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Stopping anterior chamber bleeding

Intracameral phenylephrine found to have benefit in small case series

Cheryl Guttman Krader

Posted: Tuesday, October 1, 2019

Intracameral injection of phenylephrine appears to be an effective treatment for stopping intraoperative anterior chamber bleeding, reports Mukhtar Bizrah, MD, FRCOphth.
At the 2019 meeting of the Association for Research in Vision and Ophthalmology (ARVO) in Vancouver, Canada, Dr Bizrah, Cornea fellow and senior resident, The Western Eye Hospital, Imperial College Healthcare NHS Trust, London, England, reported success using this approach in three patients.
The experience, which involved injection of 0.3mL of undiluted 2.5% phenylephrine, is also summarised in a published paper Dr Bizrah co-authored with Melanie C Corbett, MD, FRCS, FRCOphth (Ophthalmol Ther. 2019;8(1):137-141).
“To our knowledge, this is the first report of intracameral injection of phenylephrine to successfully stop anterior chamber bleeding during surgery.”
Intraocular bleeding during anterior segment surgery creates a challenging situation for the surgeon because it can obscure visualisation, and if it is not controlled, it can lead to intraoperative and postoperative complications. Intervention by tamponade using viscoelastic, air or saline can sometimes fail to control significant bleeding, or it might provide only a temporary fix with the bleeding restarting following further intraocular manoeuvres, he explained.
Furthermore, the increase in IOP that occurs with tamponading can cause pain for patients being operated on under topical anaesthesia, as well as optic nerve damage in patients with very advanced glaucoma, said Dr Bizrah.
All three patients in the case series were undergoing cataract surgery and one was having a combined procedure with suprachoroidal stent (CyPass Micro-Stent) insertion. All patients had received topical phenylephrine preoperatively for pupil dilation administered as drops or as the fixed combination phenylephrine/tropicamide conjunctival insert (Mydriasert). All cases were performed with irrigation solution containing 0.1% adrenaline.
In all cases, the bleeding stopped completely within 30-to-60 seconds after the phenylephrine injection, and the surgery was completed successfully without any further bleeding. Postoperative follow-up showed no eyes developed hyphaema.
Dr Bizrah said that the efficacy of the intracameral phenylephrine in these eyes that received phenylephrine previously by topical and irrigating solution containing adrenaline may be explained by the more potent vasoconstrictive effect of a high concentration of phenylephrine when injected intracamerally at the time of the bleeding.
“One patient who was at risk for intraoperative floppy iris syndrome had also received intracameral phenylephrine at the start of surgery. Bleeding only stopped when phenylephrine was re-injected 15-to-20 minutes later when iris bleeding started. The efficacy of the intracameral injection of phenylephrine may therefore be due to a direct vasoconstrictive effect on the exposed bleeding vessel,” he noted.

Mukhtar Bizrah: m.bizrah@doctors.org.uk