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Clinicopathologic Reports, Case Reports, and Small Case Series
August 2004

Capsular Bag Hematoma Following Trabeculectomy

Arch Ophthalmol. 2004;122(8):1229-1230. doi:10.1001/archopht.122.8.1229

Since its introduction in 1967, trabeculectomy has become the standardsurgical treatment modality for most forms of glaucoma. The early postoperativecomplications reported are hypotony, shallow or flat anterior chamber, hyphema,choroidal detachment, uveal effusion, wound leak, malignant glaucoma, suprachoroidalhemorrhage, and endophthalmitis.1,2 Wedescribe an interesting case of a capsular bag hematoma following trabeculectomy,a hitherto unreported complication.

Report of a Case

A 57-year-old man was initially examined at our tertiary care instituteand had a history of total visual loss in his left eye following surgery forglaucoma elsewhere 3 weeks earlier. On examination, his best-corrected visualacuity was 20/30 in the right eye, and hand motions close to his face withaccurate projection of rays in the left eye. Intraocular pressure in the rightand left eyes was 14 and 12 mm Hg, respectively. The left eye revealed a thinmoderate-sized bleb and a quiet anterior chamber with normal depth. Resultsof a dilated examination revealed a posterior synechia at the pupillary marginat the 1 o'clock position and a peripheral iridectomy in the same meridian.The crystalline lens appeared to have a brownish hue throughout, with a brightred collection in the anterior subcapsular area just behind the area of posteriorsynechia (Figure 1, arrow). Therewas no view of the posterior segment. Findings from a B-scan ultrasonogramrevealed a normal posterior segment in the left eye. The patient was postedfor phacoemulsification and aspiration of the blood along with intraocularlens implantation. Capsular staining with trypan blue failed to provide adequatecontrast in view of the dark reflex of intralenticular contents. Capsulorhexiswas then achieved from the anterior capsule reflex under high magnification.Phacoemulsification power was totally ineffective in removing the blood-impregnatedepinuclear shell, and it had to be manually stuffed into the port of the phacotip with a chopper. A normal red reflex was achieved as soon as this bloodclot was removed, and a hydrophilic acrylic intraocular lens was implantedin the capsular bag. The early postoperative period was uneventful, and thepatient achieved a best-corrected visual acuity of 20/30. Within the next2 months, there developed an excessive capsular bag fibrosis with mild upwarddecentration of the intraocular lens.

Left eye of the patient showing a brownish hue of intralenticularcontents. Note the area of bright red anterior subcapsular blood collection(arrow).

Left eye of the patient showing a brownish hue of intralenticularcontents. Note the area of bright red anterior subcapsular blood collection(arrow).

Comment

Although hyphema is one of the most common early postoperative complicationsfollowing trabeculectomy, to our knowledge, intralenticular collection ofblood has not been previously reported. Because of the use of an operatingmicroscope and the refinement of surgical techniques, lens injury during trabeculectomyhas been infrequently reported.3 We hypothesizedthat there had been anterior capsule injury while performing peripheral iridectomyin this case, with seepage of blood into the capsular bag.

The development of a fibrous type of posterior capsule opacificationin relation to the presence of blood in the capsular bag, as was evident fromthe exaggerated postoperative capsular bag fibrosis in this case, has beenpreviously noted.4 This case highlightsthe possibility of lens injury during trabeculectomy and provides an insightinto the problems encountered while performing phacoemulsification when thereis intralenticular blood collection.

The authors have no relevant financial interest in this article.

Correspondence: Dr Brar, Department of Ophthalmology, PostgraduateInstitute of Medical Education and Research, Chandigarh 160012, India (eyepgi@satyam.net.in).

References
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Edmunds  BThompson  JRSalmon  JFWormald  RP The National Survey of Trabeculectomy, III: early and late complications. Eye. 2002;16297- 303
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Watson  PGJakeman  COzturk  MBarnett  MFBarnett  FKhaw  KT The complications of trabeculectomy (a 20-year follow-up). Eye. 1990;4425- 438
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Swan  KCLindgren  TW Unintentional lens injury in glaucoma surgery. Trans Am Ophthalmol Soc. 1980;7855- 66
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Apple  DJSolomon  KDTetz  MR  et al.  Posterior capsule opacification. Surv Ophthalmol. 1992;3773- 116
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