A bloody mystery behind the intraocular lens

A 67-year-old male, a known case of primary open-angle glaucoma with a history of hypertension and cardiac disease, who was on blood thinners and prostaglandin analogue, presented with complaints of diminution of vision in the left eye (LE). On examination, the best corrected visual acuity (BCVA) was 6/9 in both eyes (BE) with an intraocular pressure (IOP) of 12 mmHg and 19 mmHg. The anterior and posterior segments of BE revealed immature cataracts and glaucomatous cupping, with a cup-disc ratio of 0.8. He underwent minimally invasive glaucoma surgery (MIGS) (Tanito hook) + Phaco in LE. Post-operative day (POD) 1 revealed BCVA of 6/9 with a few small blood clots in the anterior chamber (AC) with IOP of 14 mmHg. POD 15 he presented with a fresh re-bleed behind the intraocular lens (IOL), almost filling half of the bag [Fig. 1] with BCVA of 6/60 and IOP 15 mmHg. The patient underwent a meticulous AC wash and achieved 6/6 vision with IOP 11 mmHg without anti-glaucoma medication.Figure 1: Fresh re-bleed behind the intraocular lens almost filling half of the capsular bagDiscussion MIGS using Tanito hook is an ab-interno trabeculotomy which increases the natural aqueous outflow through the collector channels. The procedure involves incising the trabecular meshwork nasally over 4–5 hours to enhance the aqueous outflow through Schlemm’s canal. Hyphema, transient IOP rise, hypotony, and inflammation are the few reported complications with MIGS.[1] Most hyphemas resolve with conservative management.[2] However, few patients with high-risk factors like blood dyscrasias, chronic hypertension, and on blood thinners are prone to recurrent bleeding. Post-operative hyphema typically presents in AC; however, it is very rare to see a fresh re-bleed behind the IOL occurring 2 weeks after the surgery. The challenge in this case was accessing the bleed behind the IOL, as there were severe adhesions between the anterior lens capsule and the IOL, which required gentle manipulation using the spatula to clear the adhesions and wash away the bleed [Figs. 2-4].Figure 2: Adhesions noted between the anterior lens capsule and the intraocular lensFigure 3: Intra-operative image showing the use of a spatula to clear the adhesionsFigure 4: Intra-operative view after thorough anterior chamber washCareful pre-op assessment and stopping blood thinners before surgery may help most patients.[3,4] However, when blood thinners are restarted post-surgery, there is a risk of re-bleeding. Hence, it is crucial to have a close follow-up of these patients to identify such re-bleeds that may lead to recurrent hyphema and vision loss. Authors' contributions Tosha Gujarathi: Concept, Design, Literature search, Data Acquisition, Definition of intellectual content, Manuscript preparation, Manuscript editing. Sharmila Rajendrababu: Definition of intellectual content, Manuscript preparation, Manuscript editing, Manuscript review. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship: Nil. Conflicts of interest: There are no conflicts of interest.