural pressure across the
choroidal veins and capillaries is usu¬
ally in the vicinity of 1 to 3 mm
jjg 2IP281I Elevation of the transmural
pressure, as in a coughing episode
with the eye open, would contribute
to an extravasation of fluid from the
vessels. The porosity of the choroidal
vessels is apparent by the prevalence
of varying degrees of choroidal de¬
tachments after ocular hypotony.
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Some authors think that choroidal
detachment occurs with each in¬
traocular surgical procedure, but not
until the postoperative period.1 As il¬
lustrated by these two cases, massive
choroidal effusion and detachment
can occur during surgery when the
eye is open.
The combination of a low intraocu¬
lar pressure created by the surgical
wound, elevated transmural venous
pressure caused by coughing, and
friable vessels due to atherosclerosis,
predisposed these eyes to massive
serous choroidal effusion.
In the first case, chronic adreno-
corticosteroid ingestion perhaps con¬
tributed to the vascular fragility and
effusion. It is puzzling that three sep¬
arate sclerotomy incisions into the
suprachoroidal space and even perfo¬
ration of the choroid itself failed to
produce any substantial drainage of
fluid. There is little question that the
massive choroidal detachments were
due to serous fluid and not blood since
complete absorption had occurred
within three weeks. Possibly the fluid
in this case was distributed through¬
out the extracellular space of the
choroid and was not pooled in the
suprachoroidal space.
One wonders whether lesser de¬
grees of choroidal effusion may not
occur with some frequency and if
they perhaps are responsible for a
significant percentage of vitreous loss
with cataract extraction.
The treatment of massive effusion
parallels that of expulsive hemor¬
rhage. When the intraocular contents
are anteriorly displaced, and the
globe becomes firm, an expulsive com¬
plication should be suspected immedi¬
ately. Swift closure of the wound to
elevate intraocular pressure, tampo-
nade the vessels, and minimize effu¬
sion is essential. Posterior sclerotomy
aids in the restoration of normal in¬
traocular architecture. Reformation
of the anterior chamber with a physi¬
ologic solution aids in curtailing the
effusion as well.
At the 1972 American Academy of
Ophthalmology and Otolaryngology
meeting, a suprachoroidal effusion
mimicking expulsive hemorrhage was
described having occurred during
as
of a keratoprosthesis.4
implantation
We believe our experiences are the
first reports of a poorly recognized
entity—massive expulsive serous
choroidal effusion. All expulsvie com¬
plications of intraocular surgery,
therefore, are not due to hemorrhage,
but in some cases are rather the re¬
sult of effusion of serous fluid from
choroidal vessels.
Expulsive hemorrhage is character¬
istically accompanied by severe pain
in those cases performed with the pa¬
tient under local anesthesia. In the
one case of choroidal effusion occur¬
ring in an awake patient, the patient
had no discomfort associated with the
expulsive episode. Although our series
is limited, it may be that a differ¬
ential point between expulsive choroi¬
dal effusion and hemorrhage is lack of
pain in the former.
The importance of recognizing
massive serous choroidal effusion
rests in realizing that although some
of the intraocular contents may be
expelled and the normal anatomy dis¬
turbed, the prognosis is potentially
much more favorable than with ex¬
pulsive hemorrhage. The more ready
résorption of serum and lack of de¬
struction of the retina and choroid
often associated with expulsive hem¬
orrhage allow for a more optimistic
visual prognosis following massive
expulsive serous choroidal effusion.
This work was supported by a private grant
from the Houston Eye Fund.
Case 2 is reported through the courtesy of Mal¬
colm L. Mazow, MD.
References
1. Jaffe N: Welsh RC, Welsh J (eds): The Sec-
ond Report on Cataract Surgery. Miami, Goula-
tion Press Inc, 1971, p 119.
2. Moses RA: Adler's Physiology of the Eye, ed
5. St Louis, CV Mosby Co Publishers, 1970.
3. Brav SS: Serous choroidal detachment. Sur-
vey Ophthalmol 6:395-415, 1961.
4. Girard LJ, Spak KE, Hawkins RS, et al: Ex-
pulsive hemorrhage during intraocular surgery.
Trans Am Acad Ophthalmol Otolaryngol 77:119\x=req-\
125, 1973.