Intra-bleb hematoma and hyphema following digital ocular compression.

We report successful outcome of a huge post- trabeculectomy intra-bleb hematoma and hyphema that occurred following digital ocular compression. The patient was a 64-year-old lady suffering from bilateral primary angle closure glaucoma and cataract. She was on anti-platelet therapy. She underwent single-site phacoemulsification, intra-ocular lens implantation and trabeculectomy with mitomycin C in the right eye. The trabeculectomy was under-filtering. She was asked to perform digital ocular compression thrice daily. On 15(th) post-operative day, she presented with a huge intra-bleb hematoma and hyphema. The hematoma did not respond to conservative measures and was drained to prevent bleb failure. We recommend caution in the consideration of digital ocular compression in patients on prophylactic anti-coagulation.

Introduction

Digital ocular compression is a proven maneuver to improve the surgical success of trabeculectomy.[1] The reported complications of ocular compression are many,[1] but the list does not include intra-bleb sub-conjunctival hemorrhage, and hyphema. To our knowledge, this is the first report of such a complication in a patient on anti-platelet therapy.

Case Report

The case was a 64-year-old lady with moderate cataract, primary angle closure glaucoma, essential hyper-tension, and ischemic heart disease. She was on three topical anti-glaucoma medications besides anti-platelet therapy (Clopidogrel and Aspirin, each 75 mg/day). Her vision was 6/18, N6 in both eyes. She had a functional laser peripheral iridotomy in both eyes. The applanation pressures measured 22 and 19 mm Hg in right and left eyes, respectively. The angles were open with patchy trabecular meshwork pigmentation. The right optic disc had a cup-to-disc ratio of 0.8:1 with inferior rim loss of two clock hours. The left optic disc had a cup-to-disc ratio of 0.7:1 with inferior rim excavation of one clock hour. Humphrey visual field (Humphrey perimeter, Carl Zeiss Meditec, Dublin, CA) revealed bilateral superior arcuate scotoma, worse in the right eye [Figure 1].

Figure 1

Humphrey visual fields of the patient

She underwent single site phacotrabeculectomy (with intra-ocular lens implantation) + Mitomycin C under peri-bulbar anesthesia in the right eye. The anti-platelet agents were stopped 5 days prior to and were re-started 3 days post-surgery. The triangular scleral flap was secured with one releasable 10-0 nylon suture (GN Corporation Ltd., Japan) at the apex and two interrupted 10-0 nylon sutures at the base. The eye was unremarkable on the first post-operative day.

On eighth post-operative day, the intraocular pressure (IOP) in the right eye was 26 mm Hg. The bleb was shallow. The anterior chamber was deep. Gonioscopy ruled out internal obstruction of the sclerostomy. Digital ocular compression was ineffective. The releasable suture was removed. Subsequent digital ocular compression resulted in elevation of the bleb and reduction in IOP to 13 mm Hg. She was instructed to perform digital ocular compression. The technique was to look up and apply constant, moderate digital pressure to the inferior sclera through the lower eyelid. She was asked to perform three 5-10-second sets of ocular compressions, 10 seconds apart, three times daily.

On 15th post-operative day, she presented with rapid onset blurred vision, redness, and pain in the operated eye. A huge intra-bleb hematoma [Figure 2] and hyphema [Figure 3] were noted. The IOP was 40 mm Hg. Her bleeding time was 3 min 30 s (normal is 2-9 min), and clotting time was 5 min 20 s (normal is 5-15 min). Topical and systemic anti-glaucoma mediations were started. She was instructed to discontinue digital ocular compression.

Figure 2

Huge intra-bleb hematoma as a complication of digital ocular compression

Figure 3

Hyphema as a complication of digital ocular compression

On 19th post-operative day, the intra-bleb hematoma was unchanged, hyphema was almost resolved, and the IOP was 26 mm Hg. The intra-bleb hematoma was drained through a limited peritomy 6 mm posterior to the limbus. Needle revision of the scleral flap was done with a 27-gauge needle under direct visualization. The conjunctival incision was closed with an 8-0 polyglactin (Ethicon inc., Aurangabad, India) continuous interlocking suture. At the end, 5-Flurouracil (5-FU; 5.0 mg/0.1 mL) was injected in the sub-conjunctival space adjacent to the bleb. Anti-glaucoma medications were discontinued. Post-procedure 5-FU (5.0 mg/0.1 mL) was injected in the inferior fornix every alternate day for a week. Four weeks later, the IOP was 16 mm Hg. The bleb was shallow and diffuse. At the 3-month follow-up visit, the IOP was 18 mm Hg and the bleb was functional [Figure 4].

Figure 4

A successful outcome of the complication; a diffuse, shallow, functional conjunctival bleb

Discussion

Digital ocular compression can be useful to elevate the bleb and reduce IOP in the early post-operative period, especially after release of releasable suture(s).[1] One must rule out internal obstruction of the sclerostomy for digital ocular compression to be effective. The patient should also clearly understand the maneuver since its potential complications are many.[1] However, the maneuver can be more comfortably done after trabeculectomy and single-site phacotrabeculectomy compared to two-site phacotrabeculectomy considering the corneal incision in the latter procedure.[2] A customized force application ocular massage device to circumvent the disadvantages of the variability in the applied force during digital ocular compression has been described.[3]

Hemorrhagic complications rarely occur in the intermediate or late post-operative period following an uncomplicated trabeculectomy.[456] Such events have been reported spontaneously,[4] following release of scleral flap suture[5] or needle revision of the bleb.[6] Lalchan[4] reported spontaneous intra-bleb hemorrhage and hyphema as a late post-trabeculectomy complication in a patient of Fuchs Heterochromic Cyclitis (FHC) complicated with secondary open angle glaucoma. Like ours, the patient was on aspirin prophylaxis. There was no identifiable trigger for the hemorrhage; a combination of minor ocular trauma (rubbing/wiping the eye), FHC, and anti-platelet therapy was speculated.[4]

Patients on anti-platelet or anti-coagulation therapy are prone for an increased incidence and severity of hemorrhages, either spontaneous or following trauma, as described in eyes following phacoemulsification.[7] Inadvertent rupture of an immature blood vessel crossing the edge of the scleral flap during ocular compression is a possibility in our case. The extravagant sub-conjunctival blood might have had tracked down into the anterior chamber.

A critical review of bleeding time concluded that bleeding time is not a specific indicator of platelet function and is a poor indicator of bleeding risk.[8] Also, pre-operative aspirin was shown to have inhibitory effect on platelet activity, but no significant effect on clotting time compared to no-aspirin patients.[9]

Autologous blood is injected into the bleb to reduce over-filtration or to treat bleb leaks after filtering surgery.[110] The known complications of autologous blood injection include bleb failure.[110] In our case, there was a possibility of bleb failure, if the hematoma had been left to spontaneous resolution. We recommend caution in the consideration of digital ocular compression in patients on prophylactic anti-coagulation therapy.