Early anti-VEGF treatment for hemorrhagic occlusive retinal vasculitis as a complication of cataract surgery.

BACKGROUND: We report a case of hemorrhagic occlusive retinal vasculitis (HORV) after prophylactic intracameral vancomycin use during an uneventful cataract surgery treated with early anti-VEGF treatment. CASE PRESENTATION: A 51-year-old female underwent uneventful cataract surgery with prophylactic intracameral vancomycin during the procedure. On the seventh post-operative-day, she presented with sudden painful, visual loss. Fundus examination revealed peripheral hemorrhagic retinal vasculitis. She received anti-VEGF therapy to prevent further vision loss and retinal neovascularization due to extensive retinal ischemia. At the 6-month follow-up visit, visual acuity was 20/20 with no sign of neovascularization. CONCLUSIONS: Postoperative HORV is a devastating condition that can occur after otherwise uncomplicated cataract surgery. The nature of this rare condition remains unknown. Early anti-VEGF administration seems to demonstrate favorable results.

Prevalence of hemostatic alterations in patients with recurrent spontaneous subconjunctival hemorrhage.

BACKGROUND: Subconjunctival hemorrage (SCH) is a frequent, mild bleeding manifestation and a common cause of consultation. Hemostatic alterations are possible causes of SCH but their role and prevalence is unknown. We assessed the prevalence of hemostatic abnormalities in patients with spontaneous, recurrent SCH to clarify the role of the hemostasis laboratory in this clinical setting. METHODS: A total of 105 SCH patients (21-78 years, 65 females) with no identifiable cause (hypertension-trauma-conjunctivitis) or concomitant treatments (NSAIDs- aspirin-oral anticoagulants-antiplatelet agents) and 53 age and sex-matched healthy controls (HCs) (22-72 years, 29 females) were evaluated for skin bleeding time, PFA-100®, blood clotting screening, platelet count, light transmission aggregomery, VWF:Ag, VWF:RCo, RIPA, FVIII activity, FXIII antigen and activity and ISTH Bleeding Severity Score (BSS). RESULTS: Prevalence of hemostatic abnormalities was not higher in the SCH population than in HCs BSS was 0.83 (95% CI 0.62-1.06) in SCH and 0.66 (0.37-0.95) in HC (p=NS). Type I Von Willebrand disease was diagnosed in one SCH and none HC patients, a prevalence not significantly different (p=NS by χ2). CONCLUSIONS: The prevalence of hemostatic alterations in patients with recurrent, spontaneous SCH is not different from the general population; hemostatic screening or second level tests are of no use in patients with recurrent SCH and no other bleedings.

Dilute brimonidine to improve patient comfort and subconjunctival hemorrhage after LASIK.

PURPOSE: To investigate whether dilute brimonidine (0.025%) reduces patient discomfort, subconjunctival hemorrhage, and injection after LASIK without a significant increase in the rate of flap complications or surgical enhancements. METHODS: This randomized, double-blind, prospective study enrolled 180 patients (360 eyes) in a contralateral eye comparison of topical dilute brimonidine, naphazoline/pheniramine, or Systane Ultra (Alcon Laboratories, Inc., Fort Worth, TX) administered shortly before LASIK for any indication. Patients were evaluated for subconjunctival hemorrhage, injection, and flap dislocation 1 hour and 1 day postoperatively. Patient questionnaires measuring patient comfort and ocular symptoms were administered at these same follow-up visits. Patients were examined for 3 months to determine similar outcomes for standard indices of safety, predictability, efficacy, and enhancement rates. RESULTS: Scores of patient discomfort, subconjunctival hemorrhage, and injection were significantly lower in eyes treated with dilute brimonidine at the 1 hour and 1 day postoperative examinations. Refloats for mild-flap edge wrinkling were required in 3 brimonidine eyes (2.5%), 1 naphazoline/pheniramine eye (0.8%), and no control eyes, but this difference did not reach statistical significance (P = .18). There was no significant difference between eyes at 3 months in terms of visual acuity, refractive error, corrected distance visual acuity, or rate of enhancement. CONCLUSIONS: Use of dilute brimonidine before LASIK reduces subconjunctival hemorrhage and injection and improves patient comfort after surgery. Flap edge wrinkling requiring refloat may still be a complication with dilute brimonidine.

Bevacizumab and intraocular tumors: an intriguing paradox.

PURPOSE: Bevacizumab, a humanized monoclonal antibody to vascular endothelial growth factor-A (VEGF-A), was originally developed as an anti-tumor treatment. In ocular oncology, it is being used to treat macular edema due to radiation retinopathy, but it may also be useful for the treatment of primary uveal melanoma (UM) or its metastases. We determined the effect of bevacizumab on the growth of B16F10 cells inside the eye and on B16F10 and UM cells cultured in vitro. METHODS: B16F10 melanoma cells were placed into the anterior chamber of the eye of C57Bl/6 mice and tumor growth was monitored after injection of different doses of bevacizumab or mock injection. In addition, the effect of bevacizumab on in vitro growth of B16F10 and human UM cells and on the expression of VEGF-A, GLUT-1, and HIF-1α was evaluated. RESULTS: Following intraocular injection of bevacizumab into murine B16 tumor-containing eyes, an acceleration of tumor growth was observed, with the occurrence of anterior chamber hemorrhages. Bevacizumab did not affect proliferation of B16F10 cells in vitro, while it inhibited UM cell proliferation. Expression analysis demonstrated that addition of bevacizumab under hypoxic conditions induced VEGF-A, GLUT-1 and HIF-1α in B16F10 cells as well as in UM cell lines and two of four primary UM tumor cultures. CONCLUSIONS: In contrast with expectations, intraocular injection of bevacizumab stimulated B16F10 melanoma growth in murine eyes. In vitro exposure of B16 and human UM cells to bevacizumab led to paradoxical VEGF-A upregulation. The use of VEGF inhibitors for treatment of macular edema (due to radiation retinopathy) after irradiation of UM should be considered carefully, because of the possible adverse effects on residual UM cells.

Non-traumatic subperiosteal orbital hemorrhage secondary to barotrauma.

PURPOSE: To report a case of non-traumatic subperiosteal hemorrhage (NTSOH) secondary to barotrauma. MATERIAL AND METHODS: Observational case report. RESULTS: A 42-year-old female presented with right proptosis with bilateral petechial lid hemorrhages, chemosis and diplopia following scuba diving. This occurred in the context of a tight facemask resulting in 'mask squeeze', and performance of Valsalva maneuver to equalize ear pressure. Clinically, there were no signs of optic nerve involvement. Computed tomography (CT) demonstrated signs consistent with right subperiosteal hematoma adjacent to the orbital roof with inferolateral displacement of the superior rectus. Patient recovered well after being admitted for intravenous dexamethasone without surgical intervention. CONCLUSION: NTSOH from barotrauma can result from 'mask squeeze' under a tight-fitting mask and exacerbated by use of Valsalva maneuvers. This may be prevented with frequent pressure equalization during diving.

Can bleeding in trabeculectomy be decreased? Effectiveness of brimonidine pre-treatment.

PURPOSE: To evaluate the efficacy of preoperative topical brimonidine use to maintain visibility during trabeculectomy and control intraoperative bleeding and postoperative subconjunctival hemorrhage. METHODS: The first group comprised 35 eyes of 34 patients administered brimonidine tartrate 0.15% (Brimogut, Bilim Ilac, Turkey) eye drops 6 and 3 min before surgery, and 33 eyes of 31 patients who received no medication for vasoconstriction formed the second group. Preoperative and postoperative photographs and operation video images were taken and vision analysis software used. Black-and-white images were obtained to identify the blood vessel and surface hemorrhage areas. The surface area of the hemorrhage was calculated by counting the black pixels with Image J software. RESULTS: There was no significant difference between two groups in terms of baseline (preoperative) eye redness (p > 0.05). In the first group, the eye redness values were 344.7 ± 19.5 pixels preoperatively and 244.1 ± 23.3 pixels at the beginning of the surgery, respectively (p < 0.001). However, no significant change was observed in the second group in eye redness (348.2 ± 17.5 pixels preoperatively and 360.7 ± 26.8 pixels at the beginning of the surgery, p > 0.05). Cautery was used for an average of 11.91 ± 1.96 s in the first group and 25.57 ± 4.66 s in the second to control intraoperative bleeding (P < 0.001). CONCLUSION: Preoperative topical brimonidine use in trabeculectomy surgery significantly decreased intraoperative bleeding and postoperative subconjunctival hemorrhage and facilitated bleeding control.

[Clinical rationale for the efficiency of using the domestic antioxidant agent Histochrome].

The objective of the study was to evaluate the efficacy of the Russian drug Histochrome in the treatment of 554 children at different ages who had intraocular hemorrhages of various degrees and sites in relation to the route and time of its administration. Histochrome therapy was shown to reduce the time of resorption of hyphemas and hemophthalmos by two times and retinal hemorrhages to 2 weeks. There was a positive effect in increasing visual acuity by 0.2 or more in 70.3% of cases.

[Scleromalacia associated with varicella-zoster virus]. / Varizella-zoster-Virus-assoziierte Skleromalazie.

BACKGROUND: Scleromalacia usually appears following vasculitis in systemic rheumatoid diseases, especially as a late symptom of rheumatoid arthritis. CASE REPORT: A 67-year-old woman was referred to our hospital for further evaluation with the diagnosis of a "fast-growing tumor" of the left eye. Sixteen months ago she had suffered from herpes zoster ophthalmicus-associated keratouveitis and trabeculitis in the same eye. Scleromalacia associated with varicella-zoster virus (VZV) was diagnosed after the biomicroscopic and gonioscopic examination of the eye was completed and a systemic disease had been ruled out. One week after beginning systemic application of acyclovir (5 x 800 mg daily) and prednisolone (30 mg daily), the anterior chamber inflammation regressed and a fibrosis seemed to appear in the atrophic scleral area. CONCLUSION: Although scleral atrophy mostly appears as a late sign of systemic rheumatoid diseases, it might also develop secondary to infectious diseases. Scleromalacia associated with varicella-zoster virus has been previously described only in a few cases. Scleromalacia is a vision-threatening complication of zoster ophthalmicus which responds well to combination therapy with systemic antiviral and anti-inflammatory agents.

[Effect of exogenous donors of nitric oxide and inhibitors of its enzymatic synthesis on experimental ischemic thrombosis in conjunctive veins of the rabbit eyes].

The beneficial action of dinitrosyl iron complex with glutathione on conjunctive veins of eyes in rabbits with experimental thrombosis of conjunctive veins has been demonstrated. Aqueous solutions of dinitrosyl iron complexes were added subconjunctively at doses of 5.4-8.1 micromole per eye. The average duration of thrombosis by the action of dinitrosyl iron complex decreased from 6.4 days in control animals to 2 days. The addition of dinitrosyl iron complex resulted in blood flow recovery in occlusive vessels and prevented ischemia and necrosis of tissues. The enhancement of hemorrhagic activity induced by dinitrosyl iron complexes was abrogated with combined addition of the nonselective NO synthase inhibitor N-nitro-L-arginine. In contrast, S-nitrosoglutathione affected adversely the veins: the duration of thrombosis in experimental thrombosis of conjunctive veins increased to 7 days. Intensive hemorhage developed in the conjunctive. The formation of protein-bound dinitrosyl iron complexes was observed by the EPR method in eye tissues after the subconjunctive or parabulbar addition of dinitrosyl iron complex with glutathione. This was not the case when the complex was injected intravenously. It was shown that dinitrosyl iron complex with glutathione induces the blockade of pellet aggregation or strengthens the fibrinolytic activity of plasma of patients with eye vessel pathology. The beneficial action of dinitrosyl iron complexes on conjunctive veins was proposed to be due to the capacity of dinitrosyl iron complexes to donate NO primarily to its biological targets. The release of free NO molecules in large amounts is not characteristic for dinitrosyl iron complexes. This process is characteristic of S-nitrosoglutathione, which sharply increases the probability of the accumulation of peroxynitrite, which produces a toxic effect on cells and tissues.

Effect of subconjunctivally injected, liposome-bound, low-molecular-weight heparin on the absorption rate of subconjunctival hemorrhage in rabbits.

PURPOSE: To investigate the effect of subconjunctival injection of liposome-bound, low-molecular-weight heparin (LMWH) on the absorption rate of subconjunctival hemorrhages. METHODS: Subconjunctival hemorrhages were induced in both eyes of 30 rabbits by the subconjunctival injection of 0.1 mL of autologous blood from auricular marginal veins. After 8 hours, randomized subconjunctival injections of one of three materials were made: 5 IU/mL liposome-bound LMWH (0.1 mL) in 18 eyes (group A), only liposomes (0.1 mL) in 14 eyes (group B), the free form of LMWH (5 IU/mL, 0.1 mL) in 14 eyes (group C), or no injection in 14 eyes (group D). Subconjunctival hemorrhages were photographed with a digital camera at 8, 24, 48, 72, 96, and 120 hours after induction of subconjunctival hemorrhages, sized with an image analyzer, and compared between groups. RESULTS: Subconjunctival hemorrhages were absorbed faster in group A (liposome-bound LMWH injected) than in with group B (liposome injected). Comparison of groups A and C (free LMWH injected) showed statistical differences in the absorption rates at 96 and 120 hours except at 24, 48, and 72 hours. The mean elapsed time for the complete resorption of subconjunctival hemorrhages was shortest in group A among four groups, whereas group B and the control showed no significant differences. The ocular and systemic absorption of LMWH were significantly lower after injection of the liposome-bound than the free form. CONCLUSIONS: The subconjunctival injection of liposome-bound LMWH appears to enhance subconjunctival hemorrhage absorption in rabbits.

[Pavlyuk--antioxidant "Gistochrom" in the complex treatment of intraocular hemorrhages in children].

We studied the efficiency of Russian antioxidant Gistochrom in the treatment of intraocular hemorrhages of different genesis in children. Gistochrom was used in 407 children (449 eyes), aged 1 month to 14 years, with traumatic hyphema, hemophthalmos, hemorrhages in the eye bottom, hemorrhagic retinovasculitis, recurrent hephema, diabetic retinopathy, hemorrhages after reconstruction of the anterior chamber with cataract extraction, neuritis, retinopathy of prematures as well as with uveitis with a pronounced exudative component, with signs of retinal edema and of reactive pappilitis. Gistochrom has an intense action on blood resorption in structures of the eye ball as observed in traumas and lesions of internal eye tunics with hemorrhages. The treatment efficiency is higher when the drug is used at earlier disease stages and when it is administered into the retrobulbar space through the irrigation system. Gistrochrom is recommended for use in ophthalmic practice for the treatment of intraocular hemorrhages of different genesis as well as in retinopathy with a pronounced exudative component and in different-etiology uveitis.

[Hemophthalmia in patients with hypertensive disease].

A hundred patients with hemophthalmia were examined by ultrasound B-scanning to estimate the volume of the blood that had bled into the vitreous body and to check up the efficiency of conservative treatment. The latter used the enzyme collalysine as parabulbar injections in combination with resolving therapy. There is evidence that complex resolving therapy is an effective treatment of hemophthalmia.

Novel Treatment for Hemorrhagic Descemet Detachment After Canaloplasty.

PURPOSE: To describe a case of hemorrhagic Descemet membrane detachment after canaloplasty and to discuss its management using alteplase, a tissue plasminogen activator (TPA). METHODS: Interventional case report. RESULTS: A 60-year-old woman with advanced pseudoexfoliation glaucoma developed severe hemorrhagic Descemet detachment after canaloplasty. Initial anterior chamber and pre-Descemet washout yielded no improvement. On the fifth postoperative day, the patient received a novel pre-Descemet treatment using a TPA with an anterior chamber air bubble. The intracorneal blood clot quickly dissolved intraoperatively with the Descemet membrane almost completely reattached on postoperative day 1. CONCLUSIONS: Hemorrhagic Descemet detachment is a rare and serious complication of canaloplasty. The use of pre-Descemet TPA dissolves the intracorneal blood clot and helps reattach Descemet membrane, allowing quick rehabilitation of patient's vision and preserving integrity of the cornea.

Intraocular hemorrhage after systemic thrombolytic therapy in a patient with exudative macular degeneration.

PURPOSE: To report a hemorrhagic complication from thrombolytic therapy in a patient with exudative macular degeneration. CASE REPORT: A 75 year old patient with exudative macular degeneration developed pain and loss of vision in the left eye shortly after receiving tissue plasminogen activator (t-PA) for a myocardial infarction. Examination revealed the patient to be in angle closure. A CT scan revealed the etiology of the angle closure to be a dense vitreous hemorrhage pushing the iris-lens diaphragm forward. Intraocular pressure was treated successfully, but the final visual acuity was only light perception. CONCLUSIONS: Thrombolytic therapy can lead to devastating intraocular hemorrhages. The presence of exudative macular degeneration may potentially increase the risk of developing such complications.

Subconjunctival hemorrhage: the first presenting clinical feature of idiopathic thrombocytopenic purpura.

BACKGROUND: Subconjunctival hemorrhage as the first presenting clinical feature of idiopathic thrombocytopenic purpura, to the best of our knowledge, has not been reported earlier. CASE: A 60-year-old woman presented with an isolated finding of subconjunctival hemorrhage. She later developed hemorrhage from retinal vessels and had a single episode of hematuria. OBSERVATIONS: Her blood cell count showed an extremely low platelet count. Her medical history and clinical examination for any other systemic or ophthalmic pathology were negative. Even after treating the patient with blood and platelet transfusion and maintaining her on high doses of systemic steroids, she did not respond well. CONCLUSION: The appearance of spontaneous subconjunctival hemorrhage in a patient should be thoroughly investigated as it can be an initial sign of a grave systemic disorder.

Ocular vicarious menstruation.

Vicarious menstruation represents cyclical bleeding in extragenital organs during a normal menstrual cycle. We present an unusual case of ocular vicarious menstruation (bloody tears) in a 17-year-old girl. The indications and treatment of this rare disorder are discussed.

Pre-Descemet's hematoma in a patient of congenital glaucoma with Descemet's detachment: a unique form of hemorrhage.

A unique form of anterior segment hemorrhage called Pre-Descemet's hematoma is a previously unreported type of hemorrhage in which blood collects in the narrow space between the corneal stroma and detached Descemet's membrane, which in our case was because of congenital glaucoma associated with Haab's straie.

[Subretinal hematoma in age-related macular degeneration: treatment with intravitreal injection of tPA and gas]. / Traitement des hématomes sous-rétiniens compliquant une DMLA par injection intravitréenne de tPA et de gaz.

PURPOSE: Subretinal hemorrhage involving the macula is a devastating complication of age-related macular degeneration. It may be successfully removed by vitrectomy but this surgery cannot be practiced in all patients. We propose an alternative way to this surgery by injecting tissue plasminogen activator then gas in the vitreous. PATIENTS AND METHODS: We treated seven patients suffering from submacular hemorrhage for less than seven days. We injected in the vitreous 50 micrograms of tissue plasminogen activator followed seven days later by an another intravitreous injection of 0.3 milliliter of C3F8. The patient then had to stay in a "face down" position for seven days. RESULTS: In five cases the subretinal hemorrhage was displaced enough to identify the choroidal neovascularization accountable for the bleeding in four cases. In one case, the displacement of the subretinal hematoma was incomplete but enough to identify and treat the neovascular membrane. In one case the injections were unsuccessfull. One recurrence occurred after four days after an initial successful displacement. The best corrected acuity was increased in four cases. No complication was attributed to the intravitreous injections. DISCUSSION: Treatment of subretinal hemorrhage complicated age related macular degeneration by injected tPA and gas into the vitreous is a safe and efficacious method particularly for patients with anticoagulation therapy or in poor health.

[Vitreous hemorrhage after vitrectomy in diabetic retinopathy and tissue plasminogen activator]. / Hemorragia vítrea postvitrectomía en retinopatía diabética y activador tisular del plasminógeno.

PURPOSE: To determine if intraocular recombinant tissue plasminogen activator (r-TPA) can be used to treat fibrin blood clots (hyphemas/vitreous) after vitrectomy surgery for diabetic retinopathy. MATERIAL AND METHOD: After a retrospective review of medical records, we found 52 patients who underwent vitrectomy for diabetic retinopathy and non-resolving vitreous hemorrhage and/or hyphema during the early postoperative (6 weeks). They were administered r-TPA in dose of 25 microgr/0.1 ml. Hyphemas and vitreous hemorrhages were classified in four grades. RESULTS: Tissue Plasminogen Activator was used after vitrectomy surgery in 52 fibrin clotted eyes (52 patients), within the first 3 days post surgery. Vitreous hemorrhages were categorized as grade 2 (21%), grade 3 (67.3%) and grade 4 (11.5%). Hyphemas observed in 18 eyes presented grade 3 (38.9%) and grade 4 (61%). We saw no evidence of intraocular reactions against the r-TPA solution at the dose used in this study. CONCLUSIONS: Fibrin blood clots can successfully and effectively be treated with intraocular r-TPA in doses of 25 microgr/0.1 ml (Arch Soc Esp Oftalmol 2002; 77: 7-12).