Cryoextraction of total hyphema

Eight-ball hyphema after laser iridotomy in a patient with undiagnosed hypocellular myelodysplastic syndrome

Introduction

We report a rare case of unexpected gross hyphema in the right eye (OD) and eight-ball hyphema in the left eye (OS) from a bilateral laser iridotomy in an acute primary angle-closure patient. We also demonstrated the effectiveness of the inferior full-thickness trabeculectomy with daily intracameral air injection as an alternative treatment in eight-ball hyphema.

Case report

An 81-year-old Thai female presented with gross hyphema grade II OD and eight-ball hyphema with blood-stained cornea OS after laser iridotomy. The patient was scheduled for surgery and the preoperative blood test showed bicytopenia. We performed anterior chamber washout OD and an inferior full-thickness trabeculectomy with daily intracameral air injection OS. The hyphema completely resolved on the following day OD and 3 days after surgery OS. The inferior bleb OS did not raise with digital pressure and became nonfunctional in 7 days. No recurrent hyphema was found in both eyes (OU) during 6 months of follow-up. This patient was ultimately diagnosed with hypocellular myelodysplastic syndrome (MDS).

Conclusion

Gross hyphema after laser iridotomy can be seen in patients with hypocellular MDS. The inferior full-thickness trabeculectomy is an alternative surgical procedure for an eight-ball hyphema.

Trabeculectomy and manual clot evacuation in traumatic hyphaema with corneal blood staining

BACKGROUND

The management of traumatic hyphaema with raised intraocular pressure and corneal blood staining is difficult. Residual blood clots after anterior chamber washout are responsible for sustained postoperative elevation of intraocular pressure, even after trabeculectomy and clot evacuation.

METHODS

Thirty-five patients with traumatic hyphaema, elevated intraocular pressure and varying degrees of corneal blood staining underwent a combined trabeculectomy with manual clot evacuation from the anterior chamber in a general hospital.

RESULTS

The postoperative control of intraocular pressure was found to be adequate in all patients at the end of two months. Examination of the posterior segment was made possible earlier. Although the procedure is more complex, no significant complications were encountered.

CONCLUSION

In patients presenting with traumatic hyphaema, secondary glaucoma and corneal blood staining, trabeculectomy with manual extraction of the clot through a large incision appears to be a safe and reliable procedure where medical therapy fails to control the intraocular pressure.

Low-dose intraocular tissue plasminogen activator treatment for traumatic total hyphema, postcataract, and penetrating keratoplasty fibrinous membranes

Tissue plasminogen activator (tPA) has been used to treat severe postcataract and vitrectomy fibrinous membranes, but intraocular bleeding has occurred with doses of 25 micrograms or higher. We report three patients, one with nonclearing total hyphema and uncontrollable intraocular pressure and two with severe fibrinous membrane formation, who had treatment with low-dose (4 micrograms to 6 micrograms) intraocular tPA. Although the fibrinous membranes or hyphema resolved in all three patients, they recurred and bleeding that required additional treatment occurred in one patient. Intraocular low-dose tPA may minimize the risk of corneal and retinal toxicity and may be considered an alternative treatment in intractable cases. However, secondary intraocular hemorrhage can occur, and the timing between the initial vascular injury, treatment with tPA, and subsequent bleeding may reduce the risk of further hemorrhaging.

Trabeculectomy for traumatic hyphema with increased intraocular pressure

We reviewed the medical records of 11 consecutive patients who underwent trabeculectomy with anterior chamber washout and peripheral iridectomy as the primary surgical treatment for traumatic hyphema that was unresponsive to medical management. The mean intraocular pressure before surgery was 48 mm Hg. In ten of the patients the intraocular pressure was lowered to 21 mm Hg or lower after surgery and remained below that level up to the most recent follow-up visit, which ranged from eight to 97 months. One patient required a topical beta-blocker and oral acetazolamide to lower pressure to this level after surgery. Eight patients had visual acuity of 20/60 or better at last follow-up. Corneal blood staining occurred in eight patients. Compared with other techniques for surgical management of traumatic hyphema, trabeculectomy provides a means to keep intraocular pressure lowered while the remaining blood is clearing from the anterior chamber. Trabeculectomy with anterior chamber washout and peripheral iridectomy appears to be a safe and reliable procedure in the management of traumatic hyphemas in which medical management fails to control intraocular pressure.

Total hyphema evacuation by vitrectomy instrumentation

We describe our technique for the surgical removal of hyphema using the Ocutome vitrectomy system and report the results in 12 patients. Blood was removed successfully with just one operation in all 12 eyes. Eleven of the 12 eyes maintained intraocular tension of less than 20 mm Hg. Vision improved in 11 of 12 eyes and six had a vision of 6/18 or better. Permanent vision loss could not be attributed to the operative technique.

The role of vitrectomy instrumentation in the treatment of severe traumatic hyphema

Eight patients with severe traumatic hyphemas underwent clot evacuation with vitrectomy instrumentation. The patients were followed up for periods of one to four years. No significant intraoperative complications were noted, but one eye developed a postoperative flat anterior chamber and another developed multiple staphylomas with uncontrolled glaucoma, leading to the eventual enucleation. Seven of the eight operated eyes achieved intraocular pressure control in the early postoperative period, and this control was sustained throughout the course of follow-up without antiglaucomatous medication. These same seven eyes had final visual acuities of 6/12 (20/40) or better.