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Muñoz-Solano J, Tondini G, Zicarelli F, Staurenghi G, Oldani M, Invernizzi A. Utility of Anterior Segment OCT in the Management of Uveitic Cataract Surgery: A Fibrinoid Syndrome Case Treated with rtPA. Ocul Immunol Inflamm 2024; 32:1128-1131. [PMID: 37140351 DOI: 10.1080/09273948.2023.2203232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 02/19/2023] [Accepted: 04/11/2023] [Indexed: 05/05/2023]
Abstract
PURPOSE To highlight the importance of swept-source anterior segment optical coherence tomography (SS-ASOCT) in the peri-surgical management of cataract in uveitis. To describe a case of fibrinoid syndrome in uveitis treated with recombinant tissue plasminogen activator (rtPA). METHODS SS-ASOCT was performed at each follow-up before and after cataract surgery to assess anterior chamber inflammation and assist the clinical management of the patient. RESULTS A patient with idiopathic autoimmune uveitis was scheduled for cataract surgery. SS-ASOCT allowed to correctly plan the surgery timing. The patient developed a severe fibrinoid syndrome. Postsurgical SS-ASOCT allowed to distinguish between anterior chamber cells and fibrin thus guiding the timing for rtPA intracameral injection. Visual acuity improved from 20/400 the day after the surgery to 20/40. CONCLUSION SS-ASOCT allowed a precise assessment of the inflammatory components (cellular vs fibrinoid) after cataract surgery. Intracameral rtPA was safe and effective in the treatment fibrinoid syndrome in uveitis.
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Affiliation(s)
- Javier Muñoz-Solano
- Department of Ophthalmology, Donostia University Hospital, San Sebastian, Spain
| | - Giovanni Tondini
- Eye Clinic, Department of Biomedical and Clinical Science, University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Federico Zicarelli
- Eye Clinic, Department of Biomedical and Clinical Science, University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Giovanni Staurenghi
- Eye Clinic, Department of Biomedical and Clinical Science, University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Marta Oldani
- Eye Clinic, Department of Biomedical and Clinical Science, University of Milan, Luigi Sacco Hospital, Milan, Italy
| | - Alessandro Invernizzi
- Eye Clinic, Department of Biomedical and Clinical Science, University of Milan, Luigi Sacco Hospital, Milan, Italy
- Department of Ophthalmology, Save Sight Institute, University of Sydney, Sydney, Australia
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Osaadon P, Belfair N, Lavy I, Walter E, Levy J, Tuuminen R, Achiron A, Knyazer B. Intracameral r-tPA for the management of severe fibrinous reactions in TASS after cataract surgery. Eur J Ophthalmol 2021; 32:200-204. [PMID: 33719630 DOI: 10.1177/11206721211002064] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Perach Osaadon
- Ophthalmology Department, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Nadav Belfair
- Ophthalmology Department, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Itay Lavy
- Ophthalmology Department, Hadassah Medical Center, Jerusalem, Israel
| | - Eyal Walter
- Ophthalmology Department, Hadassah Medical Center, Jerusalem, Israel
| | - Jaime Levy
- Ophthalmology Department, Hadassah Medical Center, Jerusalem, Israel
| | - Raimo Tuuminen
- Helsinki Retina Research Group, University of Helsinki, Helsinki, Finland.,Eye Centre, Kymenlaakso Central Hospital, Kotka, Kymenlaakso, Finland
| | - Asaf Achiron
- Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boris Knyazer
- Ophthalmology Department, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Candia OA, Gerometta RM, Danias J. Tissue plasminogen activator reduces the elevated intraocular pressure induced by prednisolone in sheep. Exp Eye Res 2014; 128:114-6. [PMID: 25304217 DOI: 10.1016/j.exer.2014.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 10/01/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
We have previously shown that tissue plasminogen activator (tPA) injected in the vitreous of sheep, reduced or prevented the elevation of the intraocular pressure (IOP) normally produced by the instillation of 1% prednisolone. We now report the effect of tPA when injected into the anterior chamber (AC) in amounts of 0.01, 0.001 and 0.0001 μg diluted in a volume of 50 μL. Lyophilized tPA, obtained as Actilyse 50 mg from Boehringer Ingelheim containing arginine was utilized. The Actilyse was diluted in balanced salt solution to obtain the desired amount of tPA in 50 μL. An identical solution containing only arginine was prepared to inject into the contralateral eye as a control. Six sheep of the Corriedale breed were selected. At the beginning of the study all eyes received instillation of 1% prednisolone 3 times/day for 10 days to elevate their IOP from 10 mm Hg to about 23 mm Hg. Then, 0.0001 μg was injected into one of the eyes and its effect was followed for up to 55:00 h while the instillation of prednisolone continued in both eyes. The same protocol was implemented for the 0.001 and 0.01 μg amounts after extended washout and IOP was over 22 mm Hg. The injection of 0.0001 μg into the AC had no effect on an IOP of 23.0 mm Hg at 6:00 and 30:00 h after injection. 0.001 μg of tPA reduced IOP from 23.1 to 18.6 mm Hg at 6:00 h but IOP recovered to 22.3 mm Hg at 30:00 h. Injection of 0.01 μg produced a marked and prolonged reduction of IOP. From a baseline of 23.0, IOP was reduced to 14.0, 14.7, 21.2, and 20.9 mm Hg at 5.0, 23.0, 27.0 and 45.5 h, respectively. The 0.423 μg of arginine, which is associated with 0.01 μg tPA, was injected alone and had no effect. Recombinant human tPA injected in the AC is effective in reversing steroid-induced IOP elevation in sheep. The reduction of IOP elevation may be the result of an effect on extra-cellular matrix turnover in the TM. These findings suggest that tPA may by useful as a therapeutic agent in steroid-induced glaucomas.
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Affiliation(s)
- Oscar A Candia
- Department of Ophthalmology, Mount Sinai School of Medicine, New York, NY 10029, USA.
| | | | - John Danias
- Department of Ophthalmology, SUNY Downstate Medical Center and the SUNY Eye, Institute, Brooklyn, NY 11203, USA
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Anderson JE, Grippo TM, Sbeity Z, Ritch R. Serious complications of cosmetic NewColorIris implantation. Acta Ophthalmol 2010; 88:700-4. [PMID: 19493251 DOI: 10.1111/j.1755-3768.2008.01499.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE This case report describes serious postoperative complications and markedly elevated intraocular pressure (IOP) associated with the NewColorIris cosmetic implant. METHODS We report an interventional case series of two patients who suffered multiple complications after NewColorIris implantation carried out in Panama. Assessment included visual acuity, photography, endothelial cell count and anterior segment optical coherence tomography (OCT) when possible. RESULTS Both patients presented with endothelial cell loss, uveitis, pigment dispersion and elevated IOP. Anterior segment OCT demonstrated irregularities in the position and configuration of the implants within the anterior chamber with resultant areas of implant-iris and implant-endothelial contact. One patient had acute postoperative hyphaema that resolved with anterior chamber tissue plasminogen activator injection. Both patients required explantation OU, one eye has required trabeculectomy, and one eye with bullous keratopathy is being evaluated for Descemet's stripping endothelial keratoplasty. CONCLUSIONS Implantation of the NewColorIris cosmetic implant can lead to serious complications including hyphaema, uncontrolled IOP, severe endothelial cell loss, bullous keratopathy and anterior uveitis. Explantation may lead to improvement, but permanent damage to the trabecular meshwork and corneal endothelium persists.
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Affiliation(s)
- Justin E Anderson
- Department of Ophthalmology and Einhorn Clinical Research Center, New York Eye and Ear Infirmary, New York, New York 10003, USA
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Chung J, Park YH, Lee YC. The Effect of Nd:YAG Laser Membranotomy and Intravitreal Tissue Plasminogen Activator with Gas on Massive Diabetic Premacular Hemorrhage. Ophthalmic Surg Lasers Imaging Retina 2008; 39:114-20. [DOI: 10.3928/15428877-20080301-06] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Wu TT, Wang HH. Intracameral recombinant tissue plasminogen activator for the treatment of severe fibrin reaction in endophthalmitis. Eye (Lond) 2007; 23:101-7. [PMID: 17901882 DOI: 10.1038/sj.eye.6702984] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
PURPOSE The authors sought to evaluate the efficacy of recombinant tissue plasminogen activator (r-TPA) in the treatment of severe fibrinous anterior chamber reactions secondary to endophthalmitis. METHODS Twelve patients with endophthalmitis associated with severe fibrinous anterior chamber reactions were enrolled in the study. Various degrees of posterior synechiae were noted in 10 of these patients. TPA (25 microg/0.05 cc) was injected into the anterior chamber through the limbus as an adjunctive treatment to intravitreal antibiotic injection. Efficacy of the treatment was judged by the rate of fibrinolysis, the lysis of posterior synechiae, and the size of the dilated pupil. RESULTS After application of 25 microg of r-TPA, the fibrin reaction gradually resolved in 2-14 h. The median dilated pupil size in ratio 24 h after r-TPA injection was significantly larger than before r-TPA injection (0.41 vs 0.60; P=0.002). The median difference in pupil size in ratio in patients with posterior synechiae larger than 180 degrees was significantly larger than those with posterior synechiae equal or less than 180 degrees (0.32 vs 0.09; P=0.003). At 24 h after application of r-TPA, no eye had posterior synechiae. CONCLUSION Intracameral injection of r-TPA may be a safe and effective method for the treatment of significant fibrin reaction in endophthalmitis and thus facilitates vitreous and fundus examinations and vitrectomy if necessary.
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Affiliation(s)
- T-T Wu
- Department of Ophthalmology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.
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Riaz Y, Mehta JS, Fernando A, Ferguson V. Recombinant Tissue Plasminogen Activator (r-TPA) in Fibrin Dissolution due to Postoperative Endophthalmitis. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2006. [DOI: 10.47102/annals-acadmedsg.v35n10p723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Key words: Cataract surgery, Fibrinolysis, Infection
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Affiliation(s)
- Yasmin Riaz
- The Western Eye Hospital, Marylebone Road, London, UK
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Georgiadis N, Boboridis K, Halvatzis N, Ziakas N, Moschou V. Low-dose tissue plasminogen activator in the management of anterior chamber fibrin formation. J Cataract Refract Surg 2003; 29:729-32. [PMID: 12686240 DOI: 10.1016/s0886-3350(02)01813-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Nick Georgiadis
- Ophthalmology Department, AHEPA University Hospital, Thessaloniki, Greece
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Affiliation(s)
- Prithvi S Sankar
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, 02114, USA
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Abstract
Hyphema (blood in the anterior chamber) can occur after blunt or lacerating trauma, after intraocular surgery, spontaneously (e.g., in conditions such as rubeosis iridis, juvenile xanthogranuloma, iris melanoma, myotonic dystrophy, keratouveitis (e.g., herpes zoster), leukemia, hemophilia, von Willebrand disease, and in association with the use of substances that alter platelet or thrombin function (e.g., ethanol, aspirin, warfarin). The purpose of this review is to consider the management of hyphemas that occur after closed globe trauma. Complications of traumatic hyphema include increased intraocular pressure, peripheral anterior synechiae, optic atrophy, corneal bloodstaining, secondary hemorrhage, and accommodative impairment. The reported incidence of secondary anterior chamber hemorrhage, that is, rebleeding, in the setting of traumatic hyphema ranges from 0% to 38%. The risk of secondary hemorrhage may be higher in African-Americans than in whites. Secondary hemorrhage is generally thought to convey a worse visual prognosis, although the outcome may depend more directly on the size of the hyphema and the severity of associated ocular injuries. Some issues involved in managing a patient with hyphema are: use of various medications (e.g., cycloplegics, systemic or topical steroids, antifibrinolytic agents, analgesics, and antiglaucoma medications); the patient's activity level; use of a patch and shield; outpatient vs. inpatient management; and medical vs. surgical management. Special considerations obtain in managing children, patients with hemoglobin S, and patients with hemophilia. It is important to identify and treat associated ocular injuries, which often accompany traumatic hyphema. We consider each of these management issues and refer to the pertinent literature in formulating the following recommendations. We advise routine use of topical cycloplegics and corticosteroids, systemic antifibrinolytic agents or corticosteroids, and a rigid shield. We recommend activity restriction (quiet ambulation) and interdiction of non-steroidal anti-inflammatory agents. If there is no concern regarding compliance (with medication use or activity restrictions), follow-up, or increased risk for complications (e.g., history of sickle cell disease, hemophilia), outpatient management can be offered. Indications for surgical intervention include the presence of corneal blood staining or dangerously increased intraocular pressure despite maximum tolerated medical therapy, among others.
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Affiliation(s)
- William Walton
- Institute of Ophthalmology and Visual Science, New Jersey Medical School, Newark, New Jersey 01701-1709, USA
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Damji KF, O'Connor MD, Hill V. Tissue plasminogen activator for treatment of fibrin in endophthalmitis. CANADIAN JOURNAL OF OPHTHALMOLOGY 2001; 36:269-71. [PMID: 11548143 DOI: 10.1016/s0008-4182(01)80020-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- K F Damji
- University of Ottawa Eye Institute, ON.
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Chung J, Kim MH, Chung SM, Chang KY. The Effect of Tissue Plasminogen Activator on Premacular Hemorrhage. Ophthalmic Surg Lasers Imaging Retina 2001. [DOI: 10.3928/1542-8877-20010101-03] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
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.
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Affiliation(s)
- M Kamei
- Department of Ophthalmology, Osaka University Medical School, Suita, Japan.
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Skolnick CA, Fiscella RG, Tessler HH, Goldstein DA. Tissue plasminogen activator to treat impending pupillary block glaucoma in patients with acute fibrinous HLA-B27 positive iridocyclitis. Am J Ophthalmol 2000; 129:363-6. [PMID: 10704553 DOI: 10.1016/s0002-9394(99)00350-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- C A Skolnick
- Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago College of Medicine, Chicago, IL 60612-7243, USA
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