Persistent oozing: Are we overlooking something?

INTRODUCTION

For a minor procedure like cataract surgery, the specific laboratory or other tests required are unclear. Most cataracts are performed on older individuals with some or other systemic and ocular comorbidities. It is likely that routine pre-operative medical testing will detect medical conditions, but it is questionable whether these conditions should preclude individuals from cataract surgery or change their perioperative management. Given the high and growing number of cataract and other elective surgeries in ophthalmology, it is essential to enhance both safety and cost-efficiency of this procedure.^[1] Different guidelines suggest different assessments and investigations.

Pre-operative laboratory testing is an integral part of any elective ophthalmic surgery. Routine tests such as complete blood counts (CBCs), blood pressure, blood sugar levels, urine analysis and reactive status typically reveal most undiagnosed systemic conditions that need addressing before surgery.^[2] For patients with risk factors or those requiring general anaesthesia, more specific tests such as electrocardiogram, chest X-ray, kidney function tests and appropriate referrals may be necessary.

Only few reports exist that detail a diagnosis of haemophilia following ophthalmic surgery. Iyengar et al. documented a case in which a congenital cataract extraction led to the diagnosis of Factor XI deficiency in a 4-month-old boy.^[3] Similarly, a case reported by Aquino et al. identified haemophilia as the cause of recurrent ocular haemorrhage in an 8-year-old boy who experienced blunt trauma to his right eye.^[4]

Ocular bleeding in patients with bleeding diathesis is often overlooked or treated routinely unsuspecting of any systemic disorder; however it can have serious implications. If the bleeding is more severe than what would be expected, it should signal a more serious underlying issue warranting further investigation. Here, we present two such unusual cases where a bleeding disorder was first considered only after excessive bleeding occurred during an attempted surgery.

CASE REPORT

Case 2

A 31-year-old male patient presented with sudden onset upper eyelid bleeding following a chalazion excision in the left eye performed elsewhere 3 days ago, with no history of ocular trauma. His visual acuity, as measured on the Snellen chart, was (OU) 6/6. On examination, cauterisation marks were present over the upper palpebral conjunctiva of the left eye with an ill-defined source of bleeding [Figure 1a-c]. Rest of the anterior and posterior segment were found to be unremarkable.

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Figure 1:

(a-c) A 31-year-old male patient with Ill-defined upper palpebral conjunctival bleeding and cauterisation marks.

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A compressive dressing was applied to control the bleeding. Blood analysis revealed an abnormal coagulation profile: normal prothrombin time and International Normalised Ratio, but an altered activated partial thromboplastin time of 48 sec with low Factor 8 (25%) and high Factor 9 (20 unit/dL). The patient was referred to a haematologist and diagnosed with Haemophilia A. Treatment was initiated with an intravenous injection of Factor 8 (1500 IU stat), an intravenous injection of Tranexamic acid (1 g stat) and Etamsylate tablets (500 mg 6 hourly for 2 days). The bleeding stopped on the same day. The patient continued regular follow-up until complete healing occurred [Figure 2a-c].

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Figure 2:

(a-c) A 31-year-old male patient after the cessation of bleeding, following treatment with Factor VIII and other haemostatic agents.

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DISCUSSION

Most guidelines suggest routine blood investigations, including CBC, urine routine and microbiology, random blood sugar, serum creatinine and viral markers for hepatitis B, C and human immunodeficiency virus, along with blood pressure measurements for all ophthalmic pre-operative patients. More than half of the population visiting a government hospital is often unaware of any underlying comorbidities. Approximately 40 to 50 percentages are diagnosed with hypertension or uncontrolled diabetes mellitus just preoperatively. However, bleeding disorders are not routinely investigated leading to missed diagnosis. In a litigious society, physicians generally believe that being more cautious and conducting additional tests is a safer approach in court.^[5]

Few reports have documented the outcomes of ocular surgeries in patients with haemophilia. In a study by Fabian et al., a series of seven known haemophiliac patients underwent elective phacoemulsification without prior factor correction.^[6] The surgeries were uneventful. A 2001 case series by Jijina et al. described five haemophiliac patients who underwent surgery, including two boys with traumatic hyphaemas resulting from blunt ocular trauma.^[7] One patient with severe haemophilia had an uneventful recovery after receiving factor transfusion pre-operatively. The other, undiagnosed with moderate haemophilia B, experienced rebleeding and vitreous haemorrhage post-surgery. After factor correction and medical treatment, his vision improved. Similarly, cases published by Jiang et al.^[8] and Chan et al.^[9] have reported retinal and subhyaloid haemorrhage in patients of aplastic anaemia leading to severe visual impairment.

Complications during surgery in patients with bleeding disorders can arise especially if it is often undiagnosed before the procedure. If any unexpected or unusual complications arise during any surgery, it is crucial to keep a strong eye for suspicion for other potential systemic issues. Prompt referrals to specialists and a multidisciplinary approach, along with close post-operative monitoring, are vital for achieving the best outcomes. Each case should be considered individually, with decisions about whether or not to proceed with surgery based on the patient’s specific circumstances.

CONCLUSION

Uncontrolled non-traumatic spontaneous ocular bleeding can reveal underlying coagulation disorders. Unexpected surgical complications warrant further evaluation and often a multidisciplinary management.