Introduction:

Vitreous haemorrhages during vitrectomy are not an uncommon event, particularly in diabetic patients. However, intraoperative vitreous haemorrhages resulting from conjunctival and/or episcleral haemorrhages, after the successful closure of 23G scleral ports, is a rare finding, never before experienced by our surgical team. The authors present the case of a young man undergoing vitrectomy for persistent vitreous haze that had a vitreous haemorrhage at the end of the procedure, due to a conjunctival haemorrhage adjacent to the scleral vitrectomy entry site, after the trocar removal.

Methods:

The authors illustrate the clinical case of a 25-year old male patient, with a personal history of intravenous drug use, presenting to the emergency department of our hospital with a 1-week-long complaint of ocular pain and decreased vision of the left eye. At that time, a severe panuveitis was diagnosed, with anterior chamber cells and flare and vitreous haze. An infectious cause was suspected and, after a 1-month course of oral corticosteroid and large-spectrum antibiotic therapy, a vitrectomy was suggested. By that time, vision had decreased to light perception, with an almost complete pupillary block due to posterior synechiae, and the vitreous haze had progressed to the point of making the fundus observation impossible. The patient was then submitted to a combined 23G phaco-vitrectomy, with successful clearing of the vitreous cavity and gas tamponade. After the removal of the first surgical trocar, a conjunctival haemorrhage was noted, just above the scleral entry site. After applying external diathermia, with apparent success, the team noticed the gushing of blood into the anterior chamber. After an anterior chamber lavage, the fundus reflex had also changed to a dark red. Then, the vitreoretinal surgeon re-inspected and confirmed that the vitreous cavity was also filled with a large quantity of blood, beginning to form a large fibrin clot. The patient required an immediate review of the vitrectomy to clean the entire vitreous haemorrhage and, this time, silicone oil was the tamponade agent of choice. All scleral entry sites were tightly closed with vicryl sutures. Vitreous cultures were sterile and, after 6 months, VA is stable at 2/10.

Conclusions:

Vitreoretinal surgery is a complex field of ophthalmology, where we must expect the brutal unexpected, every step of the way. Our case illustrates just how anything can happen, even at the very end of a successful straight-forward procedure.

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David da Fonseca Martins