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Journal Français d'Ophtalmologie
Volume 40, n° 9
pages e329-e331 (novembre 2017)
Doi : 10.1016/j.jfo.2016.07.034
Lettres à l'éditeur

Recurrent vitreous hemorrhage secondary to capsular tension ring chafing syndrome: A case report
Hémorragie intravitréenne récidivante secondaire à un syndrome d’irritation de l’iris postérieur : à propos d’un cas
 

M. Delbarre a, b, , J. Akesbi b, M. Sellam c, d, J.P. Nordmann b
a Hôpital d’Instruction-des-Armées-Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France 
b Service d’ophtalmologie II, centre hospitalier national d’ophtalmologie des XV–XX, 28, rue Charenton, 75012 Paris, France 
c Service d’ophtalmologie V, centre hospitalier national d’ophtalmologie des XV–XX, 28, rue Charenton, 75012 Paris, France 
d Centre explore vision, 10, rue Croix-des-Petits-Champs, 75001 Paris, France 

Corresponding author. Hôpital d’Instruction-des-Armées-Percy, 101, avenue Henri-Barbusse, 92140 Clamart, France.
Introduction

Incidence of spontaneous vitreous haemorrhage is approximately 7 cases per 100,000 persons. Proliferative diabetic retinopathy, retinal tear, proliferative retinopathy after retinal vein occlusion and posterior vitreous detachment without retinal tear are the most common causes of spontaneous vitreous haemorrhage. Less common causes include occlusive vascular disease, retinal arterial macroaneurysm, hemoglobinopathies, macular degeneration related to age and intraocular tumors [1].

We report a case of a patient who presented recurrent unilateral vitreous haemorrhages over a 2-year period.

Observation

A 44-year-old man came to the eye emergency department following a blunt trauma. He received a punch in the face and complained of blurred vision.

His medical history revealed high myopia, with both eyes treated for retinal detachment; his right eye was lost and finally treated by enucleation and his left eye successfully treated by ab externo surgery.

Best-corrected visual acuity (BCVA) was 20/50 with −15.00 (−1.00×165°).

Biomicroscopy revealed a clear cornea, a deep and quiet anterior chamber and a cortical nuclear cataract. Fundus examination showed a clear vitreous, a flat retina and the peripheral indentation from the buckle. Cataract extraction by phacoemulsification was uneventful apart from a zonular dialysis probably in connection with the trauma, which occurred a few months ago. Postoperatively, BCVA was 20/25.

However, with a two-year follow up, a vitreous haemorrhage occurred 8 times with elevated IOP in the left eye and started 9 months following cataract surgery.

Finally, a diagnostic pars plana vitrectomy was performed but failed to determine the origin of the bleeding. A second optic pars plana vitrectomy was necessary after the first few months due to recurrence of vitreous haemorrhage. Elevated intraocular pressure persisted despite maximal topical and systemic treatment so a deep sclerectomy was decided to control the IOP.

After more than two years, the source of the bleeding was finally found with a high-frequency ultrasound biomicroscopy. The ultrasound biomicroscopy (UBM) highlighted a direct contact between the capsular tension ring (CTR) placed during cataract surgery and the ciliary body (Figure 1). One end of the CTR was not in the bag and was found in the sulcus in contact with the ciliary body. An initial UBM did not find the CTR because the technician was not lead to the possible origin.



Figure 1


Figure 1. 

Video still of a UBM demonstrating a contact between the capsular tension ring and the ciliary body.

Zoom

The patient was treated with atropine 1% eye drops. In a two-year follow up, no recurrence of vitreous hemorrhage occurred and the IOP was controlled (14mmHg) with a combination therapy (dorzolamide, timolol and atropine). Despite several intraocular pressure spikes up to 40mmHg, no white-to-white visual field defects appeared (Figure 2) (Humphrey, Carl Zeiss Medical, SITA-Standard 24-2) and BCVA was unchanged (20/25).



Figure 2


Figure 2. 

Visual field report of the left eye showing the absence of white-to-white defects in two years.

Zoom

Discussion

Vitreous haemorrhage after cataract extraction was a relatively common complication with older cataract extraction techniques. With newer phacoemulsification techniques, vitreous haemorrhage is a rare complication after cataract extraction [2].

Complications after intraocular lens (IOL) placement have been reported days to years after cataract surgery. Some of the less commonly reported complications involve iris chafing by a displaced or ciliary sulcus-placed IOL [3, 4, 5]. In our case, the capsular tension ring was responsible for recurrent vitreous haemorrhage.

Complications caused by the friction of the IOL against the iris are known under the term “posterior iris chafing syndrome”. Posterior iris chafing may cause a spectrum of disorders that include iris-pigment epithelial defect, pigment dispersion with or without elevation of intraocular pressure, intermittent microhyphemas, and the uveitis–glaucoma–hyphema (UGH) syndrome.

Uveitis–glaucoma–hyphema syndrome can lead to loss of vision from glaucomatous optic neuropathy, chronic inflammation, cystoid macular edema and intraocular haemorrhage [6].

Ghost cell glaucoma can occur after vitreous haemorrhage when the residual deformed red blood cells gain access to the anterior chamber and clog the trabecular meshwork resulting in increased intraocular pressure.

For refractory glaucoma caused by chronic obstruction of trabecular meshwork by ghost cells, trabeculectomy or usage of glaucoma drainage device is warranted [7].

These complications often require to explant the patient. In our case, we chose a first line medical treatment and began a cycloplegic treatment (atropine 1%), with the aim of decreasing frictional movement of the iris and the ciliary body over the CTR [8].

The absence of diagnosis and appropriate treatment would have most likely lead our patient to blindness by refractory glaucoma and optic neuropathy. Contact between the implanted material and the ciliary body must be looked for when a pseudo-phakic patient presents with vitreous haemorrhage, especially when the material is implanted in the sulcus space and no other obvious cause of bleeding is found. A simple topical treatment could resolve the bleeding and avoid explantation surgery, which is always tricky.

Disclosure of interest

The authors declare that they have no competing interest.

References

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