Kuo Zhao¹, Jun Ni¹, Xuegang Su¹, Qiang Li¹ and Fei Leng²*
¹Department of Ophthalmology, Shunyi Maternal and Children’s Hospital of Beijing Children’s Hospital, Beijing 101300, China
²Department of Ophthalmology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing 100045, China
Corresponding Author:
Fei Leng, Department of Ophthalmology, Beijing Children’s Hospital, Capital Medical University, National Center for Children’s Health, Beijing 100045, China.
Abstract
Patient was a 59-year-old man who presented with progressive visual blurring in his right eye for 2 weeks and was admitted on November 6, 2023. The patient reported that he experienced progressive visual blurring after using a trigger point gun to massage the right eye socket 2 weeks prior, which worsened upon lying down.
Citation
Zhao K, Ni J, Su X, Li Q, Leng F (2024) Preclinical Characteriza tion of GST-HG141, a Novel Hepatitis B Virus Capsid Assembly Modulator. SM Opthalmol J. 2024; 5(1): 1016.
CASE PRESENTATION
Patient was a 59-year-old man who presented with progressive visual blurring in his right eye for 2 weeks and was admitted on November 6, 2023. The patient reported that he experienced progressive visual blurring after using a trigger point gun to massage the right eye socket 2 weeks prior, which worsened upon lying down. There was no eye strain or eye pain. The patient had a history of hypertension for 10 years, which was controlled with oral medication, with stable blood pressure, ranging from 140/85 mmHg. The patient’s unaided visual acuity in the right eye was 0.3, while his Corrected Distance Visual Acuity (CDVA) with + 0.50/+ 2.00 × 87 = 0.3 and an Intraocular Pressure (IOP) of 15 mmHg was noted. The anterior chamber depth was deepened, and the iris, lens, and zonules were found to be trembling. There was also a cloudy lens, and upon dilating the pupil, a lower portion of the lens was visible (Figure 1).
Figure 1: Patient’s prone position during surgery.
The unaided visual acuity in the left eye was 0.8, while the CDVA with +0.50/+0.75×177=1.0 and an IOP of 16mmHg was noted. The anterior chamber depth was normal, and there was no trembling of the iris, lens, or zonules. The lens was clear. The diagnosis upon admission was right lens subluxation; right traumatic cataract; and hypertension. The planned procedure was anterior segment vitrectomy plus cataract extraction with intraocular lens suspension.
After admission, the patient was treated with lidocaine injection intraocularly under orbital anesthesia, and a scleral tunnel incision was made above the nose and temporal area, remove the anterior vitreous, and intact extract the lens capsule (Figure 2).
Figure 2: Remove the anterior vitreous, and intact extract the lens capsule
The main incision was sutured partially, the anterior segment of the vitreous body was removed, and the patient experienced eye pain and restlessness. A grayish-black elevation was subsequently found on the temporal side of the fundus, and the range of the elevation gradually increased. A large amount of viscoelastic agent was quickly injected, the surgical incision was sutured, and hemorrhage in the vitreous cavity was seen (Figure 3).
Figure 3: A grayish-black elevation was subsequently found on the temporal side of the fundus. A large amount of viscoelastic agent was quickly injected, the surgical incision was sutured, and hemorrhage in the vitreous cavity was seen.
The surgery was terminated. Postoperative patient had high IOP, which was controlled at 20-30 mmHg by 20% mannitol injection, betaxolol eye drops, brinzolamide eye drops, anterior chamber drainage, and atropine sulfate and corticosteroids for anti-inflammation.
On the first day after surgery, B-ultrasound showed a choroidal detachment, with a high to moderate echogenicity in the choroidal space (Figure 4).
Figure 4: On the first day after surgery, you can see a choroidal detachment, and the suprachoroidal space shows a moderate to high echogenicity
Ten days later, the IOP stabilized, the right eye visual acuity was 0.01, CDVA was 0.6, and the B-ultrasound showed that the echo in the supraciliary space was improved compared with the first day after surgery, and there is a temporal side choroidal detachment visible in the fundus (Figure 5).
Figure 5: On the 10th day after surgery, high-to-moderate echogenicity was seen in the suprachoroidal space, and a temporal choroidal detachment was visible on the fundus.
The patient was followed up regularly, and on postoperative week 3, the degree of choroidal detachment can be clearly improved by ultrasound examination (Figure 6).
Figure 6: The detachment of the choroid was significantly improved by the third week after surgery.
One month after surgery, a B ultrasound scan shows that the choroid has fully retracted, and the right eye visual acuity was 0.02, CDVA +10.75/-1.00×51=0.7, IOP 14mmHg. Two months post-operatively, the patient’s unaided visual acuity was 0.02, while the CDVA with + 10.50/-0.50*47=1.0. The IOP was 14mmHg, and B-ultrasound showed the choroidal reattachment (Figure 7)
The patient was scheduled to undergo anterior segment vitrectomy and intraocular lens suspension surgery on January 8, 2024, and the surgery was successful. The patient’s uncorrected visual acuity was 0.8 in the first week postoperatively, CDVA was +0.25/-0.25×98=0.9, the retina and choroid were in place (Figure 8),
Figure 8: After the suspension surgery, a B-ultrasound examination in the first week shows that the retina and choroid are in place
and the patient was followed up regularly postoperatively. The patient’s uncorrected visual acuity was 1.0 at 2 months postoperatively, and the CDVA was +0.50/-0.50×170=1.0, the lens position was normal (Figure 9),
Figure 9: A photograph taken by a slit lamp 2 months after surgery
and the retina and choroid were in place (Figure 10).
Figure 10: B-ultrasound and fundus photography at 2 months post-operation.
DISCUSSION
Explosive Suprachoroidal Hemorrhage (ESCH) is a rapid, poorly prognostic complication of intraocular surgery with a low incidence. Risk factors include: advanced age, hypertension, oral anticoagulants, glaucoma, high myopia, history of intraocular surgery, in addition to coughing, holding breath, Valsalva maneuver, high intraocular pressure before surgery and sudden decrease in intraocular pressure during surgery, loss of vitreous, posterior eye block, high intraoperative blood pressure, and prolonged surgical time, etc. The current pathogenesis is not clear, and it is generally believed that it is caused by a sudden drop in intraocular pressure, resulting in choroidal and ciliary effusion, leading to tear of the ciliary artery posterior [1]. Once explosive suprachoroidal hemorrhage occurs, the patient will experience sudden and severe eye pain, restlessness, and the surgeon should be vigilant and immediately stop the operation and close the incision. With the displacement of intraocular tissue, the intraocular tissue should be repositioned as soon as possible. Lakhanpal observed the rabbit eye model and found that immediate scleral incision drainage after hemorrhage would cause increased bleeding and blood entering the vitreous cavity and retina. This confirmed that immediate scleral incision drainage during surgery was more harmful than beneficial [2].
Some studies suggest that small, localized, and limited hemorrhages located between the ciliary margin and the equator, as well as cases where retinal adhesion resolves within 2 weeks, may have the potential for spontaneous absorption through conservative treatment and can preserve some visual function [3,4]. Other studies suggest that hemorrhages involving the macula, hemorrhages not involving the macula but exceeding two quadrants, retinal detachment, retinal adhesion, vitreous hemorrhage, vitreous entrapment, persistent high intraocular pressure, residual crystalline lens after cataract surgery, uncontrollable ocular pain, etc. require surgical treatment [5]. The surgical indication is generally 7-14 days, considering that the inflammatory response has been controlled, the blood clot has liquefied, and drainage is facilitated, thereby reducing the risk of recurrent bleeding and damage to the retina. The surgical methods include: scleral incision drainage combined with anterior chamber shaping, vitrectomy combined with silicone oil filling, and the application of recombinant tissue Plasminogen Activator (r-tPA) among others. The suspected precipitating factors in this case were hypertension and a history of trauma. The patient’s postoperative prognosis was good, which may have been related to the timely detection and diagnosis, timely filling of viscoelastic agents and closure of the incision to maintain intraocular pressure, which controlled the bleeding, limited its extent, prevented the displacement of intraocular contents, and allowed for conservative treatment of hemorrhage absorption after surgery.
Currently, the treatment options for ESCH are diverse and the effectiveness varies. The main approach is to prevent it. First, pay attention to the risk factors of ESCH and take measures such as controlling blood pressure and intraocular pressure before surgery. Second, maintain stable intraocular pressure during surgery and try to shorten the surgery time and keep the patient relaxed. Finally, instruct the patient to avoid strenuous exercise and pressure on the eye after surgery. If bleeding occurs, diagnose and close the incision in time, maintain intraocular pressure, and improve the patient’s postoperative visual effect.
