Eyeworld

by Matt Young EyeWorld Contributing Editor Evaluating subconjunctival hemorrhage in the refractive era It may be a minor problem, but it's more significant for patients than some physicians think A lthough it's fairly innocu- ous, subconjunctival hemorrhage continues as an unwanted side effect among patients because of the unflattering eye redness that it causes after eye surgery. After glaucoma surgery, patients have a lot more to be concerned about than cosmesis. Did the proce- dure work? Will potential blindness be halted? But after an elective procedure like LASIK when patients expect su- perior outcomes, the "wow" effect could be diminished if they have incredible sight but aren't an incred- ible sight to look at. Patient satisfac- tion could be diminished after refractive cataract surgery for the same reason. It's therefore important to con- sider the fallout of subconjunctival hemorrhage in the refractive age and how to prevent it from happening. A portion of cases Jay Bansal, M.D., medical director, LaserVue Eye Center, San Francisco, said subconjunctival hemorrhage is not a major issue, but it does exist. "I would say it's a problem in around 10-15% of [LASIK] cases," Dr. Bansal said. "I would also say it oc- curs around 10% of the time in cataract surgery." In LASIK, the problem surfaces more often with microkeratome usage, Dr. Bansal said. "Suction is higher with a microkeratome than with the femtosecond," Dr. Bansal explained. Dr. Bansal considers subcon- junctival hemorrhage to be an en- tirely cosmetic problem and could impact how friends of LASIK pa- tients receive them after surgery. "For coworkers and family, [sub- conjunctival hemorrhage] does take away from the 'wow' factor," said Dr. Bansal, whose point should not be taken lightly by clinicians bank- ing on word-of-mouth referrals. There are ways to prevent sub- conjunctival hemorrhage. One is using vasoconstrictors prior to LASIK and post-op, he said. Reducing the amount of suction time also may help, he said. Another option is ap- plying something cold over the eye prophylactically, like cold saline or an ice compress. Because it occurs in a minority of cases, Dr. Bansal said he is not in favor of discontinuing anticoagu- lants in LASIK patients. "At one point, we did ask all [cataract] pa- tients to discontinue anticoagu- lants," Dr. Bansal said. "But with clear corneal surgery, we have gotten away from mandating this because we're not going through the con- junctiva anymore." That said, in other types of sur- gery such as retina or glaucoma sur- gery where the conjunctiva is being touched, Dr. Bansal's patients do dis- continue anticoagulants. Eye on anatomy "We should remember that subcon- junctival hemorrhage is purely a cos- metic side effect 99.99% of the time with no visual or clinical signifi- cance," said Darrell White, M.D., president and CEO, Skyvision Cen- ters of Westlake, Ohio. "It's signifi- cant only when the patient looks in the mirror or someone makes the observation." It's hard to avoid breaking small capillaries around the limbus during LASIK surgery, which results from suction, he said. "It has a lot to do with an indi- vidual's anatomy and how resilient his or her blood vessels are," Dr. White said. "If the patient has a wide-open orbit in a relatively prominent eye, it's easy to get what- ever you're trying to get in quickly. The eye is right there for you and trauma is minimized. If the patient has a small eye or really deep orbit and you have to reseat the suction apparatus multiple times with suc- tion going on and off, you increase the risk of a hemorrhage." He doesn't use vasoconstrictors before LASIK because they have the potential to interfere with surgery. "Theoretically, you don't want to use a vasoconstrictor before LASIK because you want to have a natural pupil," Dr. White said. All vasocon- strictors are at least weak dilators, he said, and dilated pupils make it diffi- cult for patients to fixate, he said. Further, during intraocular sur- gery, when an instrument is being introduced inside the eye, the eye must be stabilized, Dr. White said. "You want to stabilize the eye so the only thing moving is the instru- ment and it goes in in a controlled fashion," Dr. White said. "If you grab the conjunctiva, you can cause a hemorrhage because the blood ves- sels are fragile. Coumadin (warfarin, Bristol-Myers Squibb, New York) blood thinner and aspirin increase the chance of bleeding. It can also become a subconjunctival hemor- rhage when these patients don't stop bleeding as quickly." Trabeculectomy patients are al- ways going to have some subcon- junctival hemorrhage, Dr. White said. Strabismus patients have a sim- ilar problem "because you have gone through such a big area of vascular tissue," he said. "When I did more trabeculec- tomy, I always put in a drop of Neo-Synephrine [phenylephrine, Hospira, Lake Forest, Ill.]," Dr. White said. "That reduced capillary oozing and increased visualization." Hence, Dr. White recommends a vasoconstrictor like Neo-Synephrine be used in a dilation mix, whether as part of a series of eye drops, a soaked pledget, or a gel slurry. On the other hand, with topical anesthesia common during cataract surgery and with the majority of cataract surgery being clear corneal or near clear corneal, there's very lit- tle vascular tissue involved. In cataract surgery, such a vasoconstric- tor may not be necessary. That said, whatever you do to ensure excellent outcomes both vi- sually and cosmetically will be ap- preciated by premium IOL patients. "In cataract surgery with ad- vanced implants, there are higher ex- pectations," Dr. White said. "It feels more like LASIK. Many of us who do more of those advanced-implant styles tend to be a little more con- scious of the cosmetic effect because it's a semi-elective procedure." EW Editors' note: Drs. Bansal and White have no financial interests related to their comments. Contact information Bansal: 800-527-3745, bansal@laservue.com White: 440-892-3931, cdunbar@skyvisioncenters.com EW REFRACTIVE SURGERY August 2011 35 Subconjunctival hemorrhage (pictured here) can affect post-LASIK patient satisfaction Source: Rick Fraunfelder, M.D.

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