We have all seen it: post-op patient comes to your clinic with a layered hyphema that just isn’t clearing, and the intra-ocular pressure is hitting the 40s or 50s. While we usually try to manage this medically, there are times when you need to act fast in the clinic to protect the optic nerve and prevent corneal blood staining.
Today’s technique by Professor Ramesh Ayyala, Chairman of USF Tampa Eye Institute, is a Slit-Lamp Air-Fluid Exchange for Hyphema Drainage. This is an elegant way to use physics to your advantage to clear the visual axis and lower the IOP without a full trip back to the OR.
The Procedure: Air-Assisted Drainage
Performing this at the slit lamp requires a calm patient and a very steady hand. An assistant to help hold the patient’s head still is helpful. Here is the step-by-step approach:
- Step 1: The Air Bubble. Using a 30-gauge needle on a syringe filled with sterile air, enter the superior aspect of the anterior chamber. Inject a large air bubble aiming for 50 to 70% fill. This does two things: it maintains the structural integrity of the AC and physically pushes the blood downward toward the inferior angle.
- Step 2: The Inferior Paracentesis. Now, using a second paracentesis blade, create a small incision at the 6 o’clock position (inferiorly).
- Step 3: The “Burp.” Gently depress the posterior lip of this inferior incision. Because the air bubble is superior and providing constant downward pressure, the blood which is heavier will be forced out of the inferior opening first.
- Step 4: Tamponade. The remaining air bubble acts as a temporary internal tamponade, which can help prevent further bleeding from the offending vessel if the hyphema was caused by a micro-hyphema or UGH syndrome. Remember, our goal is a 50 to 70% air fill.
Why This Works
By injecting the air first, you avoid the risk of a flat anterior chamber. If you simply drain the blood, the AC collapses, and you risk corneal endothelial damage or iris incarceration. The air bubble provides a “pneumatic push” that makes the drainage more complete and much safer. This is a great maneuver to have in your surgical toolkit for those high-pressure emergencies. It’s about being proactive and protecting that patient’s vision.
(you can also do an air-fluid exchange for some grades of vitreous hemorrhage in a post-vitrectomy eye — you can find that on our sister channel RetinaRounds.com)