MAY 2013

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

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Page 58 of 86

56 EW RESIDENTS May 2013 Handling continued from page 55 by the subconjunctival hematoma. Less manipulation of the conjunctival tissues might prevent continued iatrogenic injury leading to recurrent or worsening subconjunctival hemorrhage. Finally, it is most important to provide reassurance to the patient that the subconjunctival hemorrhage will resolve without impacting the final outcome of a successful cataract surgery. Shahzad Mian Terry J. Bergstrom Professor Associate chair, education Residency program director Associate professor W.K. Kellogg Eye Center University of Michigan It is not uncommon to get small subconjunctival hemorrhages with forceps or fixation rings especially in patients on anticoagulants. They are mostly self-limited similar to Figure 1 and do not interfere with surgery, vision, or postoperative outcomes other than cosmetic appearance. If the hemorrhage progresses once the We're Changing The Game with our new Model M4 valve. Model M4 Porous Plate www.ahmedvalve.com 800.832.5327 capsulorhexis has been initiated, the surgery needs to be completed. Since the hemorrhage was expanding and interfering with the incision, I would perform a conjunctival peritomy to drain the hemorrhage and reduce the elevation. If it continues to expand, thrombin gel and coagulation need to be considered. Once the surgery is complete and there is 360 degrees of hemorrhage, the patient needs to be reassured that the hemorrhage will resolve. If there are symptoms of foreign body sensation or pain, lubrication will be needed. Risk of bleeding can be reduced by using gentler fixation methods, including use of a Weck-Cel or placing a blunt spatula or forceps through the paracentesis. If the concern for bleeding is high preoperatively and it is safe to discontinue the Plavix, it can be discontinued after consultation with the primary care physician or cardiologist. Carol L. Karp, MD Professor of ophthalmology Bascom Palmer Eye Institute University of Miami School of Medicine While cataract surgery is often considered a "bloodless" procedure, there are still issues related to bleeding even with topical anesthesia. Potential complications can include mild events such as subconjunctival hemorrhage as seen in this case, ecchymosis associated with retrobulbar anesthesia, and more serious complications such as retrobulbar hemorrhage and suprachoroidal hemorrhage. Fortunately the latter two are rare, but can be devastating. It is important to inform patients on anticoagulative therapy that cataract surgery under topical anesthesia can still have rare risks related to bleeding. How to handle this case A subconjunctival hemorrhage (SCH), while considered benign, can create some issues for the patient and surgeon. One issue is the unpleasant cosmesis that may bother the patient. The other is that significant chemosis during the case can cause annoying reflections and distort the surgeon's view. For these reasons, when I see a SCH develop-

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