Peri-Operative Use Of Tranexamic Acid In The Management Of Suprachoroidal Hemorrhage During Phacoemulsification Surgery

Suprachoroidal hemorrhage (SCH) represents one of the most serious and vision-threatening complications that can arise during or immediately following intraocular surgery. Traditionally, management of SCH involves medical management with or without surgical drainage. Despite aggressive management, visual outcomes tend to be poor. The purpose of this case series is to describe and explore the use of intravenous (IV) tranexamic acid (TXA), a synthetic antifibrinolytic agent, in 2 cases of spontaneous SCH occurring in elderly patients undergoing routine phacoemulsification. The prompt administration of IV TXA helped to stabilize the clinical scenario, leading to good eventual visual outcomes without the need of any surgical intervention.

We present two cases that were managed at a high-volume tertiary ophthalmology center in Singapore. Patient records were reviewed for demographic information (age, sex, relevant systemic history), ophthalmic history, surgical details, preoperative and postoperative IOP, clinical findings, and management outcomes.

1: 68y/o underwent right phacoemulsification under regional anesthesia (RA). The anterior chamber (AC) persistently shallowed and globe became firm during cortical remnant aspiration. Intra-operative BIO showed no obvious SCH, prompting an impression of aqueous misdirection. 25G pars plana vitrectomy was performed which showed a limited SCH. IV TXA 1g was given and surgery was ended without IOL implantation. Post-operative patient was started on intensive medical therapy. Another IV TXA 1g was given 8 hours later. On day 1, VA was counting fingers 2m, IOP was 14mmHg. AC was deep. B-scan revealed a limited SCH. Patient was managed conservatively with oral TXA 0.5g BD (3 days). Subsequent visits showed gradual and complete resolution of SCH at day 22. She then had a sulcus IOL placement, ultimately achieving VA of 6/7.5-2.

2: 80y/o underwent right phacoemulsification under RA. The AC persistently shallowed with iris prolapse after IOL insertion. Red reflex was present, prompting suspicion of aqueous misdirection. AC remained shallow despite chandler’s procedure, irido-zonulo-hyaloidectomy and limited anterior vitrectomy. B-scan confirmed an acute SCH. IV TXA 0.5g was given intra-operatively. Post-operative patient was started on intensive medical therapy. On day 1, VA was hand movement, IOP 10 mmHg. B-scan showed SCH in multiple quadrants but no retinal detachment nor kissing choroidals. Over ensuing weeks, SCH gradually resolved and VA improved, ultimately achieving 6/6 vision.

Suprachoroidal hemorrhage (SCH) is a rare but serious complication of intraocular surgery. Tranexamic Acid (TXA) acts by inhibiting plasminogen activation, thereby diminishing fibrin degradation and theoretically reducing ongoing hemorrhage. We present 2 cases demonstrating that early administration of tranexamic acid (TXA) can limit bleeding, resulting in not only resolution of hemorrhage but also restoration of near normal visual acuity. Although optimal dosing and timing remain uncertain, no adverse events were observed in both our patients. Further research is warranted, but these findings suggest TXA could be a valuable adjunct in managing acute SCH.