Endocapsular Hematoma

This clinical finding may be “in the bag,” but the cause of and treatment for this exceptionally rare condition might have you perplexed.

An 84-year-old White woman presented with blurry vision in the left eye that had progressively worsened over 4 days. Pseudoexfoliation was noted on the pupillary margin in the left eye, and a well-centered IOL was present. Of note, layered blood could be seen in the lower third of the preserved capsular bag. There were minimal blood cells in the anterior chamber and no vitreous or retinal involvement. IOP in the affected eye was 20 mm Hg. All other ocular findings were within normal limits. The patient was not on any blood thinners and reported experiencing no trauma since the start of her symptoms. In 2015, she had undergone uncomplicated cataract surgery with implantation of an acrylic one-piece AcrySof IQ lens (SN60WF; Alcon).

Endocapsular hematoma occurs when blood collects in the space between an IOL and the surrounding posterior capsule.¹ There are few case reports regarding this condition because it is rare. Early reports referred to the condition as endocapsular hyphema, but more recent literature suggests that this is an inaccurate description due to the location, the minimal quantity of red blood cells, and the failure of the blood to reabsorb. For these reasons, the term hematoma has been adopted to reflect the true clinical depiction.² Most documented cases had compromised visual acuity with no pain or other ocular complications. There can be an associated hyphema or microhyphema.

In early case reports, authors suspected that the blood leaked through the posterior capsule from an anterior vitreous hemorrhage, but now most investigators believe that the blood originates from the surgical incision site in acute postoperative cases.^1-4 An iris vessel leak from neovascular processes or frictional forces between the IOL and iris or ciliary body may also contribute to this condition.^2,3 Vascular disease, anticoagulation medications, and zonular weakening may increase the risk of both IOL friction and bleeding. Other cases have been reported related to uveitis-glaucoma-hyphema syndrome and trauma.² How and why the blood fills this posterior potential space remains a mystery.

Active treatment is usually necessary for endocapsular hematoma; the body cannot reabsorb the blood because of the confined area and lack of aqueous flow through the posterior capsular space.⁵ As the amount of blood accumulation is relatively small, having it disperse into the vitreous will result in little to no vision loss. Nd:YAG capsulotomy can be performed to break the posterior capsular bag and resolve the confinement of the space, allowing the blood to disperse into the vitreous and eventually reabsorb.⁵