It is unusual to encounter bleeding in the anterior chamber during cataract surgery, but rarely it does happen. The typical source is from the iris, either from damage to the iris stroma or iris root from iatrogenic causes. Sometimes patients have neovascularization of the iris (rubeosis iridis) as a result of anterior segment ischemia from proliferative diabetic retinopathy or vascular occlusive disease. These neovascular vessels are fragile and can bleed more easily than normal blood vessels.
In this patient, however, there is no touching of the iris during surgery and there is no neovascularization either. The eye is totally healthy and without comorbidities. The patient has a history of atrial fibrillation for which daily warfarin has been prescribed. The patient’s INR is in the therapeutic range.
The source of the bleeding here is from the limbal vessels. We have written extensively about the importance of barely nicking limbal vessels in order to produce incisions which seal effectively and permanently. In this case, these vessels continued to ooze blood which tracked its way into the eye via the paracentesis.
The treatment in most cases of bleeding in the anterior chamber is to increase the intra-ocular pressure and perhaps instill a solution containing epinephrine such as 1:10,000 epinephrine made by combining 1 part epinephrine (which comes in a strength of 1:1000) to 9 parts of balanced salt solution. Epinephrine is a potent vasoconstrictor and will help to control bleeding. In this case, sealing the incisions (and raising the IOP) was very effective.
click below to watch this edited video of bleeding in the anterior chamber: