Management of postvitrectomy diabetic vitreous hemorrhage with tissue plasminogen activator (t-PA) and volume homeostatic fluid-fluid exchanger

Management of postvitrectomy diabetic vitreous hemorrhage with volume homeostatic fluid-fluid exchanger

BACKGROUND

To evaluate the clinical outcome of patients with postvitrectomy diabetic vitreous hemorrhage (PDVH) who underwent vitreous cavity lavage (VL) by volume homeostatic fluid-fluid exchange.

METHODS

We performed a retrospective chart review for 88 eyes of 80 consecutive patients who underwent VL for PDVH. Final best-corrected visual acuity after VL was compared to those before VL. Anatomic outcome, including rate of fundus clear-up, recurrent vitreous hemorrhage, increased intraocular pressure, iris neovacularization and anterior hyaloid fibrovascular proliferation were considered.

RESULTS

Between July 1999 and January 2006, 88 eyes of 80 patients underwent this procedure. Significant visual improvement was observed after VL (2.86 +/- 0.40 logMAR at baseline vs 1.71 +/- 0.97 logMAR at last visit, p < 0.0001). The fundus clear-up rate after VL was achieved in 84 out of 109 times (77.1%). Recurrent vitreous hemorrhage was found in 17 of 88 eyes (19.3%) with the mean interval of 92.6 +/- 126.7 days after VL.

CONCLUSIONS

For patients suffering from postvitrectomy diabetic vitreous hemorrhage, volume homeostatic vitreous cavity lavage can be an alternative method for removing the bloody content in the vitreous cavity efficiently and permitting rapid visual recovery.

Successful use of recombinant activated factor VII in the treatment of vitreous haemorrhage: a report of seven cases

Vitreous haemorrhage poses a serious threat to vision if untreated. Therapeutic options remain scarce and surgical intervention to resolve persistent bleeding is associated with risks that may further compromise vision. We report the use of recombinant activated factor VII (rFVIIa) in seven patients (six men, one woman; age, 30-65 years) with vitreous haemorrhage and severe reduction in visual acuity caused by trauma (n = 4) or proliferative diabetic retinopathy (n = 3). Initial doses ranged from 60 to 140 microg/kg; most patients received maintenance therapy with 20-60 microg/kg for at least 3 days. One patient received rFVIIa treatment for only 24 h and suffered a re-bleed, controlled successfully with further rFVIIa therapy. Five patients responded well to rFVIIa treatment, with reduced symptoms and improvements in visual acuity. Late presentation several days after trauma or symptom onset may have contributed to poor outcomes in the two patients who failed to respond to rFVIIa therapy. No adverse events were observed. An initial dose of rFVIIa 60-140 microg/kg, followed by 20-60 microg/kg repeated at 8-h intervals for 3-5 days, appears to be an effective therapeutic option for vitreous haemorrhage. However, further studies of rFVIIa use in this indication are warranted.

Vitreous haemorrhage in elderly patients: management and prevention

Vitreous haemorrhage can be caused by a disruption of normal retinal vessels, bleeding from diseased retinal vessels, bleeding from abnormal new vessels or extension of haemorrhage through the retina from other sources. In the elderly, vitreous haemorrhage usually occurs spontaneously and only occurs occasionally as a result of trauma. Appropriate management of vitreous haemorrhage is dependent on the most likely cause in a particular patient. As always, an accurate medical history with a careful clinical examination, static and dynamic ultrasonography performed by an experienced examiner, results of other laboratory tests and an understanding of the common causes of vitreous haemorrhage in each age group is essential to come to a 'best guess' diagnosis as to the cause of the vitreous haemorrhage and thus guide the physician toward the appropriate management. Immediate surgical removal of blood if indicated, as well as improving the vision gives the added benefit of allowing a full examination of the underlying retina. For those in whom surgical removal of blood is not recommended, a careful and frequent follow-up with serial B-scan ultrasound allows the 'best guess' diagnosis to be confirmed at each visit, until such time as the vitreous haemorrhage resolves sufficiently to allow a full and proper examination of the retina. Where there is a confirmed retinal tear, retinal detachment or other fundal pathology these are treated appropriately with laser or surgery (vitrectomy). Preventative measures are dependent on the underlying cause of vitreous haemorrhage. Some of the underlying causes such as posterior vitreous detachment cannot be prevented. In others, such as retinal vein occlusion, measures may need to be taken so as to reduce the risk of a similar event in the same or fellow eye and to reduce the risk of potentially life-threatening associated systemic conditions such as a stroke or myocardial infarction.