CHAPTER 10

INTRAOPERATIVE
CHALLENGES IN CATARACT
SURGERY: PART III
AAO READING
1. Clinical manifestation of Arterial retrobulbar
hemorrhages, except..

a. self-limited and tend to spread slowly

b. orbital swelling, marked proptosis, elevated IOP
c. reduced mobility of the globe
d. inability to separate the eyelids, and massive ecchymosis of the eyelids and
conjunctiva.
2. Treatment of acute retrobulbar hemorrhage consists of
maneuvers to lower the intraocular and orbital pressure as quickly
as possible, such as the following, except

A. digital massage
B. topical osmotic agents
C. lateran canthotomy and cantholysis
D. Localized canjungtival peritomy
3. Potential complications of retrobulbar injections,
except

a. Central retinal vein occlusion

b. ischemic optic neuropathy
c. toxic neuropathy or myopathy
d. diplopia, ptosis,
4. Risk factors of intraoperative
manipulation are..
A. Choroidal hemangioma associated with Sturge-Weber syndrome

B. prolonged postoperative hypotony

C. Hypertension and arteriosclerotic cardiovascular disease

D. Iris manipulation, such as lysis of posterior synechiae, sphincterotomies, or pupil ex-
pansion or stretching
5. Expulsive Suprachoroidal Hemorrhage usually
presents as a sudden increase in IOP accompanied by
acute onset of pain and the following, except
A. incision gape
B. iris prolapse
C. expulsion of the lens, vitreous, and bright red blood
D. pupil expansion or stretching
Hemorrhage

Suprachoroida Expulsive
Retrobulbar Intraoperative
l Effusion or Suprachoroida
Hemorrhage Hemorrhage
Hemorrhage l Hemorrhage
RETROBULBAR
HEMORRHAGE
■ Retrobulbar hemorrhages vary in
intensity and are more common with
retrobulbar anesthetic injections than
with peribulbar injections, with an
incidence of 0.44%–0.74% following
retrobulbar injection.
■ Venous retrobulbar hemorrhages are usually self-limited and tend to spread slowly.
Arterial retrobulbar hemorrhages occur more rapidly and are associated with taut
orbital swelling, marked proptosis, elevated IOP, reduced mobility of the globe,
inability to separate the eyelids, and massive ecchymosis of the eyelids and
conjunctiva.

■ This type of retrobulbar hemorrhage causes an increase in orbital volume and

associated orbital pressure, which can restrict the vascular supply to the globe. Large
orbital vessels may be occluded. Tamponade of the smaller vessels in the optic nerve
may occur, resulting in severe vision loss from anterior ischemic optic neuropathy and
subsequent optic atrophy, despite the absence of obvious retinal vascular occlusion.
■ Ophthalmologists can often make the diagnosis of retrobulbar hemorrhage by observing
the rapid onset of eyelid and conjunctival ecchymosis and tightening of the orbit.
The diagnosis can be confirmed by tonometry revealing elevated IOP. Ophthalmoscopy
may reveal pulsation or occlusion of the central retinal artery in severe cases.
Treatment of acute retrobulbar hemorrhage consists of
maneuvers to lower the intraocular and orbital pressure
as quickly as possible, such as the following:

digital massage

Intravenous osmotic agents

aqueous suppressants

lateral canthotomy and cantholysis

localized conjunctival peritomy (to allow egress of blood)

LATERAL CANTHOTOMY
■ The planned surgery should be postponed until the IOP and mobility of the globe
and eyelids are normal. To reduce the risk of a recurrent retrobulbar hemorrhage, it
may be advisable to use another form of anesthesia for the second attempt at surgery.

■ In addition to retrobulbar hemorrhage, potential complications of retrobulbar

injections include central retinal artery occlusion, ischemic optic neuropathy, toxic
neuropathy or myopathy, diplopia, ptosis, and inadvertent subdural injections with
possible central nervous system depression and apnea. Ischemic complications are more
common if epinephrine is used in the anesthetic.
INTRAOPERATIVE
HEMORRHAGE
■ Iris manipulation, such as lysis of posterior synechiae,
sphincterotomies, or pupil expansion or stretching may
result in intraoperative hemorrhage and early postoperative
hyphema. Surgical trauma to the iris, iris root, and ciliary
body can cause significant bleeding. Hemorrhage may also
originate from the angle structures when cataract surgery is
combined with minimally invasive glaucoma surgery
(MIGS)

■ Resolution of hemorrhage may take longer if vitreous is

mixed with the blood.
SUPRACHOROIDAL
EFFUSION OR
HEMORRHAGE
■ Suprachoroidal effusion with or without suprachoroidal hemorrhage usually occurs
intraoperatively but may also occur later in cases with prolonged postoperative
hypotony. Suprachoroidal effusion typically presents as a forward prolapse of ocular
structures, including iris, lens diaphragm, and vitreous, generally accompanied by a
change in the red reflex. Clinically, suprachoroidal effusion may be difficult to
differentiate from suprachoroidal hemorrhage. Patient agitation and pain followed
by an extremely firm globe suggest suprachoroidal hemorrhage
Suprachoroidal effusion and suprachoroidal hemorrhage have
been associated with

• hypertension • glaucoma

• arteriosclerotic cardiovascular disease • advanced age

• tachycardia • nanophthalmos

• obesity • choroidal hemangioma associated with

• high myopia Sturge-Weber syndrome

• chronic ocular inflammation

■ Fortunately, both suprachoroidal effusion and suprachoroidal hemorrhage are much less
likely with small-incision phacoemulsification than with larger-incision surgery because
of the relatively closed system formed by the small, self-sealing incisions. The relatively
tight fit of the phaco tip in the incision prevents prolonged hypotony and reduces
intraoperative fluctuations in IOP.

■ Suprachoroidal effusion may be a precursor to suprachoroidal hemorrhage. Exudation

of fluid from choroidal vasculature ultimately stretches veins or arteries that supply the
choroid after coursing through the sclera. If suprachoroidal hemorrhage occurs in this
situation, it is presumably a result of disruption of 1 or more of these taut blood vessels
 EXPULSIVE
SUPRACHOROIDAL
HEMORRHAGE
Expulsive suprachoroidal hemorrhage, a rare but serious
condition, generally occurs intraoperatively in eyes with
hypotony. The hemorrhage usually presents as a sudden increase
in IOP accompanied by acute onset of pain and the following:

darkening of incision gape iris prolapse expulsion of

the red reflex the lens,
vitreous, and
bright red
blood
Expusive suprachoroidal hemorrhage
■ The instant any suprachoroidal effusion or hemorrhage is recognized, the surgeon must
close the incision with sutures or digital pressure. Prolapsed vitreous is excised and uveal
tissue reposited, if possible.

■ After the wound is securely closed, the surgeon may consider posterior sclerotomies to
allow the escape of suprachoroidal blood to decompress the globe, enable repositioning
of prolapsed intraocular tissue, and facilitate permanent closure of the cataract incision.

■ Drainage of suprachoroidal blood may be achieved by performing sclerotomies in 1 or

more quadrants, 5–7 mm posterior to the limbus.
Drainage of suprachoroidal hemorrhage
■ Elevated IOP serves both to stop bleeding and to expel suprachoroidal blood. Once there
is optimal clearance of blood from the suprachoroidal space, the sclerotomies may be left
open to allow further drainage postoperatively. It may be necessary to repeat the drainage
procedure 7 days or more after an expulsive hemorrhage in cases of residual
suprachoroidal blood that threatens ocular integrity or vision. These procedures may
lower dangerously elevated IOPs and restore appropriate anatomical relationships within
the eye, but they carry some risk that bleeding will recur.
■ If the incision can be closed, more rapid tamponade of the bleeding vessel can be
achieved. without posterior sclerotomies Most surgeons would then terminate the
operation and observe the patient for 7–14 days to allow clotting and liquefaction of
the hemorrhage, while managing elevated IOP medically.

■ Referral to a vitreoretinal surgeon for management and subsequent drainage of

choroidal hemorrhage may be considered. It is important to inform the patient of the
guarded prognosis for restoration of vision.
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