Hemorrhagic complications associated with suprachoroidal buckling

Abstract

Background: Multiple surgical techniques exist for the repair of rhegmatogenous retinal detachments (RRD). Suprachoroidal buckling (SCB), consisting of injecting viscoelastic material in the suprachoroidal space to allow chorioretinal apposition, has been recently described in the repair of RRD. The aim of this study is to report the complications of SCB and to propose measures to decrease their incidence during the learning curve.

Methods: A total of 26 eyes of 26 patients who underwent a SCB procedure for the management of RRD secondary to a single or multiple retinal breaks were enrolled. Patients were operated between January 2014 and March 2017 at two academic institutions. Patient and retinal detachment characteristics were obtained from the charts. Surgical videos were reviewed for every case and intraoperative complications were recorded. Complications observed postoperatively were obtained from the charts.

Results: Sixteen eyes (62%) underwent SCB alone, 5 eyes (19%) underwent additional gas tamponade and 5 eyes (19%) had combined pars plana vitrectomy. The most common complication was hemorrhage (6 cases, 23%). There were no cases of ischemic choroidal changes or hyperpigmentation at the edge of the dome. All six complications occurred in phakic patients who had inferior RRD with retinal breaks in the inferior quadrants. Isolated subretinal hemorrhage occurred in 4 patients and isolated suprachoroidal hemorrhage in 1 patient, and those did not affect final visual outcome. Extensive combined subretinal and suprachoroidal hemorrhage occurred in one case, and was complicated by phthisis bulbi. Re-detachment occurred in 4/6 (67%) of patients, and 5/6 (83%) of patients required a secondary procedure. Three out of 6 patients (50%) had at least 2 lines of visual acuity improvement.

Conclusion: SCB performed for RRD can be associated with hemorrhagic complications. The hemorrhages are usually self-limited but may occasionally result in severe visual compromise when involving the suprachoroidal space. Specific surgical measures need to be undertaken in order to decrease the likelihood of complications and further studies are needed to assess the safety and efficacy of this technique.

Keywords: Hemorrhagic complications; Retinal detachment; Suprachoroidal buckling; Viscoelastic buckling.

Conflict of interest statement

Competing interestsThe authors declare that there is no competing interests.

© The Author(s) 2020.

Figures

Fig. 1

Step-by-step illustration of the suprachoroidal buckling procedure. a Under direct visualization using a wide-angle viewing system, the extent of the detachment and the localization of the breaks is assessed. b Subretinal fluid drainage is done under direct visualization using a 26-gauge needle mounted on a 3-ml syringe (without plunger). c–e A pressure on the sclera is carried using a scleral depressor at the same time of drainage to avoid ocular hypotony. f, g An olive-tipped 20-gauge cannula is used to inject the viscoelastic material. The cannula is guided through the suprachoroidal space and directed posteriorly towards the site of the break under visualization through the wide-field viewing system. The viscoelastic is injected to create the desired dome effect. h Under direct visualization, endolaser retinopexy is performed around the identified breaks

Fig. 2

Case 1. a Operative findings. Photo taken during the primary surgery at the time of external subretinal fluid drainage using a 26-gauge needle. It shows an inferonasal subretinal hemorrhage adjacent to the causative tear. b Operative findings. Photo taken during the secondary surgery. It shows re-bleeding from the tear leading to a localized subretinal hemorrhage

Fig. 3

Case 2. a Operative findings. Photo taken under direct visualization of the injection of viscoelastic material (Healon 5) in the suprachoroidal space using the cannula. It shows the faint beginning of a subretinal hemorrhage. b Operative findings. Photo taken after the beginning of the subretinal hemorrhage. It shows expansion of the hemorrhage inferotemporally, adjacent to the dome of the indentation created by the injection

Fig. 4

Case 3. a Operative findings. Photo taken during the external subretinal fluid drainage using a 26-gauge needle. It shows the beginning of a subretinal hemorrhage. b Operative findings. Photo taken after the beginning of the subretinal hemorrhage. It shows expansion of the hemorrhage posteriorly, through a subretinal gutter and reaching the macula

Fig. 5

Case 5. a Operative findings. Photo taken during fluid-air exchange (FAX) while aspirating subretinal fluid. It shows the beginning of a hemorrhage occurring at the dome created by the suprachoroidal buckling (SCB). b Operative findings. Photo taken during an attempt to drain subretinal hemorrhage through an inferonasal retinotomy. It shows diffuse inferior subretinal hemorrhage with a possible suprachoroidal component, spanning 180 degrees and sparring the macula

Fig. 6

Case 6. a Red-free fundus photograph taken on postoperative day 2. It shows inferotemporal suprachoroidal hemorrhage, and vitreous hemorrhage that was noted preoperatively. b Red-free fundus photograph taken on postoperative week 6. It shows an attached retina and old vitreous hemorrhage gradually resolving