This patient presents with late-onset recurrent hyphema associated with IOP spikes after cataract surgery. Possible causes related to the previous surgery include wound vascularization and IOL-related bleeding from iris touch or chafing and iris tucking. Other diagnoses to consider are neovascularization (related to diabetes, central retinal vein occlusion, ocular ischemia, and chronic uveitis), vascular anomalies (tufts, capillaries, microaneurysms, and hereditary telangiectasia), bleeding disorders (blood dyscrasias and anticoagulants), recent ocular surgery (peripheral iridotomy, trabeculectomy and microinvasive glaucoma surgery), and rare disorders (juvenile xanthogranuloma, retinoblastoma, leukemia, uveal melanoma, iris metastases, and Lowe syndrome).
Evaluations should include a complete blood count, coagulation workup, blood sugar, hemoglobin A1c, electrolytes, and liver-function tests. Carotid dopplers would be helpful in determining the risk for ocular ischemia. A chest x-ray and abdominal ultrasound (US) should be considered if there is a suspicion of malignancy and metastases. An ophthalmic US, fluorescein angiography of the iris and retina, and US biomicroscopy (UBM) of the anterior segment should be performed to look for local causes.
We are told that the recurrent hyphema may be posture related and that there was an observation suggestive of pseudophacodonesis (ie, the haptics were observed in the coloboma on 1 occasion and then not on another occasion); thus, the cause seems to be related to the IOL. Although there is no mention of iris transillumination defects or IOL-iris touch, the decentered sulcus-placed IOL is still highly suspect as the cause. The UBM should confirm this by showing IOL-iris touch or iris tuck, even in the absence of clinical findings.1
Treatment would depend on the diagnosis. In addition to treating the underlying condition, ocular management may include panretinal photocoagulation for ocular ischemia, photocoagulation of vascular anomalies, and topical management of uveitis or glaucoma. Because the likely cause is the pseudophacodonesis, stabilization of the IOL should be performed. In this case, the IOL is a 3-piece model with flexible haptics. My preferred management would be externalization of the haptics and scleral tunnel fixation of the externalized haptics as originally described by Gabor and Pavilidis2 and popularized by Agarwal et al.3
1. Pavlin CJ, Harasiewicz K, Foster FS. Ultrasound biomicroscopic analysis of haptic position in late-onset, recurrent hyphema after posterior chamber lens implantation. J Cataract Refract Surg
2. Gabor SGB, Pavilidis MM. Sutureless intrascleral posterior chamber intraocular lens fixation. J Cataract Refract Surg
3. Agarwal A, Kumar DA, Jacob S, Baid C, Agarwal A, Srinivasan S. Fibrin glue-assisted sutureless posterior chamber intraocular lens implantation in eyes with deficient posterior capsules. J Cataract Refract Surg