Suprachoroidal haemorrhage (SCH) is a severe complication of intraocular surgery. We report the first case of delayed SCH following cyclodiode laser therapy for refractory glaucoma.

Case report

The subject was a 72-year-old man with bilateral aphakia and secondary glaucoma. He had undergone multiple penetrating keratoplasties and trabeculectomies in both eyes. Previous cyclodidode laser therapy in the left eye resulted in hypotony and a choroidal detachment, which resolved after 4 weeks. He had no significant past medical history and was not on any systemic medication.

Visual acuity was 6/12 in the right eye and count fingers in the left eye. Examination revealed extensive peripheral anterior synechiae, cupped discs (0.95), and advanced field loss in both eyes. Despite maximal medical therapy of latanoprost (Xalatan, Pfizer Inc.), dorzolamide hydrochloride-timolol maleate ophthalmic solution (Cosopt, Merck & Co., Inc.), and acetazolamide 250 mg (Diamox, Wyeth) bid, intraocular pressure (IOP) in the right eye remained at 24 mmHg. It was felt that IOP in the right eye had to be urgently lowered and cyclodiode laser (60 shots each of 2.0 W and 2.0 s to 360°) was performed under retrobulbar anaesthesia. Immediately postoperative, the subject was comfortable and discharged. However, a week later, the subject stated that pain and reduced vision was experienced in the right eye 4 days postlaser. There was blood in the anterior chamber with no view of the fundus and the IOP was 5 mmHg. B-scan ultrasound revealed a SCH (Figure 1). The subject was admitted for bed rest and topical steroids. No further haemorrhage occurred and the eye became comfortable again. At last follow-up, he remained blind in the right eye.

Figure 1
figure 1

B scan showing bullous temporal SCH and bullous nasal choroidal effusion in the right eye. A posterior vitreous detachment with intragel opacities is present.

Full size image

Comment

SCH has been associated with cataract extraction, penetrating keratoplasty, glaucoma procedures, and vitreoretinal surgery. Intraoperative or expulsive SCH can cause massive bleeding, resulting in the expulsion of intraocular contents. It has an incidence of 0.03% with phacoemulsification1 and 0.15% in glaucoma filtering surgery.2 Delayed or postoperative SCH occurs in a closed system and does not usually result in the expulsion of contents. The reported incidence of SCH is 1.6% after filtering surgery3 and 6% after non-valved (Molteno) tube implantation.4

We report the first occurrence of delayed SCH following cyclodiode laser treatment. Risk factors for the patient were advanced age, glaucoma, aphakia and a previous episode of hypotony following cyclodiode laser in the contralateral eye. Other risk factors not present in this subject include hypertension, diabetes, myopia, pseudophakia, intraoperative hypertension with excessive drop in IOP, and ocular inflammation. Currently, there is no optimal treatment protocol for cyclodiode therapy and the dose–response is unpredictable. However, a recent study has suggested that high mean energy per treatment session may be associated with hypotony.5 In this case, the higher dose of cyclodiode laser used may have increased the risk of hypotony and hence SCH.

The precise mechanism of SCH is unclear but it is believed that hypotony leads to a choroidal effusion, which then stretches and tears the short or long posterior ciliary arteries.6

Cyclodiode laser is increasingly used to treat refractory glaucoma. While it is considered a relatively safe procedure, our case shows that severe and devastating complications such as SCH can still arise. The use of lower total energy levels should be considered in the treatment of high-risk cases.