Innovative surgical approach for massive suprachoroidal hemorrhage with secondary angle-closure crisis

Suprachoroidal hemorrhage (SCH) is a rare but vision-threatening complication often associated with systemic and ocular risk factors. We report the first case of SCH related to fondaparinux sodium (Arixtra®, Aspen Pharma Trading Limited, Dublin, Ireland) overdose and describe an innovative surgical approach combining drainage sclerotomy with long-duration transscleral cyclodiode laser photocoagulation. A 90-year-old woman with a history of hypertension, moderate renal insufficiency, and non-exudative age-related macular degeneration presented with sudden painful vision loss in the left eye after initiating fondaparinux sodium (Arixtra®, Aspen Pharma Trading Limited, Dublin, Ireland) for suspected deep vein thrombosis. On admission, visual acuity was reduced to hand motion, intraocular pressure (IOP) was 50 mmHg, and B-scan ultrasonography revealed a dome-shaped suprachoroidal hematoma. Laboratory testing confirmed fondaparinux overdose. Despite intensive medical therapy, IOP remained uncontrolled, and vision declined to no light perception. Emergency drainage sclerotomy combined with long-duration cyclodiode laser was performed. Postoperatively, IOP normalized, pain resolved, and the hematoma regressed completely. At one month, visual acuity remained 20/200 due to persistent corneal edema. SCH may occur in the setting of fondaparinux overdose, particularly in elderly patients with renal impairment. Early diagnosis and prompt surgical management, including adjunctive cyclodiode laser, may improve anatomical and functional outcomes in this sight-threatening condition. The potential benefit of adjunctive LD-TSCP in addition to sclerotomy needs to be evaluated in larger studies.