Refractory Angle Bleeding During Bent Ab Interno Needle Goniectomy: Successful Control With Targeted Diathermy In Combined Cataract And Migs Surgery

The most common intraoperative or postoperative complication following incisional or excisional goniotomy is hyphema. Bent ab interno needle goniectomy (BANG) is a cost-effective minimally invasive glaucoma surgery (MIGS) procedure practiced commonly in developing nations. 

The existing literature on managing pathological bleeding in MIGS is limited. Gallardo et al reported a novel use of endocyclophotocoagulation to cauterize collector channels. Espinoza et al described successful management of recurrent hyphema after GATT with pattern scanning laser (PASCAL) photocoagulation.To the best of our knowledge, the intraoperative use of abinterno diathermic electrocautery as a haemostatic salvage technique during MIGS has not been reported.

A 59-year-old  female with bilateral POAG and immature cataract underwent combined phacoemulsification with BANG in the left eye. Phacoemulsification was uneventful; however, trabecular meshwork excision over three clock hours nasally with a bent 25-gauge needle was followed by brisk, persistent angle bleeding. The hemorrhage continued despite  air tamponade, intracameral adrenaline, and viscoelastic, necessitating reoperation for clearing hyphema and definitive hemostasis. 

A 59-year-old diabetic and hypertensive female with bilateral moderate primary open-angle glaucoma on two anti-glaucoma medications and immature cataract underwent combined phacoemulsification with bent ab interno needle goniectomy (BANG) in the left eye. Phacoemulsification via a 2.8-mm temporal clear corneal incision was uneventful. Nasal trabecular meshwork excision over three clock hours was performed under Swan-Jacob gonioprism visualization using a bent 25-gauge needle. Although episcleral vessel blanching confirmed distal outflow patency, brisk bleeding persisted from the nasal angle despite a well-formed anterior chamber, air tamponade, adrenaline and viscoelastic use.

On postoperative day 1, vision was hand movements with hyphema occupying three-fourths of the anterior chamber and IOP of 52 mmHg. Coagulation profile blood workup was normal. Blood pressure fluctuations were stabilized. During the reoperation the Anterior chamber wash was performed; however, recurrent brisk angle bleeding occurred intraoperatively. Targeted unipolar diathermic electrocautery was applied to visible bleeder points after proper  angle visualization with viscoelastic, titrating 20–40 W power until hemostasis was achieved.The following day, hyphema resolved, IOP was 11 mmHg, and by day 15, vision improved to 6/18 with IOP 13 mmHg without medications.

This case highlights diathermic electrocautery as a novel salvage technique for uncontrolled reflux bleeding during BANG/MIGS procedures.

Reflux bleeding from angles during trabecular meshwork (TM)-based MIGS is usually self-limiting; however, persistent hyphaema despite air, viscoelastic and IOP, blood pressure control should prompt suspicion of a focal pathological source, commonly a collector channel ostium.

When standard measures fail, targeted ab interno unipolar diathermy offers a practical and effective salvage option. It reliably seals pinpoint bleeders and distal outflow branches, particularly in eyes with raised episcleral venous pressure, systemic hypertension or diabetic microvascular fragility.

Although endocyclophotocoagulation and PASCAL photocoagulation have been described in literature, diathermy provides immediate, controlled intraoperative haemostasis.