How do I diagnose choroidal hemorrhage in a patient with recent intra‑ocular surgery, ocular trauma, or exposure to sulfonamides or topiramate?

Diagnosing Choroidal Hemorrhage

Choroidal hemorrhage is diagnosed primarily through clinical examination findings of smooth, dome-shaped elevations extending to the ora serrata on fundoscopy, combined with B-scan ultrasonography when media opacity limits visualization, in the context of recent intraocular surgery, trauma, or exposure to sulfonamides or topiramate. 1

Initial Clinical Assessment

History Taking

Obtain a focused history targeting specific risk factors and precipitating events:

• Recent intraocular procedures: Ask specifically about cataract surgery, glaucoma filtering procedures, vitrectomy, scleral buckling, or cyclophotocoagulation 2, 3
• Ocular trauma: Document any history of blunt or penetrating injury, as trauma is a vital risk factor for suprachoroidal hemorrhage 3
• Medication exposure: Inquire about sulfonamide derivatives (including topiramate) which cause ciliochoroidal effusions that can lead to hemorrhage 4, 5, 6
• Timing of symptoms: Note when visual changes, pain, or other symptoms began relative to surgery or trauma 2, 7

Visual Function Assessment

• Measure visual acuity under standard lighting conditions both with and without correction to establish baseline vision and severity of injury 1, 8
• Document any sudden vision loss, which may indicate acute hemorrhage 2

Physical Examination Components

Pupillary Examination

• Inspect pupil shape, size, and position for irregularities that may indicate prior trauma or intraocular pathology 1, 8
• Look for mid-dilated, asymmetric, or oval pupils which may accompany acute events 4

Intraocular Pressure Measurement

• Measure IOP carefully, as it may be elevated or reduced depending on the mechanism 4, 5
• When corneal abnormalities preclude Goldmann applanation, employ alternative tonometry methods such as pneumotonometer, handheld electronic applanation, or rebound tonometer 1, 8

Slit-Lamp Biomicroscopy

• Apply specialized techniques including sclerotic scatter, specular reflection, and indirect illumination to enhance visualization of anterior segment structures 1, 8
• Examine for:
  • Shallow anterior chamber (may indicate forward displacement from posterior hemorrhage) 4, 5
  • Corneal edema (common in acute cases) 4, 5
  • Conjunctival chemosis or hyperemia 4, 5
  • Iris abnormalities or transillumination defects 8

Gonioscopy

• Perform gonioscopy to detect peripheral anterior synechiae or appositional angle closure, which may accompany secondary angle-closure mechanisms in choroidal detachment 1
• This is particularly important in topiramate-induced cases where angle closure may be present 5, 6

Fundus Examination

Direct Ophthalmoscopy Findings

• On ophthalmoscopy, choroidal hemorrhages appear as smooth, dome-shaped elevations that extend anteriorly to the ora serrata, distinguishing them from retinal detachments which do not extend this far anteriorly 1
• Examine through a dilated pupil whenever feasible 4
• Look for associated vitreous hemorrhage, which may occur concurrently 2, 3

Diagnostic Imaging

B-Scan Ultrasonography

• Obtain B-scan ultrasonography when media opacity (corneal edema, vitreous hemorrhage) or patient cooperation precludes adequate examination of the posterior segment 4, 1, 8

• B-scan will reveal:

  • Choroidal effusions or hemorrhage 5, 6
  • Ciliary body swelling (particularly in drug-induced cases) 2, 5
  • Associated vitreous hemorrhage 2, 3
  • Extent and location of hemorrhage 3

• If the initial B-scan ultrasound is equivocal, repeat the scan within 1–2 weeks to confirm or clarify the presence of choroidal hemorrhage 1, 8

Critical Diagnostic Pitfalls

Timing Considerations

• Do not assume safety based on timing alone: Suprachoroidal hemorrhage can occur intraoperatively, on postoperative day 1, or as late as 5 days after surgery 2, 3, 7
• Delayed presentations (beyond 48 hours) are possible and should not be dismissed 7

Drug-Induced Cases

• In patients on topiramate or sulfonamides presenting with acute angle closure and elevated IOP, always perform B-scan to identify choroidal effusions, as this changes management from standard angle-closure treatment 5, 6
• These cases may be refractory to conventional glaucoma treatment and require steroid therapy 6

Trauma-Related Cases

• In traumatized eyes undergoing vitrectomy, maintain strict control of intraocular pressure and avoid abrupt hypotony, as ocular trauma is a vital risk factor for intraoperative suprachoroidal hemorrhage 3
• Avoid excessive pressure on the pars plana area during examination or surgery 3