Consequences of Clot Formation and Hyphema Post-Internal Trabeculotomy for Glaucoma.

PRCIS: Clot formation and hyphema following internal trabeculotomy represent distinct clinical entities. The eyes with clot formation exhibited a more pronounced postsurgical intraocular pressure spike, longer residual intracameral bleeding, and a higher risk of reoperation. PURPOSE: The aim of this study was to investigate the consequences of clot formation and hyphema in the anterior chamber after internal trabeculotomy. MATERIALS AND METHODS: In this retrospective interventional comparative study, we investigated the surgical outcomes of internal trabeculotomy in 142 eyes of 142 patients at Sensho-kai Eye Institute. RESULTS: Concurrent clot formation and L≥2 hyphema (height of hyphema ≥1 mm) was observed in 22 eyes. In these cases, the postsurgical IOP was 29.3 mm Hg at 1 week, significantly higher than the 16.1 mm Hg in eyes that had L≥2 hyphema but without clot formation ( P =0.0002). However, the 1-week postsurgical IOP in L≥2 hyphema and clot (-) eyes, which measured 16.1 mm Hg was not significantly greater than that in L<2 hyphema and clot (-) eyes, which measured 18.7 mm Hg ( P =0.162). Thus, clot formation was identified as a significant factor contributing to high postsurgical IOP at 1 week. The resolution time for anterior chamber bleeding in eyes with concurrent clot formation and L≥2 hyphema was 12.3 days, longer than the 5.8 days observed in L≥2 hyphema eyes without clot formation ( P =0.016). Among the 22 eyes with concurrent L≥2 hyphema and clot formation, 8 required anterior chamber washout. Three of the 10 eyes that underwent washout necessitated additional trabeculectomy, a rate significantly higher than that in nonwashout eyes ( P <0.001). CONCLUSIONS: After internal trabeculotomy, the sequelae of concurrent clot formation and L≥2 hyphema in the anterior chamber were more severe than those of simple hyphema without clots. Clot formation negatively affected postoperative IOP.

Postoperative hyphema due to persistent tunica vasculosa lentis in glaucoma associated with neurofibromatosis-a case report.

An 8-month-old girl referred from her pediatrician with a diagnosis of neurofibromatosis type 1 (NF1) presented with an enlarged cloudy cornea of the left eye and a swollen left side of the face. Her left eye had intraocular pressure (IOP) of 21 mm Hg, corneal diameter of 16 mm, ectropion uvea, cup:disk ratio of 0.9, axial length of 28.06 mm, and S-shaped upper lid deformity. Uneventful combined trabeculotomy-trabeculectomy with mitomycin C was performed. On postoperative day 1, there was a new total hyphema that persisted for 2 weeks. An anterior chamber washout was performed, revealing the source of bleeding to be a persistent tunica vasculosa lentis along the zonules of the lens. Viscotamponade was performed, and the corneal wounds were closed, with the ocular tension slightly elevated. Bleeding did not recur for the following 5 months, and IOP was controlled until final follow-up.

Spontaneous Unilateral Hyphema in a Newborn With Occiput Posterior Presentation: A Case Report.

Few cases of isolated spontaneous hyphema in the newborn have been reported. A case of a term vaginally delivered female newborn who was diagnosed as having a hyphema in the left eye 18 hours after birth is presented. Delivery was complicated with fetal head malposition and the delivery was prolonged. The mother was nulliparous and without significant medical history. The hyphema resolved within 3 days without complications or sequela. The authors review the literature of spontaneous newborn hyphema and link an association with fetal head malposition. [J Pediatr Ophthalmol Strabismus. 2024;61(1):e1-e3.].

A Case of Uveitis-Glaucoma-Hyphema Syndrome Related to a Hydrus Microstent.

Uveitis-Glaucoma-Hyphema (UGH) syndrome is characterized by episodes of anterior chamber inflammation, elevated intraocular pressure and hyphema. It is caused by a mechanical chafing of the iris or ciliary body typically by a malpositioned intraocular lens. We present a rare case of UGH syndrome related to the insertion of a Hydrus Microstent. Because of the increased number of microinvasive glaucoma surgeries being performed and a reduction of UGH syndrome patients related to the insertion of intraocular lenses, it is an important diagnosis to consider in patients with recurrent postoperative inflammation.

Characterization of Ocular Injuries Caused by Orbeez Hydrated Gel Pellet Projectiles: Clinical Insights and Implications.

PURPOSE: To examine the clinical characteristics of patients who have experienced blunt ocular injuries from "Orbeez" hydrated gel pellets (Spin Master Corp.), and to describe ocular morbidity, visual acuity (VA), and intraocular pressure (IOP) after Orbeez-related ocular trauma. DESIGN: Retrospective, institutional, observational case series. METHODS: Patients sustaining Orbeez-related ocular trauma at a single institution over a 13-month period were identified. Clinical parameters including VA, IOP, and anterior and fundus examination findings were assessed upon initial and final presentation. Basic statistical testing was performed to compare differences within this cohort. RESULTS: A total of 17 eyes from 17 patients with Orbeez-related trauma were identified. Orbeez-related blunt ocular injuries included corneal abrasion (n = 7), hyphema (n = 9), commotio retinae (n = 5), intraretinal hemorrhage (n = 3), preretinal hemorrhage (n = 1), vitreous hemorrhage (n = 2), and retinal tear (n = 1). Adolescents (14-18 years of age) showed higher rates of posterior segment complications compared to other ages (P = .0152). The presence of elevated IOP and hyphema upon initial examination correlated with increased likelihood of requiring invasive treatment following Orbeez impact (P = .0275). CONCLUSION: Orbeez-related ocular trauma may be associated with severe visual morbidity and varied anterior and posterior segment intraocular sequelae. Adolescents could be at increased risk for posterior segment complications following these injuries. Initial findings of elevated IOP and hyphema may indicate a need for more aggressive interventions. Prevention remains paramount in managing Orbeez-related ocular trauma; it is critical to raise awareness regarding the importance of wearing eye protection meeting high-impact standards and minimizing exposure to such projectiles.

The effect of axial length on the short-term outcomes of cataract surgery combined with ab interno trabeculotomy.

PURPOSE: Minimally invasive glaucoma surgery is safer and effective surgical modality for patients with glaucoma. To compare the effect of axial length (AL) on the surgical outcomes of combined cataract surgery and ab interno trabeculotomy (phaco-LOT), a retrospective, non-randomized comparative study was performed. METHODS: In total, 458 eyes of 458 open-angle glaucoma patients who underwent phaco-LOT and were followed-up without any intervention for at least 6 months were enrolled. All were divided into a long-AL group (AL ≥ 26.0 mm, 123 eyes) and a not-long-AL group (AL < 26.0 mm, 335 eyes). The principal outcomes were the changes in intraocular pressure (IOP) and medication scores. We also sought a correlation between postoperative IOP spike and hyphema. RESULTS: Significant postoperative reductions in IOP and medication scores were apparent in all subjects. The IOP reductions were significant at all timepoints in the not-long-AL group, but not until 1 month postoperatively in the long-AL group, and the IOP change was significantly lower in the long-AL group from postoperative day 1 to 3 months. On subanalysis of subjects by age, the microhook used, the pre-operative IOP, and the medication score, a significantly higher incidence of IOP spike was observed in the long-AL group in weeks 1 and 2 (both p < 0.05), but this did not correlate with hyphema status, implying that a different mechanism was in play. CONCLUSION: Phaco-LOT was effective regardless of AL, but the postoperative IOP decrease was lower and the early postoperative incidence of IOP spike was higher in long-AL eyes.

Spontaneous Hyphema and Vitreous Hemorrhage Causing Secondary Glaucoma in a Patient on Apixaban.

BACKGROUND: Spontaneous hyphema is the rare occurrence of hemorrhage within the anterior chamber of the eye without a predisposing traumatic event. Hyphema can be associated with acute elevations in intraocular pressure in up to 30% of cases, which poses a significant risk for permanent vision loss if not quickly recognized and treated in the emergency department (ED). Anticoagulant and antiplatelet medications have been previously associated with cases of spontaneous hyphema; however, there are limited reports of hyphema with associated acute glaucoma in a patient taking a direct oral anticoagulant. Due to the limited data of reversal therapies for direct oral anticoagulants in intraocular hemorrhage, these patients pose a challenge in deciding whether to reverse anticoagulation in the ED. CASE REPORT: We present a case of a 79-year-old man on apixaban anticoagulation therapy who presented to the ED with spontaneous painful vision loss in the right eye with associated hyphema. Point-of-care ultrasound revealed an associated vitreous hemorrhage, and tonometry was significant for acute glaucoma. As a result, the decision was made to reverse the patient's anticoagulation with four-factor activated prothrombin complex concentrate. Why Should an Emergency Physician Be Aware of This? This case is an example of acute secondary glaucoma due to a hyphema and vitreous hemorrhage. There is limited evidence regarding anticoagulation reversal in this setting. A second site of bleeding was identified by utilization of point-of-care ultrasound, which led to the diagnosis of a vitreous hemorrhage. This allowed for shared decision-making between the emergency physician, ophthalmologist, and patient regarding the risks and potential benefits of the reversal of anticoagulation. Ultimately, the patient decided to have his anticoagulation reversed to try and preserve vision.

Spontaneous hyphema in juvenile idiopathic arthritis uveitis.

BACKGROUND: Juvenile idiopathic arthritis (JIA) is a rheumatic disease that may be associated with ocular involvement in childhood. Classical findings of JIA uveitis are cells and flare; hyphema, bleeding in the anterior chamber of the eye, is a rare finding. CASE: An 8-year-old girl presented with 3+ cells and a flare in the anterior chamber. Topical corticosteroids were started. A follow-up examination 2 days later revealed hyphema in the affected eye. There was no history of trauma or drug use, and the laboratory test results did not suggest any hematological disease. Systemic evaluation resulted in the diagnosis of JIA by the rheumatology department. The findings regressed with systemic and topical treatment. CONCLUSIONS: The most common cause of hyphema in childhood is trauma, but it can rarely be seen with anterior uveitis. This case highlights the importance of recognizing JIA-related uveitis in the differential diagnosis of hyphema in childhood.

Risk Factors for Hyphema Following Kahook Dual Blade Goniotomy Combined With Phacoemulsification.

PRCIS: Hyphema development after Kahook Dual Blade (KDB) excisional goniotomy was significantly associated with postoperative day 1 intraocular pressure (IOP) ≤12 mm Hg, male sex, and narrow iridocorneal angles, but not with continuation of anticoagulation or antiplatelet therapy. PURPOSE: To identify risk factors of hyphema development after KDB goniotomy combined with phacoemulsification. METHODS: In all, 202 eyes in 145 patients who received a KDB goniotomy combined with phacoemulsification between February 21, 2017 and February 18, 2020 were evaluated for preoperative factors that were predictive of postoperative hyphema. Hyphema was defined as the development of ≥1 mm layered blood in the anterior chamber. The primary outcome was the association between various preoperative factors and the development of postoperative hyphema. Binomial logistic regression was used to analyze risk factors of hyphema development while controlling for other variables. RESULTS: Hyphema occurred in 8.4% (17/202) of patients on day 1 after KDB goniotomy combined with phacoemulsification. Male sex ( P =0.008), angle closure glaucoma ( P =0.036), and postoperative day 1 IOP ≤12 mm Hg ( P =0.049) were significantly correlated with hyphema development while controlling for other variables. Preoperative anticoagulation and antiplatelet therapy had no association with hyphema development ( P =0.538). CONCLUSIONS: Postoperative hyphema was associated with male sex, narrow iridocorneal angles, and a postoperative day 1 IOP lower than typical episcleral venous pressure when controlling for other variables. Preoperative anticoagulation or antiplatelet therapy was not associated with developing postoperative hyphema in this study; however, further investigation is needed before recommendations can be made.

Current Concepts of the Uveitis-Glaucoma-Hyphema (UGH) Syndrome.

PURPOSE: To discuss the pathophysiology, etiology, and current management strategies of uveitis-glaucoma-hyphema (UGH) syndrome. METHODS: Literature review. RESULTS: The classic UGH syndrome associated with anterior chamber intraocular lenses (ACIOL) have decreased in incidence with the modernization of IOL design and surgical techniques. The current UGH syndrome is increasing in prevalence largely related to a parallel increase in late onset dislocations of intraocular lenses (IOLs) and the developing techniques to remedy that condition. The modern features of UGH can present as cystoid macular edema, intraocular pressure elevation typically not attributed to UGH, and recurrent vitreous hemorrhage, unlike the original description as described by Ellingson in 1978. Medical management to control inflammation, reduce intraocular pressure, and reduced the bleeding diathesis are mainstays of therapy. However, surgery with IOL repositioning or exchange should be reserved for cases that are refractory to or progressing despite medical treatment. CONCLUSIONS: UGH syndrome is an increasingly common, poorly understood, and often subtle, manifestation of an anatomic disturbance post intraocular surgery that persists with continued evolution of intraocular surgical techniques and new imaging modalities to aid in its diagnosis.

Endoscopic Visualization for Atypical Uveitis Glaucoma Hyphema Syndrome Management.

We discuss how ophthalmic endoscopy was used in the management of 6 cases with atypical uveitis glaucoma hyphema syndrome. For case 1, the endoscope was used to remove a retained haptic foreign body after an intraocular lens (IOL) exchange with an iris-sutured IOL for a complete capsular bag-IOL complex dislocation. In case 2, the endoscope was key in identifying the presence and location of vascular lesions at the site of previous pars plana sclerotomies. In case 3, the endoscope enabled visualization of a large segmental Soemmering's Ring pushing a 3-piece IOL haptic into the posterior iris. For case 4, the endoscope allowed viewing of the sharp edge of the optic where the haptic of a one-piece lens had been amputated, and the sharp edge of the cut optic was anteriorly oriented and continuing to rub the posterior iris. In case 5, the endoscope confirmed the presence of 1 haptic of a 1-piece lens out of the capsular bag and in the sulcus space. Also, it showed that the capsular bag had inadequate zonular support to attempt repositioning the haptic into the bag. In case 6, the endoscope was helpful in identifying a 1-piece plate haptic IOL in the sulcus, with synechiae and anterior location causing iris bulging inferiorly.

Timing of Ocular Hypertension After Pediatric Closed-Globe Traumatic Hyphema: Implications for Surveillance.

PURPOSE: To evaluate the timing of ocular hypertension (OHT) after pediatric closed-globe injury (CGI) and traumatic hyphema. We hypothesize that OHT will occur at different times based on injury characteristics. DESIGN: Retrospective, cohort study. METHODS: Setting: Single-center, tertiary-care, pediatric hospital. PARTICIPANTS: Subjects included patients ≤18 years of age at the time of injury who suffered CGI and traumatic hyphema between 2002 and 2019. Observation Procedure(s): Intraocular pressure and injury demographics were abstracted for every visit after injury. OHT was defined as >21 mm Hg at presentation or after a reading of ≤21 mm Hg at a prior visit. MAIN OUTCOME MEASURES: The primary outcome measure was the timing of OHT categorized into 4 periods: presentation, acute (days 1-7), subacute (days 8-28), or late (day >28). Secondary outcome measures were identification of risks factors for OHT by multivariable logistic regression. RESULTS: OHT occurred in 119 of the 305 (39%) subject eyes. OHT occurred in 35 patients at presentation, 69 times acutely, 35 times subacutely, and 36 times late. Pupil damage predicted acute-period OHT (P = .004). OHT at presentation predicted subacute period OHT (P = .004). Iridodialysis and cataract predicted late-period OHT (P = .007 and P < .001, respectively). CONCLUSIONS: OHT after CGI and traumatic hyphema in pediatric patients is common. Injury demographics predict this complication. Integration of these risk factors with current literature allows proposal of a risk-stratification tool to guide efficient surveillance for OHT.