HarvardCaseReport: Intracapsular hemorrhage in the setting o
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An 84-year-old man was referred for evaluation of decreased vision in the left eye of 3 days’ duration. His current medications included warfarin for paroxysmal atrial fibrillation, with a therapeutic international normalized ratio (INR) of 2.5, managed by an anticoagulation clinic. Past ocular history included pseudoexfoliative glaucoma and vitelliform macular dystrophy in both eyes. His past ocular surgical history included trabeculectomy in the left eye and uneventful cataract extraction with implantation of a one-piece intraocular lens (IOL) in the bag in both eyes at an outside clinic approximately 6 years prior. He denied a history of trauma to either eye.

On examination, corrected visual acuity was 20/30 in the right eye and hand motions in the left eye, decreased from his baseline visual acuity of 20/200. Intraocular pressure (IOP) was 16 mm Hg in the right eye and 8 mm Hg in the left eye. Examination of the right eye showed a well-positioned posterior chamber IOL in the bag with pseudoexfoliative material at the pupillary border, cup-to-disc ratio of 0.6, and a subfoveal vitelliform lesion. Examination of the left eye revealed a healthy bleb located in the superonasal conjunctiva, without evidence of a leak or blebitis. The anterior chamber showed 4+ red blood cells (RBCs), with a 2 mm layered hyphema obscuring a view of the posterior pole. B-scan ultrasonography revealed vitreous syneresis with intact retina. The patient was started on topical prednisolone 4 times daily and atropine twice daily.

He returned after 1 week with resolution of the hyphema but residual RBCs in the anterior chamber. His examination was most notable for settled hemorrhage between the IOL and posterior capsule (Figure 1). There was no evidence of iris transillumination defects or neovascularization. Pseudoexfoliative material on the anterior capsule, iridodonesis, and pseudophacodonesis were all noted. The posterior pole could be visualized. The cup-to-disc ratio was 0.9, and there was a subfoveal vitelliform lesion, with no evidence of posterior segment neovascularization. On gonioscopy, the angle was open, with heavily pigmented trabecular meshwork but without neovascularization of the angle. At this time, the exact etiology of his hyphema was unknown.

Three years after the initial presentation, the right eye developed a spontaneous hyphema. The IOL appeared stable and in a good position, and no other abnormal examination findings were identified, including iris transillumination defects. His INR remained in therapeutic range of 2.8. Fluorescein angiography of the anterior segment of both eyes confirmed no iris neovascularization or arteriovenous malformation.

Source: http://www.djo.harvard.edu/site.php?url=/physicians/cr/4387
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