Selective laser trabeculoplasty is an effective means of lowering intraocular pressure in patients with open-angle glaucoma with a low risk of complications. The authors report a case of hyphema noted 3 days after selective laser trabeculoplasty in a 77-year-old woman with primary open-angle glaucoma. Her intermittent use of oral nonsteroidal anti-inflammatory medications and chronic topical nonsteroidal anti-inflammatory use may have been a contributing risk factor.
Hyphema Following Selective Laser Trabeculoplasty
From Massachusetts Eye & Ear Infirmary (DJR, LRP), Boston, Massachusetts; and Loyola University Medical School (OK), Chicago, Illinois.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Douglas J. Rhee, MD, Massachusetts Eye & Ear Infirmary, 243 Charles Street, Boston, MA 02114.
Accepted: August 29, 2008
Selective laser trabeculoplasty (SLT) is an effective treatment to lower intraocular pressure (IOP) for patients with open-angle glaucoma.1–3 Although inflammation and pain are known perioperative sequelae following SLT, hyphema has not been reported to our knowledge.
A 77-year-old woman presented for ongoing management of primary open-angle glaucoma. Her ocular history included clear cornea phacoemulsification cataract extraction with posterior chamber intraocular lens implantation in the left eye with persistent cystoid macular edema despite an intact posterior capsule and bilateral peripheral laser iridotomies. The medical history was remarkable for diabetes mellitus and hypertension treated with metformin, hydrochlorothiazide, and diltiazem. She also used ibuprofen 600 mg for arthritis pain once every 2 or 3 days. Ocular medications included timolol 0.5%, dorzolamide 2%, bimatoprost 0.03%, and brimonidine 0.2% in both eyes along with nepafenac in the left eye four times a day.
Visual acuity was 20/25 in the right eye and 20/80 in the left eye with IOPs of 16 mm Hg in the right eye and 24 mm Hg in the left eye. Central corneal thicknesses were 545 μm in the right eye and 550 μm in the left eye. She had 1+ nuclear sclerosis in the right eye and a posterior chamber intraocular lens in the left eye. Iris neovascularization was absent. Gonioscopy revealed open angles (Spaeth angle classification of D30f in the right eye and D40f in the left eye, with 3+ trabecular meshwork pigmentation). Fundus examination demonstrated cup-to-disc ratios of 0.85 in the right eye and 0.6 in the left eye. There was no diabetic retinopathy but chronic cystoid macular edema was evident in the left eye. Humphrey visual field tests showed an early superior arcuate defect in the right eye and generalized reduction of sensitivity in the left eye.
SLT was planned to achieve target IOP in the low- to mid-teens for both eyes. The left eye was treated first because the IOP was higher and visual acuity was worse compared with the right eye. The Latina SLT Gonio Laser Lens (Ocular Instruments, Bellevue, WA) was used to administer 56 spots with energy between 1.46 and 1.51 mW over 360°. There were no complications during the procedure.
Three days after SLT, she presented with sudden onset of blurred vision, photophobia, and pain in the left eye. Visual acuity was 20/25 in the right eye and 20/200 in the left eye. Slit-lamp examination of the left eye revealed a 1-mm hyphema with 3+ to 4+ red blood cell count in the anterior chamber (Figure). IOPs were 18 mm Hg in the right eye and 19 mm Hg in the left eye. Repeat gonioscopy in the left eye revealed no obvious source of bleeding and angle neovascularization was absent. Repeat fundus examination did not reveal retinal neovascularization.
Figure. This Anterior Segment Photograph of the Left Eye Demonstrates a Small Layered Hyphema Inferiorly.
The hyphema resolved over 3 weeks. She underwent SLT in the right eye 2 months after her first procedure for an IOP of 18 mm Hg. At last follow-up, 4 months after her procedure in the left eye, visual acuity was 20/25 in the right eye and 20/200 in the left eye with IOPs of 13 and 14 mm Hg, respectively. The further decline in vision was attributed to persistent cystoid macular edema.
Hyphema occurring during SLT has been reported,4 but in our case it occurred several days later. One week after the onset of the hyphema, the patient remembered that she took ibuprofin 2 days prior to the trabeculoplasty; she was also taking a chronic topical nonsteroidal anti-inflammatory medication in the involved eye. There was no evidence of angle neovascularization during either the laser procedure or the postoperative period. The hyphema did not adversely affect the outcome. Hyphema can occur following SLT and nonsteroidal anti-inflammatory medications may play a contributory role.
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