Purpose
To describe patients who have experienced delayed-onset hyphema after ab interno trabeculotomy surgery with the Trabectome (Neomedix Corp) for open-angle glaucoma.
Design
Retrospective case series.
Methods
study population: Patients at Mayo Clinic, Rochester, Minnesota, who underwent Trabectome surgery between September 1, 2006, and December 31, 2010, and who had symptomatic hyphema at least 2 months after surgery. observation procedure: Patients with blurred vision at least 2 months after Trabectome surgery were examined for the presence of hyphema using a slit lamp and gonioscopy. main outcome measures: Proportion of patients experiencing delayed-onset symptomatic hyphema after Trabectome surgery. Associated factors and clinical course for these patients.
Results
Of 262 cases of Trabectome surgery, there were 12 cases of delayed-onset symptomatic hyphema (4.6%). The average age was 74.3 years (range, 66 to 82 years). Median time to onset of hyphema was 8.6 months (range, 2 to 31 months) after surgery. Symptom onset commonly occurred on awakening. The most common characteristic was maintaining a sleep position on the surgical side. Most hyphemas resolved within 1 to 2 weeks, except in 1 patient, who required trabeculectomy for a refractory intraocular pressure spike.
Conclusions
This is a series of patients with symptomatic delayed-onset hyphema after Trabectome surgery in the absence of further surgeries or trauma. Likely mechanisms are exertion-related increase in episcleral venous pressure or ocular compression from sleeping on the surgical side, followed by sudden decompression and blood reflux. Symptomatic patients should identify and avoid associated triggers because delayed-onset hyphema may be associated with intermittent intraocular pressure spikes that may require medical or surgical treatment.
The Trabectome is a novel surgical device used for ab interno trabeculotomy in open-angle glaucoma (Neomedix Corp, Tustin, California, USA). It uses electrosurgical ablation of the trabecular meshwork and the inner wall of the Schlemm canal to increase conventional outflow facility. Removal of this tissue also is presumed to result in an open communication between the episcleral venous system and the anterior chamber.
The main reported side effect of Trabectome surgery is perioperative anterior chamber blood reflux. This occurs during or immediately after instrument removal in most cases and usually resolves within 1 week after surgery. This is a case series of 12 patients at our center who have experienced single or multiple episodes of hyphema more than 2 months after Trabectome surgery. These delayed-onset episodes of hyphema occurred in the absence of further surgeries or trauma after Trabectome surgery. We identified patient or surgical risk factors for this complication, with the goal of providing information for future Trabectome surgery patients.
Methods
Subjects
Cases of symptomatic delayed-onset hyphema after Trabectome surgery were identified from a pool of 262 patients who underwent Trabectome surgery between September 1, 2006, and December 31, 2010, by 1 surgeon (A.J.S.) at the Mayo Clinic in Rochester, Minnesota. The diagnosis of hyphema or microhyphema was made on the basis of slit-lamp examination and gonioscopy results. The intraocular pressures (IOPs) at the visit before, during, and after diagnosis of hyphema were recorded and compared using paired t tests. The patient and surgical characteristics that could be related to this complication also were recorded.
Patients who underwent Trabectome surgery at our center typically had open-angle glaucoma that was refractory to medical treatment. Some patients underwent Trabectome surgery in combination with cataract extraction and intraocular lens placement. Patients who had undergone other treatments for open-angle glaucoma before Trabectome surgery, such as trabeculectomy or laser trabeculoplasty, also were included.
Surgical Procedure
The surgical procedure has been described elsewhere. In brief, the surgery was performed through a temporal clear corneal incision, and the nasal trabecular meshwork was visualized with a Swan-Jacob lens. The anterior chamber was filled with viscoelastic to facilitate insertion of the Trabectome handpiece. The Trabectome handpiece was used to ablate the trabecular meshwork and inner wall of the Schlemm canal over a 120-degree arc. For Trabectome only cases, viscoelastic then was removed using irrigation and aspiration, and carbachol was injected into the anterior chamber to constrict the pupil. The wound was closed using a single 10-0 nylon suture. For combination cases, cataract extraction and intraocular lens implantation were performed after the Trabectome surgery.
Results
Twelve cases of delayed-onset hyphema after Trabectome surgery were identified from among 262 Trabectome cases at our center. Patient and surgical characteristics of these patients are summarized in Tables 1 and 2 . The 12 subjects comprised 1 man and 11 women. The average age of these patients at the time of Trabectome surgery was 74.8 years (range, 66 to 82 years). Most patients had primary open-angle glaucoma (5 of 12 cases, 42%) or pseudoexfoliative glaucoma (4 of 12 cases, 33%). Other diagnoses included pigment dispersion (1 case), mixed mechanism (1 case), and normal tension (1 case) glaucoma. Most patients (11 of 12 cases, 92%) underwent cataract extraction in combination with Trabectome surgery.
| Case No. | Age (y) | Sex | Glaucoma Type | Operated Eye | Prior Surgery | Combination Surgery |
|---|---|---|---|---|---|---|
| 1 | 66 | F | POAG | Right | — | No |
| 2 | 77 | F | PEX | Right | — | Phaco, pcIOL, pupilloplasty |
| 3 | 82 | F | PEX | Left | Laser PI | Phaco, pcIOL |
| 4 | 79 | F | PEX | Left | Laser PI | Phaco, pcIOL |
| 5 | 77 | F | POAG | Right | — | Phaco, pcIOL |
| 6 | 74 | F | Mixed | Left | Laser PI | Phaco, pcIOL |
| 7 | 68 | F | POAG | Right | — | Phaco, pcIOL |
| 8 | 77 | F | Low tension | Right | ALT | Phaco, pcIOL |
| 9 | 78 | F | PEX | Right | — | Phaco, pcIOL |
| 10 | 76 | F | POAG | Right | ALT | Phaco, pcIOL |
| 11 | 71 | F | POAG | Right | ALT | Phaco, pcIOL |
| 12 | 66 | M | PD | Left | Trab, tube | Phaco, pcIOL, pupilloplasty |
| Patient Characteristics | No. (Unless Otherwise Indicated) |
|---|---|
| Age (at time of surgery), y | |
| Mean | 74.3 |
| Range | 66 to 82 |
| Median | 77 |
| Sex | |
| Male | 1 |
| Female | 11 |
| Laterality | |
| Right eye | 8 |
| Left eye | 4 |
| Diagnosis | |
| POAG | 5 |
| Pseudoexfoliation | 4 |
| Pigment dispersion | 1 |
| Mixed mechanism | 1 |
| Normal tension | 1 |
| Combined surgery | |
| Trabectome with cataract extraction | 11 |
| None (Trabectome only) | 1 |
| Prior surgery | |
| Laser trabeculoplasty | 3 |
| Trabeculectomy | 1 |
| Laser PI | 3 |
| Further surgeries | |
| Trabeculectomy | 1 |
| Systemic medications | |
| Aspirin/NSAIDs | 8 |
| Warfarin/heparin/Plavix | 2 |
| Steroids | 1 |
| Antihypertensives | 7 |
| Medical problems | |
| Diabetes | 1 |
| Hypertension | 9 |
The time between Trabectome surgery and onset of symptoms related to hyphema ranged between 2 and 31 months, with a median of 5 months. Eight (66%) of the 12 cases involved the right eye. The symptom at presentation in all patients was a transient decrease in vision. When questioned about the recurrence of symptoms, 6 (50%) of the 12 patients reported having 4 or more episodes; most of these patients returned to clinic with a clinically documented repeat episode. Ten patients woke up in the morning or overnight with their symptoms; most of these patients maintained a sleep position that was either on the surgical side or else face down. On examination, 2 patients had blood in the temporal angle, and 7 patients had blood in the nasal angle with a microhyphema of 3 to 4+ red blood cells (30 to 40 cells per 1 × 1-mm field) in the anterior chamber ( Figure 1 ). Three patients were found to have a layered hyphema of less than 1 mm of heme settled inferiorly without blood in the angle. Patients were initiated on prednisolone acetate 1% drops 4 times daily, and each case of hyphema resolved within 1 to 2 weeks.
