Subconjunctival Hemorrhage; "Complication" of Vitrectomy?

Subconjunctival hemorrhage looks frightening but is really quite benign. It doesn't even hurt. Randall Wong, M.D., Retina Specialist, Fairfax, VA 22030A subconjunctival hemorrhage is quite frightening, but when following vitrectomy, it is quite benign.

Similar to a Bruise

A bruise of your skin and a subconjunctival hemorrhage are the same thing.  In both cases, blood is trapped beneath tissue.  The difference is that with the eye hemorrhage, the blood is trapped underneath very thin transparent tissue.

Hence, the bright red appearance.  There is no muscle or skin to mask the bright red color.

Causes of a Subconjunctival Hemorrhage

There are many causes of a subconjunctival hemorrhage.  The blood itself is benign, painless yet ugly.  The cause of the hemorrhage could be from an infection, inadvertent poke in the eye, cough/sneeze/strain, etc.  On rare occasion the bleeding could be a sign of systemic disease, hence, your doctor must be made aware of frequent or bilateral subconjunctival hemorrhages.

Bleeding Caused by Surgery

The intent of this article was to address the bleeding following vitrectomy or scleral buckle retinal surgery.

The conjunctiva is a very thin and relatively clear tissue and is the outermost covering of the eye.  It surrounds the beginning at the edge of the cornea.

The conjunctiva has lots of tiny blood vessels.  These tiny vessels are quite fragile and can bleed easily.  Many times I’ll use a cotton swab to push on the eye…it can bleed.

Most of the time, the bleeding is caused by directly poking or cutting through the fine delicate blood vessels of the conjunctiva as I am preparing the eye for surgery or as I am finishing up surgery.

While scary, it’s a frequent occurrence (I’m deliberately avoiding the word “complication”) and probably happens about 50% of the time.

It’s Scary, but Harmless

When related to surgery, it’s scary but harmless.  So many patients get over excited by the gruesome look.  It will go away, migrate with gravity and may even change color.  A subconjunctival hemorrhage usually takes 1-2 weeks for the blood to go away.

Blood must be broken down then absorbed by the body.  The by-products of the breaking down of blood can have different hues/colors/shades.

What Does This Mean?

A subconjunctival hemorrhage is benign.  It has no relationship to whatever is going on inside the eye.  Following surgery, it’s natural to get fixated on the appearance of the eye..that’ normal.  Rest assured, however, that it is a frequent occurrence in retinal surgery.

A subconjunctival hemorrhage does not occur so often with cataract surgery.  Modern cataract surgery requires incisions (cutting into the eye) through the cornea.  The cornea is devoid of blood vessels.

If you are concerned about bleeding on the outside of your eye, you should alert your doctor.


“Other” Eye Conditions Retinal Detachments

Retinal Tears and Vitreous Hemorrhage

Vitrectomy for Retinal Tear to Remove Vitreous HemorrhageA vitreous hemorrhage may be caused by a retinal tear.  Sometimes there is so much blood in the eye that direct examination is impossible and we can only guess at the most likely cause.  It is the most difficult situation for me to handle as a doctor.

Patients lose significant vision as the blood in the middle of the eye physically blocks all light from hitting the retina.  While this is usually not permanent visual loss, the blood makes it difficult to make a definitive diagnosis as it can be impossible to see the retina.

Normally, without blood in the eye, a retinal tear may be easily diagnosed and treated with laser.

While there are other causes of vitreous hemorrhage, such as diabetic retinopathy, retinal vascular disease and others.  Still, a retinal tear causing the vitreous bleeding is quite likely.

Retinal Tears Cause Retinal Detachments

A retinal tear can cause a retinal detachment.  A retinal detachment is potentially blinding.

In cases of vitreous hemorrhage, the patient cant’ see “out” and I can’t see “in.”  My ability to examine the eye is hindered.

Options at this point are to observe (i.e. do nothing).  Observing the eye is okay as the blood is doing no harm.  But what if there is a retinal tear?  A retinal detachment could occur if there is an undiagnosed retinal tear.

Other tests, such as an ultrasound can often detect a large tear, but it is not as good as directly examining the eye.  Operating to remove the blood to facilitate proper examination is an option, too.

What Does This Mean?

I am getting older, more aggressive, but smarter.

As I have aged, i.e. gained more experience, I have become more comfortable operating in these cases.  When I was younger, I would often hesitate because I was uncomfortable offering surgery in a situation where surgery might not be necessary, but I’ve learned (through experience) that watching a waiting can be more problematic.

Most of the time I recommend operating to at least remove the blood and confirm a diagnosis.  The risks of modern vitrectomy are quite low, while the risk of a retinal detachment occurring while we are waiting is quite possible.

Vitrectomy surgery is usually performed as an outpatient.  If a tear is indeed present, it can be treated simultaneously.

At the very least, a diagnosis can be made and a potentially blinding condition avoided.

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Cataract Retina

Eye Surgery Can Blind

There are risks to eye surgery, especially intraocular operations such as cataract removal or vitrectomy.  Cataracts are the most common eye surgery and vitrectomy eye surgery is usually performed by a retina specialist for various problems of the retina and vitreous.  Infection, inside the eye, called endophthalmitis, is uncommon, yet can blind.

There are all sorts of “eye” surgery.  There is cosmetic “eye” surgery to lift the eyelids, there is “eye” muscle surgery to correct strabismus (crooked eyes), laser “eye” surgery to get rid of glasses, etc.  These are all procedures that do not invade the eyeball, and thus, are “extraocular” operations; surgeries that stay outside of the eye.

“Intraocular surgery” is surgery that cuts into the eye.  Cataract surgery, certain glaucoma operations and retina surgery are all invasive and, thus, introduce certain risks not found in other types of “eye” surgery.

Infection is the biggest risk of any intraocular procedure.  As with any surgical procedure, there is a risk of infection.  Intraoculuar infection; however, can be devastating to the vision as it can cause blindness.  Most cases of “endophthalmitis” occur shortly, within days, after intraocular surgery.  The cause is usually due to aggressive bacteria that attack the inside of the eye leading to damage of the retina.

The damaged retina, even after the infection is controlled, does not see.

Endophthalmitis following cataract surgery is estimated to be less than 1/2000.  Endophthalmitis from vitrectomy retina surgery is even less common.  I usually give the estimate of about 1/10,000 or lower.  Certain types of glaucoma surgery carry a life long chance of developing an infection.

Symptoms of endophthalmitis are pain and decreased vision, although with advances in technology, these symptoms are sometimes less apparent.  In general, if there are concerns about pain or decreased vision following eye surgery, make sure your doctor is aware.  The results can be devastating.

Early identification of possible infections is really, really key.  Treatment can range from antibiotic injections, intravenous antibiotics and vitrectomy surgery.

Retinal detachment is the second biggest risk of intraocular surgery.  By operating inside the eye, an inadvertent retinal tear can be made in the retina leading to a retinal detachment.  Retinal detachments usually do not lead to blindness, but they can.  Additional retinal surgery could be necessary to repair the retinal detachment, but some visual loss is possible.  The chance of developing a retinal detachment following intraocular surgery is somewhere from 1-3%.  Again, with advances in technology, I believe this rate has decreased over the past decade.

Other risks of intraocular procedures are relatively minor, but can include bleeding, but most bleeding into the eye is usually self-limited, sounds horrible, but usually does no permanent damage.  Cataract formation can be caused or enhanced by retina or glaucoma surgery.  This is not a true risk, per se, but hastened cataract formation following intraocular surgery is common.  Sometimes the intraocular pressure can be too high or low following surgery.  There are many reasons why either can occur.

What Does This Mean? These are the most common, and feared, complications of intraocular eye surgery.  This is not a complete listing, but certainly items that should be considered when contemplating surgery.

Your eye surgeon should be able to comfortably discuss, with you and your family, the risks and benefits of any surgery offered to you.  If not, move on.

Eye surgery, especially in America, is extremely safe.  Don’t get me wrong, cataract surgery enjoys about a 99% technical success rate, that is, over 99% of the time the cataract is removed and replaced with an implant…as planned!  Retina and glaucoma surgery, too, are both very successful and usually performed with a high rate of technical success.  Technical success is defined as the ability to perform the actual surgical task.

Complications are the risks undertaken with surgery despite technical success, and no surgery, however, is without risk.

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