Home | General Information | E-Resources | E-Consultation | E-Learning | Site Map | ORBIS | Feedback
Home > E-Resources Home > Ask a Professor Home > Cataract Home > Bleeding complication in manual SICS
QUESTION OF THE WEEK
VIDEO LIBRARY
OPHTHALMOLOGY BOOKS & MANUALS
Nursing Education
Clinical Challenges
The Ophthalmology Minute
Eye Care Equipment
Ask a Professor
mLearning
ORBIS Program Features
FREE ONLINE JOURNALS
OPHTHALMOLOGY LINKS
I Have a Question

Print ViewPrint this Page
Cataract : Bleeding complication in manual SICS
Bleeding complication in manual SICS  |  IOL Calculation  |  Timing of congenital cataract surgery  |  Management of astigmatism during cataract surgery  |  Indications for combined cataract and glaucoma surgery  |  Managing a flat anterior chamber after irrigation aspiration  |  Globe fixation in temporal sics

When performing small incision cataract surgery, using a frown shaped sclero corneal tunnel incision, there are deep perforating episcleral vessels at the inner recess of lateral wound edges within the tunnel bed which if accidentally damaged during wound construction (it being a blind procedure) tend to bleed profusely into the AC.  Leaving the bleeder within the wound causes the pool of blood or clot to press on the post lip and open up the tunnel causing a hyphema.  A full chamber AC Bubble doesn't help, as the blood trickles down the edges of the bubble into the AC.  Diluted Epinephrine sometimes controls the bleed temporarily only to cause a rebound bleed later.  Cauterizing them without damaging wound integrity (suture-less water seal) is not a possibility.  If the bleeder is at the inner recess of the lateral wall of the tunnel, it is not reachable by the cautery tip.  Suturing the wound does stop the bleed, but distorts the wound.  I plan my incision site after looking at these vessels, but the aberrant intrascleral course causes the above mentioned problem.  Is there a solution to control the bleeder without compromising wound integrity? 

There is no mention of whether the incision is temporal or superior.  Superior incisions don’t bleed much. Temporal incisions do bleed.  I use temporal incisions almost always, unless the patient has with-the-rule (WTR) astigmatism.

If you ever think that an episcelral vessel is going to bleed, you can cauterize gently before you start making the scleral groove.

But the main issue I can see here is you have not made enough corneal valve which is very essential for a scleral pocket incision.

If you have a good corneal valve [which can be made by dissecting at least 1mm in to the corneal stroma while making the tunnel] all these problems can be avoided. A good corneal valve prevents the blood from going into the anterior chamber and a good corneal valve helps to retain the air bubble successfully in the anterior chamber.

You can not go inside the internal corneal lip and cauterize. If it starts bleeding, then try to use a full air bubble to tamponade. That air bubble should be full, really full, causing corneal haziness. Reassure the patient that s/he may not see better for a day or two, but once the bubble gets absorbed the vision will be regained.

We went through this many times, but it can be helped.

We have a movie clip in the manual SICS course on the Cyber-Sight website which shows rigid pupil and hyphema. Please go through it and you can get a clue.

 -G. Madhavi Madhu
  Goutami Institute