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Case Reports and Small Case Series
October 2000

Retinal and Subhyaloid Hemorrhage as a Complication of Laser Iridectomy for Primary Angle-closure Glaucoma

Arch Ophthalmol. 2000;118(10):1446-1449. doi:

Retinal hemorrhage following glaucoma surgery is a rare complication reported as decompression retinopathy1 and central retinal vein occlusion2 following trabeculectomy for open-angle glaucoma. To our knowledge, we report the first retinal hemorrhage occurring as a complication of argon laser iridectomy for primary angle-closure glaucoma. Two patients had retinal hemorrhage and 2 others had a hemorrhage mainly in the subhyaloid space.

Report of Cases
Case 1

A 68-year-old Japanese woman with a dark iris was diagnosed with acute angle-closure glaucoma in her left eye. The initial visual acuity was hand movements OS. The intraocular pressure (IOP) was 70 mm Hg OS despite medical treatment. She suffered from mild anemia, angina pectoris, and mild hypertension, all controlled with medication. Funduscopic examination revealed a pale, edematous optic disc. After an intravenous drip infusion of a hyperosmotic agent and administration of 1% pilocarpine hydrochloride eyedrops, laser iridectomy was performed using an argon laser (wavelength, 514 nm, Coherent 930 Argon/Dye; Coherent Co, Auburn, Calif) and an Abraham iridotomy lens. Stretch burns were placed in a circle using a 200-µm spot size, 150 mW of power, and a 0.2-second duration. Punch burns were applied using a 50-µm spot size, 600 to 1000 mW of power, and a 0.05-second duration. A total of 407 burns were placed. The IOP was 24 mm Hg OS immediately following the procedure.

On day 1, the iridectomy closed and the IOP increased to 62 mm Hg. Laser iridectomy was performed again resulting in a total of 147 punch burns. The patient noticed blurred vision the next day, and funduscopic examination revealed a hemorrhage in the subhyaloid space on and around the optic disc and along the superotemporal vascular arcade (Figure 1, A). A small amount of retinal hemorrhage was also observed. Retinal veins were moderately tortuous. Fluorescein angiography revealed no prolonged retinal circulation time or occlusion of retinal vessels (Figure 1, B). The indocyanine green videoangiography showed pulsation of the central retinal vein and staining of the retinal artery and vein on the optic disc (Figure 1, C). Following phacoemulsification of the lens with intraocular lens implantation and goniosynechiolysis, the IOP was controlled at 14 mm Hg OS without medication. Biomicroscopic examination and ultrasound echography revealed a posterior vitreous detachment (PVD). Six months later, the subhyaloid hemorrhage had disappeared and the patient's visual acuity was 20/30 OS.

Figure 1.
Patient 1, left eye. A, Twenty-two days after argon laser iridectomy the subhyaloid hemorrhage is present. B, Fluorescein angiography 1 day after the second laser iridectomy revealed no central retinal vein occlusion (23 seconds after dye injection). C, The indocyanine green angiography 1 day after the second laser iridectomy showed staining of the retinal artery and vein on the optic disc (14 seconds after dye injection).

Patient 1, left eye. A, Twenty-two days after argon laser iridectomy the subhyaloid hemorrhage is present. B, Fluorescein angiography 1 day after the second laser iridectomy revealed no central retinal vein occlusion (23 seconds after dye injection). C, The indocyanine green angiography 1 day after the second laser iridectomy showed staining of the retinal artery and vein on the optic disc (14 seconds after dye injection).

Case 2

A 53-year-old Japanese woman was diagnosed with acute angle-closure glaucoma in both eyes. Her general health was good. Initial visual acuity was hand movements OD and 20/25 OS. The IOP was 76 mm Hg OD and greater than 76 mm Hg OS. Funduscopic examination revealed no remarkable change. Laser iridectomy was performed on both eyes using an argon laser, with additional enlargement by Q-switched Nd:YAG laser (Microruptor III; LASAG, Thun, Switzerland) using a single pulse of 0.5 mJ and total energy of 3.9 mJ to the right eye and 6.9 mJ to the left eye, respectively. Immediately following the procedure, the IOP decreased to 14 mm Hg OD and 53 mm Hg OS.

The next day, the IOP was 14 mm Hg OD and 34 mm Hg OS, and funduscopic examination revealed subhyaloid hemorrhage, retinal hemorrhage, tortuous and dilated retinal veins, and an edematous optic disc in the left eye. There was no abnormal change in the right fundus. Fluorescein angiography revealed no retinal vein occlusion. Ultrasound echography showed a PVD. On day 3, the subhyaloid hemorrhage proceeded to a hemorrhage in the vitreous gel. Following argon laser gonioplasty, the IOP was controlled at 18 mm Hg OD and 19 mm Hg OS. Two months later, the vitreous hemorrhage had resolved and visual acuity had improved to 20/15 OD and 20/20 OS.

Case 3

A 78-year-old Japanese woman was diagnosed with acute angle-closure glaucoma in the left eye. She had mild hypertension controlled with medication. Visual acuity was 20/40 OS and the IOP was 70 mm Hg despite receiving medication. There was no fundus abnormality and ultrasound echography revealed no PVD. Laser iridectomy was performed using an argon laser.

On day 1, the IOP was 19 mm Hg; a 4-blot hemorrhage was noted in the retina and another on the optic disc. Fluorescein angiography revealed no abnormalities. Ultrasound echography showed a PVD. Three months later, the retinal hemorrhage had resolved. Visual acuity was 20/20 OS and the IOP was controlled (<20 mm Hg) without medication.

Case 4

A 66-year-old Japanese woman was diagnosed with acute angle-closure glaucoma in the left eye. She had mild hypertension controlled with medication. Visual acuity was 20/50 OS and the IOP was 76 mm Hg despite receiving medication. There was no fundus abnormality and ultrasound echography revealed no PVD. Laser iridectomy was performed using an argon laser, and immediately after the procedure the IOP was 42 mm Hg OS.

On day 1, the IOP was 11 mm Hg OS; a 2-blot hemorrhage was noted in the retina, 1 of which had a white center (Figure 2). No optic disc edema or tortuosity of the retinal vessels was noted. Visual acuity improved to 20/20 OS and the IOP was controlled (<20 mm Hg) without medication.

Figure 2.
Patient 4, left eye. Funduscopic view of the blot retinal hemorrhage with a white center.

Patient 4, left eye. Funduscopic view of the blot retinal hemorrhage with a white center.

Comment

Retinal hemorrhage is a rare complication of glaucoma surgery. Fechtner et al1 reported retinal hemorrhage as a complication of trabeculectomy for open-angle glaucoma, referring to it as "decompression retinopathy." They suggested that acute lowering of the IOP probably reduced resistance to blood flow and that the increased blood flow likely had overwhelmed the mechanical stability of the capillaries, resulting in multiple focal endothelial leaks. Defects in the autoregulatory mechanism in patients with glaucoma3 also have been suggested as contributory to the development of hemorrhage. Although decompression retinopathy usually occurs in young and generally healthy patients, our 3 patients were elderly and hypertensive.

In patients 1 and 2, acute lowering of the IOP might have induced tortuosity of retinal veins, optic disc edema, and retinal hemorrhage. However, in these 2 patients, the hemorrhages in the subhyaloid space were marked. Retinal hemorrhage resembling central retinal vein occlusion has been reported as a complication of trabeculectomy.2 However, in our patients there was no disturbance in the retinal circulation angiographically and the hemorrhagic pattern was different from that in central retinal vein occlusion. The hemorrhage in the subhyaloid space could occur in severe decompression, but another hypothesis might be suggested as the cause of subhyaloid hemorrhage in our patients. In an acute phase of angle-closure glaucoma, the volume of aqueous humor in the posterior chamber increased markedly caused by pupillary block, and vitreous gel was pushed toward the posterior pole (Figure 3, A). In our 2 patients, the preoperative IOP in the affected eyes was extremely high, resulting in a correspondingly significant displacement of vitreous gel. However, following laser iridectomy, aqueous flowed suddenly from the posterior chamber to the anterior chamber through the iridectomy. Additionally, outflow through the trabecular meshwork and the administration of a hyperosmotic agent and carbonic anhydrase inhibitor further decrease aqueous volume, and hyperosmotic agents remove fluid from the vitreous and may accelerate contraction of the vitreous. The forward displacement and contraction of the vitreous gel would induce a rapid PVD, disrupting small vessels in the retinal surface or optic disc (Figure 3, B).4 Posterior vitreous detachment, in fact, was observed in these 2 patients after laser iridectomy, although ultrasound examination was not performed before the procedure. Posterior vitreous detachment was also observed after laser iridectomy in patient 3. However, there are still some problems to be solved in this hypothesis; eg, does the normal anterior hyaloid face offer significant resistance to aqueous passage in pupillary block? Retinal hemorrhage has been reported following the administration of hyperosmotic agents.5 Therefore, the exact mechanism resulting in subhyaloid hemorrhage remains unclear.

Figure 3.
A possible mechanism whereby subhyaloid hemorrhage occurs following argon laser iridectomy for primary angle-closure glaucoma. A, In an acute phase of angle-closure glaucoma, aqueous humor in the posterior chamber increases owing to pupillary block, and vitreous gel is pushed toward the posterior pole. B, Following iridectomy, aqueous flows from the posterior chamber to the anterior chamber, which allows the previously displaced vitreous gel to move forward, creating a posterior vitreous detachment that disrupts small vessels on the surface of the retina.

A possible mechanism whereby subhyaloid hemorrhage occurs following argon laser iridectomy for primary angle-closure glaucoma. A, In an acute phase of angle-closure glaucoma, aqueous humor in the posterior chamber increases owing to pupillary block, and vitreous gel is pushed toward the posterior pole. B, Following iridectomy, aqueous flows from the posterior chamber to the anterior chamber, which allows the previously displaced vitreous gel to move forward, creating a posterior vitreous detachment that disrupts small vessels on the surface of the retina.

Since, as our cases demonstrate, retinal and subhyaloid hemorrhage can occur after laser iridectomy for acute angle-closure glaucoma, especially in patients with extremely high preoperative IOP, surgeons should be aware of this possible complication.

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Article Information

Corresponding author: Akira Obana, MD, Department of Ophthalmology, Osaka City University Medical School, Asahi-machi 1-4-3, Abeno-ku, Osaka City 545-8585, Japan (e-mail: akira-kun@med.osaka-cu.ac.jp).

References
1.
Fechtner  RDMinckler  DWeinreb  RNFrangei  GJampol  LM Complications of glaucoma surgery: ocular decompression retinopathy. Arch Ophthalmol. 1992;110965- 968Article
2.
Dev  SHerndon  LShields  MB Retinal vein occlusion after trabeculectomy with mitomycin C. Am J Ophthalmol. 1996;122574- 575
3.
Grunwald  JERiva  CEStone  RAKeates  EUPetrig  BL Retinal autoregulation in open-angle glaucoma. Ophthalmology. 1984;911690- 1694Article
4.
Tolentino  FISchepens  CLFreeman  HM Vitreous detachment. Vitreoretinal Disorders. Philadelphia, Pa WB Saunders Co1976;130- 154
5.
Feitl  MEKrupin  T Hyperosmotic agents. Ritch  RShields  MBKrupin  TedsThe Glaucoma. St Louis, Mo CV Mosby Co1989;551- 555
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