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| CASE REPORT |
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| Year : 1996 | Volume
: 44
| Issue : 1 | Page : 44-45 |
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Expulsive haemorrhage in a case of thrombocytopenic purpura
M Srinivasan, Arup Chakrabarti, Meena Chakrabarti.
Aravind Eye Hospital & P.G. Institute of Ophthalmology, Madurai, India
Correspondence Address:
M Srinivasan
Aravind Eye Hospital, 1, Anna Nagar, Madurai 625 020
India
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 8828308 
How to cite this article:
Srinivasan M, Chakrabarti A, Chakrabarti. M. Expulsive haemorrhage in a case of thrombocytopenic purpura. Indian J Ophthalmol 1996;44:44-5 |
Intraoperative expulsive suprachoroidal haemorrhage is perhaps the most feared complication of intraocular surgery. The reported incidence is 0.05% to 0.08%.[1],[2] Expulsive haemorrhage has been reported following all intraocular surgeries, retinal detachment surgery and even spontaneously. It can occur intraoperatively or postoperatively from 3 to 6 hours to 9 days after surgery. The risk factors are advanced age, arteriosclerosis, arterial hypertension, high myopia, blood dyscrasia and diabetes.[3] Idiopathic thrombocytopenic purpura as a cause of expulsive haemorrhage following cataract surgery has rarely been reported.
| Case report | |  |
A 55 year old healthy male had cataract surgery in his left eye on 8.2.95. Relevant preoperative investigations were normal. The surgery was performed under peribulbar anaesthesia using 2% lidocaine, mixed with 1:20,000 epinephrine and hyaluronidase. Intraoperative period was uneventful. There was no positive pressure or undue bleeding from the section. A 15D three piece all PMMA posterior chamber intraocular lens (PC IOL) was used following standard extracapsular cataract surgery. No intracameral drugs were used. Wound was closed with 10-0 nylon continuous suture. Gentamicin subconjunctival (20 mg) and dexamethasone (2 mg) were injected at the end of the surgery. Transfer of the patient to the ward was smooth. Ibuprofen (400 mg) was given as a pain reliever an hour after surgery. Twenty hours after surgery there was oozing of fresh blood from the operated eye. There was no history of trauma or violet cough. There was also no history suggestive of blood dyscrasia.
On examination at slit lamp biomicroscope the eye was proptotic, fresh blood mixed with clots was spilling over the lower lid [Figure - 1]. After cleaning the blood, the surgical wound was found intact, corneal epithelium was oedematous and anterior chamber was full of fresh blood. There was no subconjunctival haemorrhage and the patient had only light perception. Intraocular pressure was high digitally. There was no signs and symptoms of haemorrhage in any other part of the body. The blood pressure was 114/74 mm Hg; bleeding time was 1 minute 45 seconds and clotting time was 4 minutes 45 seconds. Urine output and colour was normal. On the same day under retrobulbar anaesthesia the section was opened up and blood from anterior chamber was evacuated using balanced salt solution (BSS). The PC IOL was found in place. There was no red glow. Sclerotomy on either side of insertion of superior rectus was performed and altered blood was evacuated. The section was closed with 10-0 nylon. The second retrobulbar injection produced subcutaneous haemorrhage over the lower lid [Figure - 2]. Patient was shifted to intensive care unit and opinion of the physician was sought. Repeat haemogram revealed very low platelet count (30,000 cells/cmm), PCV 24%; normal red blood cell count and normal peripheral blood smear. The bleeding time now was 6 minutes 45 seconds, clotting time was 7 minutes 10 seconds and prothrombin time was 15 seconds. Hess test was negative. Two pints of matched B +ve blood was transfused and 4 mgs of dexamethasone was started intravenously every 6 hours. There was no bleeding from the eye. Vital signs were within normal limits. Two daplaser multiple ecchymotic patches over upper limbs were noticed. The intravenous steroids were replaced by oral steroids. Routine postoperative topical medication were continued. Patient was discharged five days later. At the time of discharge the anterior chamber was deep, clear, with dilated round pupil, [Figure - 3]. The uncorrected visual acuity was 1 meter and there was no fundus view. Repeat platelet count was 50,000 cell/cmm. Patient did not come for follow up though, on correspondence with his physician on 1.10.1995,the patient had visual acuity of 6/24 and normal fundus. Optics of implant was incarcerated in the pupil with posterior capsular opacification.
| Discussion | | |
Every ophthalmologist who performs intraocular surgery over a number of years is likely to encounter the dreaded complication - the expulsive choroidal haemorrhage.[4] Pau reviewed 53 cases from the world literature and reported that a third occurred during surgery. History of glaucoma, increased axial length, elevated intraocular pressure, generalised arterosclerosis and elevated intraoperative pulse were found to be associated with expulsive haemorrhage. The axial length in this subject was 24.7 mm and there was no evidence of above mentioned risk factors. The surgical procedure was smooth.
Thrombocytopenia is one of the most common acquired disorders of haemostasis. The normal platelet count is between 150,000 and 400,000/ mm,[3] but the platelet count ordinarily must be reduced below 50,000/ mm[3] before untoward bleeding is observed and even then bleeding usually does not occur unless the patient is traumatised. Spontaneous bleeding is unlikely unless the platelet count is reduced below 20,000/ mm[3]. Petechia are the characteristic lesion of thrombocytopenia. The most fatal complication of thrombocytopenia is intracerebral bleeding and forms a major cause of death. However, by appropriate management, it is possible to salvage the eye. Thrombocytopenic purpura should be included as one of the risk factors of expulsive choroidal haemorrhage[5].
| References | | |
| 1. | Srinivasan M. Expulsive choroidal haemorrhage. Ind. J. Ophthalmol 40:100-102, 1992.  |
| 2. | Speaker MG, Guerriero PN, Met JA, et al. A case control study of risk factors for intraoperative suprachoroidal expulsive haemorrhage. Ophthalmology 98:202-210, 1991. |
| 3. | Jaffe NS. Cataract surgery and its complications. 4th ed. St. Louis, C.V. Mosby Co., 1984. |
| 4. | Brubaker RF. Intraocular surgery and choroidal haemorrhage (Editorial) Arch Ophthlamol 102:1753-4, 1984. |
| 5. | Pau H. Der Zeitfaktor hei der Expulsive Blutung; Klin Monatsbi Augenheilkd 132:865-869, 1958. |
[Figure - 1], [Figure - 2], [Figure - 3]
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