Several possible risk factors for SSCH have been proposed. They include advanced age, systemic anticoagulation or thrombolysis, hypertension, atherosclerosis, age-related macular degeneration, and chronic kidney disease.1–3
Our patient had only one of these previously reported risk factors, namely, systemic anticoagulation. Diabetes mellitus, which our patient had, is associated with suprachoroidal hemorrhage during and after intraocular surgery.2
However, in a case-control study of 210 patients taking warfarin for cardiovascular disorders, diabetes mellitus did not appear to add to the increased risk of ocular bleeding (SSCH was not seen in this study).4
Although diabetes has not previously been identified as a risk factor for SSCH, there is a report of a patient with background diabetic retinopathy on warfarin therapy who developed spontaneous massive subretinal hemorrhage5
and another description of a patient with pre-proliferative diabetic retinopathy on warfarin who sustained a suprachoroidal hemorrhage 3 days after panretinal laser photocoagulation.6
Furthermore, Hidayat and Fine7
described choroidal vascular changes consistent with arteriosclerosis in a histopathologic study of 7 patients with diabetes mellitus. So, it seems reasonable that the presence of diabetic eye disease could have been an added risk factor for SSCH in our patient.
Other possible precipitators of SSCH relevant to our patient with cystic fibrosis are coughing and hypercapnia. Coughing is believed to cause rupture of fragile ciliary vessels by elevating episcleral venous pressure.2
Chronic hypercapnia may cause an increase in retinal blood flow precipitating ocular hemorrhages.8
At age 24, our patient may be the youngest to have developed SSCH in the absence of ocular surgery, trauma or congenital coagulopathy. Thirty-five cases of SSCH have been published in 29 reports since 1963. The age of these patients ranged from 27 to 90 with a mean of 72.5 years old. Only 2 patients were less than 46 years old. Saeed et al.9
reported SSCH after thrombolytic agent administration for hemodialysis in a 27-year-old patient with a history of rubeotic glaucoma. Tajika et al.10
reported SSCH in a 32-year-old patient with malignant hypertension and chronic kidney disease. In contrast to these individuals, our patient did not have glaucoma, hypertension or kidney disease.
In addition to advanced age, systemic anticoagulation or thrombolysis is the major risk factor for SSCH. Of the 35 patients who developed SSCH since 1963, 23 (66%) were on anticoagulant or thrombolytic therapy. Our patient had an INR in the therapeutic range, although her aPTT was markedly prolonged as measured an hour or two prior to her SSCH. Her advanced proliferative diabetic retinopathy and cystic fibrosis (coughing) may have also added to the risk of SSCH.
Pain management and visual acuity preservation are priorities in the management of SSCH.1
We successfully treated the elevated IOP with brimonidine. However, we decided not to pursue aggressive surgical treatment because several studies have shown poor visual prognosis—especially in patients with poor initial presentation.1