Typically, modern day phacoemsulification cataract surgery is relatively bloodless because we are making incisions in the cornea and then operating on the avascular crystalline lens. On occasion, we can encounter intra-ocular bleeding during cataract surgery and this is usually from the iris, which is a vascular structure.
In the case presented here, the patient has a history of tamsulosin use which causes intra-operative floppy iris syndrome. Towards the end of the case, after the IOL has been implanted in the capsular bag, iris prolapse tugs on the iris root and causes a rupture of one of the small iris vessels. This results in a focal area of iris bleeding. What is the best management?
There are pharmacologic therapies which can help stop bleeding, such as instilling epinephrine or phenylephrine solutions, both of which are vasoconstrictors. Another simpler option is to apply pressure. If the tissue pressure is greater than the intra-vascular pressure, then the bleeding will stop. This applies to a superficial skin injury where direct pressure will stop bleeding, and it also applies to intra-ocular bleeding. We can temporarily increase the IOP (intra-ocular pressure) by using balanced salt solution. In this case, I raise the IOP to about 50 mmHg and then simply wait. Within a short period of time, the bleeding has stopped and the blood can be washed away from the anterior chamber.
Click below to see the management of iris bleeding during cataract surgery:
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