Postoperative Suprachoroidal Hemorrhage in a Glaucoma Patient on Low Molecular Weight Heparin
A 61-year-old Saudi female patient presented to the Glaucoma clinic at King Khalid Eye Specialist Hospital, (Riyadh, Kingdom of Saudi Arabia) with high-uncontrolled intraocular pressure (IOP) in the right eye. The patient had a history of bronchial asthma on remission without any current systemic medication. She was a monocular patient with phthisis bulbi of the left eye and had advanced secondary glaucoma with high myopia in the right eye. Past history of ocular surgery of the right eye included: A complicated cataract surgery and development of corneal decompensation postoperatively resulting in explantation of the intraocular lens. Subsequently she developed aphakic bullous keratopathy which required two penetrating keratoplasties. Then she developed secondary glaucoma which was managed with an Ahmed implant. Trans-scleral diode laser cyclophotocoagulation was performed for uncontrolled IOP.\nOn examination at presentation, the vision in the right eye was 20/100 that improved with pinhole to 20/70 and the left eye had no light perception (NLP). The IOP was 39 mm Hg in the right eye on maximum topical anti-glaucoma therapy. Slit lamp examination of the right eye showed normal lid, thinning of the conjunctiva over the Ahmed tube without exposure, clear corneal graft centrally [], deep anterior chamber centrally with areas of peripheral anterior synechia. The Ahmed tube was in place away from the corneal graft with vitreous strands blocking it [], and she was aphakic. Fundus examination showed myopic changes with a pale disc and advanced cupping.\nDue to high-uncontrolled IOP even with maximal tolerated anti-glaucoma medications, triamcinolone assisted anterior vitrectomy with removal of the vitreous strands from the tube under local anesthesia was planned. The retinal consultant concurred with surgical plan with guarded prognosis. After discussion with the patient about the expected complications, risks and benefits, the patient signed an informed consent. The medical team gave the patient prophylactic LMWH (Clexane; Sanofi-Aventis, Bridgewater, NJ, USA) 4000 IU SC 2 h preoperatively. The surgery was uneventful []. On the first postoperative day, the patient complained of severe pain. Examination of the right eye indicated NLP with IOP of 70 mm Hg. Slit lamp examination showed an edematous cornea with flat anterior chamber and the retina was abutting the cornea. B-scan ultrasonography showed massive suprachoroidal hemorrhage with bullous choroidal detachment []. The patient received stat oral diamox and intravenous mannitol with methylprednisolone and topical anti-glaucoma medications. Due to the severe pain and high IOP, the retina team performed a drainage for the suprachoroidal hemorrhage with anterior chamber reformation. In the operating room, the retina was incarcerated in the tube and did not flatten. On the following day, the patient was discharged home with NLP vision. At two weeks follow-up, the vision was NLP and IOP was 8 mm Hg.