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Clinical syndrome of endocapsular hematoma: Presentation of a collected series and review of the literature

John C. Hagan III, MD, Rupert Menapace, MD, Ursula Radax, MD

M ost forms and presentations of postoperative anterior segment hemorrhage following extra­

capsular cataract extraction (ECCE) and posterior chamber intraocular lens (IOL) surgery have been famil­

iar to surgeons since the inception of the procedure. A notable exception is the post-cataract-surgery accumu­lation of blood within the intracapsular space (i.e., cap­

sular bag or sack) around and/or behind a posterior chamber 10L (Figures 1 and 2). Hemorrhage into the capsular bag following ECCE and posterior chamber IOL surgery was not reported until 1989. 1 Although initially considered rare, this phenomenon has been dis­cussed in the literature with increasing frequency. 1-14 It is sometimes referred to as an in-the-bag hyphema. I

,2

However, since a hyphema is blood within the anterior chamber of the eye, not the intracapsular space of the lens, the term is inaccurate. We believe the most accu­rate term to describe this entity is endocapsular hemato­ma,3 even though the amount of blood is sometimes so small that the suffix "-oma" may seem inappropriate. In this paper, we present additional cases of endocapsular hematoma and review the existing literature.

Report of Cases We have an ongoing interest in endocapsular

hematoma.3 ,5,6,7,8,1O,11 Because of this, we prospec-

From Midwest Eye Institute a/Kansas City, North Kansas City, Missouri (Hagan), and University Eye Hospital, Vienna, Austria (Menapace, Radax).

Reprint requests to John C. Hagan IlL MD, Midwest Eye Institute of Kansas City, 2700 Clay Edwards Drive, Suite 550, North Kansas City, Missouri 64116

tively searched our postoperative patients for endocap­

sular hematomas including small, inconspicuous,

nonvision impairing ones that might be overlooked.

We have summarized our clinical observations of all

planned ECCE and phacoemulsification with poste­rior chamber 10L surgery between 1990 to 1993 for

noted but previously unreported endocapsular

hematomas. Each of us is an experienced cataract surgeon

with an active practice. Phacoemulsification is our

preferred method of cataract removal. We use a vari­

ety of small incision techniques and different types

of posterior chamber 10Ls. Hagan has used a short, self-sealing sclerocorneal incision since 1993; prior to

that he used long, narrow scleral tunnels with radial

or horizontal sutures. Menapace and Radax used su­

tured step incisions prior to 1990 and have used self-sealing corneal lip incisions since then. Our surgi­cal techniques have been described. 15

-17 Surgical

iridectomies are not performed. Occasionally, phaco­

emulsification and posterior chamber 10L surgery is combined with a glaucoma filtering operation, usu­

ally a trabeculectomy. Iridectomies are done in these cases.

Our patients are seen 1 day and 1 and 5 weeks

postoperatively. Slitlamp examination is done at each

visit. The pupils are pharmacologically dilated at the 5

week examination and indirect ophthalmoscopy

performed.

Hagan has seen six endocapsular hematomas in

1574 phacoemulsification cases. None was associated with operative complications, observed anterior cham­

ber hyphemas, or vitreous hemorrhage. Scleral tunnel

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ENDOCAPSULAR HEMATOMA

Figure 1. (Hagan) Large endocapsular hematoma fills the pu­pillary space, including the visual axis. (Reprinted with permission from Arch Ophthalmol1991; 109:514-518. © 1991 AMA.)

incisions with a suture(s) were used in all six cases. One

case was a combined phacoemulsification, posterior

chamber IOL insertion, and trabeculectomy. The six

endocapsular hematomas were located outside the visual

axis, did not cause visual disturbances, and required no

special treatment.

Menapace and Radax have seen two endocapsular

hematomas in over 1000 phacoemulsification cases.

Neither case was associated with intraoperative compli­

cations or conspicuous anterior chamber hyphemas.

Both caused visual disturbances and required YAG laser

caps ulotomy (Figure 3). Endocapsular hematomas have

not been observed in cases in which clear corneal or

Figure 3. (Hagan) Endocapsular hematomas are more common

with combined cataractilOUfiltration surgery. This case required VAG laser capsulotomy. (Reprinted with permission from Arch Ophthalmol 1991; 109:514-518. © 1991 AMA.)

Figure 2. (Hagan) Small endocapsular hematoma behind a bi­convex posterior chamber IOL. Visual acuity is not affected.

limbo-corneal incisions were used except in one case ll

with a defective corneal lip incision.

Discussion T d 4 . 1 1-14 "c. o ate, 1 artlc es or SClentlI1C correspon-

dences dealing directly or indirectly with endocapsular

hematomas have been published. Including the ones re­

ported in this paper, this comprises almost 40 cases.

Other cases have been reported to the authors anecdot­

ally by other surgeons. With three exceptions, all cases of

en do capsular hematomas have been noted in the early

postoperative period, i.e., from immediately after sur­

gery to days or 1 to 12 weeks.

The first exception is the case reported by Auran and

coauthors.4 Their patient, who had multiple myeloma,

suddenly developed an endocapsular hematoma 7 years

after ECCE and posterior chamber IOL insertion and 5

years after a YAG laser posterior capsulotomy. The pre­

sumed etiology was an anterior vitreous hemorrhage.

The open posterior capsule allowed blood to enter the

endocapsular space from the vitreous cavity. The likely

cause of the vitreous hemorrhage was a systemic bleed­

ing diathesis. The endocapsular hematoma and the vit­

reous hemorrhage cleared spontaneously.

The other atypical cases were reported by Eifrig and

coauthors. 14 Their patients were diabetic and had pro­

liferative diabetic retinopathy. At 1 year (one case) and at

7 months (second case) after planned ECCE and inser­

tion of a posterior chamber IOL, the patients developed

380 J CATARACT REFRACT SURG-VOL 22, APRIL 1996

ENDOCAPSULAR HEMATOMA

rubeosis iridis, neovascular glaucoma, and vitreous hem­

orrhage. They were noted to have iris neovascular blood

vessels running from the iris through the positioning

holes of the posterior chamber IOL into and along the

posterior capsule. The authors termed this condition

rubeosis capsulare. The vessels bled, causing endocapsu­

lar hematomas involving the lower capsular bag. One

patient eventually became blind from phthisis bulbi.

The other responded to pars plana vitrectomy, en­

dophotocoagulation, membranectomy, and cryoabla­

tion. These cases are variants of neovascular glaucoma

and rubeosis iridis. In cases of endocapsular hematoma

the iris and angle should be carefully examined for evi­

dence of neovascularization, especially in the diabetic

patient.

All other reported cases of endocapsular hematoma

have followed planned ECCE, phacoemulsification, or

combined cataract and glaucoma surgery. All types of

posterior chamber IOLs have been involved including

those with planoconvex, biconvex, large (7 mm), small

(5 mm), round, and oval optics. Lens architecture has

included rigid and foldable, one and three piece, poste­

riorly angulated, and nonangulated types. Cases with

jagged-edge, can-opener capsulotomies or small and

large continuous curvilinear capsulorhexes (CCCs) have

been reported. Wound architecture has included large,

multistitch incisions with planned ECCE as well as

small scleral tunnel incisions with and without sutures.

To date endocapsular hematomas have not been re­

ported with anterior chamber lenses, clear corneal inci­

sions, or eye surgeries other than phacoemulsification

and planned ECCE with posterior chamber IOL inser­tion. Surgeons who observe an endocapsular hematoma

in these circumstances should document them in the

literature.

An exact incidence cannot be established, but endo­

capsular hematomas are not rare. The observed fre­

quency probably correlates with how carefully the

observer looks for the problem and the timing of post­

operative pupil dilation. Most of the cases we are report­

ing were not noted until the pupils were routinely

dilated postoperatively. An incidence rate should not be

inferred from this series or previous case reports because

some endocapsular hematomas may have escaped detec­

tion and/or been absorbed before the pupils were di­

lated. We believe that endocapsular hematomas are

more frequent with combined cataract-glaucoma sur-

gery. Three of the 10 reported cases lO occurred with

combined cataract-glaucoma surgery.

In their original article,3 Hagan and Gaasterland

speculate that biconvex lenses might prevent endocap­

sular hematoma by obliterating the space behind the

IOL and the posterior capsule. Nishi and coauthori

believe that a closely adherent capsulorhexis will avert

the problem. Radax and Menapace lO refute this in their

report of a series of en do capsular hematomas that oc­

curred with biconvex IOLs and CCc. In one third to

one half of the cases, Menapace and coauthors report seeing a narrow space behind the biconvex IOL.7 ,B, IO

They have also observed that in the first few days after

surgery a gap (Figure 4) often exists between the anterior

leaf of the capsulorhexis and the IOL optic. This space

allows ingress of blood from the anterior chamber. Fur­

ther observation shows that the capsulorhexis contracts

during the first 3 to 10 days after surgery. The apposi­

tion of the anterior capsule on the optic closes the gap

and traps blood within the sack. Nishi and Nishi 18 have

also reported this phenomenon.

The source of the blood causing the endocapsular

hematoma is almost always the scleral and/or limbal ves­

sels of the surgical incision. Only in exceptional cases

does the blood originate from the vessels of the chamber

angle, the iris, or from the vitreous cavity. Bleeding di­

athesis does not play an important role. None of our

cases had bleeding tendencies or were anticoagulated.

Conversely, none of our cataract surgical patients who

were kept on full therapeutic doses of warfarin sodium

Figure 4. (Hagan) Blood on the lower left edge of the eee is

entering the gap between the anterior capsule and the posterior

chamber IOL optic. Blood moving obliquely superior on the right in

slit beam has already migrated through the gap, around the optic

edge, and is behind the optic.

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ENDOCAPSULAR HEMATOMA

Figure 5. (Hagan) Small anterior chamber hyphema and endo­capsular hematoma occurring together. (Reprinted with permis­sion from Arch Ophthalmol1991; 109:514-518. © 1991 AMA.)

(Coumadin®) prior to their surgery (e.g., aortic valve replacements) developed hyphemas, endocapsular he­matoma, vitreous hemorrhage, or other bleeding prob­lems. Intraoperative complications have been reported infrequently and did not occur in our cases.

Large or small anterior chamber hyphemas may exist simultaneously with endocapsular hematomas

(Figure 5). The majority of reported cases do not report visible anterior chamber hyphemas. We believe anterior chamber hyphemas or erythrocytes circulating in the aqueous always precede an endocapsular hematoma but are usually not observed. We postulate the blood ema­nates from the surgical incision into the aqueous and passes through the pupil and into the cleft between the anterior optic surface and the posterior side of the ante­rior capsular leaf. Some blood often remains here

Figure 6. (Hagan) Blood lower right is behind anterior capsular leaf of CCC. layered blood is in posterior capsular space behind optic.

Figure 7. (Hagan) large nonclearing endocapsular hematoma following triple procedure. There is a whitish fluid layer above blood. (Courtesy of Gaasterland.)

(Figures 4 and 6), while the remainder may go around the optic and into the posterior capsular space behind the posterior optic surface and the anterior face of the posterior capsule.

Endocapsular hematomas can be minute (a few red blood cells) or quite large, covering most or all of the

pupil (Figures 1, 3, 5, and 7). Most cases are small, do not affect the vision, and require no treatment (Figures 2, 4, 6, and 8). They may reabsorb quickly and com­pletely or slowly; there are many instances of partial absorption (Figure 8). In some cases, an endocapsular hematoma may not reabsorb (Figures 1,3,5, and 7). If the blood clears there is often fibrosis and striae (Fig­ure 9); wrinkling (Figure 9); flat, honeycombed Elschnig pearls; brownish blood residues (Figure 10);

and opacification of the posterior capsule. Alternately,

Figure 8. (Hagan) Incomplete reabsorption of endocapsular hematoma around an IOGEl lens 6 months postoperatively.

382 J CATARACT REFRACT SURG-VOL 22. APRIL 1996

ENDOCAPSULAR HEMATOMA

Figure 9. (Hagan) After spontaneous reabsorption of endocap­sular hematoma, the posterior capsule has extensive fibrosis,

striae, and honeycomb-like Elschnig pearls.

Figure 10. (Hagan) Diffuse layer of blood residues on posterior capsule following endocapsular hematoma.

even a large endocapsular hematoma may reabsorb and leave a perfectly clear capsule. Contracture of the CCC

may sequester the red blood cells in the endocapsular

space isolated from proteolytic enzymes and normal

mechanisms for removal of aging erythrocytes. The

bright red appearance of an endocapsular hematoma of­

ten persists long after the 120 days reported as the nor­

mal lifetime of the erythrocyte.3 The whitish layer

(Figure 7) seen above some endocapsular hematomas

may represent a layer ofleukocytes or partially autolyzed

red blood cells.

Although postural drainage of an endocapsular he­

matoma has been described,l it is impractical and un­

necessary in most cases. For sight-impairing hematomas,

YAG laser capsulotoml,lO has successfully drained the

blood posteriorly into the vitreous caviry. The timing of

laser treatment varies. If rapid clearing of a symptomatic

endocapsular hematoma does not occur over several

days to a week, treatment is appropriate. The energy

required for successful capsulotomy has varied from low

amounts (1.0 to 2.0 mJ per burst) to levels considerably

above normal (3.0 to 6.0 mJ per burst). The total num­

ber of bursts has varied from as few as 5 to over 100. The

use of a YAG laser condensing lens is optional.

With small or thin layered endocapsular hematomas, it

is possible to treat centrally right through the layered or

fibrosed blood. Some endocapsular hematomas are so

large and thick that extremely large amounts of energy

would be required to penetrate them. In these cases we

begin treatment at the superior border of the hematoma

(Figure 7) and continue inferiorly as the hematoma

drains into the vitreous caviry. No complications have

been reported after YAG laser treatment.

Preventing endocapsular hematomas is problematic

as all cases have been reported by experienced, techni­

cally competent surgeons using standard procedures and

a variery of IOLs. It seems prudent to pay meticulous

attention to proper wound construction and intraoper­

ative hemostasis, restoring normal intraocular pressure

at the end of surgery, and not leaving blood in the ante­

rior chamber or the capsular bag. Although it is too early

in the development of clear corneal incisions to conclude

that they will eliminate endocapsular hematomas, none

have been reported to date.

References

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