|Year : 1969 | Volume
| Issue : 6 | Page : 273-276
Post-operative intractable hyphaema responding to anti-tubercular treatment- a report of two cases
KN Srivastava, PC Bharadwaj, CM Mehta
Department of Ophthalmology, Willingdon Hospital, New Delhi - 1, India
|Date of Web Publication||11-Jan-2008|
K N Srivastava
Department of Ophthalmology, Willingdon Hospital, New Delhi - 1
Source of Support: None, Conflict of Interest: None
|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  ; Childry et al.,  Phillips and Foster  and Agarwal,  ) with the most frequent onset on about the fourth day (Straatsma,  ) 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,  Sorsby  and Straatsma  ). The hyphaema may come from the wound, iris, or the ciliary body (Barraquer, Troutman, Richard and Rutlan  ). 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  ), vascular deficiencies, hypertension, gamma-globulin deficiency, congenital or acquired deficiency of plasma coagulation factor (Childrey et al  ). 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  , Stallard,  Phillips and Foster,  Arruga,  and Straatsma  ). 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  ), as most hyphacmas have a tendency to get absorbed in about 7 days (Stallard  ). The various reported regimes include control of intra ocular tension with the help of carbonic anhydrase inhibitors or intravenous urea. (Arruga  , Agarwal,  Barraquer et al.  and Sorsby,  ) prevention of recurrences by use of ascorbic acid or some other allied medicine which decrease capillary haemorrhage (Robb,  and Stallard  ), Local Dionin and systemic Trypsin or Chymotrypsin, retrociliary diathermy (Barraquer et al.  ). Malik, et al.  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|| |
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.
| Summary|| |
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|| |
Agarwal, L. P.: Eye Diseases, Kitab Mahal, W. D. Private Ltd. 1963.
Arruga, H.: Eye Surgery. Mc Graw Hill Book Co. New York & London. 1956,
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.
Bosso, G.: Haemorrhage in to Anterior Chamber after cataract extraction (Abstract) A. J. O. Vol. 49: 186. 1960.
Childry, J. et al.: Haemorrhage following intraocular operations (Etiology and Prophylaxis). Amer. J. Ophth. Vol. 55: 753-757, 1959.
Dobree, J. H.: Quoted by Sorsby, A In: Modern Ophthalmology Vol. 4, Butterworths, London 1964.
Fasanala, R. M.: Complications in Eye Surgery. Philadelphia & London 1965.
Kirmani, T. N.: Prognosis of cataract extraction in diabetes. Amer. J. Ophth. Vol. 57: 617, 1964.
Phillips, S. and Foster, J.: Ophthalmic Operations. 2nd Ed. Bailliers and Tindell and Cox. London, 1961.
Robb, P.: Quoted by Fasanwals. R. M. In: Complication in Eye Surgery. Philadelphai and London. 1965,
Malik, S. R. K., Sood. G. C., Choudhery, A.: Recurrent hyphaema following cataract surgery (Accepted for publication: Oriental Arch. Ophthalmology).
Schlossman, A.: Hyphaema in cataract surgery. E.E.N.T. monthly, 43: 67, 1964.
Sorsby, A. Modern Ophthalmology Vol. 4, Butterworths, London 1964.
Spaeth, E. B.: Principles and Practice of Ophthalmic Surgery Lea and Febiger, Philadelphia, 1948.
Stallard, H. B.: Eye Surgery. Bristol, John Wright & Sons Ltd., III Edition. 1958.
Swan, J. W.: Oestrogens in cataract surgery, A.H.O. Vol. 55: 1142, 1963.
Straatsma. B. R.: Arch. Ophthalmology (Chicago) 73: 558-579, 1965. (Annual Review Lens and Vitreous).
Watt, R. H.: Conjugated Oestrogens in Cataract Surgery. (Negative Report). Amer. J. Ophth. 57: 426, 1964.
Wright, R. E.: Quoted by Stallard, H.B., In: Eye Surgery.