in ophthalmologic practice , neodymium : yttrium - aluminum - garnet ( nd : yag ) laser is mainly applied for treatment of posterior capsular opacity.1 it has also been used for a variety of indications , including peripheral iridotomy,2 anterior vitreolysis,3 anterior capsule relaxing incisions,4 anterior capsulotomy in white intumescent cataracts,5 goniopuncture,6 removal of residual cortex,7 and treatment of endocapsular hematoma.8 however , to our best knowledge , the treatment of organized hyphema anterior to intraocular lens ( iol ) using nd : yag laser has never been reported .
. however , surgical intervention can often be difficult due to the risk of rebleeding , and other treatment options should be considered .
herein we present a case of successful treatment of pupil - occluding organized hyphema anterior to the iol by direct application of nd : yag laser to the hematoma .
a 78-year - old asian female underwent cataract surgery in the right eye ( oculus dexter [ od ] ) .
she had a history of ischemic heart disease and hypertension and , therefore , was taking aspirin .
cataract surgery was performed with topical anesthesia and clear corneal incision , and was uneventful until iol implantation and removal of viscoelastics .
however , she had intraoperative floppy iris syndrome and iris prolapse occurred through the main wound at the conclusion of the surgery , which led to intracameral hemorrhage .
although copious irrigation of the anterior chamber combined with aspiration of the blood clot was done , bleeding was not completely controlled , and eventually , hyphema filled half of the intracameral space .
postoperatively , oral prednisolone ( 30 mg a day for 3 days ) and topical prednisolone acetate ( 1% , six times a day ) were prescribed .
one week later , her bcva was hand motion , and intraocular pressure ( iop ) measured with goldmann applanation tonometry ( gat ) was 15 mmhg . although hyphema had decreased , organized hyphema anterior to the iol had occluded the pupil ( figure 1a ) .
one week later , her bcva was hand motion , and there was no change in the organized hyphema anterior to the iol .
using nd : yag laser ( 3.04.0 mj ) , the organized hemorrhage on the iol was lysed .
one week later , her bcva was 20/400 , and iop was 15 mmhg by gat .
however , endocapsular hematoma that occluded two - thirds of the pupil was observed ( figure 1b ) .
nd : yag laser posterior capsulotomy ( 1.02.0 mj ) was performed to disperse the blood clot from the visual axis .
two weeks later , her bcva improved to 30/60 , and iop was 14 mmhg by gat .
there was no blood occluding the visual axis , and hyphema was completely absorbed ( figure 1c ) .
written informed consent was obtained from the patient for publication of this case report and any accompanying images . as this is a single case report and only retrospective review of medical records
was needed , ethics approval was waived by the institutional review board of kangwon national university hospital .
studies showed that phacoemulsification of uncomplicated cataract with iol implantation with topical anesthesia and clear corneal incision can be safe even in patients taking anticoagulants or antiplatelet drugs.9 however , in conditions that may increase the risk of bleeding , such as small pupil , floppy iris syndrome , iris neovascularization , or pseudoexfoliation or interruption of antiplatelet or anticoagulant therapy , the risk of postoperative hematoma should be considered.9 although aspirin was stopped and coagulation panels were normal in our patient , inadvertent intracameral hemorrhage occurred associated with iris prolapse .
complete removal of the hemorrhage was impossible , which led to blood collection in the anterior chamber and capsular bag .
although the hemorrhage was partly absorbed , remnant organized hyphema anterior to the iol occluded the pupil and led to substantial decrease in vision .
however , considering that the patient had a risk for iris prolapse , additional surgical manipulation could exacerbate the hyphema .
however , the organized hyphema anterior to the iol persisted for 2 weeks , and reduced her vision significantly by occluding the pupil .
there was also a possibility that the organized hemorrhage anterior to the iol had formed a persistent fibrin membrane , necessitating intervention to improve the condition .
eventually , the remaining organized hemorrhage anterior and posterior to the iol was removed using nd : yag laser .
we chose lysis of the hematoma anterior to the iol by direct application of nd : yag laser because it can deliver strong energy to a small target without the risk of damage to the adjacent tissue .
as in the present case , intraoperative hyphema can not be completely prevented , and in these circumstances , secondary operation may often be difficult due to the risk of rebleeding .
surgical intervention of intracameral hemorrhage can sometimes be dangerous also in patients with increased bleeding tendency , such as hemophilia or liver diseases .
in these patients , nd : yag laser can be a safe option for vision recovery .
nd : yag laser was also used for the treatment of postoperative endocapsular hematoma.8 however , in these cases , the laser was used to make posterior capsular opening and to drain the blood to the vitreous cavity , as we did for the treatment of endocapsular hematoma.8 for the treatment of organized hyphema anterior to the iol , we directly applied the nd : yag laser for the lysis of the hematoma , and thus used higher energy compared to the energy level used for posterior capsulotomy .
although nd : yag laser posterior capsulotomy is relatively safe , complications including retinal detachment , macular edema , optic disc edema , uveitis , glaucoma , macular hole , and endophthalmitis have been reported.10 in the present case , the energy of the laser was concentrated on the blood clot and the possibility of damage to other tissues was low .
however , as relatively stronger energy was used , we believe attention should be paid to the possibility of complications .
in conclusion , pupil - occluding organized hyphema anterior to the iol can occur as a complication of cataract surgery , although it may be rare .
direct lysis of the hematoma using nd : yag laser can be a useful treatment option in this condition , particularly when surgical intervention is difficult due to the risk of rebleeding .
 we report , to our best knowledge , the first case of treatment of pupil - occluding postoperative organized hyphema anterior to the intraocular lens ( iol ) using neodymium : yttrium - aluminum - garnet ( nd : yag ) laser . a 78-year - old asian female underwent uneventful cataract operation . 
 she had been taking aspirin , which she discontinued 1 week before surgery . 
 iris prolapse occurred at the end of the surgery , which led to intracameral bleeding . 
 two weeks later , her best - corrected visual acuity was hand motion . 
 although hyphema had decreased , pupil - occluding organized hematoma had formed anterior to the iol . 
 the blood clot anterior to the iol was removed using nd : yag laser . 
 one week later , although the hematoma anterior to the iol resolved , endocapsular hematoma was observed , which was dispersed with nd : yag laser posterior capsulotomy . 
 two weeks later , her best - corrected visual acuity improved to 20/60 . 
 there was no complication associated with nd : yag laser . in conclusion , 
 pupil - occluding organized hyphema anterior to the iol can occur as a complication of cataract surgery , in which nd : yag laser can be a useful treatment option . 
Introduction
Case presentation
Discussion
Conclusion