Expulsive hemorrhage is a condition in which rupture of choroidal vessels leads to rapid abnormal accumulation of blood components in the suprachoroidal space. It is also referred to as expulsive bleeding or suprachoroidal hemorrhage (SCH).
It occurs during intraocular surgery or ocular trauma. It is arterial bleeding from the long or short posterior ciliary arteries, with blood accumulating in the suprachoroidal space. The vitreous cavity may be completely filled with blood.
The incidence during cataract surgery is reported to be approximately 0.04–0.1%. A UK epidemiological survey recorded an estimated incidence of 0.04% 1). The historical incidence for large-incision cataract surgery (extracapsular cataract extraction) was higher at 0.15–0.19% 2). A large US Medicare study reported a 0.06% incidence of suprachoroidal hemorrhage within one year postoperatively 3).
Extracapsular cataract extraction has a higher incidence than phacoemulsification (PEA). In micro-incision cataract surgery, the wound closes spontaneously with increased intraocular pressure, so the number of cases is decreasing.
Overall, it is a rare complication in cataract surgery, occurring in 0.04–0.1% of cases. Large-incision extracapsular extraction has a higher frequency than phacoemulsification, with historical reports of 0.15–0.19%. With the widespread use of micro-incision surgery, the current incidence is decreasing.
In surgeries under local anesthesia, patients often report moderate to severe eye pain at onset. Under general anesthesia, patient reports are unavailable, so only changes in the surgical field serve as clues.
The following signs appear as sudden changes during surgery:
In severe cases, extrusion of intraocular contents through the wound occurs.
Mild
Localized hemorrhagic choroidal detachment: Hemorrhage is confined to the subchoroidal space, and the layers are not adherent.
Intraocular containment type: Hemorrhage remains within the eye, with no extrusion through the wound. Visual recovery can be expected with a second surgery after 10–14 days.
Severe
Kissing choroidal detachment: Hemorrhagic choroidal detachments that adhere to each other centrally.
Expulsion of intraocular contents: The complete form of expulsive hemorrhage where intraocular contents protrude through the corneoscleral incision. The risk of blindness is extremely high.
B-mode ultrasonography shows large dome-shaped elevations adhering centrally. Initially, dense hyperechoic blood clots are seen under the choroid, but after about 2 weeks, the clots dissolve and become hypoechoic. B-mode ultrasound is useful for monitoring the size and characteristics of the clots over time and determining the timing of drainage.
The three main signs are sudden eye pain, shallow anterior chamber, and a rapid increase in vitreous pressure. Important intraoperative findings include elevation of the posterior capsule, observation of the retina under the posterior capsule, retinal elevation resembling choroidal detachment, and loss of the red reflex. If these are observed, immediately stop all surgical procedures and attempt to close the wound.
Risk factors for expulsive hemorrhage are classified into patient factors, systemic factors, and intraoperative factors.
| Risk Factor | Category |
|---|---|
| Advanced age | Patient factor |
| Glaucoma (history) | Ocular factor |
| High myopia | Ocular factor |
| Aphakia | Ocular factor |
| Atherosclerotic cardiovascular disease | Systemic factor |
| Hypertension | Systemic factor |
| Diabetes mellitus | Systemic factor |
| Sustained intraoperative hypotony | Intraoperative factor |
| Intraoperative high pulse rate | Intraoperative factor |
Sustained intraoperative hypotony is considered a major trigger4). The pathophysiology is thought to involve an increase in intraocular pressure and rupture of the posterior ciliary artery or vortex vein5).
Some reports indicate that oral warfarin does not significantly increase the incidence of SCH 4). Many studies support continuing anticoagulants and antiplatelet drugs during cataract surgery 4). Aspirin alone does not increase hemorrhagic complications 4). In preoperative management, it is important to individually decide whether to continue or discontinue these medications, taking into account thrombotic risk.
Reports suggest that oral warfarin does not significantly increase the frequency of SCH, and many studies support continuation during surgery. However, in patients with multiple risk factors such as hypertension and arteriosclerosis, comprehensive risk assessment is necessary.
If sudden eye pain, shallow anterior chamber, or rapid increase in vitreous pressure is observed, strongly suspect this condition. The same applies if rapid disappearance of the anterior chamber or elevation of the retinal surface is noted during surgery. If the fundus is visible, a choroidal detachment-like elevation can be observed.
| Differential diagnosis | Key points for differentiation |
|---|---|
| Choroidal effusion | Presence or absence of choroidal folds in the fundus (effusion is accompanied by folds). No hemorrhage. |
| IMS (Infusion Misdirection Syndrome) | Anterior chamber loss due to misdirection of infusion fluid. No hemorrhagic changes. |
| Vitreous prolapse due to posterior capsule rupture | Usually not accompanied by eye pain. Intraoperative findings of posterior capsule rupture precede. |
In differentiating from choroidal effusion, the presence or absence of choroidal folds in the fundus is important. If the fundus is visible, observation of folds is useful for distinguishing between expulsive hemorrhage (hemorrhagic) and effusion.
After surgery, B-mode ultrasound is performed repeatedly. Recording changes in the size, characteristics, and course of the blood clot, and determining the timing of liquefaction directly influences the timing of second-stage surgery.
The most important distinguishing point is the presence or absence of choroidal folds in the fundus. Choroidal effusion is often accompanied by folds. Expulsive hemorrhage presents with sudden severe eye pain, anterior chamber loss, and marked vitreous pressure elevation with hemorrhagic changes. B-mode ultrasound to confirm hyperechoic (hemorrhagic) or hypoechoic (effusion) is also useful for differentiation.
Treatment consists of a stepwise flow: intraoperative immediate response, waiting period, and second-stage surgery.
If onset is recognized, immediately stop all cataract surgery procedures. Close the wound, and suture the incision with as thick a thread as possible. In micro-incision cataract surgery, the wound naturally closes with increased intraocular pressure, so it is likely to settle spontaneously.
If bleeding outside the eye is severe, scleral puncture may be performed to drain choroidal hemorrhage. However, this is not performed in all cases; the decision is made based on the degree of bleeding.
Small incision surgery has the advantage of self-sealing wounds, and is safer even when SCH occurs4). Avoiding intraoperative hypotony is important for risk reduction5).
Many surgeons recommend waiting 7 to 14 days until the blood dissolves and drains more easily. B-mode ultrasound is used to monitor the characteristics of the clot and determine the timing of liquefaction.
After the clot has liquefied (generally after 10 to 14 days), the following surgery is performed.
If expulsive hemorrhage occurs in one eye, the fellow eye is also at high risk. If possible, perform surgery under general anesthesia, or consider transfer to a facility where general anesthesia is available.
If the hemorrhage is contained within the eye, some degree of visual recovery can be expected if the retina reattaches after second-stage vitrectomy performed 10 to 14 days later. On the other hand, in cases where intraocular contents have prolapsed outside the eye, blindness often results. Early wound closure and appropriately timed second-stage surgery determine the prognosis.
The cause of expulsive hemorrhage, like choroidal effusion, is not fully understood, but the following cascade has been proposed as the pathophysiology.
Larger incision surgeries tend to sustain low intraocular pressure longer and have higher risk. Phacoemulsification has lower risk due to shorter surgery time and reduced hypotensive duration4). Suprachoroidal hemorrhage has also been reported during femtosecond laser-assisted cataract surgery (FLACS)4), emphasizing the importance of risk management regardless of surgical technique.
A systematic preoperative risk scoring system has not been established at present, and an approach that individually evaluates known risk factors is considered practical.
Prognosis largely depends on the extent of hemorrhage and the presence of extrusion of intraocular contents.
| Prognosis | Condition |
|---|---|
| Relatively favorable | Hemorrhage is contained within the eye / Retinal reattachment achieved by two-stage surgery |
| Poor | When intraocular tissue prolapses outside the eye (often leads to blindness) |
| Particularly poor | When complicated by rhegmatogenous retinal detachment |
| Particularly poor | When SCH involves 2 or more quadrants |
If the bleeding is contained within the eye, vitrectomy with consideration of sclerotomy is performed 10–14 days after the subchoroidal hemorrhage liquefies. If the retina reattaches, some degree of vision can be preserved. In cases where intraocular tissue has prolapsed outside the eye, blindness often results. Rhegmatogenous retinal detachment or expulsive hemorrhage involving 2 or more quadrants is reported to have a poor prognosis.
