Suprachoroidal hemorrhage (SCH) is a condition in which the long and short posterior ciliary arteries rupture, causing blood to accumulate in the potential space between the choroid and sclera (the suprachoroidal space)1). The accumulated blood clot pushes the intraocular contents forward, leading to severe effects on intraocular structures.
The incidence during cataract surgery is reported to be approximately 0.03–0.1%3). It can occur more frequently during glaucoma surgery than during cataract surgery1). Delayed SCH after Xen45 microstent implantation has also been reported1), and attention is increasing with the spread of minimally invasive glaucoma surgery (MIGS).
Spontaneous cases also exist. Honzawa et al. (2024) reported a case of spontaneous expulsive SCH in a 50-year-old man with severe hypertension (blood pressure 228/124 mmHg) and intraocular pressure of 70 mmHg, in a cumulative report of 55 cases of spontaneous SCH2). Spontaneous cases occur without a history of ophthalmic surgery, so caution is needed in diagnosis.
Acute Expulsive
Timing of onset: During ophthalmic surgery (when the wound is open)
Mechanism: Sudden drop in intraocular pressure → vascular rupture
Features: Rapid progression of anterior chamber loss, loss of red reflex, and iris prolapse. Can lead to devastating visual impairment.
Delayed-onset
Timing: Days to weeks after surgery
Mechanism: Persistent low intraocular pressure → chronic stress on vessel walls
Features: More common after Xen45 implantation or trabeculectomy. Often noticed due to eye pain and elevated intraocular pressure1)
Spontaneous
Timing: No history of surgery
Mechanism: Severe hypertension, vascular fragility
Features: Rare. Occurs as part of hypertensive eye disease. A cumulative report of 55 cases exists2)
The incidence by main surgical procedure is shown below.
| Procedure | Incidence | Notes |
|---|---|---|
| Cataract surgery | 0.03–0.1% | Rare3) |
| Trabeculectomy | Higher than cataract | Cases after Xen reported1) |
| Spontaneous onset | Rare | Reported in severe hypertension cases2) |
Suprachoroidal hemorrhage occurs not only during surgery (acute expulsive) but also as delayed onset days to weeks after surgery, and spontaneous cases without prior surgery have been reported1, 2). In particular, delayed SCH after trabeculectomy or Xen45 implantation is easy to overlook, so attention should be paid to postoperative eye pain and elevated intraocular pressure.
The subjective symptoms of SCH vary depending on the mode of onset.
Acute ocular pain and elevated intraocular pressure after trabeculectomy or Xen45 implantation may indicate delayed SCH1). Perform B-mode ultrasonography to confirm hemorrhagic choroidal elevation. For details, see the Diagnosis and Examination Methods section.
The risk of SCH increases when multiple risk factors are present.
The classification of risk factors is shown below.
| Category | Main risk factors | Evidence |
|---|---|---|
| Systemic | Hypertension, diabetes mellitus, advanced age | Reports 2)3) |
| Ocular local | Glaucoma, long axial length | Report 3) |
| Intraoperative | Rapid intraocular pressure drop | Common knowledge |
This is the central examination method for diagnosing SCH.
It is necessary to differentiate SCH from diseases that may be confused with it.
| Disease | Ultrasound Findings | Key Differentiating Points |
|---|---|---|
| Choroidal effusion | Hypoechoic, homogeneous | No hemorrhage, mobile |
| Rhegmatogenous retinal detachment | Thin membrane-like elevation | Confirmation of retinal break |
| Choroidal tumor | Heterogeneous, solid | Enlarging tendency, blood flow present |
If SCH is suspected during surgery, the following steps should be taken.
For mild to moderate SCH, conservative management is performed.
If conservative treatment does not improve, or in cases of kissing SCH, surgical drainage is performed.
Drainage via posterior sclerotomy. Blood is drained through the incision, but the procedure is complex and carries a risk of secondary complications.
A minimally invasive drainage method using a trocar reported by Pericak et al. (2022)4).
A method was reported in which a 23G trocar is inserted into the suprachoroidal space via an inferotemporal approach, and blood is drained while maintaining an intraocular perfusion pressure of 60 mmHg4). The inferotemporal region is anatomically favorable for avoiding large vessels and is considered a safe access site.
Injection of tPA has been reported to be effective in dissolving clotted blood3).
A systematic review by Ribeiro et al. (2024) organized multiple treatment methods for perioperative SCH, including conservative management, sclerotomy drainage, and vitrectomy3). The timing of intervention is determined based on the coagulation state of the hemorrhage and the presence of retinal contact.
Conventional drainage
Method: Drain blood through posterior sclerotomy
Indication: After clot liquefaction (7–14 days later)
Challenges: Complexity of procedure and risk of secondary complications
Trocar Method (23G)
Method: Minimally invasive access with a 23G trocar
Site: Inferotemporal quadrant is optimal4)
Perfusion pressure: Safe drainage maintained at 60 mmHg4)
tPA-Assisted Drainage
Method: Liquefy the clot with tPA before drainage
Advantage: Can handle even hard clots
Evidence: Reported in cases of SCH after cataract surgery3)
When performing tamponade in cases requiring vitrectomy, air tamponade has been reported to carry a risk of postoperative rebleeding, so materials with long-term tamponade effect such as silicone oil may be considered4).
In principle, drainage is performed after confirming liquefaction of the clot by B-mode ultrasound, usually around 7–14 days after onset 3, 4). If performed too early, the clot is difficult to expel and the risk of rebleeding is high. In cases of kissing choroidals or persistent high intraocular pressure, earlier intervention may be necessary.
The central mechanism of SCH is a combination of intraocular pressure reduction and vascular wall fragility.
When intraocular pressure drops rapidly, the transmural pressure on choroidal vessels increases. In normal eyes, the lumen of the ciliary arteries is moderately compressed by intraocular pressure, but when intraocular pressure falls sharply, the outward pressure on the vessel wall increases, causing fragile posterior ciliary arteries to rupture 1).
In some cases, choroidal effusion precedes hemorrhage 2). It is thought that the effusion expands the suprachoroidal space, increasing traction on blood vessels and leading to hemorrhage. Pathophysiological analysis of spontaneous cases suggests the importance of this mechanism.
A report by Pham et al. (2023) showed that some cases of SCH after Xen45 implantation do not have clear hypotony immediately after surgery 1). In this type, vascular wall fragility and local inflammatory reaction are considered the main causes, suggesting that hypotony alone may not explain all cases of SCH.
The suprachoroidal space is normally a closed potential space, extending from the ciliary body to the vortex veins. When hemorrhage occurs here, the clot expands rapidly, compressing the retina, vitreous, and lens system anteriorly. In eyes with long axial length, the suprachoroidal space is wide, and blood tends to accumulate extensively.
With the spread of MIGS, reports of SCH after minimally invasive glaucoma surgery such as the Xen45 microstent have been accumulating.
Pham et al. (2023) reported delayed-onset SCH after Xen45 implantation 1). Even with MIGS, severe hemorrhagic complications can rarely occur, so careful observation for postoperative hypotony and eye pain is necessary.
The minimally invasive drainage method using a 23G trocar has been reported as a promising approach, but the number of cases is still limited.
Pericak et al. (2022) achieved safe drainage using a 23G trocar via an inferotemporal approach while maintaining a perfusion pressure of 60 mmHg 4). If standardized, it may become widely adopted as a minimally invasive alternative to conventional posterior sclerotomy.
Ribeiro et al. (2024) summarized the need to select a surgical technique based on a comprehensive assessment of clot status, retinal contact, and presence of vitreous hemorrhage in the surgical management of SCH 3). Establishing treatment selection criteria according to clot characteristics is a future challenge.
The combination of minimally invasive drainage using the trocar method (23G) and tPA clot lysis is attracting attention 3, 4). Additionally, developing management guidelines for delayed-onset SCH associated with the spread of MIGS is also a challenge 1). These are still in the research stage, and further accumulation of evidence is needed for establishment as standard treatment.
