Surgical evacuation may be needed for non-clearing hyphema
A patient sustained an eye injury from a champagne cork, with blood filling the anterior chamber and obscuring vision.
All ophthalmologists have seen a hyphema: blood in the anterior chamber, often after significant ocular trauma. In many cases, this blood is just a small amount, and it resolves over the course of days to weeks as aqueous in the anterior chamber turns over. In some situations, however, the hyphema can be so severe that it nearly completely fills the anterior chamber and creates a large clot that does not clear without surgical intervention.
The degree of hyphema is typically described in terms relating to the amount of the anterior chamber that is filled with blood. The red blood cells tend to sink in the aqueous and then collect in the inferior angle. A moderate hyphema may cause a layering of a few millimeters; this can be documented and the patient followed serially to ensure that it is resolving spontaneously. The blood can cause side effects in the eye such as increased IOP, obscuration of vision, inflammation and even corneal staining. For mild to moderate hyphemas, medical management of these conditions is warranted during the recovery process.
In the case shown here, the hyphema is significant, filling about 80% of the anterior chamber (Figure 1). The blood has clotted and is completely obscuring the pupil, resulting in vision of light perception only. The patient has elevated IOP that is not well controlled despite being on maximal topical therapy as well as systemic acetazolamide. The ultrasound study shows that the posterior segment is normal with a clear vitreous and an attached retina. This patient needs surgical intervention to clear the hyphema and restore normal anatomy and function to his eye.
Our patient is just 40 years old and before this trauma had normal vision in both eyes, with a distance acuity of 20/20. He sustained an injury from a champagne cork that hit him squarely in the eye, landing between his orbital bones. The trauma was 2 weeks ago, and the blood is simply not clearing. When we perform a surgical evacuation of the hyphema, we must carefully remove the clot without touching the crystalline lens. We want to avoid causing a cataract in a patient of this age.
Our technique for this surgery will involve two small incisions, each just 1 mm wide, which are made at the edge of the cornea and just barely nicking the limbal blood vessels. In each of these incisions, we will place a 23-gauge instrument: in one hand the infusion cannula and in the other the vitrectomy cutter. We do not intend to perform a vitrectomy, but instead we are using that instrument to help aspirate and then cut pieces from the blood clot.
To remove the clot, we use the suction of the vitrector to firmly hold the coagulated material and then gently pull it away from the angle of the eye (Figure 2). The cutter action can be engaged to break the clot into smaller pieces for easier aspiration once it has been freed from the iris. During these maneuvers, it is important to stay away from the anterior lens capsule and avoid touching the crystalline lens in order to prevent cataract formation.
Once we remove the blood clot, we also want to ensure that a rebleed does not occur. Adding epinephrine to the infusion fluid or instilling it into the anterior chamber in a diluted concentration can help to give vasoconstriction and reduce the risk for a rebleed.
The settings of the phaco machine are of paramount importance to prevent an iatrogenic cataract. The 23-gauge anterior vitrectomy handpiece and infusion cannula are set up, and the machine is primed and tested. We want to make sure that the machine mode is “I/A cut,” which means that foot position 1 is irrigation, 2 is aspiration, and 3 is engaging the cutting function. We also drop the cut rate down to 100 cuts per minute, which is about one cut every half-second. This is enough to break up the clot to be able to aspirate it without clogging the port.
The infusion pressure (or bottle height) must be raised significantly in order to deepen the anterior chamber and give more working room without the risk for touching the crystalline lens (Figure 3). Also, the higher infusion pressure can help prevent a rebleed as the clot is peeled away from the original site of bleeding. The vacuum level is high at 350 mm Hg in order to provide enough grip and holding power to pull the clot away from the attachment points on the iris. Finally, the aspiration flow rate is intentionally kept low at just 10 mL per minute so that we do not outstrip the inflow rate, especially with the smaller 23-gauge instrumentation.
This surgical case took just a few minutes to complete, and the patient did well with full recovery of normal vision. And we suggested that he use safety glasses the next time he wishes to open a champagne bottle.
Full video of this case is available at CataractCoach.com.
- For more information:
- Uday Devgan, MD, is in private practice at Devgan Eye Surgery, Chief of Ophthalmology at Olive View UCLA Medical Center and Clinical Professor of Ophthalmology at the Jules Stein Eye Institute, UCLA School of Medicine. He can be reached at 11600 Wilshire Blvd. #200, Los Angeles, CA 90025; email: email@example.com; website: www.CataractCoach.com.
Disclosure: Devgan reports he owns CataractCoach.com, which is a free teaching website.