Case No. 1
An 85-year-old white female underwent uncomplicated, planned extracapsular cataract extraction (ECCE) and insertion of a posterior chamber IOL (PCIOL) with a convex-plano optic. On the first postoperative day, the patient displayed a 65% anterior chamber hyphema and elevated IOP. I administered timolol to lower her IOP, and the hyphema slowly reabsorbed. As the hyphema cleared, I noted blood behind the IOL optic (Figure 1) and in front of an intact posterior capsule (endocapsular hematoma). This blood failed to clear over 3 months, and the patient's vision was 20/60. As a result, she was unhappy with her surgical outcome.
Case No. 2
An 84-year-old white male underwent an uncomplicated ECCE and insertion of a convex-plano PCIOL. On the first postoperative day, I noticed a large endocapsular hematoma (Figure 2). Although it failed to clear, the patient's vision improved to 20/20, and he had no complaints.
Case No. 3
An elderly white male underwent phacoemulsification and cataract extraction through a small, self-sealing scleral tunnel incision. My colleagues and I inserted a biconvex IOL in the capsular bag. On the first postoperative day, we no-ted a large endocapsular hematoma (Figure 3). The patient complained of blurred vision and glare, and the blood failed to clear over the course of several months' observation.
1. Which patients should you treat?
2. What treatment should you use?
3. How should you perform this treatment?
4. What surgical techniques or types of implants might you use to prevent endocapsular hematomas in other patients?
SURGICAL COURSEs AND OUTCOMEs
Case No. 1
I used a YAG laser capsulotomy to drain the posterior capsular blood into the vitreous cavity. The postoperative treatment course was uneventful, and the patient's vision improved to 20/30.
Case No. 2
Although the endocapsular hematoma looked large and visually disabling, the patient was satisfied with the surgical result and did not experience glare problems. I could easily visualize the posterior segment of the eye through the layer of blood. I did not perform further treatment.
Case No. 3
My colleagues and I used a YAG laser capsulotomy to open the blood-stained posterior capsule. The postoperative treatment course was uneventful, and the patient's vision improved to 20/20.
During the 1980s and 1990s, surgeons performed planned ECCEs and insertions of PCIOLs through relatively large, sutured incisions, and they regularly reported endocapsular hematomas. Although some surgeons reporting their cases used the term posterior chamber hyphema, the more accurate term, now accepted by clinicians worldwide1,2 to describe the condition of blood in the posterior chamber behind an IOL optic, is endocapsular hematoma.
Many cases of postoperative endocapsular hematomas occurred in glaucoma patients undergoing either ECCE with PCIOL insertion or ECCE with PCIOL insertion and glaucoma filtration surgery (usually a trabeculectomy). The surgery was usually uncomplicated, and surgeons often noted a hyphema of varying size on the first postoperative day. The source of the blood was from the surgical incision.
Patients are sometimes asymptomatic, especially if the blood is located outside the visual axis, small in quantity, thin in depth, or reabsorbs partially or completely. An anatomical or vascular predisposition may exist if patients have experienced bilateral endocapsular hematomas.
Treatment is generally straightforward. Lower significant IOP with anti-glaucoma medication and allow time for the blood to settle and/or reabsorb. Severely restricting activity or prescribing bed rest is not appropriate, and surgical intervention by irrigating the blood from behind the IOL optic is also unnecessary. It is important to note that these recommendations refer only to endocapsular hematomas; blood in the anterior chamber-hyphemas is a different complication and may require more aggressive therapy.
A YAG laser capsulotomy has been uniformly curative for endocapsular hematoma. The surgeon can drain the blood into the vitreous cavity by opening the capsule superiorly and extending the capsulotomy inferiorly as the blood behind the optic egresses. If the capsule is blood-stained, the surgeon may open it with a standard YAG capsulotomy procedure. The surgeon may vary the laser energy levels, the number of spots applied, or the use of burst mode during this procedure, but these techniques should not be difficult for a surgeon who feels comfortable with routine YAG capsulotomies for opaque capsules.
There are no firm guidelines on timing the YAG laser capsulotomy drainage of endocapsular hematomas. If the patient is symptomatic (ie, has glare or blurred vision) and vision impaired, and the blood is not clearing with 1 or 2 weeks of observation, I recommend proceeding with treatment. In some instances (such as case No. 2), if the patient has no visual complaints and satisfactory visual acuity, and if you can sufficiently visualize the posterior pole, then you may forgo a YAG laser capsulotomy.
With the gradual evolution and acceptance of sutureless, small phacoemulsification incisions, which have generally moved from scleral to limbal, near-clear, and clear corneal placement, the incidence of endocapsular hematomas has greatly diminished. To date, an endocapsular hematoma has not been reported with clear corneal incisions for cataract phacoemulsification and PCIOL placement.John C. Hagan III, MD, is the Editor of Missouri Medicine: The Medical Journal of the Missouri State Medical Association. He practices ophthalmology at the Discover Vision Centers in Kansas City, Missouri. Dr. Hagan may be reached at (816) 478-1230; email@example.com.
1. Hagan III JC, Gaasterland DE. Endocapsular Hematoma: Description and Treatment of a Unique Form of Postoperative Hemorrhage. Arch Ophthalmol. 1991;109:514-518.
2. Hagan III JC, Menapace R, Radax U. Clinical Syndrome of Endocapsular Hematoma: Presentation of a Collected Series and Review of the Literature. J Cataract Refract Surg. 1996;22:379-384.