International Journal of Retina (IJRETINA) 2025. Volume 8. Number 1. P-ISSN. E-ISSN. SUPRACHOROIDAL HAEMORRHAGE CAUSED BY VALSALVA MANEUVER DURING VITRECTOMY: A CASE REPORT Nur Ainun Rahma. Sindy Br Sembiring. Andrea Radotma Silitonga. Christina YY Bangun Department of Ophthalmology. SMEC Hospital. Medan. Indonesia Abstract Introduction: Suprachoroidal hemorrhage is a rare but significant complication that can occur during intraocular surgery due to valsalva maneuver while patient awake. A rapid blood accumulation in the suprachoroidal space due to increased tension such as valsalva manuever can caused by rupture of the posterior ciliary arteries or vortex veins. Case report : A 43-year-old man with drop IOL following eventful cataract surgery underwent vitrectomy. IOL explantation and iris claw IOL implantation under general anesthesia. After core vitrectomy and IOL explantation the patient suddenly awake. Iris claw IOL implantation was At the end of surgery massive suprachoroidal hemorrhage was found. One day postoperative the visual acuity was hand movement. Suprachoroidal and vitreous hemorrhage were Oral and topical steroid were administered. Three months post operative the visual acuity 20/50 and residual suprachoroidal hemorrhage was observed. Discussion: Suprachoroidal Hemorrhage incidence during intraoperative is not known because it occurs very rarely. Our case highlights the Valsalva maneuver event during vitrectomy which cause sudden suprachoroidal hemorrhage. Conclusions: Valsava maneuver during vitrectomy could cause a devastating complication such as suprachoroidal hemorrhage. Although it is one of the reversible complications of anesthesia awareness during vitrectomy, it can be resulted severe visual impairment. Keywords: Suprachoroidal hemorrhage. Vitrectomy. Valsalva maneuver. General Anaesthesia Cite This Article: RAHMA. Nur Ainun et al. SUPRACHOROIDAL HAEMORRHAGE CAUSED BY VALSALVA MANEUVER DURING VITRECTOMY. International Journal of Retina, [S. ], v. 8, n. 1, p. 65, mar. ISSN 2614-8536. Available at: . Date accessed: 05 mar. doi: https://doi. org/10. 35479/ijretina. Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. sudden increase in venous pressure may lead to INTRODUCTION Correspondence to: Suprachoroidal vessel-wall rupture by an apparently excessive Nur Ainun Rahma. SMEC Hospital. Medan. Indonesia, hemorrhage (SCH) is a rare pressure gradient across the vessel wall. 6 The but significant complication intraoperative suprachoroidal hemorrhage is an rahmanurainun@gmail. that can occur following uncommon but devastating complication of PPV. The The purpose of this case report to demonstrate a actual incidence of this uncommon complication in vitrectomy is not clearly established because small vitrectomy under general anaesthesia caused by hemorrhages may go unnoticed or unrecorded in intraoperative awareness. clinical records unless they are systematically The CASE REPORT hemorrhage complicates the analysis of its causes. A 43 years old man presented with sudden outcomes, prevention, and treatment. 2 It has been decrease of vision one week after eventful cataract observed in connection with various procedures The visual acuity was 1/60 and the IOP was 3 Pars 15 mmHg. Anterior chamber was quite, iris vitrectomy (PPV) has IOL acknowledged as an The patient surgical intervention for a wide range of underwent pars plana vitreoretinal diseases. vitrectomy (PPV). IOL Suprachoroidal retropillary iris claw- IOL vitreoretinal surgery. suprachoroidal space During accumulation in the However, the patient suddenly tension and rupture of the posterior ciliary arteries or vortex veins. complication of pars plana vitrectomy (PPV) that can be associated with a guarded visual prognosis. Suprachoroidal hemorrhage can also be associated with subretinal neovascular membranes, laser photocoagulation, blood clotting disorders, and valsalva maneuver. 5 In a Valsalva maneuver, a and IOL explantation Fig. 1 Massive suprachoroidal hemorrhage observed during vitrectomy following valsalva maneuver. Suprachoroidal It occurs as a result of awake and massive suprachoroidal hemorrhage occurred (Fig. Nevertheless iris claw IOL was implanted retropupillary. One day postoperative, the visual acuity was hand movement and IOP was 15 mmHg. Ultrasonography showed vitreous hemorrhage and suprachoroidal hemorrhage (Fig. 2A). Cornea was clear and the IOL was enclaved retropupillary (Fig. 2B). Oral and topical steroid was given. Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. One week after the surgery, the visual acuity At 3 months of follow up, the suprachoroidal improved to 20/60 and intraocular pressure was 22 haemorrhage residual, the final best corrected visual mmHg. Ultrasonography demonstrating vitreous acuity (BCVA) was 20/50 with intraocular pressure opacities and suprachoroidal hemorrhage improved (IOP) 22 mmHg. Ultrasonography showing Posterior (Fig. 3A). Fundus photograph showed chorioretinal folds (Fig. 3B). haemorrhage (Fig. 4A). Fundus at his last follow-up hemorrhage (Fig. 4B). Fig. 2 First day post-surgery examinations. (A) Ultrasonography of the left eye showed round smooth dome shaped inferiorly and superiorly attached to the optic disc. The fluid in the suprachoroidal space appeared to be anechoic . erous choroidal detachmen. and some had mild to moderated echo amplitude . emorrhagic choroidal detachmen. (B) Slit lamp examination showed clear cornea, round pupil and centrally placed retropupil iris claw. Fig. 3 One week follow up post-surgery. (A) Ultrasonography examination showed mildly elevated dome shaped choroidal detachment with minimal echoic of fluid in the suprachoroidal space, indicating resolving serous and hemorrhagic choroidal (B) Fundus photo showed mild vitreous hemorrhage and minimal chorioretinal folds. showed vitreous hemorrhage mild and chorioretinal folds. Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. Fig. 4 Three months follow up post-surgery. (A) Ultrasonography examination showed very minimal choroidal detachment. (B) Fundus photo was showed attach retina with residual chorioretinal folds in the periphery. Chandra et al showed significant risk factors for DISCUSSION Suprachoroidal developing suprachoroidal hemorrhage in Pars accumulation of blood in the potential space Plana Vitrectomy included older age, systemic between the choroid and sclera, with the source of the blood being the long or short posterior ciliary rhegmatogenous retinal detachment (RRD) and The hemorrhage is not known because it occurs very pseudophakia/aphakia, presence of a dropped lens A review of Chandra et al study conducted Pollack and associates report that over 10 years involving 5459 patients, the incidence valsalva maneuver, during vitrectomy, occurring of suprachoroidal hemorrhage during Pars Plana either as bucking during premature emergence from Vitrectomy (PPV) was 56 cases. This suggests a rate general anesthesia or severe coughing during local A 1999 study by Chu et al performed the anesthesia, is another risk factor for suprachoroidal most extensive retrospective literature review in the 10 In this case, the suprachoroidal past 25 years of the major ophthalmologic surgeries hemorrhage occurred during vitrectomy under where suprachoroidal hemorrhage occurred. They general anesthesia. The patient experienced a found that risk was higher for patients undergoing sudden, severe cough due to light anesthesia, which vitreoretinal surgery . ange: 0. 17% to 1. 9%). Piper et al found that the incidence of suprachoroidal hemorrhage in their study involving pars plana vitrectomy was 13 out of 683 cases . 9%). Among these, ten cases . 5%) were first observed during the surgery, while three cases . 44%) were detected during the postoperative period. 8 Qureshi and associates described 20 cases of suprachoroidal hemorrhage during intraocular surgery. Of the 20 patients, only 2 cases of suprachoroidal hemorrhage Suprachoroidal hemorrhage is a rare but well described complication of ophthalmic surgery. is believed to have triggered the valsalva maneuver. The Valsalva maneuver caused a significant increase in venous pressure, leading to the rupture of the choroidal vessels. The Valsalva maneuver can cause choroidal hemorrhage by triggering a coughing fit during general anesthesia, which increases both arterial and venous pressures, eventually leads to the rupture of choroidal vessels. The Valsalva maneuver occurs as a forced exhalation against a closed glottis, resulting in increased intrathoracic pressure, which leads to complex respiratory and vascular responses. The Valsalva maneuver can be divided into four phases: Phase 1: Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. In this initial phase, there is a transient increase in increase in systemic arterial pressure and the intrathoracic pressure and arterial blood pressure. appearance of reflex bradycardia. 11Ae13 The increase in intrathoracic pressure due to tension temporarily enhances left ventricular ejection, which is cause blood to be expelled from thoracic vessels, leading to an increase in arterial pressure. Phase 2 (Strain Phas. : During this phase, it begins with a progressive fall in systolic, diastolic, and pulse pressure as a The increase in central venous pressure and systemic arterial blood pressure, characteristic of the late phase of the Valsalva maneuver, leads to an increase in choroidal blood flow. Particularly, the rise in central venous pressure causes resistance in the episcleral veins, which is reducing aqueous outflow. The narrowed during valsalva The cause a higher venous return humor outflow resistance and pressure (IOP). Intraocular Fig. 5 Representation of mean arterial pressure and heart rate during phases in Valsalva Maneuver. which is can be noticed by the increase of jugular Concurrently, the filling of the right and left sides of the heart decreases, which results in a decrease in mean arterial pressure and pulse pressure, leading to an increase in heart rate. Phase 3 (The release of airway closure phas. : As the tension ceases, the intrathoracic pressure starts to Meanwhile, the blood pressure suddenly drops causing from the pooling of blood in pulmonary vessels. This mechanism makes venous return, diastolic filling, and stroke volume increase and a rise in heart rate. Phase 4 (Post-Strain Phas. In this final phase, heart rate and total peripheral resistance increase, causing a rapid and significant rise in arterial pressure, referred to as the "phase 4 " This phase is characterized by an normally 16 A mmHg. During intraoperation the intraocular pressure must be maintain within this normal range to ensure constant corneal curvature and proper refracting index of the A sudden increase in systolic blood pressure such as valsalva maneuver can cause a transient acute rise in IOP. 14 On the other hand, some literature reported that valsalva maneuvers can cause thickening of the anterior and the ciliary body during the phase 2. In the management of suprachoroidal hemorrhage, the choice of treatment is guided by the extent of Treatment sclerotomy drainage, sclerotomy drainage with or without anterior chamber formation, limited anterior vitrectomy or pars plana vitrectomy, and Published by: INAVRS https://w. org/ | International Journal of Retina https://ijretina. the use of intraocular tamponade. 16 Indications for (BCVA) was 20/50 with intraocular pressure (IOP) 22 surgery include: kissing choroidal detachments, mmHg. This may caused by the etiology is IOL drop, large non-kissing choroidal detachments involving the macula, associated vitreous incarceration or suprachoroidal hemorrhage complexity with retinal hemorrhage, retinal incarceration or detachment, intraocular pressure (IOP), and/or persistent eye 9 In considering the underlying diagnosis for our patient is IOL drop. This means that the retina is still attached and does not require tamponade. This is different from a case of retinal detachment where, if no drainage is performed, the volume of silicone tamponade will be inadequate. Therefore, in this case, there is no indication for surgical intervention. Conservative management is implemented for this CONCLUSION Suprachoroidal hemorrhage is an extremely rare yet potentially serious complication of vitrectomy. conclusion, the Valsalva maneuver during vitrectomy can lead to significant suprachoroidal hemorrhage. In our case, despite the presence of minimal residual hemorrhage, the patient's vision improved, although it did not fully return to normal. Intraoperative suprachoroidal hemorrhage, though uncommon, is a catastrophic complication of pars plana vitrectomy (PPV) that can dramatically worsen the surgical Visual outcome after suprachoroidal hemorrhage during intraocular surgery is influenced by the etiology and extent of the haemorrhage, the presence of concurrent retinal detachment, and outcome if not managed appropriately. REFERENCES