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Nd:YAG Laser Treatment for Recurrent Hyphemas in Pseudophakia
Vol. I l l , No. 4
Letters to the Journal
Nd:YAG Laser T r e a t m e n t for Recurrent H y p h e m a s in Pseudophakia Lawrence J. Geisse, M . D . Department of Ophthalmology, St. Mary Medical Center. Inquiries to Lawrence J. Geisse, Ave., Long Beach, CA 90806.
M.D., 2572
Atlantic
R e c u r r e n t h y p h e m a s after c a t a r a c t s u r g e r y and p l a c e m e n t o f an i n t r a o c u l a r l e n s h a v e a variety of c a u s e s . M o d e r n s u r g i c a l t e c h n i q u e s have m a d e v a s c u l a r i n g r o w t h o f the i n c i s i o n r e l a t i v e l y u n c o m m o n . ' Iris b l o o d v e s s e l s s u b j e c t e d to r e p e a t e d m e c h a n i c a l t r a u m a b y an i n t r a o c u l a r l e n s are c u r r e n t l y the m o s t c o m m o n s o u r c e o f the b l e e d i n g . W i t h i r i s - p l a n e l e n s e s , the l e a k i n g iris v e s s e l s are u s u a l l y at the p u p i l lary m a r g i n . ^ ' W i t h p o s t e r i o r c h a m b e r a n d a n t e r i o r c h a m b e r l e n s e s , iris v e s s e l s c a n b e affected at s e v e r a l different l o c a t i o n s . ' ' ' I d e n t i f y i n g the e x a c t l o c a t i o n o f the b l e e d i n g is often difficult, a l t h o u g h the f o l l o w i n g m a y b e helpful: iris a n g i o g r a p h y ; e x a m i n i n g the p a t i e n t during an a c t i v e h e m o r r h a g e ; finding a clot on a v e s s e l ; a n d finding d i s c r e t e a r e a s o f iris e r o s i o n b y r e t r o i l l u m i n a t i o n . ' ' T r e a t m e n t s u c c e s s c a n often b e a c h i e v e d b y m e d i c a l m e a n s ( t h a t i s , m y d r i a s i s or m i o s i s ) . I f e y e d r o p s fail, t h e n a r g o n l a s e r t r e a t m e n t to t h e l e a k i n g site m a y b e a t t e m p t e d . R e p e a t e d l a s e r t r e a t m e n t s are often n e c e s s a r y , h o w e v e r , w h i c h leave an i r r e g u l a r , d i l a t e d p u p i l a n d s u b j e c t the p a t i e n t to further b l e e d i n g . O c c a s i o n a l l y , r e m o v a l o f the i n t r a o c u l a r l e n s m a y b e n e c e s s a r y . I s u c c e s s f u l l y u s e d an N d : Y A G l a s e r to treat two p a t i e n t s w i t h p o s t e r i o r c h a m b e r i n t r a o c u lar l e n s e s w h o h a d r e c u r r e n t h y p h e m a s for more than one year. Medical treatment was ineffective in b o t h p a t i e n t s . A r g o n l a s e r t r e a t m e n t d i r e c t e d b y iris a n g i o g r a p h y w a s p e r f o r m e d in o n e p a t i e n t b u t h a d n o t s t o p p e d the b l e e d i n g . H e m o r r h a g e s o c c u r r e d in b o t h p a t i e n t s every four to five w e e k s a n d r a n g e d from m i n o r b l u r r i n g o f v i s i o n to m a c r o s c o p i c h y p h e m a s o f 3 0 % o f the total a n t e r i o r c h a m b e r v o l ume. U p o n e x a m i n a t i o n , e a c h p a t i e n t w a s f o u n d to have a t r a n s i l l u m i n a t i o n d e f e c t o f the iris c o r r e s p o n d i n g to c o n t a c t o f the iris w i t h t h e o p t i c o f the i n t r a o c u l a r l e n s . In b o t h p a t i e n t s , an iris v e s s e l c o u l d b e s e e n t r a v e r s i n g this a r e a . It w a s t h o u g h t t h a t i n t e r m i t t e n t t r a u m a to t h i s v e s s e l was r e s p o n s i b l e for the r e c u r r e n t b l e e d i n g . T h e v e s s e l was f o l l o w e d p e r i p h e r a l l y u n t i l it
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c o u l d b e s e e n o u t s i d e the t r a n s i l l u m i n a t i o n defect ( a n d the i n t r a o c u l a r l e n s o p t i c ) . A n irid o t o m y w a s t h e n c r e a t e d w i t h an N d : Y A G l a s e r to i n c l u d e the p r e v i o u s l y i d e n t i f i e d v e s s e l out side ( p e r i p h e r a l t o ) t h e e d g e o f the t r a n s i l l u m i n a t i o n d e f e c t ( o n e to four p u l s e s at 5 m J d e l i v e r e d t h r o u g h an A b r a h a m i r i d e c t o m y c o n t a c t lens). A small a m o u n t of bleeding occurred but stopped immediately with slight pressure. Since this procedure, neither patient has had a h e m o r r h a g e in m o r e t h a n t w o y e a r s o f f o l l o w u p . A t r o p h y o f the iris v e s s e l c e n t r a l to the i r i d o t o m y c o u l d b e s e e n , w h i c h e l i m i n a t e d the p o s s i b i l i t y o f r e b l e e d i n g . N o o t h e r c h a n g e s in the iris or the e y e w e r e n o t e d . In c a s e s o f r e c u r r e n t h y p h e m a s after c a t a r a c t e x t r a c t i o n w i t h p l a c e m e n t o f an i n t r a o c u l a r l e n s in w h i c h a l e a k i n g iris v e s s e l c a n b e i d e n t i fied, N d : Y A G l a s e r d i s r u p t i o n of t h i s v e s s e l p e r i p h e r a l t o t h e e d g e o f t h e i n t r a o c u l a r l e n s is s i m p l e , effective, a n d h a s the a d v a n t a g e o f avoiding chronic p h a r m a c o l o g i c treatment or l a s e r - i n d u c e d d i s t o r t i o n s o f the p u p i l .
References 1. Swan, K. C : Hyphema due to wound vascular ization after cataract extraction. Arch. Ophthalmol. 89:87, 1 9 7 3 . 2. Ellingson, F. T.; The uveitis-glaucomahyphema syndrome associated with the Mark VIII anterior chamber lens implant. Am. Intraocular Im plant Soc. J. 4 : 5 0 , 1 9 7 8 . 3. Lieppman, M. E.: Intermittent visual "whiteout." A new intraocular lens complication. Ophthal mology 89:109, 1 9 8 2 . 4. Johnson, S. H., Kratz, R. P., and Olson, P. F.: Iris transillumination defect and microhyphema syn drome. Am. Intraocular Implant Soc. J. 10:425, 1984.
Chronic Ciliary Pain S e c o n d a r y to Posterior C h a m b e r Intraocular L e n s Loop I n c a r c e r a t i o n Ulrich F. C. Legler, M . D . , David J. Apple, M.D., Paul Hund, M.D., and Waite S. Kirkconnell, M . D . Departments of Ophthalmology (U.F.C.L., D.J.Α., P.Η.) and Pathology (D.J.Α.), Center for Intraocular Lens Research, Storm Eye Institute, Medical Univer sity of South Carolina. Dr. Kirkconnell is in private practice in Tampa, Florida.
Letters to the Journal
Nd:YAG Laser T r e a t m e n t for Recurrent H y p h e m a s in Pseudophakia Lawrence J. Geisse, M . D . Department of Ophthalmology, St. Mary Medical Center. Inquiries to Lawrence J. Geisse, Ave., Long Beach, CA 90806.
M.D., 2572
Atlantic
R e c u r r e n t h y p h e m a s after c a t a r a c t s u r g e r y and p l a c e m e n t o f an i n t r a o c u l a r l e n s h a v e a variety of c a u s e s . M o d e r n s u r g i c a l t e c h n i q u e s have m a d e v a s c u l a r i n g r o w t h o f the i n c i s i o n r e l a t i v e l y u n c o m m o n . ' Iris b l o o d v e s s e l s s u b j e c t e d to r e p e a t e d m e c h a n i c a l t r a u m a b y an i n t r a o c u l a r l e n s are c u r r e n t l y the m o s t c o m m o n s o u r c e o f the b l e e d i n g . W i t h i r i s - p l a n e l e n s e s , the l e a k i n g iris v e s s e l s are u s u a l l y at the p u p i l lary m a r g i n . ^ ' W i t h p o s t e r i o r c h a m b e r a n d a n t e r i o r c h a m b e r l e n s e s , iris v e s s e l s c a n b e affected at s e v e r a l different l o c a t i o n s . ' ' ' I d e n t i f y i n g the e x a c t l o c a t i o n o f the b l e e d i n g is often difficult, a l t h o u g h the f o l l o w i n g m a y b e helpful: iris a n g i o g r a p h y ; e x a m i n i n g the p a t i e n t during an a c t i v e h e m o r r h a g e ; finding a clot on a v e s s e l ; a n d finding d i s c r e t e a r e a s o f iris e r o s i o n b y r e t r o i l l u m i n a t i o n . ' ' T r e a t m e n t s u c c e s s c a n often b e a c h i e v e d b y m e d i c a l m e a n s ( t h a t i s , m y d r i a s i s or m i o s i s ) . I f e y e d r o p s fail, t h e n a r g o n l a s e r t r e a t m e n t to t h e l e a k i n g site m a y b e a t t e m p t e d . R e p e a t e d l a s e r t r e a t m e n t s are often n e c e s s a r y , h o w e v e r , w h i c h leave an i r r e g u l a r , d i l a t e d p u p i l a n d s u b j e c t the p a t i e n t to further b l e e d i n g . O c c a s i o n a l l y , r e m o v a l o f the i n t r a o c u l a r l e n s m a y b e n e c e s s a r y . I s u c c e s s f u l l y u s e d an N d : Y A G l a s e r to treat two p a t i e n t s w i t h p o s t e r i o r c h a m b e r i n t r a o c u lar l e n s e s w h o h a d r e c u r r e n t h y p h e m a s for more than one year. Medical treatment was ineffective in b o t h p a t i e n t s . A r g o n l a s e r t r e a t m e n t d i r e c t e d b y iris a n g i o g r a p h y w a s p e r f o r m e d in o n e p a t i e n t b u t h a d n o t s t o p p e d the b l e e d i n g . H e m o r r h a g e s o c c u r r e d in b o t h p a t i e n t s every four to five w e e k s a n d r a n g e d from m i n o r b l u r r i n g o f v i s i o n to m a c r o s c o p i c h y p h e m a s o f 3 0 % o f the total a n t e r i o r c h a m b e r v o l ume. U p o n e x a m i n a t i o n , e a c h p a t i e n t w a s f o u n d to have a t r a n s i l l u m i n a t i o n d e f e c t o f the iris c o r r e s p o n d i n g to c o n t a c t o f the iris w i t h t h e o p t i c o f the i n t r a o c u l a r l e n s . In b o t h p a t i e n t s , an iris v e s s e l c o u l d b e s e e n t r a v e r s i n g this a r e a . It w a s t h o u g h t t h a t i n t e r m i t t e n t t r a u m a to t h i s v e s s e l was r e s p o n s i b l e for the r e c u r r e n t b l e e d i n g . T h e v e s s e l was f o l l o w e d p e r i p h e r a l l y u n t i l it
513
c o u l d b e s e e n o u t s i d e the t r a n s i l l u m i n a t i o n defect ( a n d the i n t r a o c u l a r l e n s o p t i c ) . A n irid o t o m y w a s t h e n c r e a t e d w i t h an N d : Y A G l a s e r to i n c l u d e the p r e v i o u s l y i d e n t i f i e d v e s s e l out side ( p e r i p h e r a l t o ) t h e e d g e o f the t r a n s i l l u m i n a t i o n d e f e c t ( o n e to four p u l s e s at 5 m J d e l i v e r e d t h r o u g h an A b r a h a m i r i d e c t o m y c o n t a c t lens). A small a m o u n t of bleeding occurred but stopped immediately with slight pressure. Since this procedure, neither patient has had a h e m o r r h a g e in m o r e t h a n t w o y e a r s o f f o l l o w u p . A t r o p h y o f the iris v e s s e l c e n t r a l to the i r i d o t o m y c o u l d b e s e e n , w h i c h e l i m i n a t e d the p o s s i b i l i t y o f r e b l e e d i n g . N o o t h e r c h a n g e s in the iris or the e y e w e r e n o t e d . In c a s e s o f r e c u r r e n t h y p h e m a s after c a t a r a c t e x t r a c t i o n w i t h p l a c e m e n t o f an i n t r a o c u l a r l e n s in w h i c h a l e a k i n g iris v e s s e l c a n b e i d e n t i fied, N d : Y A G l a s e r d i s r u p t i o n of t h i s v e s s e l p e r i p h e r a l t o t h e e d g e o f t h e i n t r a o c u l a r l e n s is s i m p l e , effective, a n d h a s the a d v a n t a g e o f avoiding chronic p h a r m a c o l o g i c treatment or l a s e r - i n d u c e d d i s t o r t i o n s o f the p u p i l .
References 1. Swan, K. C : Hyphema due to wound vascular ization after cataract extraction. Arch. Ophthalmol. 89:87, 1 9 7 3 . 2. Ellingson, F. T.; The uveitis-glaucomahyphema syndrome associated with the Mark VIII anterior chamber lens implant. Am. Intraocular Im plant Soc. J. 4 : 5 0 , 1 9 7 8 . 3. Lieppman, M. E.: Intermittent visual "whiteout." A new intraocular lens complication. Ophthal mology 89:109, 1 9 8 2 . 4. Johnson, S. H., Kratz, R. P., and Olson, P. F.: Iris transillumination defect and microhyphema syn drome. Am. Intraocular Implant Soc. J. 10:425, 1984.
Chronic Ciliary Pain S e c o n d a r y to Posterior C h a m b e r Intraocular L e n s Loop I n c a r c e r a t i o n Ulrich F. C. Legler, M . D . , David J. Apple, M.D., Paul Hund, M.D., and Waite S. Kirkconnell, M . D . Departments of Ophthalmology (U.F.C.L., D.J.Α., P.Η.) and Pathology (D.J.Α.), Center for Intraocular Lens Research, Storm Eye Institute, Medical Univer sity of South Carolina. Dr. Kirkconnell is in private practice in Tampa, Florida.