This ultrasound was taken of a patient who developed complication during phacoemulsification. No intraocular lens was implanted.

What can you see in this B-scan?

Answer
There are dome-shaped elevations consistent with choroidal detachments.
The spaces between the sclera and the elevation are opaque indicating the presence of blood. There are also opacities in the vitreal cavity. The picture and the history are suggestive of suprachoroidal or expulsive haemorrhage.

What physical signs during the operation may alert you to this problem?

Answer
The physical signs that may suggest expulsive haemorrhage during operation 
are: shallowing of the anterior chamber, prolapse of iris, vitreous extrusion, 
loss of red reflex, dark mass behind the pupil and extrusion of the intraocular contents. The globe is hard solid.

What are the risk factors for this complication?

Answer
Expulsive haemorrhage is an unpredictable condition but fortunately rare. Conditions that predispose the patients to this complication can be
classified into ocular risk factors and systemic risk factors. 
The ocular risk factors are: raised intraocular pressure or glaucoma, high myopia and posterior capsule rupture during surgery. 
Systemic risk factors are: hypertension, arteriosclerosis, presence of chronic airway obstructive disease and obesity. 
Finally, extracapsular cataract extraction is associated with a higher risk than phacoemulsification.

How would you manage this patient during the operation?

Answer
Intraoperatively, surgery should be stopped followed by immediate closure
of the wound using strong suture such as 4/0 or 5/0 silk. The intraocular pressure is reduced with mannitol if the patient has no contraindication.
Some surgeons advocate posterior sclerotomy to drain the blood but this is controversial and can worsen the bleeding.

What precaution would you take when operating on the fellow eye?

Answer
Precautions involves modification of risk factors that can be changed and this include:
modification of technique: if the operation has been performed with a large 
incision operation such as extracapular technique one should choose a
smaller incision procedure as in phacoemulsification. An experienced
surgeon for the fellow eye as posterior capsule rupture is a risk factor.
modification of ocular risk factors: raised intraocular pressure should be controlled prior to surgery
modification of systemic risk factors: control of hypertension and chronic airway disease, weight reduction.