Interactive Case Reports

Endocapsular hematoma following combined phacoemulsification, endoscopic cyclophotocoagulation, and Kahook dual-blade goniotomy

Case Report Details

First Author: M.Chachanidze USA

Co Author(s):    A. Yuan   E. Klug   D. Solá-Del Valle              

Abstract Details

Purpose:

We report a case of endocapsular hematoma limiting visual recovery following uncomplicated phacoemulsification, endoscopic cyclophotocoagulation (ECP), and Kahook dual-blade goniotomy (KDB) in a patient with primary open-angle glaucoma (POAG). The hematoma was cleared successfully with Nd:YAG laser capsulotomy.

Setting:

This patient underwent preoperative evaluation, surgery and postoperative management at Massachusetts Eye and Ear, Harvard Medical School, Boston, USA.

Report of Case:

A 73-year-old woman with bilateral mild-to-moderate stage POAG underwent uncomplicated phacoemulsification and in-the-bag implantation of a toric intraocular lens (IOL) combined with ECP and KDB in her left eye for visually significant cataract and uncontrolled intraocular pressure (IOP). Her preoperative best-corrected visual acuity (BCVA) was 20/60 and her IOP was 17 mmHg on four different IOP-lowering drops. Her medical history was notable for daily naproxen use, which was discontinued 10 days prior to surgery. On postoperative day 1, she had a 1.9mm layered hyphema with 4+ mixed cells in the anterior chamber (AC). On postoperative week (POW) 1, her layered hyphema had resolved and AC inflammation had resolved sufficiently to permit a view of her IOL. At this time, a large endocapsular hematoma was seen, trapped between the posterior IOL and the posterior capsule, encompassing 80% of the capsule inferiorly. By POW 7 her BCVA had improved to 20/30 with approximately 50% resolution of the hematoma. She was maintained on a prolonged topical steroid taper over 3 months. At postoperative month 6, she reported worsening blurry vision. Her BCVA was stable at 20/30 but her uncorrected Snellen acuity had declined to 20/60 from 20/40. Her endocapsular hematoma was unchanged in size compared to POW 7, now with the appearance of two distinct layers of inferiorly layered erythrocytes and a narrower superior band of white material, which may represent layered leukocytes or dehemoglobinized blood. Her posterior capsule had central dense opacification. She underwent Nd:YAG capsulotomy at POM 7, which successfully cleared her visual axis and resolved the endocapsular hematoma.

Conclusion/Take Home Message:

Endocapsular hematoma is a rare type of anterior segment complication in which blood accumulates in the capsule posterior to the posterior chamber IOL.It has been described following 0.2-0.3% of phacoemulsification cases and has also been reported in extracapsular cataract extraction and combined cataract and glaucoma surgeries.The genesis of the blood is presumably either from hyphema,scleral wounds, neovascularization of the iris,or vitreous hemorrhage.Management of endocapsular hematoma includes observation, postural drainage, Nd:YAG capsulotomy, and intraocular lens exchange with anterior vitrectomy. Long-term sequelae of an untreated hematoma includes wrinkling and fibrosis of the posterior capsule. Kahook dual blade is a minimally invasive glaucoma surgery in which the most common complication is hyphema,likely exacerbated in this patient due to her routine use of a naproxen.We describe the first case of endocapsular hematoma after combined phacoemulsification and minimally invasive glaucoma surgery.Nd:YAG laser capsulotomy is a safe and effective way to drain the hematoma.

Financial Disclosure:

None