Severe choroidal detachment with hemorrhagic suprachoroidal fluid associated with persistent leakage from a blade-created anterior chamber paracentesis wound after intravitreal aflibercept: a case report

Inside the human eye, a delicate balance of fluid pressure keeps the globe firm and the vision clear. When doctors need to treat conditions like age-related macular degeneration, they often inject medicine directly into this fluid-filled space. Sometimes, this injection causes the eye to become dangerously over-pressurized, like a balloon that has been blown too full. To prevent damage, doctors perform a quick procedure called anterior chamber paracentesis, which involves making a tiny opening in the clear front window of the eye to let a small amount of fluid escape and lower the pressure. This is generally considered a safe and routine step, a standard tool in the ophthalmologist's kit for managing immediate pressure spikes. However, the safety of this procedure relies on one critical assumption: that the tiny opening seals itself back up immediately after the fluid is released. If that seal fails, fluid continues to leak out, the eye collapses, and the internal structures can separate, leading to severe vision loss.

A recent case report from Japan details a rare but serious instance where this self-sealing mechanism failed, turning a routine pressure-relief step into a complex surgical emergency. The story begins with a 63-year-old woman who had received her twenty-fourth injection of a drug called aflibercept to treat wet macular degeneration in her right eye. The injection went in through the white part of the eye, but afterward, the globe felt unusually tight and tense when the doctor pressed on it with a cotton swab. Concerned that the pressure had risen too high, the surgeon immediately performed the pressure-relief procedure. Using a specialized blade, similar to the one used to create side openings during cataract surgery, the doctor made a small incision in the clear cornea to drain fluid. The procedure was done under a microscope, and as the blade was pulled out, clear fluid was seen flowing away. To the surgeon, the flow appeared to stop, and the eye seemed stable enough to conclude the visit.

The following morning, however, the situation had deteriorated rapidly. The woman's vision had dropped to the point where she could only see the movement of a hand. Her eye pressure was critically low, and the front chamber of the eye had become dangerously shallow. A test using a special dye revealed that the tiny incision made the day before was still leaking fluid, a condition known as a positive Seidel test. While the injection site on the white part of the eye was sealed tight, the corneal wound was not. Ultrasound and CT scans confirmed the worst: the layers of tissue at the back of the eye had detached from the wall, creating a large space filled with a mixture of fluid and blood. This separation, called a choroidal detachment, was extensive and worsening.

The patient was referred to a university hospital for urgent care. By the time she arrived six days after the initial incident, the detachment had progressed further, and the fluid inside the eye was a mix of clear liquid and blood. The medical team performed surgery to fix the problem. First, they attempted to close the leaking corneal wound by swelling the tissue with fluid, a technique called stromal hydration, but the leak persisted. Only after placing a single, fine nylon stitch did the wound finally seal and stop leaking. With the front of the eye secured, the surgeons turned their attention to the back. They created a small opening in the white part of the eye to drain the hemorrhagic fluid that had accumulated behind the retina. Because the fluid was trapped deep in the back of the eye, they temporarily injected a heavy, clear liquid called perfluorocarbon to push the remaining fluid forward toward the drainage hole. Once the fluid was removed and the back of the eye was flat again, the heavy liquid was taken out, and the eye was closed.

The outcome of this intervention was successful in terms of structural repair. By the second week after surgery, the detachment had completely resolved, and the eye pressure returned to a normal range. Over the next twelve months, the patient received eight more injections of a different medication, faricimab, without any further need for pressure relief or signs of leakage. Her vision stabilized, though it did not return to its pre-incident level, likely due to the underlying disease affecting the macula. The key takeaway from this case is that a blade-created incision in the cornea does not always seal itself, even when it appears to have stopped leaking during the procedure. The authors emphasize that visible fluid stopping does not guarantee a watertight seal. When a patient shows signs of persistent leakage, a shallow front chamber, or early signs of tissue detachment, waiting for the eye to heal on its own may be too risky. Instead, the report suggests that doctors should consider closing the wound with a stitch immediately and assessing the back of the eye without delay. For patients who require repeated pressure-relief procedures, the authors recommend deliberately choosing a new entry site each time, avoiding areas that have been cut before or show signs of scarring, to reduce the risk of this complication.