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Endoscopy assisted vitrectomy ( eav) for expulsive hemorrage .

Claude Boscher

Paris, France

Objective : evaluation of eav for expulsive hemorrage in this rare but devastating complication of ocular surgery : informations provided , results .

Purpose : endoscopy allows 1) viewing on 360°,through non transparent media, without scleral indentation ( potentially problematic after recent anterior surgery 2) viewing of the anterior " zonular " vitreous base , involved in anterior PVR and cyclitic membranes. Little recent information is provided by the litterature about expulsive hemorrage ; its treatment is challenging because of 1) frequent poor visualization due to emergency uncontrolled constrained maneuvers during the causative procedure , and to fresh corneal wound 2 ) frequent poor prognosis and phtisis bulbi.

Methods : retrospective non randomized non comparative consecutive interventional case series ; 13 eyes in 13 patients (3 monocular) , between 69 and 90 years old (mean 74 years ) ( except one high myopic , aged 50) were referred between January 1996 and February 2002 , after anterior segment surgery in 11 eyes (85%) ( cataract : 7 eyes (with capsular rupture in 3 ) , combined cataract-trabeculectomy : 1 eye , repeated trabeculectomy : 1 eye , penetrating keratoplasty :1 eye , secondary IOL repositioning in 1 eyewith previous trabeculectomy ) , after retinal detachment (encircling buckle ,drainage , under anticoagulants) in 1 eye, and vitrectomy for lens dislocation in 1 eye . Primary surgery had been performed under local anesthesia in all eyes . Expulsive hemorrage was simultaneous to the causative procedure in all but 2 eyes (delay 1 and 5 days ). Timing for vitrectomy varyied from 2 to 34 days (mean 18 days), according to referal delay . 6 eyes were aphakic , 6 eyes pseudophakic, 1 eye phakic ; 2 eyes were high myopic . Preoperative visual acuity was limited to light perception in all eyes . Anterior segment condition was severely altered in 4 eyes ( 31 %) (hemocornea in 1 eye , severe corneal edema in 2 eyes , iridodialysis in 1 eye , iris inclusion in the corneal wound in 1 eye , hyphema in 3 eyes ); intraocular pressure was high in 5 eyes , low in 2 eyes . A fiber optics endoscopic probe including a laser channel , and a peristaltic pump vitrectomy machine, were used ; patients charts , operative reports and video recording have been reviewed . Follow up data were provided by the referring ophthalmologists . 1 patient deceased after 2 years of follow up , 1 patient is lost after 3 years follow up.

Results : 1) anatomical observations : a) choroid : " kissing choroidals " in 3 eyes ( 23% ) ( with inferior retinal incarceration in the corneal wound in 1 case ) , fluid choroidal hemorrage in 9 eyes (69%), solid clots hematomas in 2 eyes (15%) (timing for vitrectomy : 7 days ) , exclusively fibrotic organized suprachoroidal hematoma , in 2 eyes (timing for vitrectomy : 22 and 34 days ) (with chronic choroidal detachment preventing PFCL choroidal and retinal flattening , despite fibrotic hematoma browsing , in the late case ) . b) cyclitic membrane was found in 2 eyes (15%) (timing for vitrectomy : 30 and 34 days ) : complicated by rhegmatogenous - tractional RD with tears regarding the sclerotomy sites , anterior and posterior PVR ( epi and subretinal ) , in 1 patient referred after failure of conventional vitrectomy ; complicated by tractional detachment only , and pre atrophic white ciliary processes in the other eye. c ) vitreous : PVD and anterior retraction in all but one high myopic eye (posterior vitreoschisis ), fluid dense red hemorrage in 4 eyes, organized with fibrin in 5 eyes . d) retina : RD was present in 4 eyes ( 31%) (inferior retina incarceration in the corneal wound : 1 case , anterior and posterior PVR after failure of conventional vitrectomy : 1 case, tractionnal RD from contr action of posterior border of anterior vitreous base in 2 eyes ; submacular fluid blood was found in 4 eyes ( 31%) , submacular fibrotic clot in 1 eye e) lens : dislocated nucleus fragments in 3 eyes , IOL dislocation in 1 eye . 2 ) perioperative complications : entry site problems , despite anterior sclerotomy ( 2.5 to 3 mm ) : a) control of the penetration of the endoscopic probe itself because of blood obscuration of the tip , with subsequent 1 week post poning of the vitreous surgery in 2 cases (15%) (timing of vitrectomy : 7 days) b) infusion line incarceration inside pars plana , despite controlled perforation by MVR blade , and despite ciliary hematoma/detachment drainage, because of swelling of elastic ciliary tissue , requiring subsequent placement of infusion line in anterior chamber in 2 eyes (15%) .
3) associated perioperative maneuvers were :anterior segment revision : 3 eyes ; ciliary drainage alone in 6 eyes (46%) , ciliary and equatorial choroidal drainage in 3 eyes (23%), browsing of a fibrotic suprachoroidal hematoma in 1 eye , pars plana phakoemulsification in 1 eye , lens nucleus fragments evacuation through limbus in 2 eyes , intravitreal PFCL injection in 7 eyes , IOL explantation in 1 eye , sulcus IOL implantation in 2 eyes (with suturing in 1 eye) , TPa intravitreal injection in 1 eye , gas internal tamponade in 10 eyes , silicone oil in 2 eyes , inferior iridectomy in 2 eyes , scleral buckling in 2 eyes.
4) Follow up : 3 ( 23 %) patients were reoperated (macular pucker peeling in : 1 eye , silicone oil injection in 1 eye) , tractional RD occured one year later in the first eye of the series , where anterior vitreous base peeling had been incomplete . Retina is attached in 12 ( 92%) eyes . Silicone oil is still present in 3 eyes .1 eye ( 8%) (refered after failure of conventional vitrectomy ) is atrophic . 6 eyes ( 46%) achieved best corrected visual acuity ³ 20/100 ; in 6 eyes functional results are limited by previous ocular condition , and / or associated corneal damage .

Conclusions : eav 1) allowed to overcome visualization problems created by anterior segment alteration 2) to obviate anterior ciliary vitreous retinal displacement and to prevent entry site related complications in all primary cases 3 ) however obscuration of the endoscopic probe tip by massive intravitreal hemorrage can prevent visualization in cases operated at 1 week . 4) endoscopic close dissection of anterior vitreous base allows prevention of anterior PVR , prevention and treatment of cyclitic membrane, provided that a) endoscopic cleansing af anterior vitreous base is absolutely complete b) surgery is not delayed nor jeopardized by previous incomplete vitrectomy ; retinal stabilization by PFCL injection greatly facilitates and secures this time consuming and potentially iatrogenic maneuver . As in trauma a) training in endoscopy ( orientation , video control) is mandatory in these complicated cases b) satisfactory timing for eav seems to be between 1 and 2 weeks , depending on the severity of intravitreal hemorrage , to ensure clarity through the endoscopic probe itself.