MAY 2013

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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May 2013 EW RESIDENTS 55 Cataract M&M rounds Handling a hemorrhage W e were performing cataract surgery on a patient who was taking clopidogrel (Plavix, Bristol-Myers Squibb, New York). The surgery was done under topical anesthesia and so the patient did not stop any medication. During the incision the fixation ring slipped and injured a conjunctival vessel causing hemorrhage (Figure 1). As the case progressed the hemorrhage got worse and became quite elevated and expanded in size (Figure 2). The elevation of the conjunctiva made the case difficult as it interfered with the adjacent wound and distorted the view at times. Following the surgery and despite a postoperative pressure patch, the hemorrhage progressed 360 degrees around the limbus, which was alarming to the patient. The hemorrhage was gone by the one-month postoperative visit. Questions: How would you handle the hemorrhage? How would you prevent this complication? Thomas Oetting, MD, Cataract M&M rounds editor Watch this video on your smartphone or iPad using your QR code reader. (Scanner available for free at your app store.) Figure 1: Ring caused hemorrhage to start Figure 2: Hemorrhage elevated the conjunctiva Source (all): Thomas Oetting, MD Vikas "Vik" Chopra, MD Associate residency program director Associate clinical chief, glaucoma service Medical director, clinical operations Doheny Eye Institute USC Department of Ophthalmology Los Angeles In the typical surgeon-in-training's mind, a successful cataract surgery is to "get the lens in the bag" without having capsular rupture or vitreous loss. Any obstacle preventing attainment of this goal needs to be recognized and dealt with accordingly. The primary focus of the surgeon often is concentrated on the "critical" steps of the surgery including creation of incision and capsulorhexis, nuclear disassembly, and cortex removal. In contrast, it is not uncommon for the surgeon-in-training to pay less attention to smaller maneuvers such as paracentesis creation or eye stabilization with the fixation ring, which can also have significant implications toward surgical success. Several take-home points can be derived from the clinical case described above. First, it may be important to consider discontinuing any systemic anticoagulant therapy (if permissible by the patient's primary care physician) prior to cataract surgery. This would make the potential of hemorrhage less likely during the management of complex situations such as conversion from clearcornea phacoemulsification to largeincision extracapsular cataract extraction. Second, this case illustrates the importance of learning the proper use and the potential for complications even during the seemingly simplistic maneuvers of cataract surgery including stabilization of the eye with a fixation ring. It is important to recognize that even a small mishap such as the fixation ring slippage that initially causes a small, flat conjunctival hemorrhage can progress to a larger, elevated subconjunctival hematoma. Third, it demonstrates that the earlier a complication develops during the time-course of the surgery, the more challenging it can be for each of the subsequent steps of the surgery. Encountering a subconjunctival hemorrhage during topical anesthesia cataract surgery is typically inconsequential except as in the case presented here. The patient's condition is complicated by the fact that he/she is maintained on a "blood thinner." One consideration would be to simply ignore the hemorrhage, continue surgery, and hope for the best. However, it might be better advised to consider intervention for management. Several management options could be considered to prevent the hemorrhage from leading to a more significant complication. The primary option would be to stop the hemorrhage from getting worse. This is certainly easier said than done because the patient is currently maintained on oral anticoagulant treatment that was not discontinued prior to surgery. If the initial site of hemorrhage could be identified, then cauterization with a fine-tip cautery could be applied to the actively bleeding conjunctival vessel. A second option could be to cut into the subconjunctival hematoma to release the blood and reduce the elevation. However, the additional cutting has the potential of worsening the hemorrhage by causing further bleeding. Third, it might be more advisable to apply phenylephrine 2.5% drops topically to achieve vasoconstriction. Furthermore, a dry Weck-Cel (Beaver Visitec, Waltham, Mass.) spear or similar sponge could be used to apply pressure to tamponade the bleeding. To continue surgery to achieve a successful outcome, proper visualization is essential in this case. The elevated subconjunctival hematoma can lead to obscuration of the surgical view due to a "fluid lake" from pooling of irrigation fluid on and around the cornea-limbal region. To prevent poor visualization due to the "fluid lake" over the cornea, it is better to limit the amount of irrigation on the cornea typically provided by the assistant. In fact, a Weck-Cel spear or similar sponge should be used periodically to dry the limbal-gutter region to remove excess fluid. Furthermore, it would be advisable to apply a coating of viscoelastic on the cornea to prevent corneal desiccation while at the same time providing excellent visualization of intraocular structures. The hematoma may also cause difficulty accessing the corneal incision. It may be advisable to avoid constantly removing and reinserting instruments through the incision that is already potentially blocked continued on page 56

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