Entry wound complications: Unexpected entry site hemorrhage proved difficult to manage

Using valved cannulas during phacovitrectomy is highly recommended when an unexpected site hemorrhage becomes difficult to manage, according to David Fonseca Martins, MD.

Dr. Martins of Lisbon, Portugal, described the case of a 25-year-old male patient with a personal history of intravenous drug use and uveitis. The patient underwent a combined 23-gauge phacovitrectomy to remove a secondary cataract and clear the vitreous. There were numerous inflammatory membranes in the posterior pole and optic disc that were carefully removed.

The case was presenting during a session on retina complications at Retina Subspecialty Day prior to the 2015 American Academy of Ophthalmology annual meeting in New Orleans.

“We decided to peel the epiretinal membrane and the internal limiting membrane using a mixture of Trypan blue and Brilliant Blue,” Dr. Martins said. “At the end, we did a fluid-air exchange to tamponade the eye.”

Dr. Martins noticed some conjunctival hemorrhage just above the scleral entry site after removal of the first surgical trocar, and applied external diathermia. Although that appeared successful, there was a “gushing of blood into the anterior chamber coming from behind the iris. In a few seconds, the entire anterior chamber was filled with blood,” he said.

To see Dr. Martins perform this procedure, click here to skip to the last page. 

What was the cause?

What was the cause?

Panelist Francesco Boscia, MD, associate professor and chairman, Department of Ophthalmology, Sassari University, Italy, suggested two possible explanations – first, the blood might be coming directly from the conjunctiva. A small vessel can leak some blood that might then leak inside, or “one of the ciliary vessels might bleed,” he said.

Dr. Martins noted the infusion cannula should always be the last instrument removed to ensure consistent pressure during the surgery.

Panelist Antonio Capone, Jr., MD, director of Ophthalmology Clinical Research, Beaumont Hospital, Royal Oak, MI, added that using diathermia externally across the sclerotomy might also have been the provocation.

“While I agree with Dr. Boscia’s analysis of the two sources of bleeding, it could be from a choroidal vasculature,” Dr. Martinssaid. “I believe that with the diathermia that was stretched, and with the stretch, it bleeds.”

Dr. Martins clarified that he had performed the diathermia only through the conjunctiva and not across or inside the sclerotomy.

This type of complication can occur during the trocar removal – as the surgeon inadvertently nudges one of the ciliary body vessels. In all likelihood, the panelists noted, the patient was likely anticoagulated (even though the patient denied it).

“My feeling is that the blood came directly from the conjunctiva and scleral vessels near the 2 o’clock entry site,” Dr. Martins explained. “Without valved trocars, the 10 o’clock cannula was opened because the plug was pushed away by the air. So, the eye softened and this facilitated more of the ‘aspiration’ of the blood inside the eye through the entry site.”

What to do?

What to do?

Dr. Martins said the fundus reflex had also changed to a darker red, “prompting us to re-inspect the vitreous cavity. We opened the conjunctiva to reinsert the surgical trocar and all scleral and conjunctival bleedings were cauterized.”

There was obvious blood inside the scleral entry site, and the vitreous cavity had also filled with “a large quantity of blood.” Dr. Martins performed fluid-air exchange and a cyropexy in the peripheral retina.

“This time, silicone oil was the chosen tamponade agent,” Dr. Martins said. “All scleral entry sites were tightly closed with Vicryl suture.”

However, because valved cannulas were not used initially, it allowed the eye to remain open. Once Dr. Martins inserted the plug, that seemed to “lock up the eye pretty tight, very quickly,” observed Rishi Singh, MD, Cole Eye Institute, Cleveland Clinic, one of the panelists.

Given that the patient had uveitis, “probably a thickened choroid, this side was hot and had a higher risk of bleeding,” said panelist Raymond Iezzi, MD, associate professor of ophthalmology, Mayo Clinic, Rochester, MN. “I tend to use valved cannulas for all my cases and you have to be cognizant of controlling intraocular pressure.”

Since this incident, Dr. Martins also recommends valved cannulas – and when he encountered a similar complication in late 2015, “I entered immediately inside the eye and with the indentation,” he added “I could observe and see the reason of the hemorrhage.”

In that case, the hemorrhage was caused from the sclerotomy and the entry sites, confirmed with the blood around the eye in the peripheral retina.

“I saw the reflex, and was able to promptly and rapidly correct the complication,” he said. It is imperative for surgeons to maintain a secure eye when closing the wounds, and alleviating pressure quickly.

“Hemorrhages originating close to the scleral 23-guage entry site may result in unexpected complications,” Dr. Martins explained. “When extensive external bleeding occurs after trocar removal, air/intraocular pressure should be increased immediately while keeping all other port occluded tightly.

“The conjunctiva should be opened and the scleral wound should be sutured safely,” he added. “Performing isolated diathermia or compressing/massaging the conjunctiva, without a sufficient positive pressure differential from the vitreous cavity, may have the unintended effect of forcing the blood to drain interiorly. We believe that ignoring these events and not checking the posterior segment for complications may result in a possible need for re-intervention.”