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Intraoperative suprachoroidal hemorrhage occurs during combined phaco-trabeculectomy
Vitreous tap allows completion of case following sudden intraoperative IOP rise accompanied by iris prolapse.
by David F. Chang, MD
Special to OCULAR SURGERY NEWS
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She was first examined 2.5 years prior to surgery, with applanation pressures of 22 and 26 mm Hg, and advanced cupping of the left disk. She has a twin sister who also had been diagnosed with glaucoma. She had moderately narrow angles graded 2+ deep on gonioscopy. Humphrey visual fields showed more advanced field loss in the left eye than in the right eye. Medical management Repeat tonometry yielded pressures of 25 and 28 mm Hg, and she was started on Betoptic (betoptic hydrochloride, Alcon) 0.25% in both eyes. Despite adding pilocarpine in increasing strengths up to 4%, her left pressure remained 25 mm Hg, and a left eye 180 argon trabeculoplasty was performed 2 years prior to surgery. Her pressures remained in the 17 to 18 mm Hg range in both eyes for 18 months. The Betoptic was eventually replaced with Propine (dipivefrin hydrochloride, Allergan) 0.1% because of her COPD, and Neptazane (methazolamide tablets, Storz Ophthalmics) 50 mg was added. However, because of progression of the visual field defects, argon trabeculoplasty of the remaining 180° was performed 9 months prior to surgery.She developed symptomatic progression of her cataracts, decreasing her vision to 20/60 in both eyes and hindering driving and reading. Because her pressures remained in the 17 to 20 mm Hg range despite Propine, pilocarpine 4%, Iopidine (apraclonidine hydrochloride, Alcon), oral Neptazane and 360° of argon trabeculoplasty, a combined left cataract extraction and trabeculectomy were scheduled. Preop biometry revealed bilateral axial lengths of 22.8 mm. Surgery Preop a pressure reducing Buys mercury bag was placed on the left eye for 45 minutes. After discontinuing the pilocarpine 1 week preop, dilating drops and Ocufen were given, resulting in a 3-mm pupil. Surgery was performed under local anesthesia, with anesthesiology on stand by, using a 3.5-cc retrobulbar block of a 1:1 mixture of Xylocaine 2% (lidocaine hydrochloride, Astra) and 0.75% Marcaine hydrochloride (bupivacaine hydrochloride, Sanofi Winthrop). A limbus based conjunctival flap was created in the superonasal quadrant of the left eye. A rectangular piece of Weck sponge soaked in 0.4 mg/cc mitomycin C was placed beneath the conjunctival flap for 2 minutes. A 4 x 4 mm half thickness triangular scleral flap was fashioned, and a crescent blade was used to carry the dissection into clear cornea. Viscoat (chondroitin sulfate, sodium hyaluronate, Alcon) was instilled following a 3-mm keratome entry. A 3-mm capsulorrhexis was performed within the small pupil, and the nucleus was hydrodissected. Phaco was performed using a bimanual phaco chop technique. Approximately half way through this procedure, not deepen, and the iris prolapsed through the wound. The eye was extremely firm to digital palpation, and a choroidal effusion or hemorrhage was assumed. With the posterior capsule intact, there was no vitreous loss, but the eye still remained firm after several minutes. A Volk (Mentor, Ohio) Superfield lens was used with the operating microscope to determine that there were no visible, bullous choroidal detachments.
Completing the case Because of the advanced glaucoma, a decision was made to attempt to complete the case. A disposable 20-ga MVR (Alcon, Fort Worth, Texas) blade was used to make a sclerotomy 3.5 mm behind the limbus and just lateral to the scleral flap. The vitrectomy handpiece, without irrigation, was used to perform a vitreous tap, removing less than 1 cc of liquid vitreous. The instrument was visualized through the pupil, and positioned anteriorly, just behind the posterior capsule. Viscoat was immediately injected through the lateral paracentesis site, resulting in deepening of the anterior chamber. The prolapsed iris was reposited into the eye with a cyclodialysis spatula placed through the side port paracentesis. The chamber remained deep, and an excellent red reflex was present. A Kelley Descemet punch was used to make the trabeculectomy opening. A 21.0 D foldable silicone IOL (Allergen, Irvine, Calif., Model SI 30 NB) was inserted and dialed into the bag, and a peripheral iridectomy was performed. The pupil appeared round. No attempt was made to remove the viscoelastic. The triangular scleral flap was closed tightly with five interrupted 10-0 nylon sutures. There was no aqueous flow out of the flap. The sclerotomy site also was sutured. Tenon's layer was closed with a running 9-0 Vicryl suture on a BV- 100 vascular needle. The conjunctival layer was closed, with a running 10-0 nylon suture on a BV-75 vascular needle. During suturing the cornea was covered, and 12.5 g of mannitol and 500 mg of Diamox (acetazolamide, Lederle) were administered IV. Three milligrams of Celestone (sterile betamethasone sodium phosphate and betamethasone acetate suspension, Schein Pharmaceutical) was injected subconjunctivally. A collagen shield soaked in Kefzol (cefazolin sodium, Lilly) and Tobradex (tobramycin and dexamethasone, Alcon) was placed on the eye along with Iopidine 1%. The eye was patched, and the patient was discharged. Postop course The patient was examined in the office approximately 7 hours after surgery. She reported no pain. Vision in the left eye was counting fingers at 5 ft, and the intraoperative pressure (IOP) was 13 ft by applanation. The bleb was flat, there was 1+ corneal striae, and the chamber was 2 to 3+ deep centrally. The pupil was 3 mm round, the IOL was in good position, and the posterior capsule was intact. Indirect ophthalmoscopy revealed a 3+ bullous, focal choroidal detachment temporally. Shallower detachments extended slightly superiorly and inferiorly from this area. The patient was given Iopidine 1%, repatched and restarted on Neptazane 50 mg bid. The following morning, the vision was 20/400, and the IOP was 26 mm Hg by applanation. The bleb remained flat, and the chamber was now 4+ deep centrally and 3+ peripherally. The large, temporally-located bullous choroidal detachment was unchanged. An anterior chamber "burp" was performed at the slit lamp with a sterile 25-ga needle pressing on the posterior lip of the paracentesis. The resulting egress of aqueous and viscoelastic lowered the IOP to 10. Pred Forte 1% and Ocuflox drops were added to the topical Iopidine and oral Neptazane. By the second postop day, the pressure was only 12 and the Naptazane was stopped. By the third postop day, the uncorrected acuity was 20/70, and the pressure was 20. The anterior chamber was deep and the choroidal detachment was unchanged. The Iopidine was stopped and 5 mg of 5FU was injected subconjunctivally. The shots were repeated upon subsequent visits on postoperative days six and eight. On the 13th postop day, the IOP was 24 and the choroidal detachment was still approximately the same size. Laser suturelysis of the apical scleral flap suture was performed in the office, followed by another 5-FU shot. On the 14th postop day, the IOP was 19 with a slight elevation of the bleb. A second flap suture was Iysed, followed by the fifth and final 5-FU shot. The patient reported pain the following morning. The uncorrected acuity was only 20/200. The pressure had dropped to 5 accompanied by an elevated bleb. The anterior chamber had shallowed to 2+ depth, and there was increased 4+ flare. A new large, bul lous choroidal detachment had appeared nasally. She was kept on frequent topical steroid and her activities were restricted. The anterior chamber gradually returned to 4+ depth over the next 2 weeks. The pressure, bleb, 4+ flare and choroidal detachments remained unchanged until 5 weeks postop, when the choroidal detachments appeared to have decreased in size. By the 2-month postop visit, the choroidal detachments and AC flare had completely disappeared. The vision was correctable to 20/25, and the pressure was 7 with a diffusely elevated bleb. Two years following the surgery, the vision remains 20/30, the pressure is 3 and the bleb (see photos) is elevated. The visual field has been stable, and the patient is considering surgery on the other eye. Conclusions Small incisions have undoubtedly helped us in the management of intraoperative choroidal hemorrhage or effusion. In this case, because of the internally self-sealing wound, the anterior chamber could be reformed with viscoelastic following a vitreous tap. This allowed the case to be successfully completed. To avoid expansion of the choroidal detachment, the tra beculectomy flap was tightly sutured and the viscoelastic was not removed. To delay suturelysis, the paracentesis "burp" was used to remove viscoelastic at the slit lamp early on. A vitreous tap can be performed with the vitrectomy handpiece. One must first rule out the presence of a bullous choroidal detachment in that quadrant with either an indirect ophthalmoscope or a wide field lens, such as the yolk Superfield. Injection of viscoelastic through the side port paracentesis must be done quickly before expansion of the choroidal detachment rapidly remflattens the chamber. The use of intraoperative and supplemental p o stop anti-m etabolite s in this case allowed filtration to be successfully re-established by laser suturelysis fully 2 weeks after surgery. The persistence of the choroidal detachments for many weeks in this case are consistent with a hemorrhagic etiology. For Your Information: David F.Chang, MD, is an associate clinical professor of ophthalmology at the University of California, San Francisco. He is in private practice specializing in cataract surgery. He can be reached at 762 Altos Oaks Dr., Ste. 1, Los Altos, CA 94024; (415) 948-9123, fax: (415) 948-0563. Dr Chang has no financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned. Complications Management
The sudden increase of intraocular pressure often associated with iris prolapse during an intraocular surgical procedure is indicative of either a subchoroidal hemorrhage or effusion. How the ophthalmic surgeon deals with this problem is related to the surgeon's experience and dexterity, as well as to the type of procedure being performed. In this issue, David F Chang, MD, discusses his management of this type of intraoperative complication in an elderly patient with poorly controlled glaucoma and an advanced cataract. The procedures used by Dr Chang, as well as the patient's preop preparation and postop management, will be of great interest to all ophthalmic surgeons who perform combined cataract, glaucoma and IOL procedures. -David B. Soll, MD |
The patient, an 81-year-old
woman, had bilateral cataracts and advanced glaucoma both of which were worse
in the left eye. Her general medical history was remarkable for congestive heart
failure and severe chronic obstructive pulmonary disease (COPD). Her medications
included Lasix (furosemide. Hoechst-Roussel), digoxin, Theo-Dur (theophylline,
Key) and inhalers. Her blood pressure was normal.
David B. Soll, MD, is head
of the division of ophthalmology, University Medicine and Dentistry of New Jersey
at Camden. He can be reached at Soll Eye Associates, 5001 Frankford Ave., Philadelphia,
PA 19124; (215) 288-5000, fax: (215) 288-5601.