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Arch Ophthalmol. 2001;119:1213-1215.

Recurrent transient visual loss in the elderly is mostly associated with cardiovascular disorders. Other causes include giant cell arteritis, migraine, increased intracranial pressure, orbital mass, and idiopathy. We describe a patient with unusual recurrent transient visual loss after deep sclerectomy with collagen implant (DSCI).

Report of a Case
A 75-year-old woman was referred for investigation of possible amaurosis fugax. She complained of recurrent painless blurred vision in her left eye for the past 6 months. Her medical history was relevant for common migraine and systemic hypertension. Systemic medications included losartan potassium, hydrochlorothiazide, lorazepam, carvedilol, and aspirin. Severe bilateral glaucoma necessitated trabeculectomy in the right eye in 1994 and DSCI in the left eye in 1996. Both procedures were uneventful.

The episodes of visual loss in the left eye occurred on average once a week, lasted up to 24 hours, and affected her ability to read. Some episodes occurred after performing gymnastic exercises, after bending forward, and once after sneezing. She had no symptoms or signs suggesting giant cell arteritis.

Best-corrected visual acuity was 20/40 OD and 20/25 OS. Pupil examination revealed a 2+ right relative afferent defect. Intraocular pressure (IOP) was 11 mm Hg in the right eye and 14 mm Hg in the left. Fundus examination revealed bilateral glaucomatous disc atrophy that was severe in the right eye (cup-disc ratio, 0.9) and moderate in the left eye (cup-disc ratio, 0.5). Visual field defect was severe in the right eye and moderate in the left.

Results of investigations, including a complete blood cell count, erythrocyte sedimentation rate, cardiovascular examination, precerebral Doppler and cerebral magnetic resonance imaging, and angiography, were normal.

Several similar episodes have occurred since she was examined. A few hours after onset of the latest episode, examination of the left eye showed visual acuity of 20/50^-2, 2 mm of hyphema (Figure 1), and IOP of 38 mm Hg; gonioscopy revealed active bleeding through a microperforation in the trabeculo-Descemet membrane at the site of surgery (Figure 2).

View larger version (44K): [in this window] [in a new window] Figure 1. Hyphema (2 mm) in the left eye.

View larger version (18K): [in this window] [in a new window] Figure 2. Gonioscopy revealed actively bleeding blood vessels at the site of the trabeculo-Descemet membrane.

Because of repeated bleeding episodes and increased IOP in the left eye, the site of DSCI underwent reoperation. Many actively bleeding blood vessels surrounding the Schlemm canal orifice were found and coagulated. No further bleeding has occurred since, and the IOP remained less than 15 mm Hg without therapy.

Comment
Transient visual loss secondary to recurrent hyphema has been reported after trabeculectomy¹ and after cataract surgery with either an iris suture² or an anterior chamber implant³ but not after nonpenetrating filtering surgery. Nowadays, DSCI is becoming a common technique to safely lower IOP and is believed to be less traumatic than trabeculectomy because of the nonpenetrating technique.⁴ More than 1500 patients have undergone DSCI in our department (unpublished data); however, recurrent hyphema occurred only in the present case. During surgery, no obvious perforation was noted, but we cannot rule out the possibility of a microperforation of the trabeculo-Descemet membrane.

Recurrent hyphema after DSCI could result from spontaneous bleeding of anomalous scleral blood vessels at the site of surgery (such as in the present case), venous hypertension (Valsalva phenomenon) with blood reflux in the Schlemm canal, or a combination of both. Aspirin therapy might have also contributed to the bleeding.

History of previous filtering surgery in the setting of transient visual loss should then prompt gonioscopy and a careful anterior chamber examination for the presence of hyphema or blood reflux through the trabeculo-Descemet membrane.

AUTHOR INFORMATION

Aude Ambresin, MD; François-Xavier Borruat, MD; André Mermoud, MD
Lausanne, Switzerland

Corresponding author: François-Xavier Borruat, MD, Hôpital Ophtalmique Jules Gonin, Avenue de France 15, CH-1004 Lausanne, Switzerland (e-mail: fborruat{at}hola.hospvd.ch).

REFERENCES
1. Glaser JS. In: Glaser JS, ed. Neuro-ophthalmology. 2nd ed. Philadelphia, Pa: JB Lippincott; 1990:92. 2. Kosmorsky GS, Rosenfeld SI, Burde RM. Transient monocular obscuration—amaurosis fugax: a case report. Br J Ophthalmol. 1985;69:688-690. FREE FULL TEXT 3. Anton A, Weinreb N. Recurrent hyphema secondary to anterior chamber lens implant. Surv Ophthalmol. 1997;41:414-416. PUBMED 4. Mermoud A, Schnyder CC. Nonpenetrating filtering surgery. Curr Opin Ophthalmol. 2000;11:151-157. FULL TEXT | PUBMED

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