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Grand Rounds Conference Brett Mueller, D.O., Ph.D. 6/17/2016 University of Louisville Department of Ophthalmology and Visual Sciences Patient Presentation CC: From Neurology attending: “My patient has blood in her eye.” HPI: 87 yo WF presented to the hospital with 2 hrs of L sided facial droop and L sided weakness. Received tissue plasminogen activator (tPA), and a repeat head CT demonstrated a 1.61 cm by 0.68 cm intraochemorrhage History POHx: Cataract surgery OU PMHx: Dementia, HTN, CAD, cerebral aneurysm s/p coiling, and an old stroke with residual L sided weakness FAMHx: none ROS: none MEDS: Lisinopril, statin, ASA, memantine ALLERGIES: none Head CT w/o Contrast Pre-tPA A Post-tPA B Hyperdense area in OD measuring 1.61 cm by 0.68 cm Exam VA Blink to light Blink to light EOM: Unable to obtain CVF: Unable to obtain 3--2 P 13 T 3--2 No APD 14 Exam OD OS LIDS/LASHES WNL WNL CONJ WNL WNL CORNEA WNL WNL IRIS WNL WNL LENS PCIOL PCIOL OD Fundus Photos OS Color fundus photos: OD: a large inferior suprachoroidal hemorrhage, subretinal hemorrhages and temporal hemorrhagic retinal detachment OS: nasal subretinal and suprachoroidal hemorrhage and multiple small intra-retinal hemorrhages, and a hemorrhagic retinal detachment Summary 87 y/o WF w/ bilateral suprachoroidal hemorrhages with hemorrhagic retinal detachments OD>OS, 2ndary to the administration of tPA for a nonhemorrhagic stroke PLAN: Observe Choroidal Effusion • Abnormal accumulation of fluid in the suprachoroidal space (between the sclera and choroid) • Common complications of glaucoma surgery, other intraocular surgeries, inflammatory and infectious diseases, trauma, neoplasms, and drug rxns, • Can be either serous (painless and can by asymptomatic) or hemorrhagic (painful and marked reduction in VA) Treatment of Choroidal Effusion • After glaucoma surgery choroidals are generally treated conservatively • If bleb is overfiltrating can taper steroids quickly to promote bleb scarring, and cycloplegic agents can be used to deepen the anterior chamber • Surgical drainage indications: flat anterior chamber, decreased vision, long-lasting choroidal effusions, appositional choroidals, and suprachoroidal hemorrhages Treatment of Choroidal Effusion • Surgical drainage is accomplished by performing a conj peritomy, a 2- to 3-mm radial incision is made in the sclera 3-4 mm posterior to the limbus • The incision is deepened until the suprachoroidal space is entered and fluid is released • The sclerotomy site is left open with closure of overlying conj Tissue Plasminogen Activator • Implicated in the treatment for blood clots: pulmonary embolism, MI, and stroke • Stroke: Guidelines recommend tx w/ tPA for all pts presenting with stroke like symptoms w/in a 3-4.5 hr window • PE: heparin commonly used, but if PE causes severe instability, then tPA is recommended • MI: tPA can be administered w/in 12 hrs of symptoms if pt cant get a cath tPA Causing Suprachoroidal Hemorrhages • Only reported in 5 case reports where patients were getting tPA for a MI • First reported case of a pt having a stroke who developed bilateral suprachoroidal hemorrhages after the administration of tPA • Neurologist need to be aware of this rare complication associated with tPA administration, as it may be more common than we think THANK YOU References 1) Chu TG, Green RL. 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