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Pre-Descemet’s membrane hemorrhage after secondary intraocular lens implantation
Pre-Descemet’s membrane hemorrhage after secondary intraocular lens implantation ˙Ismet Durak, MD, Sevgi T. Ferliel, MD, Meltem So¨ylev, MD, Osman Saatc¸i, MD ABSTRACT A 6.0 ⫻ 4.0 mm pre-Descemet’s membrane hemorrhage with very sharp borders appeared at the temporal portion of the cornea. There was no hyphema in the anterior chamber on the first day after secondary intraocular lens implantation. The hemorrhage resolved almost totally in 1 year without intervention, leaving slight, deep pigmentary changes and minimal diffuse corneal edema. J Cataract Refract Surg 1999; 25: 1554 –1556 © 1999 ASCRS and ESCRS
I
ntracorneal hemorrhage is a rarely seen phenomenon. It is reported after intraocular surgery, usually after cataract extraction or ocular trauma. It may also be associated with inflammatory corneal disease and secondary to aphakic contact lens wear.1–10 Intracorneal hemorrhage may be seen as intrastromal, pre-Descemet’s membrane, or subepithelial. We present a case of pre-Descemet’s membrane hemorrhage that occurred after secondary intraocular lens (IOL) implantation. To the best of our knowledge, this is the first reported case of this complication.
Case Report A 64-year-old man, seen in our clinic in June 1994, had a history of extracapsular cataract extraction without IOL implantation in the right eye complicated by vitreous loss 3 years previously. His best corrected visual acuity was 6/15 in the right eye and 6/7.5 in the left eye. Intraocular pressure by applanation tonometry was 17 and 15 mm Hg, respectively. Examination of the right eye showed vitreous in the anterior chamber, a superiorly displaced pupil, a ruptured posterior capsule, extensive peripheral anterior synechias, and deep corReprint requests to ˙Ismet Durak, MD, Mithatpas¸a Cad. Gurup Apt, No: 259/8, 35340 Balc¸ova, ˙Izmir, Turkey. © 1999 ASCRS and ESCRS Published by Elsevier Science Inc.
neal vascularization at the superior quadrant. Secondary posterior chamber IOL implantation with anterior segment reconstruction in the right eye was planned. After an approximately 100 degree peritomy and wetfield bipolar cautery, a 7.0 mm limbal incision was prepared superiorly. Moderate anterior vitrectomy was performed with an automatic vitrector via the limbus. Hemorrhage from the iris occurred during the lysis of the peripheral anterior synechias and iridocapsular adhesion. The hemorrhage was totally controlled. The anterior chamber was washed out, and a single-piece poly(methyl methacrylate) IOL with 10 degrees of vaulting, a 6.5 mm optic, and 13.5 mm overall length (Oculaid 292Y, Ophtec) was implanted in the posterior chamber. Iridoplasty was performed to obtain a round pupil, and the incision was closed with a 10-0 nylon suture. There was no blood in the anterior chamber at the end of the surgery. A kidney-shaped, 6.0 ⫻ 4.0 mm diameter, pre-Descemet’s membrane hemorrhage covering the temporal portion of the cornea was seen on the first postoperative day without hyphema in the anterior chamber (Figure 1). There was minimal diffuse stromal edema. Visual acuity was 6/30, and IOP was 17 mm Hg by applanation tonometry. Three weeks later, the hemorrhage remained the same, with sharp borders. It started to dissolve 2 months later (Figure 2). One year later, the hemorrhage had totally dissolved, leaving slight, deep pigmentary changes. There was minimal corneal edema over the hemorrhage area as well as the cornea. Visual acuity was 6/30 with correction, and IOP was 18 mm Hg by applanation tonometry. 0886-3350/99/$–see front matter PII S0886-3350(99)00249-7
CASE REPORTS: DURAK
Figure 1. (Durak) A kidney-shaped temporal pre-Descemet’s membrane hemorrhage on the first postoperative day.
Discussion In 1973, Muenzler1 reviewed the literature and found approximately 30 cases of corneal hemorrhage; about half of the cases were subepithelial and half, intrastromal. One third of corneal hemorrhages occur after intraocular surgery, usually after cataract extraction. Another third occur after ocular trauma, and the final third are associated with inflammatory corneal disease. Intracorneal hemorrhage may also occur spontaneously, mostly as a result of corneal vascularization, which usually occurs after keratitis, inflammation,4,5,7,8,11 and contact lens wear.2,6,9 –12 Secondary IOL implantation is a safe, effective procedure. Complications occur infrequently. Implantation may be difficult, and complications may happen in complicated cases. In our case, a pre-Descemet’s membrane hemorrhage occurred at the temporal quadrant after secondary IOL implantation. Blood in the anterior
chamber may have entered the cornea via Descemet’s membrane breaks, but there was no hyphema postoperatively. The sharp borders of the hemorrhage may indicate the presence of Descemet’s membrane detachment. The corneal hemorrhage was probably a result of postoperative bleeding from superior corneal vascularization to the Descemet’s membrane detachment area, which occurred during surgery. Resolution may take a long time with deeper corneal hemorrhages, and blood staining of the cornea may occur despite normal IOP. Resolution of the hemorrhage took about 1 year in our case and resulted in slight corneal edema, not only over the hemorrhage but diffusely over the entire cornea. Diffuse corneal edema was probably not due to hemorrhage but may have been the result of endothelial cell loss from the previous 2 complicated intraocular surgeries. It is not known for certain whether follow-up of or puncturing the hemorrhage would lead to a better prognosis. A surgical approach to the treatment of deep corneal hemorrhages has rarely been attempted. Ba´rdy8 successfully treated a case with pre-Descemet’s membrane hematoma by puncturing it 2 weeks postoperatively. Renardel de Lavalette and Van Rij7 performed a peripheral iridectomy and punctured the deep corneal hemorrhage because it protruded into the anterior chamber and caused high IOP. Despite this puncturing, visual acuity remained very low and corneal transplantation was performed later, with good visual outcome. Corneal incisions in cases with corneal vascularization may result in a pre-Descemet’s membrane hemorrhage, especially if Descemet’s membrane detachment is present. Thus, an incision from the site of the corneal vascularization should be avoided if possible. If it cannot be, maximum care should be taken to avoid Descemet’s membrane detachment.
References
Figure 2. (Durak) Pre-Descemet’s membrane hemorrhage that started to dissolve 2 months later still had sharp borders.
1. Muenzler WS. Intracorneal hemorrhage. Am J Ophthalmol 1973; 76:440 – 443 2. Al-Hussaini AK, Friedlander MH, Karciog˘lu ZA. Intracorneal hemorrhage secondary to aphakic contact lens wear. Cornea 1992; 11:73–76; errata, 184 3. Go¨rdu¨ren S. Cases of intracorneal hemorrhages. Tip Faku¨ltesi Mecmuasi 1947; 95:1–2 4. Baratz KH, Allf BE, Foulks GN. Intracorneal hemorrhage with acute glaucoma (letter). Am J Ophthalmol 1993; 116:376 –377
J CATARACT REFRACT SURG—VOL 25, NOVEMBER 1999
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CASE REPORTS: DURAK
5. Yoshimura M, Sameshima M, Fujita S, Ohba N. Blood staining of the cornea in Hansen’s disease, a light- and electron-microscope study. Ophthalmologica 1980; 181: 314 –319 6. Laroche RR, Campbell RC. Intracorneal hemorrhage induced by chronic extended wear of a soft contact lens. CLAO J 1987; 13:39 – 40 7. Renardel de Lavalette JGC, Van Rij G. Intracorneal haemorrhage. Doc Ophthalmol 1982; 52:397– 403 8. Ba´rdy K. Beitrag zum tiefen hornhautha¨matom. Klin Monatsbl Augenheilkd 1965; 147:838 – 848 9. Hurwitz BS. Spontaneous intracorneal hemorrhage caused by aphakic contact lens wear. Ann Ophthalmol 1981; 13:57–59
1556
10. Donnenfeld ED, Ingraham H, Perry HD, et al. Contact lens-related deep stromal intracorneal hemorrhage. Ophthalmology 1991; 98:1793–1796 11. Cote MA, Gaster RN. Keratohematoma leading to acquired posterior keratoconus. Cornea 1994; 13:534 –538 12. Yeoh RLS, Cox N, Falcon MG. Spontaneous intracorneal haemorrhage. Br J Ophthalmol 1989; 73:363–364 Accepted for publication May 20, 1999. From the Dokuz Eylu¨l University, School of Medicine, Department of Ophthalmology, ˙Ismir, Turkey. None of the authors has a proprietary or financial interest in any product or company mentioned.
J CATARACT REFRACT SURG—VOL 25, NOVEMBER 1999
I
ntracorneal hemorrhage is a rarely seen phenomenon. It is reported after intraocular surgery, usually after cataract extraction or ocular trauma. It may also be associated with inflammatory corneal disease and secondary to aphakic contact lens wear.1–10 Intracorneal hemorrhage may be seen as intrastromal, pre-Descemet’s membrane, or subepithelial. We present a case of pre-Descemet’s membrane hemorrhage that occurred after secondary intraocular lens (IOL) implantation. To the best of our knowledge, this is the first reported case of this complication.
Case Report A 64-year-old man, seen in our clinic in June 1994, had a history of extracapsular cataract extraction without IOL implantation in the right eye complicated by vitreous loss 3 years previously. His best corrected visual acuity was 6/15 in the right eye and 6/7.5 in the left eye. Intraocular pressure by applanation tonometry was 17 and 15 mm Hg, respectively. Examination of the right eye showed vitreous in the anterior chamber, a superiorly displaced pupil, a ruptured posterior capsule, extensive peripheral anterior synechias, and deep corReprint requests to ˙Ismet Durak, MD, Mithatpas¸a Cad. Gurup Apt, No: 259/8, 35340 Balc¸ova, ˙Izmir, Turkey. © 1999 ASCRS and ESCRS Published by Elsevier Science Inc.
neal vascularization at the superior quadrant. Secondary posterior chamber IOL implantation with anterior segment reconstruction in the right eye was planned. After an approximately 100 degree peritomy and wetfield bipolar cautery, a 7.0 mm limbal incision was prepared superiorly. Moderate anterior vitrectomy was performed with an automatic vitrector via the limbus. Hemorrhage from the iris occurred during the lysis of the peripheral anterior synechias and iridocapsular adhesion. The hemorrhage was totally controlled. The anterior chamber was washed out, and a single-piece poly(methyl methacrylate) IOL with 10 degrees of vaulting, a 6.5 mm optic, and 13.5 mm overall length (Oculaid 292Y, Ophtec) was implanted in the posterior chamber. Iridoplasty was performed to obtain a round pupil, and the incision was closed with a 10-0 nylon suture. There was no blood in the anterior chamber at the end of the surgery. A kidney-shaped, 6.0 ⫻ 4.0 mm diameter, pre-Descemet’s membrane hemorrhage covering the temporal portion of the cornea was seen on the first postoperative day without hyphema in the anterior chamber (Figure 1). There was minimal diffuse stromal edema. Visual acuity was 6/30, and IOP was 17 mm Hg by applanation tonometry. Three weeks later, the hemorrhage remained the same, with sharp borders. It started to dissolve 2 months later (Figure 2). One year later, the hemorrhage had totally dissolved, leaving slight, deep pigmentary changes. There was minimal corneal edema over the hemorrhage area as well as the cornea. Visual acuity was 6/30 with correction, and IOP was 18 mm Hg by applanation tonometry. 0886-3350/99/$–see front matter PII S0886-3350(99)00249-7
CASE REPORTS: DURAK
Figure 1. (Durak) A kidney-shaped temporal pre-Descemet’s membrane hemorrhage on the first postoperative day.
Discussion In 1973, Muenzler1 reviewed the literature and found approximately 30 cases of corneal hemorrhage; about half of the cases were subepithelial and half, intrastromal. One third of corneal hemorrhages occur after intraocular surgery, usually after cataract extraction. Another third occur after ocular trauma, and the final third are associated with inflammatory corneal disease. Intracorneal hemorrhage may also occur spontaneously, mostly as a result of corneal vascularization, which usually occurs after keratitis, inflammation,4,5,7,8,11 and contact lens wear.2,6,9 –12 Secondary IOL implantation is a safe, effective procedure. Complications occur infrequently. Implantation may be difficult, and complications may happen in complicated cases. In our case, a pre-Descemet’s membrane hemorrhage occurred at the temporal quadrant after secondary IOL implantation. Blood in the anterior
chamber may have entered the cornea via Descemet’s membrane breaks, but there was no hyphema postoperatively. The sharp borders of the hemorrhage may indicate the presence of Descemet’s membrane detachment. The corneal hemorrhage was probably a result of postoperative bleeding from superior corneal vascularization to the Descemet’s membrane detachment area, which occurred during surgery. Resolution may take a long time with deeper corneal hemorrhages, and blood staining of the cornea may occur despite normal IOP. Resolution of the hemorrhage took about 1 year in our case and resulted in slight corneal edema, not only over the hemorrhage but diffusely over the entire cornea. Diffuse corneal edema was probably not due to hemorrhage but may have been the result of endothelial cell loss from the previous 2 complicated intraocular surgeries. It is not known for certain whether follow-up of or puncturing the hemorrhage would lead to a better prognosis. A surgical approach to the treatment of deep corneal hemorrhages has rarely been attempted. Ba´rdy8 successfully treated a case with pre-Descemet’s membrane hematoma by puncturing it 2 weeks postoperatively. Renardel de Lavalette and Van Rij7 performed a peripheral iridectomy and punctured the deep corneal hemorrhage because it protruded into the anterior chamber and caused high IOP. Despite this puncturing, visual acuity remained very low and corneal transplantation was performed later, with good visual outcome. Corneal incisions in cases with corneal vascularization may result in a pre-Descemet’s membrane hemorrhage, especially if Descemet’s membrane detachment is present. Thus, an incision from the site of the corneal vascularization should be avoided if possible. If it cannot be, maximum care should be taken to avoid Descemet’s membrane detachment.
References
Figure 2. (Durak) Pre-Descemet’s membrane hemorrhage that started to dissolve 2 months later still had sharp borders.
1. Muenzler WS. Intracorneal hemorrhage. Am J Ophthalmol 1973; 76:440 – 443 2. Al-Hussaini AK, Friedlander MH, Karciog˘lu ZA. Intracorneal hemorrhage secondary to aphakic contact lens wear. Cornea 1992; 11:73–76; errata, 184 3. Go¨rdu¨ren S. Cases of intracorneal hemorrhages. Tip Faku¨ltesi Mecmuasi 1947; 95:1–2 4. Baratz KH, Allf BE, Foulks GN. Intracorneal hemorrhage with acute glaucoma (letter). Am J Ophthalmol 1993; 116:376 –377
J CATARACT REFRACT SURG—VOL 25, NOVEMBER 1999
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CASE REPORTS: DURAK
5. Yoshimura M, Sameshima M, Fujita S, Ohba N. Blood staining of the cornea in Hansen’s disease, a light- and electron-microscope study. Ophthalmologica 1980; 181: 314 –319 6. Laroche RR, Campbell RC. Intracorneal hemorrhage induced by chronic extended wear of a soft contact lens. CLAO J 1987; 13:39 – 40 7. Renardel de Lavalette JGC, Van Rij G. Intracorneal haemorrhage. Doc Ophthalmol 1982; 52:397– 403 8. Ba´rdy K. Beitrag zum tiefen hornhautha¨matom. Klin Monatsbl Augenheilkd 1965; 147:838 – 848 9. Hurwitz BS. Spontaneous intracorneal hemorrhage caused by aphakic contact lens wear. Ann Ophthalmol 1981; 13:57–59
1556
10. Donnenfeld ED, Ingraham H, Perry HD, et al. Contact lens-related deep stromal intracorneal hemorrhage. Ophthalmology 1991; 98:1793–1796 11. Cote MA, Gaster RN. Keratohematoma leading to acquired posterior keratoconus. Cornea 1994; 13:534 –538 12. Yeoh RLS, Cox N, Falcon MG. Spontaneous intracorneal haemorrhage. Br J Ophthalmol 1989; 73:363–364 Accepted for publication May 20, 1999. From the Dokuz Eylu¨l University, School of Medicine, Department of Ophthalmology, ˙Ismir, Turkey. None of the authors has a proprietary or financial interest in any product or company mentioned.
J CATARACT REFRACT SURG—VOL 25, NOVEMBER 1999