An 81-year-old Thai female was referred to our hospital because of gross hyphema grade II in the right eye (OD) and eight-ball hyphema with blood-stained cornea in the left eye (OS) (). She underwent laser iridotomy in both eyes (OU) 7 days prior for prophylaxis and treatment of acute primary angle-closure OD and OS, respectively. The hyphema occurred immediately after the laser iridotomy and the patient was treated conservatively. At our hospital, best corrected visual acuity (BCVA) was hand motion OU and intraocular pressure (IOP) was 52 mmHg OU. Accordingly, surgical intervention for the hyphema OU was indicated. The preoperative blood test showed bicytopenia (hematocrit 22% and platelet 15,000/mm3). A hematologist was consulted to workup causes and preoperative evaluation. The patient was given leukocyte-depleted platelet concentrate, which raised the platelet count to 140,000/mm3 before surgery. We performed anterior chamber washout using an irrigating Simcoe cannula OD. The blood clot was left undisturbed at the iridotomy site to prevent iatrogenic injury to the posterior structure of the iris. The hyphema completely resolved on the following day (). At the 2-month follow-up (), BCVA was 20/100 OD with nuclear sclerosis grade 2, IOP was 10 mmHg OD with three anti-glaucoma medications and gonioscopy showed 180° peripheral anterior synechiae (PAS) on the nasal and superior angles. Therefore, phacoemulsification with a 180° goniosynechialysis (GSL) was planned. We performed a limbal-based, inferior full-thickness trabeculectomy with intracameral air injection OS as an alternative surgical procedure. Postoperatively, the patient was placed in an upright position and given a daily intracameral air injection until the air occupied 60–80% of the anterior chamber space to prevent shallowing of the anterior chamber and to hasten blood drainage inferiorly into the bleb. The hyphema completely resolved within 3 days (). The inferior bleb did not raise with digital pressure and eventually became nonfunctional in 7 days and the IOP was 10 mmHg OS without anti-glaucoma medication. Two months later, slit-lamp biomicroscopy demonstrated a deep anterior chamber and resolved corneal blood staining (). IOP was 16 mmHg OS without anti-glaucoma medication, BCVA was 10/400 OS due to nuclear sclerosis grade 3 and inflammatory membrane obscuring the pupillary axis. Gonioscopy showed a 90° PAS OS. Therefore, phacoemulsification with intraoperative direct gonioscopy was planned. Following bone marrow aspiration and biopsy, the patient was ultimately diagnosed with hypocellular MDS. At the 4-month follow-up, the combined phacoemulsification with 180° GSL was performed OD. At the 6-month follow-up (), BCVA was 20/50 OD and 10/400 OS. IOP was 13 mmHg OD and 15 mmHg OS without anti-glaucoma medication OU. Gonioscopy showed a 360° open anterior chamber angle after GSL OD (as shown in ) and a 270° open anterior chamber angle OS. However, the unstable medical condition of the patient caused the phacoemulsification OS to be postponed.