Recurrent transient visual loss in the elderly is mostly associated
with cardiovascular disorders. Other causes include giant cell arteritis,
migraine, increased intracranial pressure, orbital mass, and idiopathy. We
describe a patient with unusual recurrent transient visual loss after deep
sclerectomy with collagen implant (DSCI).
A 75-year-old woman was referred for investigation of possible amaurosis
fugax. She complained of recurrent painless blurred vision in her left eye
for the past 6 months. Her medical history was relevant for common migraine
and systemic hypertension. Systemic medications included losartan potassium,
hydrochlorothiazide, lorazepam, carvedilol, and aspirin. Severe bilateral
glaucoma necessitated trabeculectomy in the right eye in 1994 and DSCI in
the left eye in 1996. Both procedures were uneventful.
The episodes of visual loss in the left eye occurred on average once
a week, lasted up to 24 hours, and affected her ability to read. Some episodes
occurred after performing gymnastic exercises, after bending forward, and
once after sneezing. She had no symptoms or signs suggesting giant cell arteritis.
Best-corrected visual acuity was 20/40 OD and 20/25 OS. Pupil examination
revealed a 2+ right relative afferent defect. Intraocular pressure (IOP) was
11 mm Hg in the right eye and 14 mm Hg in the left. Fundus examination revealed
bilateral glaucomatous disc atrophy that was severe in the right eye (cup-disc
ratio, 0.9) and moderate in the left eye (cup-disc ratio, 0.5). Visual field
defect was severe in the right eye and moderate in the left.
Results of investigations, including a complete blood cell count, erythrocyte
sedimentation rate, cardiovascular examination, precerebral Doppler and cerebral
magnetic resonance imaging, and angiography, were normal.
Several similar episodes have occurred since she was examined. A few
hours after onset of the latest episode, examination of the left eye showed
visual acuity of 20/50−2, 2 mm of hyphema (Figure 1), and IOP of 38 mm Hg; gonioscopy revealed active bleeding
through a microperforation in the trabeculo-Descemet membrane at the site
of surgery (Figure 2).
Hyphema (2 mm) in the left eye.
Gonioscopy revealed actively bleeding
blood vessels at the site of the trabeculo-Descemet membrane.
Because of repeated bleeding episodes and increased IOP in the left
eye, the site of DSCI underwent reoperation. Many actively bleeding blood
vessels surrounding the Schlemm canal orifice were found and coagulated. No
further bleeding has occurred since, and the IOP remained less than 15 mm
Hg without therapy.
Transient visual loss secondary to recurrent hyphema has been reported
after trabeculectomy1 and after cataract
surgery with either an iris suture2 or an
anterior chamber implant3 but not after
nonpenetrating filtering surgery. Nowadays, DSCI is becoming a common technique
to safely lower IOP and is believed to be less traumatic than trabeculectomy
because of the nonpenetrating technique.4
More than 1500 patients have undergone DSCI in our department (unpublished
data); however, recurrent hyphema occurred only in the present case. During
surgery, no obvious perforation was noted, but we cannot rule out the possibility
of a microperforation of the trabeculo-Descemet membrane.
Recurrent hyphema after DSCI could result from spontaneous bleeding
of anomalous scleral blood vessels at the site of surgery (such as in the
present case), venous hypertension (Valsalva phenomenon) with blood reflux
in the Schlemm canal, or a combination of both. Aspirin therapy might have
also contributed to the bleeding.
History of previous filtering surgery in the setting of transient visual
loss should then prompt gonioscopy and a careful anterior chamber examination
for the presence of hyphema or blood reflux through the trabeculo-Descemet
Corresponding author: François-Xavier Borruat, MD, Hôpital
Ophtalmique Jules Gonin, Avenue de France 15, CH-1004 Lausanne, Switzerland
Ambresin A, Borruat F, Mermoud A. Recurrent Transient Visual Loss After Deep Sclerectomy. Arch Ophthalmol. 2001;119(8):1213-1215. doi: