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Letter
Delayed suprachoroidal haemorrhage following Boston Keratoprosthesis in two aniridic patients
  1. Cynthia Xin-ya Qian1,
  2. Mona Harissi-Dagher2
  1. 1Department of Ophthalmology, Université de Montréal, Québec, Canada
  2. 2Department of Ophthalmology, Hôpital Notre-Dame—Centre Hospitalier Universitaire de Montréal, Québec, Canada
  1. Correspondence to Dr Cynthia Xin-ya Qian, Department of Ophthalmology, University of Montreal, Hôpital Maisonneuve Rosemont, Centre ambulatoire Ophtalmologie Local F 101, 5415 boul. de l'Assomption, Montréal, Qc H1T 2M4, Canada; xin-ya.qian{at}umontreal.ca

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In recent years, the heightened success of the Boston Keratoprosthesis type I (KPro) has broadened its indications and also uncovered new complications, the most common being retroprosthetic membrane formation, endophthalmitis, progression of glaucoma and infectious keratitis.1 This study reports on the development of delayed appositional suprachoroidal haemorrhage in two aniridic patients, a rare complication post-KPro surgery.

Case 1

A 69-year-old woman with aniridia and glaucoma presented 3 days post-KPro surgery OD with pain and decreased vision. Ocular history included an extracapsular cataract extraction with vitrectomy OD and a KPro surgery OS. Medical history was non-contributory. On exam, visual acuity was light perception (CF (counting fingers) preop and HM (hand motion) on postop 1 day) and the intraocular pressure (IOP) on manual palpation was 5 mm Hg OD and 15 mm Hg OS. Biomicroscopy revealed an injected conjunctiva, a formed anterior chamber, intact sutures and a well-placed KPro covered by a soft contact lens. B-scan confirmed the presence of a suprachoroidal haemorrhage. The patient was hospitalised, and prescribed analgesics and antiemetics before undergoing vitrectomy, suprachoroidal drainage and a fluid–gas exchange 2 days later (figure 1). Despite good initial improvement, she developed proliferative vitreoretinopathy. At last follow-up 6 months post-SCH, a total, inoperable retinal detachment was diagnosed.

Figure 1

Evolution of patient 1. (A) 69-year-old patient with aniridic keratopathy 2 months preop for Boston Keratoprosthesis type I surgery. (B) imaging via B-scan ultrasound revealing appositional choroidals secondary to suprachoroidal haemorrhage.

Case 2

A 52-year-old woman with aniridia and glaucoma and uncomplicated KPro surgery OD 6 months prior presented with ocular pain and visual loss. Ocular surgeries included a trabeculectomy OD 10 years ago supplemented by Ahmed valve implant 1 year later. On exam, vision was HM (20/80 on follow-up 2 weeks ago). Slit-lamp examination was unrevealing. Manual palpation revealed an IOP of approximately 5 mm Hg. B-scan confirmed multiple hyperdense cystic collections. The patient was discharged home with appropriate analgesics. The next day, vision worsened to LP, and a B-scan revealed kissing choroids. Surgical drainage and intravitreal injection of Healon and BSS was performed. She began to improve visually until the 4th day postdrainage, when a rebleed was detected. Redrainage combined with vitrectomy and air–fluid exchange was performed under general anaesthesia (figure 2). Owing to persistent hypotony postop, the Ahmed valve was removed. At last follow-up 6 months post-SCH, vision had stabilised at CF.

Figure 2

Evolution of patient 2. (A) 52-year-old patient with aniridic keratopathy preoperatively for Boston Keratoprosthesis type I surgery. (B) The same patient 1 month postoperative for Boston KPro surgery. Notice the vascularisation of surrounding donor cornea. The prosthesis remains clear centrally. (C) Imaging via B-scan ultrasound revealing appositional choroidals secondary to suprachoroidal haemorrhage. (D) Postop 1 day after initial drainage of suprachoroidal haemorrhage.

Discussion

Suprachoroidal haemorrhage (SCH) is defined by an accumulation of blood in the suprachoroidal potential space. Estimates of incidence vary from 1.6 to 6.1%. It can be classified according to the precipitating factor (surgery or trauma), the extent of haemorrhage and the time of development. Postoperatively, SCH is often termed delayed suprachoroidal haemorrhage (DSCH).2 3

Pathogenesis is attributed to the rupture of long or short ciliary arteries either from necrosis or from compressive forces of choroidal effusions. Risk factors include early postoperative hypotony, myopia, aphakia, glaucoma and prior surgery with vitreous manipulation. Systemic risk factors include old age, hypertension, arteriosclerosis, preoperative anticoagulation, cardiac and respiratory diseases.2–6

The DSCH in our patients was associated with their preoperative ocular status. First, both were chronically glaucomatous and aphakic. Ghadfan et al have observed that the absence of a structure delineating the two chambers may decrease the eye's ability to tamponade against internal compression.4 Patient 1 had also undergone a vitrectomy, creating an empty space that favours scleral collapse. Patient 2 had an Ahmed valve implant, and although Ahmed valves blunt the postoperative hypotony, there could be a leak around the implant which could be hard to detect. In addition, early postoperative hypotony monitoring is challenging, since IOP can only be estimated through manual palpation.

It is also possible that aniridia is associated with DSCH. Bradley et al reported only two cases of choroidal effusion/haemorrhage in a retrospective study of UC Davis KPro patients over a 4-year span, one of whom was aniridic.5 Akpek et al conducted the largest multicentre retrospective case study on KPro outcome in aniridic patients and did not demonstrate such a correlation.6

Although KPro surgery does not seem to predispose to DSCH more than any other intraocular surgery, ophthalmologists should gain an understanding of its pathophysiology and must exercise extra caution when managing patients with multiple cormorbid risk factors of DSCH development.

References

Footnotes

  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval Ethics approval was provided by the Ethics Committee Centre Hospitalier Université de Montreal.

  • Provenance and peer review Not commissioned; not externally peer reviewed.