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ARTICLE
Year : 1970  |  Volume : 18  |  Issue : 1  |  Page : 23-24

Expulsive haemorrhage- a case report


Department of Ophthalmology, Postgraduate Institute of Medical Education & Research, Chandigarh, India

Correspondence Address:
Sah Dev
Department of Ophthalmology, Postgraduate Institute of Medical Education & Research, Chandigarh
India
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How to cite this article:
Dev S, Jain I S, Nagpaul K C. Expulsive haemorrhage- a case report. Indian J Ophthalmol 1970;18:23-4

How to cite this URL:
Dev S, Jain I S, Nagpaul K C. Expulsive haemorrhage- a case report. Indian J Ophthalmol [serial online] 1970 [cited 2020 May 28];18:23-4. Available from: http://www.ijo.in/text.asp?1970/18/1/23/35055

Expulsive haemorrhage is a rare but fatal complication of intraocular surgery for the eye. The incidence reported from time to time by various authors has varied mostly between 1:500 and 1:1000. Owens and Hughes [2] found the incidence of expulsive haemorrhage to be 0.3% of the 18,866 cataract extractions reported in the literature.

The aetiology is not quite clear. Various factors such as vascular sclerosis, (general or local), vascular fragility, congenital and familial weak­ness of choroidal vessels, arterial hypertension, polycythemia, glaucoma, sudden changes in atmospheric baro­metric pressure, old age, diabetes and very high myopia have all been blamed.

Jain [1] reported three cases of expulsive haemorrhage out of 3000 cataract extractions. All of these had black or brown cataracts. The follo­wing case is also one of expulsive haemorrhage in an eye with brown black cataract. Expulsive haemorrhage has been recorded even 4 weeks after the intraocular surgery though it is seen most often within the first 24 hours.


  Case Report Top


P. a male aged 55 years, presented in the ophthalmic out patient of the institute on 15th November, 1968. He complained of progressive loss of vision R/E for the last nine months. The diminution of vision was gradual and painless, without any apparent history of injury or other complaint. About a year back the patient had an attack of severe pain in the left eye following which he lost vision from this same eye completely. Clinical examina­tion at that time revealed.

Left eye Phthisical eye

Right eye V. A. P1 + PR - ve, Hazy cornea, A. C. was on the shallow side in the lower part and normal in the upper part. Iris was atrophic with slight tremulousness, pupillary margin was atrophic and it showed whitish deposits. It was semi dilated and very poorly reacting. There was pseudoexfoliation of the lens. Tension recorded was 26 mm. The patient was advised lens extraction on the right side which he refused. Again he returned on 23rd March, 1969. The clinical findings were essentially the same as recorded earlier and the tension was 29 mm Hg. The patient was admitted and was put on Diamox tablets, one tablet twice daily. Glycerol 50 cc was given by month on the morning of the operation.

Investigations .

The blood pressure was 130/85 mm Hg. Conjunctival swab was negative on culture. The tension recorded on the morning of operation was 17 min. Nothing else abnormal was detected in the general examination.

Operation Notes

A 3 mm wide limbal based conjunc­tival flap was made extending from 9 O'clock to 3 O'clock. A gutter was made with a knife and a preplaced suture applied. The section was completed with keratome and scissors. A complete iridectomy was done and the lens was removed with the help of vectis. Immediately after the removal of the lens the intraocular pressure was low and the cornea cupped. While the suture was being tied, the section started gaping. Vitreous and choroid started coming out of the wound. Immediately expulsive choroidal hae­morrhage was diagnosed and a posterior sclerotomy carried out with a keratome. Only a little blood came out and it was not of much help. The protruding blood clots and the uveal tissue were snipped with scissors and the knot tied. A tight pad and bandage were applied. On subsequent dressings after 24 and 48 hours the eye pads were found soaked with blood. To avoid continuous bleeding an evisceration was done on 29th March, 1969.


  Discussion Top


The association of black or brown cataract and expulsive haemorrhage has not been sufficienbly stressed in the literature. Jain [1] drew attention to this fact as all his three cases of expulsive haemorrhage were associated with black or brown cataracts. He postulated that black cataracts are possibly more often accompanied by arteriosclerotic changes in the body and particularly in the eye which may be the cause of expulsive haemorrhage. In our case also apart from the presence of black cataract no other cause could be detected. Although there does not seem to be any cause and effect relationship between black cataract and the expulsive haemorrhage but the association appears to be fairly strong. A study of the state of blood vessels - both systemic and in the eye, in greater details in all cases of nuclear cataracts and its comparison with that in cortical types of cataracts might help to elucidate this factor further.

How much role the preoperative tension of 29 mm played in the occurrence of this type of catastrophe in this case remains conjectural. The authors do not feel that this should have played any significant role as the tension was brought to well within normal limits of 17 mm of Hg, and moreover the cornea showed beautiful cupping after the delivery of the lens. This sign proved that pressure in the posterior segment was not at all raised. The modern trend to do cataract in a glaucomatous eye as a single stage procedure also supports that cataract extraction with well controlled preope­rative intraocular tension is relatively a safe procedure, Therefore, the authors feel that the presence of per-operative tension of 29 in the case report was fortuitous rather than causal in the occurrence of the expulsive haemorrhage.

 
  References Top

1.
Jain, I. S., Expulsive haemorrhage and black cataract. Oriental Arch. Ophthal., 3, 141-143, (1965).  Back to cited text no. 1
    
2.
Owens, W. C. and Hughes, W. F., Jr. Intraocular haemorrhage in cataract extraction. Arch. Ophthal. (Chicago) 37 : 561-571, (1947).  Back to cited text no. 2
    




 

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