Evaluation of recurrent hyphema after trabeculectomy with ultrabiomicroscopy 50-80 MHz: a case report
© Mannino et al.; licensee BioMed Central Ltd. 2012
Received: 23 May 2012
Accepted: 17 September 2012
Published: 4 October 2012
Hyphema is a complication that can occur after glaucoma filtering surgery. Biomicroscopic examination of the anterior segment is commonly used to diagnose it and gonioscopy may provide a useful support to find the source of the haemorrhage. Unfortunately, when the blood hides the structure of the anterior segment the gonioscopic examination fails. In this case we performed ultrabiomiscroscopy with 50–80 MHz probes to overcome the limits of gonioscopy. The use of this technique to study the anterior segment of the eye has previously been reported in literature, but we illustrates its importance for performing a correct diagnosis in a specific case of hyphema.
We report a case of a sixty-year-old caucasian male with recurrent hyphema in the left eye. The episodes of hyphema were four in two years and the patient came to the hospital for the first time in the last occasion. The past episodes were managed with topical corticosteroids and mydriatic drops. He referred surgical trabeculectomy in both eyes 5 years before the first symptoms and no specific eye trauma before the first episode. The examination of the anterior segment revealed a 2 mm hyphema in the left eye due to blood leakage through the superior iridectomy. Gonioscopy could not identify the source of the haemorrhage. B-scan ultrasound and ultrabiomiscroscopy, with 50–80 MHz probes, were performed. Ultrabiomiscroscopy, mainly with the probe of 80 MHz, provided images of high resolution of the structures of the anterior segment and it allowed the visualization of an abnormal vessel at the inner margin of the trabeculectomy opening, probably responsible of the recurrent hyphema.
Ultrabiomicroscopy proved to be a useful diagnostic technique for identifying the cause of the recurrent hyphema when other examination techniques are not applicable.
Hyphema is a complication that can occur after glaucoma filtering surgery, although the causes are not always well known[1, 2]. In some cases abnormal vessels have been detected at the internal margin of the trabeculectomy opening and they are supposed to be the cause of the haemorrhage.
Gonioscopy normally, when present, can show the neovascularization of the irido-corneal angle but it has a limited application when blood hides the structures of the anterior segment.
In these cases ultrabiomicroscopy (UBM), using 50 MHz and 80 MHz probes, can provide images of high resolution of the anterior segment revealing the cause of the haemorrhage. We have reported a case of recurrent hyphema in a patient with an abnormal vessel at the internal margin of the trabeculectomy successfully found with UBM.
The aim of the therapy of glaucoma is to preserve the visual function and to avoid progressive anatomical and functional damages with minimal side effects. The reduction of intraocular pressure is commonly obtained by the use of topical drugs as the first-line treatment of glaucoma. When this therapy fails, both laser and surgical therapies are useful in the management of glaucoma. Filtering trabeculectomy remains the “gold standard” therapy for long-lasting intraocular pressure reduction in uncontrolled glaucoma. It works through a trans-scleral fistula that allows the outflow of the aqueous humour in the subconjunctival space, establishing a filtering bleb. The most known complications of trabeculectomy surgery are bleb leakage and failure, hyphema, retinal and choroidal haemorrhages, endophthalmitis, chronic hypotony, cataract[1, 2].
Hyphema consists in the presence of blood in the anterior chamber of the eye. It may appear as a reddish tinge or it may appear as a small pool in the lower part of the anterior chamber. Hyphema is often caused by injury and according with its extension it may partially or completely block vision. Among the other causes of hyphema there are uveitis, intraocular tumours, congenital disorders, systemic hypertension, retinal detachment, haematological diseases and cataract surgery[6, 7]. Hyphema can be rarely associated with antiplatelet or anticoagulant therapy and also with Fuchs’ heterochromic cyclitis (FHC). In our case we also excluded the uveitis-glaucoma-hyphema (UGH) syndrome, which may occur after cataract surgery. Moreover recurrent hyphema has been described as both an early and late complication of glaucoma filtering surgery[1, 3]. Wilensky hypothesized that after trabeculectomy the cases of recurrent hyphema are more frequent than those reported. This happens mainly in older patients who have a poor visual acuity because of the contemporary presence of cataract and glaucoma, in which slight changes of visual acuity might not be noticed. Most of hyphemas spontaneously resolve without complications but in some cases they may require a specific treatment. In fact a long-standing hyphema may result in hemosiderosis and heterochromia. Blood accumulation may also cause an increase of the intraocular pressure, which is dangerous mostly in glaucomatous eyes. In most of the cases of hyphema the interruption of any antiplatelet or antitrombotic drugs, the elevation of the head of approximately 45 degrees associated with bedrest are sufficient to its resolution. In refractory cases or in those with associated high intraocular pressure, argon laser treatment is useful to stop directly the source of the haemorrhage. The identification of the source of bleeding is crucial and UBM can be helpful to get it.
In this case report, the patient complained of recurrent hyphema after a failed glaucoma filtering surgery and it was decided to perform a laser treatment because of the recurrent episodes of hyphema. Slit-lamp examination revealed an active bleeding through the superior iridectomy but it was not capable of finding the source of the haemorrhage. B-scan ocular ultrasound with 10 MHz probe, did not show any pathological echoes in the vitreous chamber and according to literature, UBM with 50 and 80 MHz probes was carried out to explore the trabeculectomy area, the anterior and the posterior segments[11, 12]. UBM with 50 MHz probe showed no active bleeding from iris or ciliar processes related to IOL and it revealed a hyperreflective area at the internal margin of the trabeculectomy. These features were better studied with UBM 80 MHz probe that showed a hyperreflective area from which hyperreflective elements jutted in the anterior chamber. These images likely corresponded to an anomalous bleeding vessel at the internal margin of the trabeculectomy and probably the hyperreflective elements were blood cells.
Comparing UBM using 80 MHz probe with the other above mentioned diagnostic techniques, we suggest the usefulness of its high resolution images for detecting the precise site of the haemorrhage on which a successful targeted argon laser coagulation was performed.
Moreover ultrabiomicroscopy may prove a suitable diagnostic technique in all those conditions in which detailed images of the eye structure are required. This is valid both for primary ocular diseases and for ocular involvement in systemic conditions.
In our opinion, ultrabiomicroscopy proved to be a useful diagnostic technique for identifying the cause of the recurrent hyphema when other examination techniques are not applicable.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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