Eyeworld

EW NEWS & OPINION 16 February 2016 Anterior segment grand rounds (ASGR) by Steven Safran, MD she would not be in pain. However, it also lowers the IOP and might allow more bleeding to occur—and put you back behind the 8-ball. So I would try and stick with just medi- cal treatment if possible. "If the IOP was hard to reduce even with all topicals and acetazol- amide—and she remained in pain—I would consider a washout in the exam room. This is a technique that in the eye at the end of the case, you would be very happy. "I would manage this medically, if possible, in the office, and I would confidently reassure her that we can fix this. I might also have considered a paracentesis—or releasing aqueous from the incision or side port—if pain made it very difficult for her to cooperate. A paracentesis would reduce the IOP immediately so that Patient with uneventful cataract surgery and placement of iStent develops recurrent hyphema after surgery. Experts share their thoughts on how to approach this situation iStumped over iStent Figure 1. Trail of blood appears to come from iStent. Note that details are blurred because of RBCs in anterior chamber obscuring the view. Figure 2. Gonioscopic view of the iStent seen after blood had cleared and view was improved. IOP was now in the teens. Source: Steven Safran, MD Case presentation T he patient is a very active 65-year-old woman with mild pseudoexfoliation glaucoma and cataract. I performed uneventful cataract surgery with iStent (Glaukos, Laguna Hills, Calif.) placement on a Monday. Day 1 her vision was 20/20 uncorrected with an IOP of 13, and all was well. However, she came in 3 days postoperative because she experienced mild blurred vision on awakening. When I examined her, she was 20/20-2 with IOP of 17, but I saw moderate RBCs floating in the anterior chamber. I reassured her and sent her home. The next day she came in again with more blurred vision on awakening, and her IOP was 34 with more RBCs seen in the AC. I restarted her on bimatoprost, which she had been using prior to surgery. The next day, Saturday, she paged me because she woke up with much worse vision and pain so I came in to see her. Her vision was a blurry 20/30 with an anterior chamber that was full of floating RBCs blurring my view of anatomic detail at the slit lamp, and her IOP was 43. Gonioscopy showed that there was blood in Schlemm's canal and a well-placed stent with a trail of blood that appeared to have come from the vicinity of the stent but was no longer actively doing so (Figure 1). She was extremely upset, frightened, and crying about the situation. I was perplexed about what to do. I had an OR day scheduled for Monday, and on Tuesday I was going on vacation for the rest of the week and would not be around to intervene if needed. I asked some esteemed colleagues how they would manage this case. Steven Safran, MD, ASGR editor R eay Brown, MD, Atlanta, commented: "This is a puzzling case. It seems impossible for an eye that is 20/20 on the first day with a good IOP to have this kind of trouble on day 5. And the amount of bleeding seems miniscule. If you were washing out a hyphema and wound up with that much blood left Blood in Schlemm's canal iStent in canal Trail of blood coming from region of stent placement

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