Ординатура / Офтальмология / Английские материалы / Master's Guide to Manual Small Incision Cataract Surgery (MSICS)_Garg_2009

Figure 37.9: Postoperative iridodialysis (Courtesy: Online Journal of Ophthalmology–Author: Carsten Meyer, MD, Marburg, Germany)

Prevention Iridodialysis can be prevented by proper wound construction. When the wire vectus is insinuated under the nucleus, the iris at 6 o’clock should not be caught in vectus, otherwise it will lead to iridodialysis.

Treatment In cases of small iridodialysis no treatment is required. But in cases of large iridodialysis suturing with 10/0 prolene is done.

SHALLOW ANTERIOR CHAMBER

This is another common complication, which is seen intraoperatively. It can occur at any stage of the operation and is associated with increase in intraocular pressure and subsequent iris prolapse.

High intraocular pressure is seen in Malignant glaucoma.

Low intraocular pressure is seen in wound leak and in Choroidal detachment.

The complication related to this may be more severe in open wound surgery like cataract but it is less in closed chamber surgery like SICS / Phaco.

It can be due to:

•Tensed eyeball preoperatively due to improper digital massage.

•Tight superior rectus sutures.

•Stout wire speculum

•Squeezing of eyes by uncooperative patient. This is commonly seen in topical anesthesia.

•Suprachoroidal hemorrhage.

Always check the intraocular pressure before starting the surgery. This will prevent many intraoperative and postoperative complication.

Management Release the superior rectus sutures and remove wire speculum. Iris reposition is done or one can do iridectomy. Inject viscoelastics to increase the depth of anterior chamber.

If the anterior chamber is shallow then give IV Mannitol and then wait for 10-15 minutes and then proceed with the surgery. Do not proceed the surgery with shallow chamber as posterior capsule is pushed forwards and this will increase incidence of capsular tears. In case of cortical wash first clear the central pupillary area free of cortex and then implant the lens. After implantation one can proceed with peripheral cortical removal.

COMPLICATIONS RELATED TO

INTRAOCULAR LENS4

The commonest lens used in cataract surgery nowadays is the Posterior Chamber IOL. The posterior chamber lens may be implanted at three sited mainly

•In the Bag,

•In the Sulcus, and

•Scleral fixated lens.

The complications related to its positioning are:

Pupillary Capture

This complication occurs when part of IOL or whole optic moves anterior to iris surface to get entrapped in the pupil. This is commonly seen.

a.When IOL is implanted in sulcus

b.In presence of PC tear with vitreous loss.

It is associated with secondary postoperative uveitis and pigment dispersion. Lenses with angulated loops reduce the incidence of pupillary capture.

Treatment

•Initial treatment includes pupillary dilatation. This causes the part of IOL or optic to move backwards.

•Pupil is then constricted after IOL is well placed in the bag.

•Redialing of IOL may also be required.

•Laser iridotomy may be done to prevent late complications of pupillary capture like pupillary glaucoma.

Decentered IOL

This includes the following syndromes:

a.Sunrise syndrome

b.Sunset syndrome

c.East-West syndrome

The variety of syndrome will depend on position at which IOL is subluxated.

This decentration occurs mainly:

a.When one haptic is in bag and other is in sulcus.

b.When PCIOL is implanted in presence of PC tear with vitreous loss

c.Due to zonular dialysis or capsular fibrosis.

Treatment

•Initial treatment involves evaluation of degree of decentration of IOL.

•If the amount of aphakic part is minimal then there is no need of any intervention. (The lens covers visual areas).

•Also if the patient is asymptomatic then no treatment is required.

Surgical treatment

1.Redialing of IOL to its proper position. Care should be taken that the IOL does not get dislocated posteriorly. This complication is common in case of large posterior capsular tear.

2.If patient complains of diplopia due to exposed aphakic part then iridoplasty is done. This causes closure of aphakic part thus visual axis is covered by the lens only.

3.If there is large subluxation then IOL is removed and replaced/exchanged with scleral fixated IOL or Anterior Chamber IOL is implanted.

Windshield Wiper Syndrome

It is complication in which the IOL moves from side to side with head movement. This usually occurs when the diameter of implant is too small for the eye. It is seen mainly in (a) myopic eyes or (b) when the loops are placed in the sulcus and (c) When there is failure of adhesion of superior loop to posterior capsule.

Treatment Fixating the loop of lens with McCannel suture. This prevents the movement of IOL.

Posterior Dislocation of IOL

This complication is mainly seen intraoperatively or immediate or early postoperatively. But in some cases it can occur in later period also.

Posterior Iris Shafing Syndrome

These are associated with Shafing of the posterior surface of iris by sulcus-fixated lens. It is rubbing of the iris surface with lens loop. It is referred as white out syndromes.

Erosion and Perforation of Ciliary Body

This is also seen in scleral fixated lens.

UGH Syndrome

This complication of Uveitis Glaucoma and Hyphema syndrome is seen in cases of anterior chamber lens.

POSTOPERATIVE COMPLICATIONS6

Manual small incision cataract surgery has minimized the rate of postoperative complication, which was seen before in conventional Extracapsular Cataract Extraction.

It can be divided into:

•Choroidal detachment Secondary glaucoma.

•Endophthalmitis

•Macular edema

Wound Leak

It is common complication seen if there is no proper wound construction.

This can occur in following cases

•Irregular dissection of the tunnel: If scleral tunnel is split into layers then self sealing action is lost. It is mainly seen in case of blunt instruments and also when beginners start learning small incision surgery. It can be prevented by using sharp instruments for all the cases as far as possible. Intraocular buttonholing of the tunnel can also increase the incidence of postoperative wound leak.

Treatment is suturing of the wound.

•Size of wound is large: The proper self-sealing action of the wound to lost. In these cases wound leak is prevented by taking single suture after the surgery is over.

•Side port entry: The size of opening becomes more. This will increase the leakage of aqueous through the port and thus leading to wound leak. This can be prevented by using sharp blade with proper technique. It can be treated by taking single suture if leaking is seen postoperatively. Hydration of side port and main wound also ensures self-sealing action of wound and reduce incidence of postoperative wound leak.

Intraocular pressure of about 20 should be present at end of surgery for tight closure of scleral tunnel.

Shallow AC

Common cause of shallow AC

a.Wound leak: They may occur through the main wound usually and sometimes through side port. The management of wound leak has already been discussed above.

b.Choroidal detachment: It is another important cause of shallow anterior chambers. It can lead to reduce intraocular pressure.

Management Initial treatment includes pressure pad and bandage, which is given for 24 hrs. This can lead to formation of anterior chamber and then settling of choroids back into its normal site. Medical treat- ment—includes systemic steroids and local mydriatic eyedrops. Inspite of the above management the chamber remains shallow then surgical management is required. This includes drainage of suprachoroidal space. After drainage air bubble is kept into anterior chamber.

Iris Prolapse2

This is another important complication seen postoperatively (Figure 37.10). This may be due to:

•Wound gapingSecondary to improper wound construction of the wound and in cases of large size tunnel.

•Sudden increase in intraocular pressure in patients with chronic cough and bronchial ashthma.

•Postoperative blunt trauma.

Early treatment is very important to prevent the complications such as endophthalmitis.

Management Immediate iris prolapse is treated by iris reposition and formation of anterior chamber with viscoelastics and resuturing of scleral tunnel.

a.If iris is epithelized then iris abscission is done.

b.The scleral tunnel should be free of any uveal tissue. A single suture is taken to form the

Figure 37.10: Iris prolapse. (Courtesy: Online Journal of Ophthalmology. Prof J Wollensak, Berlin, Germany)

Figure 37.11: Striate keratopathy

anterior chamber. Iris prolapse usually cause shift in position of the lens. The lens is dialed properly so that it is well placed.

Corneal Complications

This is one of most important vision threatening complication seen postoperatively. This includes:

a.Striate keratopathy: this is characterized by folds in Descemet’s membrane (Figure 37.11).

b.Corneal edema: Important cause – for corneal edema includes:

—Preoperative corneal degeneration – which includes corneal guttata or from low endothelium count.

—Hard nuclear cataract.

—Endothelial touch with the instrumentthis is usually seen in small tunnel and hard cataract

—Diabetes

—Increase in intraocular pressure

Management Corneal complication arising from endothelial damage can be prevented by using high molecular weight viscoelastics. The chamber should be always deep. Viscoelastics acts as support for the endothelium and prevents if from getting damage from hard cataract.

Immediate management includes:

•Frequent instillation of local steroids.

•Topical mydriatics

Mild corned edema usually gets cleared with this management within 7-10 days. Initial one week of management is very important in treatment of corneal edema.

In case of severe corneal edema-local instillation of 5 percent sodium chloride is very important. It is available in eyedrop and ointment forms. Corneal endothelial cells recover function and regain its clarity very soon. But these eyedrops should not be used for more than one month.

Topical antiglaucoma agents can be instilled in order to reduce intraocular pressure, which may be increased in cases of severe corneal edema.

Very severe corneal edema usually does not respond to this management. This will eventually lead to corneal decompensation. These patients usually require–Penetrating Keratoplasty.

Iritis

Inflammation of uveal tissue commonly occurs:

a.Secondary to increase handling. The handling of uveal tissue – seen in cases of hard cataracts, small rigid pupils, small tunnel and due to instrumental trauma.

b.Viscoelastics in AC can also cause iris reaction.

c.If cortical wash is incomplete.

d.In case of PC tear with vitreous loss if not managed properly.

Prevention

a.Decrease handling of uveal tissue

b.Wash away all viscoelastics from AC

c.Try to remove as much cortex as possible.

d.Do a good automated vitrectomy.

Management

a.Local steroids: Eyedrops like Prednisolone eyedrops or Hydrocortisone eyedrops are used. These are instilled at a frequent interval initially. The frequency is gradually reduced as inflammation reduces.

b.Local mydriatics: Atropine or Atropine substitutes like Homatropine can be used. These drops cause

breaking of posterior synechiae and gives rest to eyeball.

c.Systemic Steroids like Prednisolone 1 mg/kg can be used in cases of severe reactions.

Hyphema

Common source of blood in anterior chamber includes:

a.Bleeding from scleral tunnel

b.Trauma to iris

c.Expulsion hemorrhage

Improper cauterization of episcleral blood vessels

can lead to blood clots in anterior chamber. These can be present intraoperatively also. If scleral tunnel is not self-sealing, blood can flow into the anterior chamber from the conjunctival vessels.

Intraoperative increase handling of iris or instrumental trauma of uveal tissue can lead to hyphema postoperatively.

Prevention

a.Proper cauterization of episcleral blood vessels

b.Good wound construction.

c.Decrease uveal tissue handling

Management The absorption of hyphema occurs through two routes. Main route is canal of Schlemm and other route is iris vessels.

a.Propped up position.

b.If IOP is high – start antiglaucoma agents which mainly include local β-blockers

c.Topical steroids and oral steroids–are also started

d.Cycloplegic eyedrops

e.Systemic vitamin C

Hyphema may take 5-7 days to clear. But if there is severe hyphema then paracentesis with drainage of anterior chamber can be done. Irrigation of the anterior chamber with BSS with or without fibrinolysin is performed.

Decentered IOL

The common condition in which decentration of IOLs are seen:

a.Implantation of IOL in presence of PC tear and vitreous loss due to large tear–IOL may slide downwards or sideward, leading to decentration.

b.In case of can opener capsulotomy – haptic of IOL may get entangled in capsular flap – leading to

decentration of IOL

c. IOLs with small optics

d.Improper implantation of IOLs.

e.Implantation of lens in sulcus.

Prevention Proper implantation of lens in the bag is very important. In large PC tear in many cases scleral fixated lens are used. Proper dialing of IOL is also important. IOL tap test should always be done.

Management This will depend on:

a.Degree of decentration

b.Complaint of patient

If degree of decentration is minimal and without any complaints. No intervention is carried out. If there is obvious decentration – then redialing of IOLs should be done. In presence of PC tear and vitreous loss, lens implantation is a very important step and should be done with minimal handling. There are chances of IOL getting displaced into vitreous. One can also remove the IOL and replace it or fix the IOL transclerally. Try to construct the pupil and then examine the amount of aphakic part of pupil. If there is large aphakic area then intervention is required.

Distorted or Irregular Pupil

In many cases only pupillary dilatation can correct pupillary capturem, i.e. cases in which optics get entangles in iris tissues. If vitreous gets incarcerated then Nd: YAG Laser can be used to cut the tractional bands or in case of thick fibrosis bands, Vitrectomy is done.

This change in shape of pupil is caused by:

a.Presence of posterior synechiae – formed due to iris handling.

Prevention

a.Complete cleaning of viscoelastic material from the anterior chamber.

b.Size of air bubble kept in AC should be small. After injecting air bubble in AC, always flush irrigating saline through side port behind the air bubble. This will reduce the size of bubble and will help in its absorption.

Treatment

a.Local/systemic steroids given to reduce the tissues reaction seen due to retained cortical matter.

b.If cortical matter is more, then AC wash is done to remove the cortical matter. If it is seen in vitreous then pars plana removal of cortical matter is done.

c.Vitreous incarceration will require surgical vitrectomy

d.Peripheral iridectomy and antiglaucoma medication may need to be started

e.Treatment of suprachoroidal hemorrhage includes drainage of suprachoroidal fluid.

Hypotony

Important causes leading to decrease in intraocular pressure are:

a.Wound leak.

b.Choroidal detachment

c.Retinal detachment

Management of wound leak has already been covered and treatment of retinal and choroidal detachment is dealt in other Chapter.

Raised Intraocular Pressure/Secondary Glaucoma

Immediate rise in IOP postoperatively may due to

a.Presence of viscoelastic material.

b.Air bubble in anterior chamber.

c.Pupillary block glaucoma due to vitreous

d.Uveitis secondary to retained cortical matter

e.Suprachoroidal hemorrhage with shallow AC.

f.Malignant glaucoma.

These agents can be used for 2 to 3 months and the response is seen. Usually long standing Bullous keratopathy fails to respond to the therapy and these are the cases, which will respond best to penetrating Keratopathy.

Conjunctival Flap Retraction6

When large conjunctival flap is taken with excess of cauterization, the conjunctival flap fails to cover the

scleral funnel properly. Use of excess of topical steroids also causes non-healing of conjunctival flap.

This complication can be prevented by avoiding excessive cauterization, use of adequate conjunctival flap and covering the tunnel by cauterization of conjunctiva with forceps. This helps in covering the scleral wound adequately.

Pupillary Capture of IOL6

Common causes of pupillary capture includes:

a.Placement of IOL in sulcus.

b.Implantation of IOL in presence of large PC tear with vitreos loss

c.Presence of vitreous in AC can cause traction leading to pupillary capture.

Management Long standing pupillary capture can lead to adhesion between iris and lens. This adhesion may cause disturbance in stability of the lens leading to pupillary capture. Inject Viscoelastics and try to break the synechiae and release the adhesion. This can reduce the pupillary capture of IOL. If the patient is asymptomatic with good visual acuity then the pupillary capture is left behind. The incidence of uveal reaction is more after rehandling of the lens.

Posterior Capsular Opacification

This is most common cause of decrease visual acuity after cataract surgery. Commonest causes are:

a.In almost all pediatric cataract.

b.Patients in which cortical matter is left behind

c.Patients with large posterior capsular tear with vitreous loss some amount of retained cortical matter can cause capsular opacification.

d.High incidence in surgical aphakics (ECCE).

Management Includes mainly slit lamp examination to confirm the diagnosis and evaluate the thickness of PCO. In case of surgical aphakia the PCO is of fibrous variety (Figure 37.12).

Treatment

A.Nd: YAG Laser Capsulotomy: It is many times OPD procedure. In this case capsulotomy is done with No. 26 needle. This treatment requires accurate focusing and use of minimum amount of energy to puncture the capsule. The wavelength used is 532 m. In Q Switched laser the power setting is between 1 and 2.5 mj/pulse and with mode locked laser it is between 3 and 5 mj/ pulse (Figure 37.13).

Figure 37.12: Elschnigs Pearl

(Courtesy: Eye Atlas, the Online Atlas of Ophthalmology)

Figure 37.13: Nd: YAG laser capsulotomy. (Courtesy: Online Journal of Ophthalmology. Prof J Wollensak, Berlin, Germany)

Antiglaucoma agent is instilled prior to laser therapy to prevent rise in intraocular pressure. While performing YAG capsulotomy, it is important not to damage the IOL. An opening of 3 mm is usually sufficient to improve the visual acuity. The opening should be made in the visual axis.

A.Surgical capsulotomy This is mainly indicated in cases of thick capsular opacification, which is not breaking with YAG Laser. It is also used for pediatric cases and in mentally retarded patients who have difficulty in focusing for laser treatment. This is done

by using No. 26 needle or with the help of IOL dealer. In cases of thick fibrous PCO – vannas scissor can be used to cut the fibrous band.

Expulsive Hemorrhage4

It is one of the most dreaded complications of cataract surgery. The incidence in open chamber surgery is more than closed chamber operation, like Manual Small Incision Surgery and Phacoemulsification. The first report of expulsive hemorrhage associated with cataract surgery is attributed to de Wenzel who described it in 1786.

Types: Hemorrhage may be limited or massive (explusive).

Expulsive hemorrhage may occur:

a.On the table.

b.Postoperatively.

Prevention

a.Always check the intraocular pressure digitally before starting the surgery.

b.Avoid open chamber surgery.

c.Try to go for phacoemulsification or manual small incision surgery.

d.Check the blood pressure preoperatively.

Treatment

a.Immediately close the wound. This ensures no exit area for the contents to move. Take multiple sutures for firm closure of wound,

b.Immediate posterior sclerotomy to release the suprachoroidal blood. Forced injection of fluid such as saline or BSS into the anterior chamber helps in pushing the retina and choroids backward. This also promotes evacuation of subchoroidal hemorrhage.

c.After bleeding has stopped, reopen the wound and do good anterior vitrectomy. This is done to prevent the fibroplastic reaction caused due to disturbed vitreous and blood within the eye. Then the anterior chamber is formed and resuturing is done.

Pars plana vitrectomy is indicated in case of severe intraocular hemorrhage. Evaluation of peripheral retina is also important. If there is associated retinal detachment then it is managed accordingly.

Postoperative Management

Main aim is to reduce the inflammation. Corticosteroids are used. They are given both systemically and topically.

Mydriatics are also given to give rest to eyeball. Systemic Nonsteroidal antiinflammatory agents are used to reduce the pain.

REFERENCES

1.Gholam A Payman, Donald R, Sanders, Morton F. Goldberg. The lens cataract and its management, principle and practice of ophthalmology 580-618.

2.Jack J. Kanski Disorders of the lens. Clinical Ophthalmology, 286-309.

3.Howard Fine, Mark Packer, Richard S. Hoffman. Small Incision Cataract Surgery 349-56.

4.Norman S. Jaffe, Mark S. Jaffe, Gary F. Jaffe. Cataract Surgery and its Complications

5.KPS Malik, Ruchi Goel. Intraoperative complications of SICS – Manual of Small Incision Cataract Surgery 7785.

6.KPS Malik, Ruchi Goel. Postoperative complications of SICS, Manual of Small Incision Cataract Surgery 89-96

7.KR Murthy. Phaco Surgery and Foldable IOLs. Complications during phacoemulsification 11.1-11.2.

8.Colman R. Kraff and Manus C. Kraff. Cataract Surgery. Complications in Ophthalmic Surgery 4.2-4.22.

9.Mary Abraham. Complications of Phacoemulsifications. Modern Ophthalmology.

10.Jaffe NS. Results of intraocular lens Implantation surgery. Third Binkhorst Medal Lecture. Am J Ophthalm 1978;85;13-23.

11.Sparks GM. Descemetopexy; Surgical reattachment of stripped Descemet membrane. Arch Ophthalmology 1967;78:31-4.

12.Sugar HS. Prognosis in stripping of the Descemet’s membrane in cataract extraction. Am Journal of Ophthalm 1967;63;140-3.

13.Christensen L. Postoperative Flat Chamber. In Symposium in Cataract. New Orleans Acad of Ophthalm. 1965 The CV Mosby Co.

14.Leipmann ME. Intermittent visual “White Out“ a new intraocular lens implantation. Ophthalmology 1982;89: 109-12.

15.Apple DJ, Reidy JJ, Olson RJ, et al. The Comparison of Ciliary Sulcus and capsular bag fixation of the IOL. J Am Intraocular Implant Society 1985;11:44-63.

16.Bloom SM. Wyszynski RE. Brucker AJ. Scelral fixation suture for dislocated posterior chamber IOL. Ophthalmology 1990;21:851-4.

17.Girad LJ, Mino N, Wesson M, et al. Scleral fixation of Subluxated postchamber lens. Journal of cataract and Refractive Surgery 1998;14:326-7.

18.Clinical Practice in Ophthalmology 230-33.

Cataract surgery can lead to various posterior segment complications. The complications seen are:

1.Cystoid macular edema.

2.Vitreous hemorrhage.

3.Dislocated IOLs.

4.Suprachoroidal hemorrhage.

5.Endophthalmitis.

6.Retinal detachment.

7.Choroidal detachment.

8.Vitritis.

CYSTOID MACULAR EDEMA

Management

Main aim of management is to compare the visual acuity after decreasing the macular edema.

Treatment includes:

a.Medical

b.Surgical

MEDICAL

Therapeutic agents need for treatment of CME includes:

1.Corticosteroids preparations

2.Non-inflammatory agents steroidal anti

3.Carbon anhydrase inhibitor agents.

It represents one of the most common cause of poor visual acuity after cataract surgery (Figures 38.1, 38.2A and B). The various theories put forward to explain the pathogenesis are:

a.Vitreous traction on macula: If there is posterior rupture with vitreous loss there is capsular traction caused on macula from the vitreous. In cataract extraction there is high incidence of vitreomacular traction syndrome leading to cystoid macular edema.

b.Vitreous incarceration in wound:19 Vitreous gets incarcerated in case when complete vitrectomy is not done. The incidence is quite less nowadays due to use of automated vitrectomy.

c.Secondary inflammation: This can cause of breakdown of blood aqueous barriers and lead to formation of cystoid macular edema.

d.Inflammatory mediators like prostaglandin can also cause formation of cystoid macular edema.

1.Corticosteroids: Steroids decrease the release of arachidonic acid from the cell membrane thereby reduces the level of prostaglandin. This will help in treatment of cystoid macular edema. Various preparations available are:

a.Topical: Prednisinone. Acetate eyedrops 1% Dexamethasone eyedrops.

b.Peribulbar: Triamcinolone 20 mg. This is injected in Subtenons space.

c.Oral/Systemic: Predn. Tablets 1 mg/kg.

The long-term improvement in CME is not well seen and so steroids are not a main line of management.

2.Non-steroidal anti-inflammatory agents: These drops block the cyclooxygenase enzyme and thus reduce the level of prostaglandins. These drugs are very useful in decreasing the macular edema.

Preparations available are:

1.Systemic: Indomethacin is the best drug available for the treatment of CME.9 It is also available in

Figure 38.1: Fundus photograph

Cystoid macular edema

Figure 38.2A: Fundus fluorescein angiography Cystoid macular edema

Figure 38.2B: Optical coherence tomography Cystoid macular edema

sustained release form. Indomethacin 25 mg QID is given for 4-6 weeks to reduce the edema.

2.Topical: Flurbiprofen eyedrops (0.3%) Diclofenac eyedrops (0.3%) Ketorolac eyedrops

These agents have to be given for at least 4 to 6 weeks to show its response.

Carbon anhydrase inhibitor: These agents have shown to reduce the level of macular edema if given postoperatively. They help in pumping the edema fluid out.

Preparations

i.Acetazolamide 250 mg. Tab.

ii.Methazolamide.

Long-terms are of these agents are not indicated due to its adverse side effects.

SURGICAL

It includes:

a.YAG Laser Vitreolysis, and

b.Vitrectomy.

Nd: YAG Laser Vitreolysis: Patients with CME and

vitreous incarceration responds slowly to management than individual without vitreous. Thus, presence of vitreous increases the time of resolution of CME.

Therefore, Nd: YAG Laser vitreolysis breaks down the vitreous strands, which get absorbed and reduces macular edema. Fibrosed vitreous strands are difficult to break. This will require vitrectomy.

VITRECTOMY

The main role of vitrectomy is:

1.Removal of vitreous adhesions

2.Removal of inflammatory mediator in vitreous.

Vitrectomy is usually delayed till CME is stable. Vitrectomy is beneficial in cases of aphakia chronic cystoid macular edema. Indications18 for vitrectomy based on randomized controlled study on chronic aphakic macular edema.

A.Vitrectomy should not be considered until the visual acuity has been stable for 2-3 months.

B.Vitrectomy should be considered if visual acuity is 20/80 or worse.

C.Vitrectomy can be performed by pars plana or limbal route.

D.Hypertension is regarded as bad prognostic factor.

• Main line of management of CME: It includes: Topical corticosteroids + Topical NSAIDs for

about 4 to 6 weeks

↓

If no response

↓

Peribulbar or subtenon depot injections can be given

↓

If no response

↓

Start on carbonic anhydrase inhibitor

↓

Last step is the surgical management

•Nd: YAG laser vitreolysis

•Vitrectomy.

Prognosis

The prognosis for full restoration of visual acuity is generally good. The macula regains its normal appearance after edema subsides.

Last step is surgical treatment:

a.YAG laser vitreolysis

b.Vitrectomy.

Photocoagulation may be tried but it is not quite

successful.

Vitreous Hemorrhage

Vitreous hemorrhage7 is defined as the presence of extravasated blood with the space outlined by internal limiting membrane posteriorly and laterally, the nonpigment epithelium of ciliary body anterolaterally and the lens zonules and postero lens capsule anteriorly.

The occurrence of massive vitreous hemorrhage to impair the vision seriously after cataract surgery is uncommon. But mild variety of hemorrhage is common.

Blood from vitreous can gain entrance into anterior chamber and vice versa via rent in anterior hyaloid membrane. Most intravitreal hemorrhages are caused by rupture of diseased blood vessels. Massive intravitreal hemorrhage results from rupture of short posterior ciliary artery, long posterior ciliary artery or choroidal artery (Figure 38.3).

Fate of Blood within the Vitreous1

a.Blood may undergo absorption resulting in no or little damage.

b.Hemorrhage within the vitreous may organize rapidly and form fibrous bands.

Figure 38.3: Vitreous hemorrhage

Treatment: The choice of treatment depends on several factors.1 They include:

1.The patient’s age

2.The duration of disease

3.Visual acuity

4.Intraocular pressure

5.Amount of hemorrhage

6.Status of retina

7.Neovascularization of iris

8.Associated conditions like diabetes and hypertension.

The treatment options available are:7

1.Observation

2.Laser photocoagulation

3.Anterior retinal cryotherapy

4.Vitrectomy

1.Observation: Fresh vitreous hemorrhage often clears in days to weeks, and therefore, critical observation is very important. Reevaluation of retina is very important if absorption does not take place, we should proceed to next step.

Eyes suitable for treatment are those with:

•Poor visual acuity

•No improvement in vitreous transparency has occurred

•Anterior segment is healthy.

2.Anterior retinal cryotherapy (ARC):7 It is indicated in eyes with fresh vitreous hemorrhage. ARC causes breakdown of blood retinal barrier, which leads to clearance of liquefied blood.

3.Vitrectomy: Indications for vitrectomy are: