Supplementary Material for: Intraoperative Hemorrhage During Implantable Collamer Lens (ICL) Surgery: A Case Report and Management Strategy

Purpose: To report the intraoperative signs, management and postoperative outcomes of iris hemorrhage during implantable collamer lens (ICL) surgery. Case description: A 32-year-old Asian woman experienced iris bleeding via a superior incision during distal haptics delivery in ICL surgery for her right eye. The inferior iris was displaced against the ocular wall, resulting in traction-induced vertical elongation and elliptical distortion of the pupil, which indicated excessive iris traction and ultimately led to focal rupture of delicate iris vessels with intraoperative hemorrhage. Immediate injection with ophthalmic viscosurgical device (OVD) into the anterior chamber aimed to tamponade the bleeding from the broken vessels, after confirming cessation of active bleeding, the surgery was proceeded and completed uneventfully. Results: During postoperative follow-up, slit lamp examination showed persistent intraocular inflammation, increased intraocular pressure (IOP) and hyphema. Right eye was treated with anterior chamber paracentesis for the elevation of the IOP, IOP-lowering medications and topical anti-inflammation eyedrops were continued. No further interventions were performed. Slit-lamp examination demonstrated progressive recovery in anterior chamber reaction. No further complications occurred during the follow-up. Conclusion: Intraoperative iris hemorrhage is a rare but potentially serious complication for ICL surgery, timely intraoperative recognition of the pupil distortion and closely postoperative patient monitoring with medical management can avoid the irreversible damage to the eye.