Gloor B, Kalman A
Augenklinik des Universitätsspitals Zürich.
Klin Monbl Augenheilkd. 1993 Mar;202(3):224-37. doi: 10.1055/s-2008-1045587.
The aim of this study was, to analyze in cases of choroidal effusion and expulsive hemorrhage the surgical procedures and to derive recommendations to handle the expulsive event properly and adapted to the phase of the surgical procedure.
We report on 25 patients (27 eyes), 17 women and 8 male, who suffered from choroidal effusion and/or expulsive hemorrhage during or following surgery, in which the eye was opened. The age at the time of the event was between 52 and 90 years (median 80). 21 times the complication arrived during cataract surgery (age 57-90 years (median 81), five times during or following fistulating glaucoma surgery (age 55-84 years (median 63) and once during corneal transplant surgery (age 52 years).
Old age (50% of the patients > or = 81 years old), local anesthesia (except in one case), then arterial hypertension, coronary heart disease, myocardial infarction are accompanying characteristics in patients with this event. Choroidal effusion and expulsive hemorrhage can usually be managed, if wound closure is always possible and the necessary counterpressure can be applied. This is the case with a step incision and with at least three preplaced strong silk "safety" sutures (7.0 silk). With this technique all our own patients could be managed, but the characteristic of the six patients who were referred to us was, that no safety sutures had been placed. Three cases developed choroidal effusion following filtering procedures in glaucomatous eyes. After revision at the 10th to 15th day following expulsive hemorrhage with evacuation of the suprachoroidal hemorrhage, restoration of the anterior segment and of the vitreous cavity, in three of five desperate patients useful function from hand movement to 0.6 could be reached. Echography is used to determine the time the coagula are liquified and the moment to evacuate the hemorrhage. This is between 10 to 15 days.
Basically any expulsive event has to be managed by creating counterpressure. This means working in a closed system as long as possible. As long as not a tunnel incision is made, respectively when an expression technique with a large incision is used, together with a step incision at least three strong silk 7.0 "safety" sutures have to be preplaced, to allow a secure closure of the wound in any moment during surgery. If an expulsive event is the cause of protrusion of vitreous, vitrectomy is wrong because this lowers intraocular pressure. Urgent is the closure of the wound, even if vitreous and iris become squeezed into the wound. A sclerotomy is indicated only, if the wound can't be closed. Even if the expulsive hemorrhage leads first to amaurosis, evacuation of the hemorrhage together with revision of the anterior segment, vitrectomy and refilling may bring back some useful visual function. The surgical technique for revision, but also for measures in the different phases of cataract surgery are described in detail.
本研究的目的是分析脉络膜渗漏和暴发性出血病例的手术过程，并得出适当处理暴发性事件的建议，使其适应手术过程的阶段。
我们报告了25例患者（27只眼），其中17例为女性，8例为男性，他们在手术期间或手术后出现脉络膜渗漏和/或暴发性出血，且眼球已切开。事件发生时的年龄在52岁至90岁之间（中位数为80岁）。21次并发症发生在白内障手术期间（年龄57 - 90岁（中位数81岁）），5次发生在青光眼造瘘手术期间或之后（年龄55 - 84岁（中位数63岁）），1次发生在角膜移植手术期间（年龄52岁）。
高龄（50%的患者年龄≥81岁）、局部麻醉（仅1例除外）、动脉高血压、冠心病、心肌梗死是发生该事件患者的伴随特征。如果始终能够关闭伤口并施加必要的对抗压力，脉络膜渗漏和暴发性出血通常可以得到处理。采用阶梯式切口并至少预先放置三根强力丝线“安全”缝线（7.0丝线）时就是这种情况。运用这种技术，我们自己的所有患者都得到了处理，但转诊至我们这里的6例患者的特点是未放置安全缝线。3例青光眼滤过手术后出现脉络膜渗漏。在暴发性出血后第10至15天进行修复，清除脉络膜上腔出血，恢复前段和玻璃体腔，5例绝望患者中有3例从手动视力恢复到了0.6的有用视力。超声检查用于确定凝血块液化的时间以及清除出血的时机。这个时间在10至15天之间。
基本上，任何暴发性事件都必须通过产生对抗压力来处理。这意味着尽可能在封闭系统中操作。只要没有制作隧道切口，或者当使用大切口的挤压技术时，连同阶梯式切口至少要预先放置三根强力7.0丝线“安全”缝线，以便在手术期间的任何时刻都能安全地关闭伤口。如果暴发性事件是玻璃体突出的原因，玻璃体切除术是错误的，因为这会降低眼压。即使玻璃体和虹膜被挤入伤口，紧急的是关闭伤口。仅在伤口无法关闭时才进行巩膜切开术。即使暴发性出血首先导致失明，清除出血并同时修复前段、进行玻璃体切除术和再填充可能会恢复一些有用的视觉功能。详细描述了修复手术技术以及白内障手术不同阶段的措施。
