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Treatment of vascular tufts at the pupillary margin before cataract surgery
  1. M Winnick,
  2. E Margalit,
  3. A P Schachat,
  4. W J Stark
  1. Cornea, Cataract and Refractive Service and the Retinal Vascular Center, Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
  1. Correspondence to: Walter J Stark, MD, Corneal and Cataract Services, Wilmer Eye Institute, 327 Maumenee Building, 600 N. Wolfe Street, Baltimore, MD 21287-9238, USA; wstark{at}jhmi.edu

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Iris vascular tufts or microhaemangiomas are an infrequent finding on ophthalmic evaluation. Previous reports have attributed vascular tufts at the papillary margin of the iris to diabetes, myotonic dystrophy,1 in association with Sturge-Weber syndrome,2 or in association with haemangioma of the orbit or eyelid. We describe a patient with multiple cutaneous and iris margin haemangiomas who had a history of recurrent hyphaema and underwent successful argon laser treatment of pupillary margin haemangiomas before extracapsular cataract extraction with intraocular lens implantation.

Case report

The patient is a 75 year old man first seen 2 years earlier by the retinovascular service at the Wilmer Eye Institute, Baltimore, MD, USA, for recurrent hyphaema in the left eye. He was noted to have multiple haemangiomas on the pupillary border of both eyes as well as numerous cutaneous haemangiomas on his trunk. A small hyphaema was appreciated inferiorly in the left eye with no active bleeding. Gonioscopic examination was normal except for blood in the inferior angle and the intraocular pressure was 16 mm Hg in each eye. There was no corneal endothelial blood staining. He was treated with homatropine hydrobromide ophthalmic solution 5% (Ciba Vision, Duluth, GA, USA) twice a day and prednisolone acetate 1% (Falcon Pharmaceuticals, Fort Worth, TX, USA) four times a day for 1 week to decrease light sensitivity and to prevent intraocular inflammation. The hyphaema subsequently resolved without sequelae. It was suggested that if he suffered a rare occasional haemorrhage he would be treated symptomatically, but multiple repeat haemorrhages would be treated with laser coagulation or surgical excision.

He now presents to the cornea, cataract, and refractive service at the Wilmer Eye Institute for reduced visual acuity primarily in the right eye. On examination, Snellen visual acuity measured 20/400 in the right eye with an intraocular pressure measuring 15 mm Hg. Pupils were round and reactive without an afferent pupillary defect. External examination was significant for multiple 1–2 mm raised cutaneous haemangiomas on the chest, neck, and back (Fig 1). The lesions were painless to touch, and according to the patient, have been increasing in number since childhood yet hadn’t increased in size, changed colour, nor caused bleeding. Slit lamp biomicroscopic examination was significant for multiple small vascular loops along the pupillary margin of the iris in each eye (Fig 2). Gonioscopic examination showed no neovascularisation of the anterior chamber angle. After dilatation, there was no active bleeding but evidence of pigment clumps on the anterior capsule in each eye. The right crystalline lens showed dense nuclear sclerosis and posterior subcapsular cataractous change. Funduscopic examination demonstrated a cup to disc ratio of 0.7 in the right eye. The disc, macula, and vessels were normal except for mild arteriolar narrowing. The examination of the left eye was significant for venous congestion with a small superficial nerve fibre layer haemorrhage on the inferior border of the disc. This possibly represented an impending vein occlusion.

Figure 1

Multiple cutaneous haemangiomas on the trunk.

Figure 2

Slit lamp biomicroscopic image of pupillary margin vascular loops (arrows).

Although it was believed that cataract surgery could be done safely without addressing the management of the angiomas, the risk of lasering the angiomas was low and if closure of the vascular loops was achieved, the intraoperative risk for bleeding might be reduced. The patient was taken off aspirin before the laser treatment and an iris angiogram was performed to guide treatment in order not to miss any subclinical leaking vascular tufts (Fig 3). Argon laser was used with 200 μm spot size, power of 200 mW for 0.1 second duration. A total of 50 spots were administered to close all tufts appreciated clinically and angiographically. No bleeding was noted during the procedure. The patient subsequently underwent uncomplicated extracapsular cataract extraction through a clear corneal incision under topical anaesthesia. Upon insertion of the intraocular lens, a small amount of blood was noticed in the anterior chamber, most probably secondary to iris trauma during the manoeuvre. This was washed out with balanced salt solution. No blood was noticed in the anterior chamber on the first postoperative day nor during a 10 month postoperative follow up period.

Figure 3

Iris angiogram showing multiple leaking vascular tufts at the pupillary margin.

Comment

Vascular anomalies of the pupillary margin are rarely seen but have been previously implicated as a possible cause of spontaneous hyphaema.3 More unusual are iris haemangiomas associated with cutaneous haemangiomas. Generalised cutaneous and visceral haemangiomas have been described as diffuse congenital haemangiomatosis in neonates,4 but iris and cutaneous haemangiomas in adults are infrequently described.

Vascular tufts at the pupillary margins are usually asymptomatic and if hyphaema does occur, recurrence is unlikely.5 Past treatment had been reserved for patients with recurrent hyphaema or bleeds recalcitrant to medical management. Argon laser treatment of a bleeding iris vascular tuft has been described twice previously for active bleeding resulting in hyphaema with increased intraocular pressure. In both case reports, few laser applications easily stopped the haemorrhaging.6,7 Our patient suffered recurrent hyphaemas in one eye and presented with a mature cataract in the other. Surgical decompression of the globe, surgical manipulation causing trauma to the fragile vascular loops, hypotony, and frequent postoperative use of mydriatics causing pupillary “gymnastics” can all cause haemorrhage in patients with otherwise asymptomatic vascular tufts.8 Although no previous study demonstrated bleeding of the fragile vascular tufts with surgical decompression, it was theorised that closure of the haemangiomas would reduce the intraoperative risk of bleeding during cataract surgery. The major risk of the laser was bleeding during the procedure, but this was considered low compared to a possible bleeding process during surgery because a closed eye procedure would allow for a more rapid tamponade of any bleeding process. Another risk was the possible damage to the lens that would be extracted in any case. Other laser risks were intraocular inflammation due to iris or lens damage and glaucoma, which can be caused by an inflammatory process or the result of hyphaema.

We observed only minimal bleeding from the iris during cataract surgery and no further hyphaema in the postoperative period and therefore recommend considering argon laser treatment to pupillary margin vascular tufts before surgery to decrease the possibility of intraoperative and well as postoperative complications of uncontrolled haemorrhaging.

References

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Footnotes

  • Financial interest: none.

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