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.

Pseudoxantoma elástico / Pseudoxanthoma elastic

Resumo O pseudoxantoma elástico é uma doença generalizada do tecido conjuntivo envolvendo a pele, olhos e sistema cardiovascular desencadeando a fragmentação e calcificação das fibras elásticas. Geralmente ocorre após a puberdade, as manifestações características são manchas pequenas, circunscritas, amareladas, localizadas no pescoço, axila e pregas inguinais. Estrias angioides na retina, tendência à hemorragia e insuficiência arterial são as complicações mais comuns. Esta doença pode ser herdada como autossômica dominante ou recessiva. O tratamento das manifestações oculares convencional é através da fototerapia a laser impedindo a ocorrência de hemorragias locais. Entretanto, novas abordagens terapêuticas estão sendo desenvolvidas como a utilização em longo prazo de drogas antiangiogênicas, as quais atuam inibindo a neovascularização ocular. Apesar de não ter ainda efetivamente substituído o tratamento original, pesquisas recentes já evidenciam benefícios da nova técnica. O objetivo deste estudo é relatar sobre o caso de uma paciente de 37 anos, portadora do pseudoxantoma elástico, com estrias angioides e hemorragia ocular, e o tratamento eficaz com a terapia antiangiogênica no ambulatório de oftalmologia em Nova Iguaçu, Rio de Janeiro.

Abstract The pseudoxanthoma elasticum is a generalized disease of the connective tissue involving the skin, eyes and cardiovascular system triggering the fragmentation and calcification of elastic fibers. Usually occurs after puberty, the manifestations characteristics are small spots, circumscribed, yellowish, located on the neck, axilla and inguinal folds. Angioid streaks in the retina, tendency to hemorrhage and arterial insufficiency are the most common complications. This disease can be inherited as autosomal dominant or recessive. The treatment of ocular manifestations is through the conventional phototherapy laser preventing the occurrence of local hemorrhages. However, new therapeutic approaches are being developed as the long-term use of drugs antiangiogenic, which act by inhibiting the ocular neovascularization. Despite not having yet effectively replaced the original treatment, recent research already show benefits of new technique. The objective of this study is to report on a case of a patient of 37 years, the carrier of the Pseudoxanthoma Elasticum, with angioid streaks and ocular hemorrhage, and the effective treatment with antiangiogenic therapy at the clinic of Ophthalmology in Nova Iguaçu, Rio de Janeiro.

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.

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.

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.

Antivascular endothelial growth factor bevacizumab for radiation optic neuropathy: secondary to plaque radiotherapy.

PURPOSE: To evaluate the intravitreal antivascular endothelial growth factor, bevacizumab, for treatment of radiation optic neuropathy (RON). METHODS AND MATERIALS: A prospective interventional clinical case series was performed of 14 patients with RON related to plaque radiotherapy for choroidal melanoma. The RON was characterized by optic disc edema, hemorrhages, microangiopathy, and neovascularization. The entry criteria included a subjective or objective loss of vision, coupled with findings of RON. The study subjects received a minimum of two initial injections of intravitreal bevacizumab (1.25 mg in 0.05 mL) every 6-8 weeks. The primary objectives included safety and tolerability. The secondary objectives included the efficacy as measured using the Early Treatment Diabetic Retinopathy Study chart for visual acuity, fundus photography, angiography, and optical coherence tomography/scanning laser ophthalmoscopy. RESULTS: Reductions in optic disc hemorrhage and edema were noted in all patients. The visual acuity was stable or improved in 9 (64%) of the 14 patients. Of the 5 patients who had lost vision, 2 had relatively large posterior tumors, 1 had had the vision decrease because of intraocular hemorrhage, and 1 had developed optic atrophy. The fifth patient who lost vision was noncompliant. No treatment-related ocular or systemic side effects were observed. CONCLUSIONS: Intravitreal antivascular endothelial growth factor bevacizumab was tolerated and generally associated with improved vision, reduced papillary hemorrhage, and resolution of optic disc edema. Persistent optic disc neovascularization and fluorescein angiographic leakage were invariably noted. The results of the present study support additional evaluation of antivascular endothelial growth factor medications as treatment of RON.

Effect of subconjunctivally injected liposome-encapsulated tissue plasminogen activator on the absorption rate of subconjunctival hemorrhages in rabbits.

PURPOSE: To evaluate the effect of subconjunctivally injected liposome-encapsulated tissue plasminogen activator (tPA) on the absorption rate of subconjunctival hemorrhages (SHs). METHODS: SHs were induced in 1 eye each of 36 rabbits by subconjunctival injection of 0.05 mL of autologous blood. After 8 hours, randomized subconjunctival injections were performed: 26,000 IU/mL liposome-encapsulated tPA (0.05 mL) in 9 eyes (group A), free-form tPA (26,000 IU/mL; 0.05 mL) in 9 eyes (group B), only liposomes (0.05 mL) in 9 eyes (group C), or no injection in 9 eyes (group D). The sizes of the SHs at 8, 24, 48, 72, 96, and 120 hours after induction were measured using an image analyzer and were compared among the 4 groups. RESULTS: Group A showed significantly more rapid absorption rates than all the other groups at 24, 48, and 72 hours and had the significantly shortest mean elapsed time for the complete resorption of SHs. The tPA activity in ocular tissue except conjunctiva and plasma were negligible beyond 24 hours after SH induction with both forms of tPA. In the conjunctiva, the tPA activity was significantly prolonged in the liposome-encapsulated tPA group than in the free tPA group. CONCLUSIONS: Subconjunctival injection of liposome-encapsulated tPA seems to enhance SH absorption in rabbits, especially during the early stages with minimal systemic and ocular absorption.

Submacular haemorrhages associated with neovascular age-related macular degeneration.

The exact incidence of submacular haemorrhage (SMH) in patients with neovascular age-related macular degeneration (nAMD) is unknown, and risk factors for its occurrence ill defined. It is known, however, to be a relatively common problem and important because the visual prognosis of these patients is poor. Unfortunately, patients with significant SMH were excluded from all the recent major randomised control trials for nAMD with antivascular endothelial growth factor (VEGF) agents and photodynamic therapy, and as such, the optimum management of patients is uncertain. SMH can present initially or during treatment of nAMD. The location, size, thickness and duration of SMH have an important bearing on treatment and outcomes. Thin or extrafoveal SMH are probably best treated with anti-VEGF agents alone. It has been proposed that patients with moderate-sized SMH, particularly thick haemorrhages, have an improved prognosis with surgical SMH displacement combined with treatment of CNVM if present. SMH drainage, macular translocation and RPE patch grafting are reserved for more severe extensive cases of SMH. Using these techniques, outcomes better than the natural history have been achieved. This review aims to summarise what is known about SMH in nAMD and will discuss a variety of therapeutic interventions.

[Hemorrhagic Descemet's membrane detachment after viscocanalostomy]. / Desprendimiento hemorrágico de la membrana de Descemet tras viscocanalostomía.

INTRODUCTION: Viscocanalostomy is an option in the surgical treatment of glaucoma. This non-penetrating technique favours aqueous drainage through the Schlemm channel while avoiding filtering blebs and their related pathologies. Complications associated to this surgery are unusual, one of which is Decemet's membrane detachment (DMD) CLINICAL CASE: A 64 year-old female diagnosed with open-angle chronic glaucoma, whose had undergone a viscocanalostomy of the left eye. In the immediate postoperative period we noticed a hemorrhagic DMD in the lower temporal quadrant. After adopting a wait and see attitude, we did not find improvement 15 days after surgery and corneal edema was established with vision decrease. We proceeded to a surgical reapplication by means of Descemet's membrane micropuncture and SF6 injection into the anterior chamber and achieving an anatomical and functional improvement DISCUSSION: We believe that the intrusion of viscoelastic material into the supradescemetic was a consequence of the high-pressure during the high-density hyaluronate injection. Hemorrhagic DMD management is mainly determined by its location, size and evolution. In our case, the posterior endothelial micropuncture and descematopexy by means of 20% SF6 injection into the anterior chamber was useful in resolving this complication.

[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.

Subconjunctivally injected, liposome-encapsulated streptokinase enhances the absorption rate of subconjunctival hemorrhages in rabbits.

Liposome-encapsulated streptokinase (SK) was prepared with distearoyl-phosphatidyl-ethanolamine-N-[methoxy(polyethyleneglycol)-2000] (DSPE-PEG(2000)). In vitro release assay demonstrated over 81% of SK was released from liposomes at 48 h, and the effect of its subconjunctival injection on the absorption rate of induced subconjunctival hemorrhage (SH) in rabbits was evaluated. After 8h of SH induction, eyes were randomly assigned to one of four subconjunctival injection groups (10 eyes each): group A: the free form of SK (1000 IU/mL); group B: liposome-encapsulated SK (1000 IU/mL); group C: 0.1 mL of liposomes; and group D: no injection. SHs were photographed at 8, 24, 48, 72, and 120 h after SH induction and their sizes were compared. Size decrease of the SH was faster in groups A and B than in groups C and D. Group B displayed significantly different absorption rates than group A at 24 and 48 h and with groups C and D at 24, 48, and 72 h, with the shortest mean elapsed time among all groups. The ocular absorption of SK was lower after the injection of the liposome-encapsulated SK than the free form. These results demonstrated that subconjunctival injection of liposome-encapsulated SK enhances the rate of SH absorption, especially in the early phases.

[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.

Palpebral subconjunctival hemorrhages in herpes zoster ophthalmicus.

A 75-year-old previously healthy woman was referred for evaluation of pain and foreign body sensation in her left eye of 4 days' duration. Two weeks before presentation she was diagnosed with herpes zoster involving the left forehead and temple area and started on famciclovir treatment. Examination of her left cornea revealed inferior superficial punctate keratitis, but no dendrites or pseudodendrites. Upper eyelid eversion disclosed unusual raised palpebral subconjunctival hemorrhages on the left side. She was started on topical prednisolone eyedrops in the left eye, and her symptoms improved over the following week. Herpes zoster ophthalmicus can initially present in the eyelids. Careful follow-up with particular attention to the eyelids and eyelid eversion is recommended in any patient presenting with herpes zoster to detect early ocular involvement.

[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 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.