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ARTICLE
Year : 1969  |  Volume : 17  |  Issue : 6  |  Page : 273-276

Post-operative intractable hyphaema responding to anti-tubercular treatment- a report of two cases


Department of Ophthalmology, Willingdon Hospital, New Delhi - 1, India

Date of Web Publication11-Jan-2008

Correspondence Address:
K N Srivastava
Department of Ophthalmology, Willingdon Hospital, New Delhi - 1
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Srivastava K N, Bharadwaj P C, Mehta C M. Post-operative intractable hyphaema responding to anti-tubercular treatment- a report of two cases. Indian J Ophthalmol 1969;17:273-6

How to cite this URL:
Srivastava K N, Bharadwaj P C, Mehta C M. Post-operative intractable hyphaema responding to anti-tubercular treatment- a report of two cases. Indian J Ophthalmol [serial online] 1969 [cited 2020 Aug 4];17:273-6. Available from: http://www.ijo.in/text.asp?1969/17/6/273/38555

One of the commonest complications masking successful cataract surgery is haphxma, which becomes a problem to the surgeon and is of grave prog­nosis for the patient if it becomes re­current. It may eventually impair the eyesight by blood staining of the cor­nea, formation of organized exudates in the anterior chamber, resultant se­condary glaucoma, or extension of the blood to vitreous causing vitreous haemorrhages with subsequent vitreous opacities. Usually it occurs between 3-5 days (Stallard [13] ; Childry et al., [5] Phillips and Foster [8] and Agarwal, [1] ) with the most frequent onset on about the fourth day (Straatsma, [15] ) as by this time the patient becomes ambula­tory and the wound starts healing with the formation of new vessels. The in­cidence of post-operative hyph ema varies from 2-20% but it occurs more in diabetics than in non-diabetics (Kirmani, [7] Sorsby [11] and Straatsma [15] ). The hyphaema may come from the wound, iris, or the ciliary body (Barraquer, Troutman, Richard and Rutlan [3] ). The various important causes include certain blood dys­crasias, abnormal vasularization, iri­dodialysis, or injury to the ciliary body at the time of operation (Barra­quer et al), large conjunctval flap par­ticularly a bridge flap (Wright [17] ), vascular deficiencies, hypertension, gamma-globulin deficiency, congenital or acquired deficiency of plasma coa­gulation factor (Childrey et al [5] ). The latter think that abnormal capillary fra­gility and hypertension appear to be significant etiological factors of hyph­ama rather than the variation of sur­gical technique. These authors have reported in some cases a vascular defi­ciency known as "Senile Purpura." This is caused by a decrease of elastic supportive tissue around the blood ves­sels accompanying senile atrophic changes.

The origin of hyphxma is most pro­bably from the rupture of small vas­cular channels of episcleral plexus at the site of the incision, which are growing in between the wound edges (Spaeth [12] , Stallard, [13] Phillips and Fos­ter, [8] Arruga, [2] and Straatsma [15] ). Mention is also made of common precipitating factors for hyphaema i.e. slight move­ment between the lips of the section, sudden rise of blood pressure caused by abdominal distension and anxiety, sud­den jerky movements of the head, direct interference of the patient with the dressings, diabetes, myopia, glaucoma, old iritis etc. The most frequent cause is strain of the wound consequent on the patient's bending his head or by a knock with the hand while asleep. The treatment of post-operative hyphxma particularly in recurrent cases is again a problem. It is really tempting to do paraccntesis and wash the chamber with saline or fibrinolysins, but the resultant side effects such as the introduction of infection and endophthalmitis are also not very uncommon. Most of the authors agree on a careful watch on the hyphaema and the intra­ ocular tension in the initial stages (Dobree, Barraquer, and Robb [6] ), as most hyphacmas have a tendency to get absorbed in about 7 days (Stal­lard [13] ). The various reported regimes include control of intra ocular tension with the help of carbonic anhydrase in­hibitors or intravenous urea. (Arruga [2] , Agarwal, [1] Barraquer et al. [3] and Sorsby, [11] ) prevention of recurrences by use of ascorbic acid or some other al­lied medicine which decrease capillary haemorrhage (Robb, [9] and Stallard [13] ), Local Dionin and systemic Trypsin or Chymotrypsin, retrociliary diathermy (Barraquer et al. [3] ). Malik, et al. [10] have reported the use of simple heat cautery of the superficial conjunctival vessels which might have abnormal connec­tions with the vessels of the angle re­gion.

The role of anti-tubercular therapy in the treatment of recurrent hyphaema has not been mentioned so far. Two such cases of recurrent post-operative hyphaema treated successfully by anti­tubercular treatment are presented.

Case I : S. D., 52 years female was admitted to the eye department of Willingdon Hospital, New Delhi in the month of July 1967 for the treat­ment of senile cataract left eye. The past and the family history were un­eventful. The general, systemic or local examinations did not reveal any abnormality except senile uncompli­cated mature cataract. Intracapsular extraction of the lens was performed successfully using Bard-Parker knife section, small conjunctival flap, one preplaced corneoscleral stitch, and complete iridectomy. Sterile air was injected into the chamber and the eye was bandaged with atropin drops 1 % and chloromycetin applicaps after in­jecting sub-conjunctival streptopeni­cillin. She progressed very well for three days when on the fourth day we noticed the presence of fresh blood in the anerior chamber. Thinking it could be due to a mild trauma which the pa­tient might have had while asleep, we did not give her any treatment except bandage to both the eyes. The haem­orrhage which took three days to ab­sorb completely, recurred again on the eighth post-operative day. This time the hyphaema was more and had filled the whole chamber. She was put on tablet Diamox 250 mg. stat and re­peated every alternate day till the hyphaema cleared. She responded well to the treatment but before the old hyphaema could absorb fully, the pre­sence of fresh blood made the condi­tion still more annoying. She was then once again fully investigated for any causative factor. X-ray chest showed calcified lymph glands and prominent hilar shadows. E.S.R. was normal. It was thought to give a trial to anti­tubercular treatment as the previous treatment was being continued but the recurrence had not come to an end. She was finally put on a course of anti­tubercular therapy (Isonex, tablet 100 mg. T.D.S. and Inj. Streptomycin l gm. intramusclarly, O.D.). The local treatment consisted of binocular band­age and raising of the head end of the bed. Diamox was continued in the usual doses but we had stopped intra­venous injections and had supplement­ed only intramusclar Vitamin C 500 mg) O.D. The patient started improv­ing and the whole hyphTma absorbed in about 5 days. The fundus which was not possible to be seen in the initial stages became clearly visible, and was normal. The case was kept for 10 days more after the absorption of hyphaema, so as to watch for any fresh recurren­ces, but they were none. She was dis­charged in good condition and has been attending our post-operative clinic regularly and no reccurence has been discovered.

Case II: A.D., 42 years, female was admitted to the eye department of Willingdon Hospital, New Delhi, for the treatment of glaucoma right eye in September 1967. There was nothing significant in the past and family history. The general and systemic ex­aminations were normal. On local ex­amination she had a narrow angle glau­coma. Anterior sclerectomy (Punch) with broad basal iridectomy was done successfully after making a small cor­neal scleral incision. She progressed well for four days when we noticed the presence of fresh blood in the anterior chamber, which again was recurrent. She was treated on the same lines as in the above case and was finally investi­gated again. She was found to have a raised E.S.R. and lymphocytosis. The X-ray was normal. She too was put on anti-tubercular therapy and had res­ponded well. The hyphaema had all cleared and there was no recurrence. She has been attending our glaucoma clinic and no recurrence has been ob­served.


  Discussion Top


Recurrent hyphaemas have always been a problem to manage. The blood in most cases comes from an area of the section into the anterior chamber. Ir­respective of the various methods of treatment, the hyphaema in most cases is transitory and non recurrent and gets absorbed early with fairly good vision.

The cases reported by us are in­teresting from the fact that the hyphaema was recurrent and had no ap­parent etiology except the presence of prominent hilar shadows and a few calcified glands. Poverty, coupled with overcrowding, absence of sunlight and malnutrition is responsible for fre­quent occurrence of tuberculosis here. Majority of people carry healed foci in the respiratory tract, abdomen or genito-urinary tract, and the poor health keeps them on the border line of energy and allergy.

The surgical trauma, the restricted diet during the pre-operative and post­operative phase, the lying in period, the consequently diminished appetite, decrease the resistance of the body and tilt the balance of the body to the ad­vantage of hypersensitivity. The new­ly forming vessels of granulation tissue bridging across the surgical wound, being most vulnerable to, to otherwise subclinical transient bacteriaemia or tuberculo-proteins, are sites of hyper­sensitive reactions. Thrombosis and rupture of capillaries as a part of Arthur phenomenon, may explain the recurrent hyphaema. Though due to absence of proved data, the explana­tion is only hypothetical, yet the posi­tive response to anti-tubercular ther­apy, in the above cases is very sug­gestive. The conservative regime of bed rest, Vitamin C, steroids, having failed earlier and the exhibition of Streptomycin and I.N.H. with encoura­ging results, bears tesimony to the tu­bercular etiology of post-operative hyphaema in the above cases.[19]


  Summary Top


Two cases of recurrent post-operative hypaema following intra-ocular surgery are reported.

No apparent causative factors could be proved responsible for the hyph­aema.

There was remarkable response in cessation of the hyphaema after the start of anti-tubercular treatment.

It is presumed that the patients had old healed tubercular lesion in the body, and local hypersentive reaction which flared after the surgical trauma.

 
  References Top

1.
Agarwal, L. P.: Eye Diseases, Kitab Mahal, W. D. Private Ltd. 1963.  Back to cited text no. 1
    
2.
Arruga, H.: Eye Surgery. Mc Graw Hill Book Co. New York & London. 1956,  Back to cited text no. 2
    
3.
Barraquer, J., Troutman, Richard, C., and Rutlan, J. Surgery of the An­terior Segment of the Eye The Blakiston Division, Me Graw Hill Co. New York, 1964.  Back to cited text no. 3
    
4.
Bosso, G.: Haemorrhage in to Anterior Chamber after cataract extraction (Ab­stract) A. J. O. Vol. 49: 186. 1960.  Back to cited text no. 4
    
5.
Childry, J. et al.: Haemorrhage follow­ing intraocular operations (Etiology and Prophylaxis). Amer. J. Ophth. Vol. 55: 753-757, 1959.  Back to cited text no. 5
    
6.
Dobree, J. H.: Quoted by Sorsby, A In: Modern Ophthalmology Vol. 4, Butterworths, London 1964.  Back to cited text no. 6
    
7.
Fasanala, R. M.: Complications in Eye Surgery. Philadelphia & London 1965.  Back to cited text no. 7
    
8.
Kirmani, T. N.: Prognosis of cataract extraction in diabetes. Amer. J. Ophth. Vol. 57: 617, 1964.  Back to cited text no. 8
    
9.
Phillips, S. and Foster, J.: Ophthalmic Operations. 2nd Ed. Bailliers and Tin­dell and Cox. London, 1961.  Back to cited text no. 9
    
10.
Robb, P.: Quoted by Fasanwals. R. M. In: Complication in Eye Surgery. Phi­ladelphai and London. 1965,  Back to cited text no. 10
    
11.
Malik, S. R. K., Sood. G. C., Chou­dhery, A.: Recurrent hyphaema follow­ing cataract surgery (Accepted for pub­lication: Oriental Arch. Ophthalmo­logy).  Back to cited text no. 11
    
12.
Schlossman, A.: Hyphaema in cataract surgery. E.E.N.T. monthly, 43: 67, 1964.  Back to cited text no. 12
    
13.
Sorsby, A. Modern Ophthalmology Vol. 4, Butterworths, London 1964.  Back to cited text no. 13
    
14.
Spaeth, E. B.: Principles and Practice of Ophthalmic Surgery Lea and Fe­biger, Philadelphia, 1948.  Back to cited text no. 14
    
15.
Stallard, H. B.: Eye Surgery. Bristol, John Wright & Sons Ltd., III Edition. 1958.  Back to cited text no. 15
    
16.
Swan, J. W.: Oestrogens in cataract surgery, A.H.O. Vol. 55: 1142, 1963.  Back to cited text no. 16
    
17.
Straatsma. B. R.: Arch. Ophthalmology (Chicago) 73: 558-579, 1965. (Annual Review Lens and Vitreous).  Back to cited text no. 17
    
18.
Watt, R. H.: Conjugated Oestrogens in Cataract Surgery. (Negative Report). Amer. J. Ophth. 57: 426, 1964.  Back to cited text no. 18
    
19.
Wright, R. E.: Quoted by Stallard, H.B., In: Eye Surgery.  Back to cited text no. 19
    




 

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