Endocapsular Hematoma
ate
To the Editor.\p=m-\We read with great interest the article by Hagan and Gaasterland1 on endocapsular hematoma in the April 1991 issue of the Archives. The authors believe that this type of postoperative hemorrhage is a "previously unreported entity." However, to our knowledge, their article is the third report. In 1989, Thomas et al2 first described a case of endocapsular hematoma in which patients underwent postural drainage. Our report immediately followed.3 We treated patients with this condition conservatively, and it took about 100 days for its disappearance. The delayed absorption in all these cases clearly shows that proteolytic enzymes and phagocytes cannot easily reach and remove the accumulated blood cells in the capsular bag.
Okihiro Nishi, MD Kayo Nishi, MD Motoko Nishi, MD
postoperative bleeding include bleeding from an iridec¬
tomy site that is placed too basal, and in the later postopera¬ tive period, bleeding from wound vascularization, or uveal tissue chafing by the posterior chamber intraocular lens, ie,
uveitis-glaucoma-hyphema syndrome or microhyphema syn¬ drome. A final source of bleeding is neovascularization of the
anterior segment, mainly in diabetic patients. It is intriguing to consider whether the style of the intra¬ ocular lens is implicated in the frequency of this hemorrhage as reported by the authors. I believe that the rarity of this type of hematoma, considering the frequency of this proce¬ dure in the United States, may concern the popularity of biconvex vs convexoplano posterior chamber intraocular lenses, and the tendency toward smaller wound size. I also commend the authors on their astuteness in noninvasively treating the condition with neodymium-YAG laser
capsulotomy.
Osaka, Japan HaganJCIII,
Gaasterland DE. Endocapsular hematoma: description and unique form of postoperative hemorrhage. Arch Ophthalmol. 1991;109:514-518. 2. Thomas R, Aylward GW, Bilson FA. 'In-the-bag' hyphaema: a rare complication of posterior chamber lens implantation. Br J Ophthalmol. 1989;73:474-475. 3. Nishi K, Nishi M, Nishi O. A case of'in-the-bag'hyphaema after posterior chamber lens implantation. Eur J Implant RefSurg. 1990;2:217-218.
1.
treatment of a
To the Editor.\p=m-\I read with interest the article by Hagan and Gaasterland describing six patients with a postoperative capsular bag hyphema following "uncomplicated" extracapsular cataract extractions with posterior chamber intraocular lens
implantation.
One type of hyphema confined to the capsular bag has been previously described by Eifrig et al.1 It occurred in a diabetic patient who had evidence of neovascularization of both the iris and the capsular bag. In this case, the bleeding did not occur immediately following the surgical procedure, but months later. Eifrig et al termed this separate but related entity rubeosis capsulare. In their "Comment" section, Hagan and Gaasterland do not discuss the history of glaucoma preoperatively in three of the six cases reported. In my experience, patients with glaucoma
tend to bleed more and have increased inflammation and intraocular pressure spikes in the immediate postoperative cataract period. This is probably due to their long-term topical antiglaucoma therapy and additional procedures needed to enlarge the pupil intraoperatively. Since four of the six patients had an associated anterior chamber hemorrhage, I agree with the authors that the source of the bleeding was most probably the incision in the sclera. Both early postoperative hypotony and preoperative clotting problems may potentiate oozing from the wound. The authors point out, and I agree, that a posteriorly placed cataract wound tends to bleed more. Other causes of immedi-
1. Eifrig DE, Hermsen V, McManus P, J Cataract Refract Surg. 1990;16:633.
Paul E.
McManus, MD Decatur, Ga Cunningham R. Rubeosis capsulare.
To the Editor. \p=m-\Thedescription and treatment of blood on the anterior surface on the posterior capsule reported by Hagan and Gaasterland is of great interest. I have had two similar cases that I termed posterior capsule blood staining. Both events followed phacoemulsification and intraocular lens insertion using a small incision. One of the procedures was combined with a trabeculectomy. In that case, there was a documented rise in intraocular pressure to 35 mm Hg in addition to hyphema. Both cases involved the implantation of a biconvex posterior chamber lens and required neodymiumYAG capsulotomy. Based on the slit-lamp examination and the appearance of the capsule following neodymium-YAG capsulotomy, the blood appeared to be on the anterior surface of the posterior capsule as opposed to being trapped between the posterior surface of the intraocular lens and the anterior surface of the posterior capsule. One may assume that the etiology of this "blood staining" is secondary to the passage of red blood cells from the anterior chamber through the pupil¬ lary aperture around the lens periphery, eventually coming to rest on the anterior surface of the posterior capsule. The authors state that "the biconvex configuration might offer advantages in preventing endocapsular hematoma or limiting the amount or thickness of the blood layer by obliteration of potential space behind the optic or inhibition of cellular migra¬ tion." Based on my experience, this phenomenon may occur with planoconvex or bioconvex lenses and is more likely to occur with a combination of hyphema and elevated intraocular pressure similar to corneal blood staining with an "eight ball hemorrhage." The authors are to be congratulated for identi¬ fying and reporting this condition, which is probably more common than we think. Hal D. Balyeat, MD Oklahoma City, Okla
Downloaded From: http://archopht.jamanetwork.com/ by a Karolinska Institutet University Library User on 06/02/2015
ate
To the Editor.\p=m-\We read with great interest the article by Hagan and Gaasterland1 on endocapsular hematoma in the April 1991 issue of the Archives. The authors believe that this type of postoperative hemorrhage is a "previously unreported entity." However, to our knowledge, their article is the third report. In 1989, Thomas et al2 first described a case of endocapsular hematoma in which patients underwent postural drainage. Our report immediately followed.3 We treated patients with this condition conservatively, and it took about 100 days for its disappearance. The delayed absorption in all these cases clearly shows that proteolytic enzymes and phagocytes cannot easily reach and remove the accumulated blood cells in the capsular bag.
Okihiro Nishi, MD Kayo Nishi, MD Motoko Nishi, MD
postoperative bleeding include bleeding from an iridec¬
tomy site that is placed too basal, and in the later postopera¬ tive period, bleeding from wound vascularization, or uveal tissue chafing by the posterior chamber intraocular lens, ie,
uveitis-glaucoma-hyphema syndrome or microhyphema syn¬ drome. A final source of bleeding is neovascularization of the
anterior segment, mainly in diabetic patients. It is intriguing to consider whether the style of the intra¬ ocular lens is implicated in the frequency of this hemorrhage as reported by the authors. I believe that the rarity of this type of hematoma, considering the frequency of this proce¬ dure in the United States, may concern the popularity of biconvex vs convexoplano posterior chamber intraocular lenses, and the tendency toward smaller wound size. I also commend the authors on their astuteness in noninvasively treating the condition with neodymium-YAG laser
capsulotomy.
Osaka, Japan HaganJCIII,
Gaasterland DE. Endocapsular hematoma: description and unique form of postoperative hemorrhage. Arch Ophthalmol. 1991;109:514-518. 2. Thomas R, Aylward GW, Bilson FA. 'In-the-bag' hyphaema: a rare complication of posterior chamber lens implantation. Br J Ophthalmol. 1989;73:474-475. 3. Nishi K, Nishi M, Nishi O. A case of'in-the-bag'hyphaema after posterior chamber lens implantation. Eur J Implant RefSurg. 1990;2:217-218.
1.
treatment of a
To the Editor.\p=m-\I read with interest the article by Hagan and Gaasterland describing six patients with a postoperative capsular bag hyphema following "uncomplicated" extracapsular cataract extractions with posterior chamber intraocular lens
implantation.
One type of hyphema confined to the capsular bag has been previously described by Eifrig et al.1 It occurred in a diabetic patient who had evidence of neovascularization of both the iris and the capsular bag. In this case, the bleeding did not occur immediately following the surgical procedure, but months later. Eifrig et al termed this separate but related entity rubeosis capsulare. In their "Comment" section, Hagan and Gaasterland do not discuss the history of glaucoma preoperatively in three of the six cases reported. In my experience, patients with glaucoma
tend to bleed more and have increased inflammation and intraocular pressure spikes in the immediate postoperative cataract period. This is probably due to their long-term topical antiglaucoma therapy and additional procedures needed to enlarge the pupil intraoperatively. Since four of the six patients had an associated anterior chamber hemorrhage, I agree with the authors that the source of the bleeding was most probably the incision in the sclera. Both early postoperative hypotony and preoperative clotting problems may potentiate oozing from the wound. The authors point out, and I agree, that a posteriorly placed cataract wound tends to bleed more. Other causes of immedi-
1. Eifrig DE, Hermsen V, McManus P, J Cataract Refract Surg. 1990;16:633.
Paul E.
McManus, MD Decatur, Ga Cunningham R. Rubeosis capsulare.
To the Editor. \p=m-\Thedescription and treatment of blood on the anterior surface on the posterior capsule reported by Hagan and Gaasterland is of great interest. I have had two similar cases that I termed posterior capsule blood staining. Both events followed phacoemulsification and intraocular lens insertion using a small incision. One of the procedures was combined with a trabeculectomy. In that case, there was a documented rise in intraocular pressure to 35 mm Hg in addition to hyphema. Both cases involved the implantation of a biconvex posterior chamber lens and required neodymiumYAG capsulotomy. Based on the slit-lamp examination and the appearance of the capsule following neodymium-YAG capsulotomy, the blood appeared to be on the anterior surface of the posterior capsule as opposed to being trapped between the posterior surface of the intraocular lens and the anterior surface of the posterior capsule. One may assume that the etiology of this "blood staining" is secondary to the passage of red blood cells from the anterior chamber through the pupil¬ lary aperture around the lens periphery, eventually coming to rest on the anterior surface of the posterior capsule. The authors state that "the biconvex configuration might offer advantages in preventing endocapsular hematoma or limiting the amount or thickness of the blood layer by obliteration of potential space behind the optic or inhibition of cellular migra¬ tion." Based on my experience, this phenomenon may occur with planoconvex or bioconvex lenses and is more likely to occur with a combination of hyphema and elevated intraocular pressure similar to corneal blood staining with an "eight ball hemorrhage." The authors are to be congratulated for identi¬ fying and reporting this condition, which is probably more common than we think. Hal D. Balyeat, MD Oklahoma City, Okla
Downloaded From: http://archopht.jamanetwork.com/ by a Karolinska Institutet University Library User on 06/02/2015
