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Show ]oUI7UlI of Clinical NeurCHlphlhalmology 13(4): 293-294, 1993. Feature Photo An Unusual Cause of Recurrent Vitreous Hemorrhage J. Lawton Smith M.D. ~ 1993 Raven Press, Ltd., New York A 69-year-old retired university professor was seen on July 23, 1993 with a chief complaint of cloudy vision in the left eye for 9 months. The patient stated that he had cataract surgery on his right eye 8 years ago, and 1 year later the left eye was done. He did very well thereafter and enjoyed 20/15 vision in both eyes without glasses at distance, and required glasses for reading only. However, in October 1992, while teeing off on the golf course, he noted, rather abruptly, the onset of blurred vision in his left eye. He was seen promptly by an ophthalmologist who told him he had a vitreous hemorrhage in the eye. He was also seen by a retinal consultant who confirmed the vitreous hemorrhage in the eye. He was also seen by a retinal consultant who confirmed the vitreous hemorrhage, but saw no evidence of a retinal lesion. The patient was advised to have a magnetic resonance scan and an echocardiogram, and these were normal. Since then, the patient states he had as many as 50 recurrences of small vitreous hemorrhages in the left eye. These are usually painless, but occasionally slight discomfort and photophobia would, accompany them. He found that taking Procardia seemed to decrease the incidence of these hemorrhages. The only other complaint was that recently he noted that objects appeared slightly smaller in the left eye and for 3 months described slight "waviness" of lines before the left eye. He had no problems at all with the right eye an~ enjoyed good health otherwise but for some labIle hypertension. Examination revealed a best-corrected vision of 293 20/20 in the right eye and 20/50 + 2 in the left eye. Externally, the patient's eyes appeared white and quiet, and he had bilateral posterior chamber intraocular lenses, with normally reactive pupils. No afferent pupil was seen. Applanation tension was 18 in each eye. Slit lamp examination showed clear posterior chamber intraocular lenses, with a peripheral iridectomy above in the left eye, and no flare or cells. Ophthalmoscopy revealed a slight haze from vitreous blood below in the left eye, and a bit of cystoid macular edema in this eye. The right eye was normal. What is your diagnosis? What would be your next step in workup? FIG. 1. Anterior view of left eye. 294 FIG. 2. Slit lamp view of iridectomyabove shows that the prolapsed haptic cannot be seen without gonioscopy. Answer: Gonioscopy of left eye. Gonioscopy of left eye revealed that the upper haptic of the posterior chamber intraocular lens had prolapsed through the iridectomy above and was impinging on the iris, and actually was seen to be digging into the iris stroma more when it was dilated than it did FIG. 3. Gonioscopic view of left eye showing the upper haptic prolapsed through the iridectomy in the angle and impacting upper iris stroma. JClin Neuro-ophthalmol, Vol. 13, No.4, 1993 before. With a contact lens, more vitreous blood was seen in the inferior fundus and there was some slight chronic cystoid macular edema in this eye. It was evident that the prolapsed haptic rubbing against the peripheral iris was the source of bleeding in this patient. He had never had uveitis, glaucoma, or hyphema. However, one could see a slight trail of red cells following the haptic down as a wick and proceeding into inferior vitreous below in this eye. The method of management of this patient raised several differences of opinion. These varied from removing the intraocular lens, replacing the intraocular lens, rotating the haptic from behind via vitrectomy approach, laser occlusion of iris vessels around the haptic tip, and the like. The patient had a vitrectomy approach with rotation of the prolapsed haptic and removal of the small amount of vitreous blood below. Postoperatively, he had 20/40 vision in the eye. Unfortunately, the lens later rotated back into former position, the patient had another vitreous hemorrhage, and then developed a retinal detachment in this eye, which required a scleral buckling procedure. This patient did not show the classic features of the "UGH" syndrome (uveitis, glaucoma, hyphema) but simply manifested recurrent uniocular vitreous hemorrhages. The importance of goniscopy in diagnosis is evident in this case. [CLintraocularlenses] |
