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Capsular Bag Hematoma Following Trabeculectomy
Arch Ophthalmol. 2004;122:1229-1230.
Since its introduction in 1967, trabeculectomy has become the standard surgical treatment modality for most forms of glaucoma. The early postoperative complications reported are hypotony, shallow or flat anterior chamber, hyphema, choroidal detachment, uveal effusion, wound leak, malignant glaucoma, suprachoroidal hemorrhage, and endophthalmitis.1-2 We describe an interesting case of a capsular bag hematoma following trabeculectomy, a hitherto unreported complication.
Report of a Case
A 57-year-old man was initially examined at our tertiary care institute and had a history of total visual loss in his left eye following surgery for glaucoma elsewhere 3 weeks earlier. On examination, his best-corrected visual acuity was 20/30 in the right eye, and hand motions close to his face with accurate projection of rays in the left eye. Intraocular pressure in the right and left eyes was 14 and 12 mm Hg, respectively. The left eye revealed a thin moderate-sized bleb and a quiet anterior chamber with normal depth. Results of a dilated examination revealed a posterior synechia at the pupillary margin at the 1 o'clock position and a peripheral iridectomy in the same meridian. The crystalline lens appeared to have a brownish hue throughout, with a bright red collection in the anterior subcapsular area just behind the area of posterior synechia (Figure 1, arrow). There was no view of the posterior segment. Findings from a B-scan ultrasonogram revealed a normal posterior segment in the left eye. The patient was posted for phacoemulsification and aspiration of the blood along with intraocular lens implantation. Capsular staining with trypan blue failed to provide adequate contrast in view of the dark reflex of intralenticular contents. Capsulorhexis was then achieved from the anterior capsule reflex under high magnification. Phacoemulsification power was totally ineffective in removing the blood-impregnated epinuclear shell, and it had to be manually stuffed into the port of the phaco tip with a chopper. A normal red reflex was achieved as soon as this blood clot was removed, and a hydrophilic acrylic intraocular lens was implanted in the capsular bag. The early postoperative period was uneventful, and the patient achieved a best-corrected visual acuity of 20/30. Within the next 2 months, there developed an excessive capsular bag fibrosis with mild upward decentration of the intraocular lens.
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Left eye of the patient showing a brownish hue of intralenticular contents. Note the area of bright red anterior subcapsular blood collection (arrow).
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Comment
Although hyphema is one of the most common early postoperative complications following trabeculectomy, to our knowledge, intralenticular collection of blood has not been previously reported. Because of the use of an operating microscope and the refinement of surgical techniques, lens injury during trabeculectomy has been infrequently reported.3 We hypothesized that there had been anterior capsule injury while performing peripheral iridectomy in this case, with seepage of blood into the capsular bag.
The development of a fibrous type of posterior capsule opacification in relation to the presence of blood in the capsular bag, as was evident from the exaggerated postoperative capsular bag fibrosis in this case, has been previously noted.4 This case highlights the possibility of lens injury during trabeculectomy and provides an insight into the problems encountered while performing phacoemulsification when there is intralenticular blood collection.
The authors have no relevant financial interest in this article.
AUTHOR INFORMATION
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G. S. Brar, MS;
Jagat Ram, MS;
Jaspreet Singh, MS;
Ravinder Kaur, MS;
Amod Gupta, MS
Correspondence: Dr Brar, Department of Ophthalmology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India (eyepgi{at}satyam.net.in).
REFERENCES
1. Edmunds B, Thompson JR, Salmon JF, Wormald RP. The National Survey of Trabeculectomy, III: early and late complications. Eye. 2002;16:297-303.
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2. Watson PG, Jakeman C, Ozturk M, Barnett MF, Barnett F, Khaw KT. The complications of trabeculectomy (a 20-year follow-up). Eye. 1990;4:425-438.
3. Swan KC, Lindgren TW. Unintentional lens injury in glaucoma surgery. Trans Am Ophthalmol Soc. 1980;78:55-66.
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4. Apple DJ, Solomon KD, Tetz MR, et al. Posterior capsule opacification. Surv Ophthalmol. 1992;37:73-116.
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