- Email: [email protected]
Intraocular lens implant and total hyphema: a case report
intraocular lens implant and total hyphema: a case report Chandrappa 5. Reshmi, M.D. Edward C. Kondrot. Pittsburgh, Pennsylvania I:'Iyphema is an occ~sional complication following extractIOn 1 ,2 and cataract extraction lens implant. 3 ,4 A recent experience wIth a total hrphema a~pearing five days after cataract ext~actIOn and mtraocular lens implant p.rompted thIS report. To our knowledge this is the fIrst reported case of this occurrence. r~utI~e cataract w~th mtraocular
Case Report An eighty year old white female was admitted to St. Francis General Hospital on June 15 1976 for an elective cataract extraction and intraoc~lar lens im~lantation in her right eye. Her ophthalmic examinatIOn revealed best corrected visual acuity in the right eye was hand motion and in the left eye 20170. Intraocular ~ressure with applanation tonometry was. 20mm. Hg. m each eye. The slit lamp examination of the ~nterior segment was normal except the presence of bIlateral nuclear cataracts, right eye being more d~nse. than the left. The right fundus was not vIsualIzed and the left fundus was poorly visualized. ~hysical exam~nation showed a fairly healthy lookmg elderly. white female in no apparent distress, however, she dId appear anxious. Her pulse rate was 70lminute and regular. Her blood pressure was 140/80mm. Hg. Review of the systems was unremarkable except a grade 2-4 systolic murmur heard over the pre~or.deal area. Her p~st medical history included an admIssIOn to the hospItal in 1969 for congestive heart failure and anemia. She was known to be hypertensive, however controlled with medication. She denie? history of diabetes, bleeding disorders or any allergIes. Chest x-ray showed mild left ventricular enlargement of the heart. The aorta showed calcification within. the wall of the arch. The lungs were clear. ElectrocardIOgram showed left axis deviation consistent wit~ left anterior hemi-block. S-T sagging in Vs and V6 WIth prolonged QT interval. Non-specific ST-T changes which suggested metabolic defect. On June 16, 1976, the patient underwent an uneventful intracapsular cataract extraction with two From.: The pepartment of Ophthalmology, St. Francis General HospItal, ?lttsburgh, Pennsylvania. Edward C. Kondrot presently is a senior medical student at Hahn.emann Medical College, Philadelphia, Pennsylvania. ThIS case was presented at the American Intraocular Implant Society Annual Meeting (Problem Case Symposium) October 5, 1976, Las Vegas, Nevada. 84
peripheral iridotomies (McLean technique) and Binkhorst !our-l~>op intraocular lens implantation. Surgical technIque mcluded the following: local anesthesia w~th 3/4~ ~arcaine, 2% xylocaine and wydase and 5 mmute dIgItal massage. About 3mm. limbus based conjunctival flap, groove at the limbus using a lange blade, three pre-placed 7-0 black silk (McLean type) sutures, biplane incision to about 1600 and two peripheral iridotomies, about 0.25 cc. of 1/5,000 alpha-chym.otrypsin was introduced into the posterior c~amber, timed for one minute and then irrigated WIth balanced salt solution. Using a cyroprobe the ~e?s ~as .extracted intracapsularly by sliding. The ms-clip Bmkhorst intraocular lens was mounted on ~he Binkhorst !ens irrigating forceps and introduced mto the a~tenor chamber by open sky technique. The postenor loops were placed behind the iris horizontally through the mid-dilated pupil using gentle .side to side manipulation. The replaced sutures ~ere tIed. A. few drops of 1/100 acetylcholine were mtroduced mto the anterior chamber to induce ~io.sis. Two drops of 4% pilocarpine were then mstIlled on the cornea. The anterior chamber was clear and deep. The pupil was miotic and the intraocular lens was in place. Combined steriod and antibiotic drops and ointment were applied. Her first post-operative day was uneventful and she ~as discharged on the ~ollowing day. The patient was mstructed to use combmed steriod and antibiotic drops four times daily and ointment at night. One drop of 4% pi!ocarpine was also continued once daily. She was also mstructed to use a protective shield over the eye at night. The patient was seen in the office subsequently o.n the s~co~d and third post-operative days. The VIsual aCUIty m the operated eye was 20/40 without any additional correction. The anterior chamber was deep and clear. The pupil was miotic and the lens was in place. The intraocular pressure was normal. On the fifth post-operative day when the patient returned to the office she complained of sudden loss of vision in the . oper~ted ey.e when s~e woke up. The patient denIed pam or dIscomfort m the eye. She also denied any trauma to the eye. Visual acuity on examination was light perception in the operated eye. The cornea was clear and a total hyphema was observed which ?bscured the lens and the iris detail (fig. 1). The • mtraocular pressure with applanation tonometry was 18mm. Hg. in the operated eye. The patient was advised hospital admission but she refused. In view of her refusal to be admitted to the hospital, she was instructed to remain at home, advised bed rest with the. h~a~ elevated t~ 45 0 , unilateral eye patching and antibIOtiC and sterOId drops four times a day. She was followed in the office on a daily basis for eleven days. During this time the hyphema was very slow to
She was continued on the same regime until all of her hyphema had resolved and she was discharged on July 14, 1976. The anterior chamber was completely clear except for a small clot at the 10 o'clock position. (fig. 3) The cornea was clear and the lens was in the proper position.
Fig. 1 (Reshmi and Kondrot). Fifth post-operative day the right eye showing a total hyphema obscuring the intraocular lens and iris detail. Vision: light perception.
resolve, however the intraocular pressure remained within normal limits. As the patient was getting anxious and apprehensive, relatives finally forced the patient to be hospitalized and she reluctantly consented to re-admission to St. Francis General Hospital on July 2, 1976. On admission prothrombin time, PPT, bleeding time, coagulation time and complete blood work was normal. The patient was treated conservatively with unilateral patching, bed rest with bathroom privileges, head elevated to 45° and daily monitoring of intraocular pressures. The combined antibiotics and steroid drops were continued four times daily. Neither miotics or mydriatics were used during the patient's hospitalization. On this regime in the hospital the hyphema started showing slow resorption. On the 15th post-operative day the patient had a 3mm. hyphema, a large clot covering the entire intraocular lens except for a small portion of nasal loop. (fig. 2)
Fig. 2 (Reshmi and Kondrot). Fifteenth post-operative day. Right eye showing a 3mm. hyphema and a large clot covering the entire intraocular lens except for a small portion of nasal loop.
Fig. 3 (Reshmi and Kondrot). Twenty-eighth post-operative day the right eye was almost clear of the hyphema except for a small clot at the 10 o'clock position.
After the eighth post-operative week her visual acuity was 20/20 with spectacle correction of residual refractive error, and the intraocular pressure was normal. As weeks passed by the patient appeared less anxious and less apprehensive. She related an emotional problem preceding the day of the hyphema and a possibility of inadvertently rubbing the eye while crying on the fourth post-operative day. Discussion Hyphema is an occasional post-operative occurrence following cataract surgery. Usually appearing between the 3rd and 5th post-operative day.2 Taylor et al reported a higher incidence of hyphema following cataract surgery with the use of the Copeland intraocular lens over that usually seen without lens insertion. 4 They observed variable amounts of blood in the anterior chamber in 20% of the patients with lens insertion, while in cataract extraction without lens insertion hyphema was presented in 2% of the patients. In the author's (C.S.R.) experience the incidence of variable amount of hyphema using Binkhorst iris clip lens implant is about 5%. Post-operative hyphema may arise from the operative wound, the iris or ciliary body. S External pressure on the eye during the post-operative period may rupture the newly formed vessels bridging the incision to cause bleeding.s This mechanism is a possible explanation of the hyphema which developed in our patient. Although much has been written concerning the management of post-operative hyphema after cataract 85
surgery from conservative medical to surgical intervention depending on the nature of the hyphema, the intraocular pressure and corneal endothelial staining. 6 ,7,8 When one is confronted with a hyphema, as presented in the case reported here, it seems safer to follow a conservative treatment in the absence of complications. Our case illustrates that conservative treatment was successful in a total hyphema following cataract extraction and intraocular lens implant surgery. References 1. McDonald, P. R.: Complications in Eye Surgery, (Fasanella, R. M., Editor) Philadelphia, W.B. Saunders Co., 1965, p. 223. 2. Duke-Elder: System of Ophthalmology, Vol. XI., St. Louis, C.V. Mosby Co., 1976, p. 279. 3. Jaffe, N. S.: Cataract Surgery and its Complications. St. Louis, C.V. Mosby Co., 1976, p. 128. 4. Taylor, D. M., Dalburg, L. A., Consention, R. T., Howard, R. 0.: Intraocular Lenses: One Hundred Consecutive Cases of Intracapsular Cataract Extraction with Copeland Iris Plane Lens Implantation. Ophthal. Surg. 6:13, 1975. 5. Reshmi, C. S.: Unpublished Data. 6. Jaffe, N. S.: Cataract Surgery and its Complications, St. Louis, C.V. Mosby Co., 1976, p. 321. 7. Havener, W. H.: Ocular Pharmacology, St. Louis, C.V. Mosby Co., 1975, p. 3. 8. Devoe, A. G.: Hemorrhage After Cataract Extraction. Arch. Ophthalmology 28:1069,1942. 9. Owens, W., and Hughes, W.: Intraocular Hemorrhage in Cataract Extraction, Arch. Ophthalmology 37:561, 1947.
86
Case Report An eighty year old white female was admitted to St. Francis General Hospital on June 15 1976 for an elective cataract extraction and intraoc~lar lens im~lantation in her right eye. Her ophthalmic examinatIOn revealed best corrected visual acuity in the right eye was hand motion and in the left eye 20170. Intraocular ~ressure with applanation tonometry was. 20mm. Hg. m each eye. The slit lamp examination of the ~nterior segment was normal except the presence of bIlateral nuclear cataracts, right eye being more d~nse. than the left. The right fundus was not vIsualIzed and the left fundus was poorly visualized. ~hysical exam~nation showed a fairly healthy lookmg elderly. white female in no apparent distress, however, she dId appear anxious. Her pulse rate was 70lminute and regular. Her blood pressure was 140/80mm. Hg. Review of the systems was unremarkable except a grade 2-4 systolic murmur heard over the pre~or.deal area. Her p~st medical history included an admIssIOn to the hospItal in 1969 for congestive heart failure and anemia. She was known to be hypertensive, however controlled with medication. She denie? history of diabetes, bleeding disorders or any allergIes. Chest x-ray showed mild left ventricular enlargement of the heart. The aorta showed calcification within. the wall of the arch. The lungs were clear. ElectrocardIOgram showed left axis deviation consistent wit~ left anterior hemi-block. S-T sagging in Vs and V6 WIth prolonged QT interval. Non-specific ST-T changes which suggested metabolic defect. On June 16, 1976, the patient underwent an uneventful intracapsular cataract extraction with two From.: The pepartment of Ophthalmology, St. Francis General HospItal, ?lttsburgh, Pennsylvania. Edward C. Kondrot presently is a senior medical student at Hahn.emann Medical College, Philadelphia, Pennsylvania. ThIS case was presented at the American Intraocular Implant Society Annual Meeting (Problem Case Symposium) October 5, 1976, Las Vegas, Nevada. 84
peripheral iridotomies (McLean technique) and Binkhorst !our-l~>op intraocular lens implantation. Surgical technIque mcluded the following: local anesthesia w~th 3/4~ ~arcaine, 2% xylocaine and wydase and 5 mmute dIgItal massage. About 3mm. limbus based conjunctival flap, groove at the limbus using a lange blade, three pre-placed 7-0 black silk (McLean type) sutures, biplane incision to about 1600 and two peripheral iridotomies, about 0.25 cc. of 1/5,000 alpha-chym.otrypsin was introduced into the posterior c~amber, timed for one minute and then irrigated WIth balanced salt solution. Using a cyroprobe the ~e?s ~as .extracted intracapsularly by sliding. The ms-clip Bmkhorst intraocular lens was mounted on ~he Binkhorst !ens irrigating forceps and introduced mto the a~tenor chamber by open sky technique. The postenor loops were placed behind the iris horizontally through the mid-dilated pupil using gentle .side to side manipulation. The replaced sutures ~ere tIed. A. few drops of 1/100 acetylcholine were mtroduced mto the anterior chamber to induce ~io.sis. Two drops of 4% pilocarpine were then mstIlled on the cornea. The anterior chamber was clear and deep. The pupil was miotic and the intraocular lens was in place. Combined steriod and antibiotic drops and ointment were applied. Her first post-operative day was uneventful and she ~as discharged on the ~ollowing day. The patient was mstructed to use combmed steriod and antibiotic drops four times daily and ointment at night. One drop of 4% pi!ocarpine was also continued once daily. She was also mstructed to use a protective shield over the eye at night. The patient was seen in the office subsequently o.n the s~co~d and third post-operative days. The VIsual aCUIty m the operated eye was 20/40 without any additional correction. The anterior chamber was deep and clear. The pupil was miotic and the lens was in place. The intraocular pressure was normal. On the fifth post-operative day when the patient returned to the office she complained of sudden loss of vision in the . oper~ted ey.e when s~e woke up. The patient denIed pam or dIscomfort m the eye. She also denied any trauma to the eye. Visual acuity on examination was light perception in the operated eye. The cornea was clear and a total hyphema was observed which ?bscured the lens and the iris detail (fig. 1). The • mtraocular pressure with applanation tonometry was 18mm. Hg. in the operated eye. The patient was advised hospital admission but she refused. In view of her refusal to be admitted to the hospital, she was instructed to remain at home, advised bed rest with the. h~a~ elevated t~ 45 0 , unilateral eye patching and antibIOtiC and sterOId drops four times a day. She was followed in the office on a daily basis for eleven days. During this time the hyphema was very slow to
She was continued on the same regime until all of her hyphema had resolved and she was discharged on July 14, 1976. The anterior chamber was completely clear except for a small clot at the 10 o'clock position. (fig. 3) The cornea was clear and the lens was in the proper position.
Fig. 1 (Reshmi and Kondrot). Fifth post-operative day the right eye showing a total hyphema obscuring the intraocular lens and iris detail. Vision: light perception.
resolve, however the intraocular pressure remained within normal limits. As the patient was getting anxious and apprehensive, relatives finally forced the patient to be hospitalized and she reluctantly consented to re-admission to St. Francis General Hospital on July 2, 1976. On admission prothrombin time, PPT, bleeding time, coagulation time and complete blood work was normal. The patient was treated conservatively with unilateral patching, bed rest with bathroom privileges, head elevated to 45° and daily monitoring of intraocular pressures. The combined antibiotics and steroid drops were continued four times daily. Neither miotics or mydriatics were used during the patient's hospitalization. On this regime in the hospital the hyphema started showing slow resorption. On the 15th post-operative day the patient had a 3mm. hyphema, a large clot covering the entire intraocular lens except for a small portion of nasal loop. (fig. 2)
Fig. 2 (Reshmi and Kondrot). Fifteenth post-operative day. Right eye showing a 3mm. hyphema and a large clot covering the entire intraocular lens except for a small portion of nasal loop.
Fig. 3 (Reshmi and Kondrot). Twenty-eighth post-operative day the right eye was almost clear of the hyphema except for a small clot at the 10 o'clock position.
After the eighth post-operative week her visual acuity was 20/20 with spectacle correction of residual refractive error, and the intraocular pressure was normal. As weeks passed by the patient appeared less anxious and less apprehensive. She related an emotional problem preceding the day of the hyphema and a possibility of inadvertently rubbing the eye while crying on the fourth post-operative day. Discussion Hyphema is an occasional post-operative occurrence following cataract surgery. Usually appearing between the 3rd and 5th post-operative day.2 Taylor et al reported a higher incidence of hyphema following cataract surgery with the use of the Copeland intraocular lens over that usually seen without lens insertion. 4 They observed variable amounts of blood in the anterior chamber in 20% of the patients with lens insertion, while in cataract extraction without lens insertion hyphema was presented in 2% of the patients. In the author's (C.S.R.) experience the incidence of variable amount of hyphema using Binkhorst iris clip lens implant is about 5%. Post-operative hyphema may arise from the operative wound, the iris or ciliary body. S External pressure on the eye during the post-operative period may rupture the newly formed vessels bridging the incision to cause bleeding.s This mechanism is a possible explanation of the hyphema which developed in our patient. Although much has been written concerning the management of post-operative hyphema after cataract 85
surgery from conservative medical to surgical intervention depending on the nature of the hyphema, the intraocular pressure and corneal endothelial staining. 6 ,7,8 When one is confronted with a hyphema, as presented in the case reported here, it seems safer to follow a conservative treatment in the absence of complications. Our case illustrates that conservative treatment was successful in a total hyphema following cataract extraction and intraocular lens implant surgery. References 1. McDonald, P. R.: Complications in Eye Surgery, (Fasanella, R. M., Editor) Philadelphia, W.B. Saunders Co., 1965, p. 223. 2. Duke-Elder: System of Ophthalmology, Vol. XI., St. Louis, C.V. Mosby Co., 1976, p. 279. 3. Jaffe, N. S.: Cataract Surgery and its Complications. St. Louis, C.V. Mosby Co., 1976, p. 128. 4. Taylor, D. M., Dalburg, L. A., Consention, R. T., Howard, R. 0.: Intraocular Lenses: One Hundred Consecutive Cases of Intracapsular Cataract Extraction with Copeland Iris Plane Lens Implantation. Ophthal. Surg. 6:13, 1975. 5. Reshmi, C. S.: Unpublished Data. 6. Jaffe, N. S.: Cataract Surgery and its Complications, St. Louis, C.V. Mosby Co., 1976, p. 321. 7. Havener, W. H.: Ocular Pharmacology, St. Louis, C.V. Mosby Co., 1975, p. 3. 8. Devoe, A. G.: Hemorrhage After Cataract Extraction. Arch. Ophthalmology 28:1069,1942. 9. Owens, W., and Hughes, W.: Intraocular Hemorrhage in Cataract Extraction, Arch. Ophthalmology 37:561, 1947.
86