Iris prolapse; vitrious leak and Chorodial hemmoraghe

[Botro]

My dad underwent cataract surgery a few weeks ago. During the surgery he had the following complications
First the doctor said his iris prolapsed. When he went to fix that he said he found alot of vitreous fluid leaking out of the posterior chamber. He also saw what he called a peripheral shadow intraoperatively in dad's pupil. He said he developed what he called a massive hemmoraghic choroidal detachment which he said started during the surgery but then increased afterwards. The doctor said he corrected the iris prolapse and closed the hole in the chamber after removing the vitreous. The doctor said it was all because my father was "Squeezing" during the surgery.  But now my dad cant see and needs more surgeries
Can anyone explain in regular people terms what happened and if my dad's sight will come back.
He cant almost see nothing. My parents both want to understand what happened.

[John C Hagan III, MD, FACS, FAAO]

The bleeding is not visible to the cataract surgery because it is in the back of the eye. The operating microscope does not focus that far back. The dark shadow is usually the blood in the choroid under the retina. If the retina does not rupture but "holds" the bright red blood does not come through the pupil and into view.

Use Google images and Google the term, its much easier to understand if you can visualize the structure of the eye and where the blood comes from. Also use Google Web and read the section in Wikipedia.com

I will have no further comments as I have carried this discussion as far as I can.

you might also read my blog on considerations prior to cataract surgery especially #13.

http://www.medhelp.org/user_journals/show/841991/Consider-ALL-the-Options-Before-Your-Cataract-Surgery-Working-Through-Whats-Best-For-You

JCH MD

[Botro]

so he sent him to a retinal specialist the next day and he has had multiple surgeries but he still cannot see. He did have it drained the next day and again and again.  I got the records- the cataract doc told the retinal doctor that the bleeding began during the surgery but in his own operation report he says there was not bleeding. But what about the shadow. I just get more and more confused about this

[John C Hagan III, MD, FACS, FAAO]

No the "treatment" is either leave alone (like after a stroke) and hope the eye repairs itself or have a retina surgeon drain the middle layer (choroidal) hemorrhage from the outside and/or remove blood from the interior of the eye, repair any tears in retina and fix any retinal detachments.

But like a bullet going through the brain, eye, heart, abdomen the "damage is already done" and the choroidal hemorrhage often cannot be fixed or the eye or vision saved.

JCH MD

[flossy93]

In a case such as this, are there any steps such a lasering the bleeding vessels or using anti-VEGF injections or photodynamic therapy to help patients such as these with the resulting trauma after the choroidal hemorrhage has occurred?

I understand that these therapies are typically directed at patients with abnormal blood vessel growth, rather than spontaneous rupture and bleeding during a surgery.  Just wondering whether any of these therapies - or any other treatments - can possibly help patients such as Botro's father.

Botro, I am very sorry for your father's complications, and hope he sees some improvement in the future.

[John C Hagan III, MD, FACS, FAAO]

No that's not what I'm saying. Up until the early 80's surgery was done by "Intra-capsular" or "Planned extra-capsular" surgery. The incision based on where the white part (sclera) and cornea (clear part) meet (limbus) measured 4 to 6 "clock hours" and required stitches to close. Surgery now is almost always done with phacoemulsification and the incision is 2 clock hours and requires no or one stitch and is placed towards the cornea which has no blood vessels. So I was saying this problem was much more common before the change in technique that occurred in the 80's. The patient of mine that lost his eye was done in the late 70's with the big incision.

There is no way to stop the bleeding because it isn't coming from the incision or front of the eye but from the back far removed from the surgical incision.

JCH MD

[Botro]

Doctor
  Thank you so much. We are not blaming the doctor here. Just trying to figure out what happened. Are you saying that the cut was too large to begin with. He originally said it was just the iris prolapse and vitreous leakage and that  t the choroidal bleeding started hours  after the surgery. But two retinal specialist said what you said that the bleeding began during the surgery. Can you please clarify anyone more. Im so sorry. This stuff is so complicated and Im trying to get someone who will explain as you clearly as you
Assuming he began to bleed during the surgery; was there any way to stop it?

[John C Hagan III, MD, FACS, FAAO]

Cataract surgery is the most common operation done on adults, has a very low complication rate. However no operation is entirely safe just like no trip in your automobile is entirely safe. Each year some 55,000 people are killed in automobile accidents. Each year there are several thousand eyes that suffer complete blindness or severe visual loss secondary to cataract surgery even when done with competent, skill experienced surgeons used the most modern equipment.  The most common causes of this are massive infection (endophthalmitis), retinal detachment and intra-operative or immediate post operative hemorrhage within the eye.  The most feared complication in cataract surgery is intraoperative explusive choroidal hemorrhage. This is almost assuredly what your father had. The problem is much less common now when we use very small incisions than prior to early 80's when we used large incisions which often were 180 degrees along the cornea.

The problem is much more common in the very elderly (greater than 80 years of age, in people with hardening of the arteries due to smoking, high blood pressure, diabetes, or high cholesterol). Basically when the surgical incision is made into the eye the pressure is lowered inside the eye. In explusive choroidal hemorrhage the middle layer of the back of the eye (Choroid) is filled with thin walled blood vessels. These expand rapidly like varicose veins and start to push out the contents (hense the iris prolapse, vitreous loss and the "black shadow" which is the blood (hematoma) in the eye. The veins can rupture filling the eye with blood.

It can occur if a patient coughs, sneezes, jerks around or strains (valsalva maneuver). However most occur without these problems and are the result of bad luck and brittle, hard vessels in the eye. (Think of it like the eye having a hemorrhagic stroke).  In my surgical career of maybe 12,000 cataract/IOL procedures I have had maybe a dozen of these. Most were not massive however one resulted in complete loss of the eye (late 70's big incision). So it literally is "one in a thousand" complication.

You will need to get specifics from the surgeon and the retina surgeon that will try and help. NOTE: when this happens in one eye the change of it happening in the other eye is much higher than one in a thousand.

JCH MD