(1)
St. Johns, FL, USA
(2)
Helen Keller Foundation for Research and Education, International Society of Ocular Trauma, Birmingham, AL, USA
(3)
Consultant and Vitreoretinal Surgeon, Milos Eye Hospital, Belgrade, Serbia
(4)
Consultant and Vitreoretinal Surgeon, Zagórskiego Eye Hospital, Cracow, Poland
40.1 Hemorrhage1
Of all possible intraoperative complications, this is the most threatening.
Pearl
Truly expulsive bleeding (ECH) does not occur during PPV since the operation is a closed-globe procedure. Nevertheless, a major bleeding can seriously interfere with the operation’s original goals and cause significant tissue damage. The surgeon may be forced to completely change his original plan or even abandon the operation.
Because the IOP during PPV is actually higher than it otherwise would be, major arterial bleeding from the choroid is extremely rare; should it occur, the IOP must instantly be elevated2 to stop the bleeding. See Table 40.1 for all other types of hemorrhage.
Table 40.1
Intraoperative hemorrhages and their management
Tissue | Comment and managementa | |
|---|---|---|
Uvea | At sclerotomy siteb | The bleeding is usually minimal, in which case no intervention is needed. If the bleeding is significant, use diathermy from the outside or from the insidec |
Iris | Most commonly it accompanies the creation of an iridectomy.d To prevent it, the surgeon may consider using diathermy but only if neovascular tissue is suspected behind the iris. The bleeding is usually minimal, in which case no intervention is needed. If the bleeding is significant, use diathermy, but be aware that it is applied blindly since the actual source is almost never visible | |
Ciliary body | The bleeding can be profuse to the point that the exact location is impossible to find. Switch to air at high pressure, try to locate the source, and then diathermize it (see Sect. 32.5) | |
Posterior choroid | Most commonly an iatrogenic injury occurred; the bleeding is usually self-limiting,e in which case no intervention is needed, other than subsequently removing the clot by aspiration or with forceps. If the bleeding is significant,f use diathermy, but make sure that the power is high and the duration long so that you do not cause an even more severe hemorrhage with the diathermy probe’s sharp tip. The blood may have to be irrigated (see Sect. 36.3) | |
Retina | Major vessel | It is virtually always the result of an iatrogenic injury. Switch to air at high pressure and see if the bleeding stops. If not, try to inject PFCL or silicone oil to contain it. Note that the clot will need to be removed, which may restart the bleeding. Light diathermy may be employed, but be careful not to completely close the vessel, because this would lead to a different set of postoperative complications |
Small vessel | Most commonly seen in ILM peeling. The bleeding is usually minimal, in which case no intervention is needed (see Sect. 32.1.3) | |
Proliferative/neovascularg | Iris | Occurs when an adherent membrane or lens capsule is removed. If the bleeding is significant, use diathermy, but be aware that it is applied blindly since the bleeding vessel is not visible anteriorly |
Ciliary body | The hemorrhage may originate in the ciliary body itself or in the newly formed membranes; in the latter case the feeding vessel may lie very deep. The bleeding can be profuse to the point that the exact location is impossible to find (see above). Switch to air at high pressure, try to locate the source, and then diathermize it
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