[Band-like keratopathy after treatment of postoperative fibrin reaction with tissue plasminogen activator]

EDTA chelation for symptomatic band keratopathy: results and recurrence

PurposeTo identify causes of symptomatic band keratopathy, and assess the results and long-term recurrence rates following chelation with topical ethylene-diamine-tetra-acetic acid (EDTA).Patients and methodsA retrospective review of surgical logbooks identified patients managed by EDTA chelation for symptomatic band keratopathy from 2009 to 2015.ResultsWe identified 108 cases; 89 case notes were available for analysis. Most cases of band keratopathy were idiopathic (36%). The most commonly identified underlying diagnosis was long-term topical glaucoma therapy (27%). Median presenting visual acuity was 6/18 (range 6/6-NPL) with the visual axis affected in 97.8% of cases. Treatment involved corneal epithelium removal, recurrent application of topical EDTA, and subsequent debridement. The mean duration of the operation was 20 min (range 10-45). Mean initial follow-up time was 40 days, and the visual axis was clear in 97.8%. Visual acuity was maintained or improved in 79.8%, with 13.5% improving by two lines or more. The mean length of follow-up was 581 days (median 374, maximum 2438). Twenty-five eyes (28.1%) showed localised recurrence of calcium with a mean time of 546 days (median 374), but only four cases required repeat EDTA chelation. The median time between operations was 430 days. Thirty-two per cent of the recurrence cases were associated with hypotony or chronic presence of silicone oil.ConclusionsChelation of calcium with topical EDTA is a safe and effective treatment for band keratopathy. Visual acuity improves in most eyes and while the rate of recurrence is moderate, the need for retreatment is low (4.5% overall).

Resolution of hyphaema following intracameral injection of tenecteplase in a Stock Horse

Intracameral injection of tissue plasminogen activator has been suggested as a means of hastening the clearance of blood from the anterior chamber and reducing the risk of synechia and fibrotic membrane formation in horses with hyphaema. The following report describes a case of ocular trauma in which intracameral injection of tenecteplase (TNK), a new-generation plasminogen activator, resulted in rapid resolution of hyphaema and successful outcome. However, a large dose (1 mg) was administered and may have been associated with retinopathy and keratopathy. TNK may be an effective treatment for equine hyphaema and further controlled clinical or experimental studies are required to determine its efficacy and safety profiles.

Rapid development of band keratopathy of corneal graft associated with treatment with intracameral recombinant tissue plasminogen activator for postoperative fibrin reaction

PURPOSE

To report a corneal transplant complication associated with intracameral recombinant tissue plasminogen activator (rTPA) treatment of postoperative fibrin reaction.

METHODS

In a 71-year-old patient, a triple procedure was performed for perforated rheumatic ulcer and secondary cataract.

RESULTS

A dense band keratopathy developed rapidly within 36 hours after the use of intracameral injection of rTPA for the treatment of a dense fibrin clot.

CONCLUSIONS

This is the first report of rapid development of massive band keratopathy in a corneal graft after triple procedure and treatment with intracameral rTPA. Intracameral rTPA should be used with caution in patients with attenuated endothelium.

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.

EDTA chelation for calcific band keratopathy: results and long-term follow-up

PURPOSE

To determine the etiologies and management of calcific band keratopathy (CBK), and assess the results and long-term follow-up after ethylenediamine-tetraacetic acid (EDTA) chelation.

DESIGN

Retrospective interventional case series.

METHODS

Two hundred thirty patients with clinically significant CBK were included from January 1996 to July 2002. Among these, 54 patients (65 eyes) underwent EDTA chelation. Outcome measures included symptomatic relief, visual improvement, and recurrences. The improvement or worsening of the number of lines of Snellen best-corrected visual acuity was determined at 1 month and at last follow-up visit.

RESULTS

The most common causes of CBK were chronic corneal edema in 80 eyes (28%) and idiopathic in 74 eyes (25.9%). The mean follow-up time after EDTA chelation was 36.6 months (range, 1 month to 29.6 years). Forty-four of 45 patients (98%) reported partial or complete symptomatic relief. Seventeen eyes (33.3%) improved 2 or more lines at 1 month and 18 eyes (35.2%) at last follow-up visit (P =.0001). In patients with an initial visual acuity between 20/50 and 20/400, 15 eyes (47%) improved 2 or more lines at 1 month and 16 eyes (50%) at last follow-up visit. Ten of 56 eyes (17.8%) had a recurrence at a mean time of 17.7 years (range, 1 month to 26 years). The highest number of recurrences was in three of five eyes with uveitis (60%; P =.03).

CONCLUSION

Chelation with EDTA is an effective treatment of CBK. Visual acuity improves most in eyes with acuity between 20/50 and 20/400. This treatment can be used as the initial surgical intervention after conservative measures fail.

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.

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.