Treatment of postcataract fibrinous membranes with tissue plasminogen activator

Intracameral r-tPA for the management of severe fibrinous reactions in TASS after cataract surgery

BACKGROUND

To describe the use of intracameral recombinant tissue plasminogen activator (r-tPA) in the treatment of severe fibrinous reactions in toxic anterior segment syndrome (TASS) after cataract surgery.

METHODS

A case series of 59 eyes of 59 patients with severe fibrinous anterior chamber reaction following cataract surgery who received intracameral r-tPA (25 µg/0.1 ml). The main outcome measures after intracameral r-tPA were the incidence of complete fibrinolysis, time of maximal effect, visual acuity, and complications.

RESULTS

Severe fibrinous reactions appeared 11.5 ± 5.3 days after cataract surgery. Fibrinolysis was observed 2.33 ± 2.70 days after rtPA use and 36 eyes (61%) exhibited resolution of the fibrin by the end of the first day following injection (p < 0.001). Transient corneal edema observed at 1-day after injection was the only complication reported during the injection of r-tPA or at follow-up. Eight eyes (13.6%) required a second r-tPA injection. Best-corrected visual acuity improved from 0.88 ± 0.67 logMAR units before rtPA injection to 0.48 ± 0.49 logMAR units at 1-month (p < 0.001).

CONCLUSIONS

The application of r-tPA was a quick and efficacious therapeutic approach for the management of severe fibrinous reactions in TASS after cataract surgery. In a clinical setting, intracameral r-tPA may be useful when rapid visual recovery is needed.

Factors Predisposing to Postoperative Intraocular Inflammation

This prospective study of 123 patients undergoing cataract extraction determined the preoperative and surgical factors predisposing to an exaggerated postoperative inflammatory response. It is important to identify the patients at increased risk of complications requiring additional prophylaxis or more intensive postoperative care, particularly when selecting patients for day case surgery. Previous intraocular inflammation or surgery was the factor most strongly associated with marked inflammation on the first postoperative day (p < 0.01, compared to uncomplicated patients). As a result, patients stayed in hospital an average of one day longer (p < 0.001) and required significantly more steroid drops (p < 0.001). Other factors of significance, but reducing importance were: difficult surgery, non-caucasian race and brown irides. Amongst uncomplicated patients, the difficulty of surgery was most significantly related to a high inflammation score (p < 0.01). Non-caucasian patients stayed in hospital significantly longer than their caucasian counterparts (p < 0.05), and required more steroid drops (p < 0.001). Of caucasian patients, those with brown irides were inpatients for significantly longer than those with blue or hazel (p < 0.05). No other factors studied significantly altered postoperative inflammation: neither the presence of diabetes, nor the technique of cataract extraction.

Intraocular Lens Opacification following Intracameral Injection of Recombinant Tissue Plasminogen Activator to Treat Inflammatory Membranes after Cataract Surgery

Purpose. To report 7 cases of intraocular lens (IOL) opacification following treatment of postoperative anterior chamber fibrin with recombinant tissue plasminogen activator (rtPA) after cataract surgery. Methods. Retrospective case series of 7 eyes in 7 patients who developed IOL opacification after receiving rtPA for anterior chamber inflammatory membrane formation resulting from phacoemulsification cataract surgery. Three explanted IOLs were investigated with light microscopy, histochemical analysis, scanning electron microscopy, and X-ray spectrometry. Results. All patients underwent uncomplicated cataract surgery and posterior chamber hydrophilic IOL implantation. Anterior chamber inflammatory membranes developed between 1 and 4 weeks of surgery and were treated with intracameral rtPA. IOL opacification was noted between 4 weeks and 6 years after rtPA treatment with reduced visual acuity, and IOL exchange was carried out in 3 patients. Light microscopy evaluation revealed diffuse fine granular deposits on the anterior surface/subsurface of IOL optic that stained positive for calcium salts. Scanning electron microscopy (SEM) and energy-dispersive X-ray spectrometry (EDS) confirmed the presence of calcium and phosphate on the IOL. Conclusions. Intracameral rtPA, though rapidly effective in the treatment of anterior chamber inflammatory membranes following cataract surgery, may be associated with IOL opacification.

LMWH inhibits anterior chamber inflammation after extra capsular lens extraction through down regulation of bFGF content in aqueous humor

AIM

To observe the changes of basic fibroblast growth factor (bFGF) content in anterior chamber before and after extra capsular lens extraction for investigating the mechanism of low molecular weight heparin (LMWH) inhibiting anterior chamber inflammation.

METHODS

Eighty-four rabbits were randomly divided into control and experimental group, 42 rabbits in each group. Extra capsular lens extraction was done on unilateral eye in each rabbit. LMWH was perfused into anterior chamber by the concentration of 50U/mL at the end of operation in experimental group. The degrees of corneal edema, aqueous flare and fibrin were evaluated with slit lamp microscope on postoperative day 1, 3, 6, 15, 30, 45 and 60, respectively. Six eyes of each group were at each time point. Contents of bFGF in aqueous humor were determined by ELISA after animals were killed. Another six eyes were used for determining the base line level of bFGF in aqueous humor.

RESULTS

The degrees of corneal edema, aqueous flare and fibrin in experimental group were significantly lighter than those in control group (P<0.01) on postoperative day 1, 3 and 6, respectively. No difference was showed between the two groups at other point time. Contents of bFGF in aqueous humor increased at the same time. bFGF content reached peak on postoperative day 1 in experimental group, while on postoperative day 6 in control group. Contents of bFGF in the two groups declined slowly after reaching peak. The bFGF content in control group were significantly higher than that in experimental group 1-30 days after surgery (P<0.05). No significant differences were shown between the two groups on postoperative day 45 and 60, respectively.

CONCLUSION

Perfusion with LMWH by the concentration of 50U/mL can significantly reduce anterior chamber inflammation after extra capsular lens extraction in rabbits, which may be related to down regulation of bFGF content in aqueous humor.

Intracameral tissue plasminogen activator to prevent severe fibrinous effusion after congenital cataract surgery

BACKGROUND/AIMS

To evaluate the efficacy of intracameral recombinant tissue plasminogen activator (r-TPA) in prevention of fibrinous effusion after lensectomy, anterior vitrectomy, and posterior chamber intraocular lens (PCIOL) implantation in patients with congenital cataract.

METHODS

The study was done as a double masked randomised clinical trial between April 2002 and November 2003 in Farabi Eye Hospital. 34 eyes of 26 patients with congenital cataract were included in the study and randomised into two groups (18 cases and 16 controls). Mean age was 8.1 years (3--14 years). Each eye underwent lensectomy and anterior vitrectomy with PCIOL implantation. At the end of surgery 20 microg r-TPA was injected intra-camerally in the case group. The control group received only balanced salt solution. All patients received periocular, systemic, and topical steroids after surgery. Patients underwent follow up examinations for 3 months.

RESULTS

The incidence of intraocular fibrin membrane formation was significantly lower in the case group on days 1, 3, 7, 14 (p=0.02, p=0.01, p=0.01, and p=0.01, respectively, chi(2) test), but there was no significant difference on days 30 and 90. The frequency of pigmented intraocular lens precipitates was significantly lower in the case group at the end of the third month (p<0.001, chi(2) test). No gross ocular side effects were noted after r-TPA injection.

CONCLUSION

It seems that prophylactic intracameral r-TPA is effective in prevention of fibrinous effusion at least in the first 2 weeks after cataract extraction in the paediatric age group and decreases the incidence of pigmented IOL precipitates.

Therapeutic application of tissue plasminogen activator for fibrin reaction after cataract surgery

PURPOSE

To evaluate the efficacy and safety of therapeutic application of recombinant tissue plasminogen activator (rtPA) for fibrin reaction after uneventful cataract surgery.

SETTING

Department of Ophthalmology, SSK Istanbul Hospital, Istanbul, Turkey.

METHOD

In a prospective study between January and June 2000, 26 eyes of 26 patients with fibrin reaction after uneventful cataract surgery received 3 microg of intracameral rtPA. Patients were evaluated for recurrences of fibrin reaction or complications by slitlamp biomicroscopy 2, 12, and 24 hours, 1 week, and 1 and 6 months after rtPA application. Intraocular pressure (IOP) was measured by Goldmann applanation tonometry. Visual acuity was tested using a standard Snellen chart 1 week after rtPA application.

RESULTS

All 26 eyes had complete fibrinolysis. Three eyes (11.5%) had corneal edema that lasted fewer than 24 hours. Visual acuity improved by 0 to 7 lines in 19 patients (73.1%). No patient had an increase in IOP. At 6 months, no patient had hyphema or recurrence of fibrin reaction.

CONCLUSIONS

Complete lysis of fibrin after cataract surgery with conventional topical medications can take a long time and is not successful in some patients. Intracameral application of 3 microg rtPA was an efficient, safe method for the treatment of fibrin reaction after cataract surgery.

Low-dose tissue plasminogen activator in the management of anterior chamber fibrin formation

PURPOSE

To investigate the efficacy of tissue plasminogen activator (tPA) in the treatment of severe fibrinous anterior chamber reactions after intraocular surgery.

SETTING

Ophthalmology Department, AHEPA University Hospital, Thessaloniki, Greece.

METHODS

The study comprised routine surgical and postoperative cases selected in a nonrandomized fashion. Low-dose tPA infusion (0.2 mL of 125 microg/mL) was administered through a side-port in the anterior chamber in 25 patients with recent or long-standing fibrin formation after cataract extraction (n = 13), trabeculectomy (n = 5), combined procedure (n = 5), or penetrating keratoplasty (n = 2). Patients were treated 4 to 25 days postoperatively (mean 7 days).

RESULTS

Fibrin lysis was observed 2 to 12 hours after tPA infusion. No hemorrhage or other complications occurred, and no further treatment was necessary in any patient. Three cases of delayed partial fibrin lysis resolved with intense topical steroid treatment. There were no recurrences over the 3-month follow-up.

CONCLUSIONS

Low-dose tPA was an effective and safe method for the management of anterior chamber fibrin formation. Treatment was well tolerated and gave excellent results with no complications.

Uveitis and pupillary block glaucoma in an aphakic dog

Unilateral uveitis with pupillary occlusion and secondary glaucoma was treated with neodymium:YAG laser iridotomy and iridencleisis in an aphakic 2-year-old male Miniature Schnuauzer. The dog presented 4 months after bilateral phacoemulsification with a complaint of blepharospasm of the left eye. Examination revealed anterior uveitis with pupillary occlusion and iris bombé. A slit-lamp mounted Q-switched Nd:YAG laser was used to create a central iridotomy to deepen the anterior chamber and an iridencleisis was performed to recreate a pupil. The eye remained visual and normotensive over a 6-month follow-up period.

Recombinant tissue plasminogen activator following paediatric cataract surgery

BACKGROUND

The use of recombinant tissue plasminogen activator (r-TPA) has been advocated in the treatment of postsurgical fibrinous membrane formation following cataract surgery in adults. Its use in paediatric cases is not well documented.

METHOD

A retrospective review of paediatric cataract extractions performed at Moorfields Eye Hospital between 1 January 1997 and 4 April 1999 was carried out.

RESULTS

Cataract extractions were performed in 37 patients, 22 in males 15 in females. Four (9.2%) underwent intracameral injection of 25 microg r-TPA. They were all females of Afro-Caribbean origin. The time to injection varied from 4-14 days, mean 7.2 days. Complete resolution of the fibrinous membrane was seen in all cases. There were no complications by the 3 month follow up.

CONCLUSION

r-TPA may be used safely and effectively at a dose of 25 microg for the treatment of severe fibrinous membranes following paediatric cataract extraction. It aided the visual recovery of the children and also allowed a reduced regimen of topical steroid therapy to be used postoperatively.

Treatment of recent onset central retinal vein occlusion with intravitreal tissue plasminogen activator: a pilot study

AIMS

To study the effects of intravitreal tissue plasminogen activator (tPA) in recent onset central retinal vein occlusion (CRVO).

METHODS

15 patients with recent onset CRVO (from 1-21 days' duration, mean 8 days) were given 75-100 microg of tPA intravitreally associate with low dose low molecular weight heparin. CRVO was perfused in nine patients and with mild ischaemia not exceeding 100 disc diameters in six patients. Follow up ranged from 5 to 21 months for 14 patients (mean 8 months). Visual acuity measurement, macular threshold (Humphrey perimeter), fluorescein angiography with the scanning laser ophthalmoscope with special emphasis on retinal circulation times, and retinal perfusion were performed at days 0, 1, and 8 and months 1, 3, and 6.

RESULTS

Visual acuity was significantly improved on the first day after treatment in only one eye, and decreased transiently in six eyes (40%). Retinal blood velocity was not significantly modified by tPA injection. Retinal ischaemia developed in six eyes (43%), leading to panretinal photocoagulation in five eyes including one with rubeosis iridis. At the end of follow up, visual acuity had improved to 20/30 or better in five eyes (36%), including two with complete recovery; visual acuity was worse than 20/200 in three eyes (28%). No complication of tPA injection was observed.

CONCLUSION

Intravitreal tPA treatment for CRVO appears to be simple and safe, but did not significantly modify the course of the occlusion in our patients immediately after treatment. Final visual outcome did not differ significantly from that observed in the natural course of the disease, but final visual acuity seemed to be slightly better. A randomised study is required to determine if intravitreal tPA actually improves visual outcome in CRVO.

Tissue plasminogen activator in the treatment of vitreoretinal diseases

Tissue plasminogen activator (tPA) is a thrombolytic agent that activates plasminogen into plasmin almost exclusively in the presence of fibrin. Intraocular injection of tPA has been proposed for the treatment of vitreoretinal diseases, such as vitreous hemorrhage, postvitrectomy fibrin formation, submacular hemorrhage, retinal vascular occlusive disorders, suprachoroidal hemorrhage and endophthalmitis. Currently, intraocular tPA is only used in the treatment of postvitrectomy fibrin formation and submacular hemorrhage. For other indications, tPA has not been shown to be safe or effective. This article reviews the use of tPA in the treatment of vitreoretinal disorders.

Tissue plasminogen activator to treat impending pupillary block glaucoma in patients with acute fibrinous HLA-B27 positive iridocyclitis

PURPOSE

To report the use of intracameral tissue plasminogen activator to dissolve fibrinous membranes and break posterior synechiae in patients with acute HLA-B27-positive iridocyclitis with impending pupillary block.

METHODS

Two patients with severe acute fibrinous iridocyclitis and seclusio pupillae were identified. Because of the concern of impending pupillary block, intracameral tissue plasminogen activator (12.5 microg in 0.1 ml, Activase; Genentech, Inc, South San Francisco, California) was injected with a 25-gauge needle through the corneal limbus.

RESULTS

Both patients showed complete dissolution of fibrin with disruption of posterior synechiae. There were no adverse events after injection. Neither patient required further invasive intervention, and both fully recovered with medical management.

CONCLUSIONS

Intracameral tissue plasminogen activator is a safe and effective agent for patients with severe acute iridocyclitis and pupillary seclusion. Patients with clinical signs suggestive of impending pupillary block glaucoma may be considered for tissue plasminogen activator injection to avoid the possible need for emergency surgical iridectomy and synechiolysis.

Intraocular recombinant tissue-plasminogen activator fibrinolysis of fibrin formation after cataract surgery in children

PURPOSE

To evaluate the efficacy and safety of intracameral recombinant tissue plasminogen activator (rt-PA) application for fibrinolysis of fibrin formation after cataract surgery in children.

SETTING

Johann Wolfgang Goethe-University, Department of Ophthalmology, Frankfurt am Main, Germany.

METHODS

This study comprised 11 eyes of 10 patients aged 3 to 13 years (mean 7.2 +/- 3.68 [SD]) who developed severe fibrin formation after cataract surgery and IOL implantation despite intensive topical steroid therapy. Under general anesthesia, fibrinolysis was performed with 10 micrograms of rt-PA 7.18 +/- 2.04 days after intraocular surgery. Follow-up included slitlamp examination, tonometry, visual acuity testing, and-ophthalmoscopy. Anterior chamber flare measurements could be performed in 6 eyes.

RESULTS

Complete resolution of fibrin formations occurred in 90% of the patients in these cases, no recurrent fibrinous reaction or adverse effects were noted. In 2 eyes of the same patient with a history of juvenile rheumatoid arthritis and chronic uveitis, fibrin clot dissolution was incomplete. A recurrent fibrinous formation could be observed after 2 and 4 weeks, respectively. A beginning band keratopathy excluding the central and limbal cornea was noted after 6 and 8 weeks, respectively.

CONCLUSION

Intraocular application of rt-PA appears to be a safe and efficacious therapeutic approach in the management of severe fibrinous reactions after pediatric cataract surgery.

Recombinant tissue plasminogen activator in cases with fibrin formation after cataract surgery: a prospective randomised multicentre study

AIMS

This study investigated the effect of tissue plasminogen activator (tPA) in patients with severe intracameral fibrin after extracapsular cataract extraction or phacoemulsification with posterior chamber intraocular lens implantation.

METHODS

A randomised prospective multicentre study was carried out in 86 patients with intraocular fibrin formation 2-8 days after cataract surgery. While the first group (n = 41) received only anti-inflammatory drugs, a single anterior chamber injection of tPA (10 micrograms) as an additional treatment to the standard was given in the second group (n = 44). On days 1, 2, 14, and 90 after randomisation, the visual acuities, slit lamp findings, and intraocular pressures were documented in standardised protocols. Efficacy of treatment was judged by the rate of fibrinolysis (primary objective), the frequency of synechiae, and central capsular fibrosis (secondary objectives).

RESULTS

The incidence and quantity of intraocular fibrin were significantly lower in the patients treated with tPA than in the control group (p < 0.05). The frequencies of synechiae were reduced by tPA injection. The capsule fibrosis noted after 3 months was significantly lower in the tPA group (p = 0.027). No ocular side effects were noted after the tPA injections.

CONCLUSIONS

Lysis of postcataract fibrin formation is accelerated and increased by a single intracameral injection of 10 micrograms tPA in addition to standard anti-inflammatory treatment. The findings suggest that the tPA injection reduces posterior capsule fibrosis, which still has to be addressed in larger study populations and with a long term follow up.

Intracameral tissue plasminogen activator to treat severe fibrinous effusion after cataract surgery

PURPOSE

To evaluate the efficacy and complications of intracameral recombinant tissue plasminogen activator (r-tPA) in the treatment of severe fibrinous effusion after cataract and combined cataract and glaucoma surgery.

SETTING

University Eye Hospital Vienna, Austria.

METHODS

In a prospective study, 40 eyes of 39 patients with severe fibrinous anterior chamber reaction in the early postoperative course received 25 microg r-tPA intracamerally through a temporal paracentesis. The main outcome measures were rate of complete fibrinolysis, time of maximal effect, and complications.

RESULTS

Complete fibrinolysis occurred in 33 eyes (83%) after a mean of 3.2 hours +/- 0.9 (SD). The rate of complete fibrinolysis was higher in eyes having cataract surgery only (24 eyes, 89%) than in those having combined surgery (9 eyes, 69%). Recurrent fibrin was seen in 3 eyes (7%), small anterior chamber hemorrhage in 7 (18%), increased intraocular pressure in 3 (7%), and posterior synechias in 13 (33%). Complications were managed conservatively.

CONCLUSION

The intracameral injection of 25 microg r-tPA proved to be a safe, efficient, and low-risk supplement in the treatment of severe postoperative fibrinous reactions.

Dissolution of pseudophakic fibrinous exudate with intraocular streptokinase

A fibrinous exudate developed in 8 children after cataract extraction. Blunt trauma was the cause of cataract formation in 6 children; the other 2 presented with congenital cataract. In 4 of 6 children with traumatic cataract, iris damage was evident. Seven children had an intraocular lens implanted. The development of fibrinous exudate in the anterior chamber was noted despite routine post-operative topically administered steroids. It typically formed 1-4 days after surgery. In all cases topical fortified steroids were unsuccessful in hastening dissolution. Intracameral injection of streptokinase (500-1000 IU) caused dissolution of fibrin in all cases. No adverse effects were apparent clinically with intraocular administration of streptokinase.

Low-dose intraocular tissue plasminogen activator treatment for traumatic total hyphema, postcataract, and penetrating keratoplasty fibrinous membranes

Tissue plasminogen activator (tPA) has been used to treat severe postcataract and vitrectomy fibrinous membranes, but intraocular bleeding has occurred with doses of 25 micrograms or higher. We report three patients, one with nonclearing total hyphema and uncontrollable intraocular pressure and two with severe fibrinous membrane formation, who had treatment with low-dose (4 micrograms to 6 micrograms) intraocular tPA. Although the fibrinous membranes or hyphema resolved in all three patients, they recurred and bleeding that required additional treatment occurred in one patient. Intraocular low-dose tPA may minimize the risk of corneal and retinal toxicity and may be considered an alternative treatment in intractable cases. However, secondary intraocular hemorrhage can occur, and the timing between the initial vascular injury, treatment with tPA, and subsequent bleeding may reduce the risk of further hemorrhaging.

The use of recombinant tissue plasminogen activator for intracameral fibrinolysis following cataract surgery

In a prospective study performed between June 1992 and March 1994 19 eyes of 19 patients with dense fibrinous pupillary membranes following cataract surgery were treated with intracameral injections of 25 micrograms recombinant tissue plasminogen activator (r-tPA). Injections were performed between the second and twenty-third postoperative day (mean 5.6 +/- 6.9 days). Complete fibrinolysis within one to 4 hours (mean: 3.3 +/- 0.89 hours) was observed in 18 (94.7%) eyes. In one (5.3%) eye fibrinolysis was incomplete despite a second injection. In 2 (10.5%) eyes. No recurrence of a distinct fibrinous membrane was noted which then cleared spontaneously with topical treatment. A small hyphema developed in 2 (10.5%) eyes and intraocular pressure exceeded 25 mmHg in 2 (10.5%) eyes. No increase of keratopathy nor any toxic intraocular side effect of 25 micrograms intracameral r-tPA was observed throughout the study. The intracameral injection of r-tPA clinically proved to safely accelerate the resorption of dense fibrinous membranes following cataract surgery and thus enhance visual recovery minimizing subsequent complications and systemic or subconjunctival anti-inflammatory treatment.