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Editor,—During the early postoperative period after glaucoma filtration surgery the sclerostomy can be blocked by haemorrhage or fibrin clot.1-4 In these cases tissue plasminogen activator (tPA) can be injected into the anterior chamber after paracentesis or subconjunctivally. It works rapidly so that within 3 hours the effect is usually apparent. This report describes a patient who had massive ocular bleeding after intraocular injection of tPA.
A 76 year old white man with uncontrolled advanced primary open angle glaucoma in the left eye underwent trabeculectomy with mitomycin C. Past ocular history was relevant for trabeculectomy with 5-fluorouracil, 8 years earlier, and a combined mitomycin C trabeculectomy, phacoemulsification, and intraocular lens implantation 2 years before. Medical history regarding bleeding or coagulation disorders was negative, although tests to exclude abnormalities in the coagulation system were not done. The patient did not take coagulation inhibitors before or after surgery.
The surgery was uneventful. One day after surgery the intraocular pressure (IOP) was 10 mm Hg and there was a large superotemporal filtering bleb. One week later the IOP was 30 mm Hg, with a very vascularised low bleb and a deep anterior chamber. Laser suture lysis (two sutures) and digital ocular compression did not lower the IOP. An intracameral injection of 15 μg of tPA was done. The following day the patient had a large (40%) hyphaema and a dense subconjunctival haemorrhage extending to the eyelids and the orbital rim (Figs 1 and2). A mild vitreous haemorrhage was also present. Vision was hand movements and IOP was 5 mm Hg. Ocular trauma had not occurred. The blood resorbed over 3 weeks, and the function of the bleb remained satisfactory.
Recombinant tPA is a serine protease with clot specific fibrinolytic activity. tPA has been used successfully to lyse blood, fibrinous clots, and/or membranes after pars plana vitrectomy, cataract surgery, and glaucoma surgery. A dose of up to 25 μg of tPA is used for ophthalmic procedures. Hyphaema is the most frequent complication of intracameral tPA injection after glaucoma surgery (up to 36% of cases).4 Lundy et al suggested that a dose of 6–12.5 μg may be equally effective and reduces the risk of hyphaemas.4
In this patient the bleeding source was probably intraocular, which extended to the subconjunctival space through the fistula (functioning after the tPA injection), and to the preseptal periocular tissues because of the large volume of the haemorrhage. It is not know whether previous surgeries and/or ocular scarring might have contributed to the intensity of the bleeding. The use of mitomycin C and laser suture lysis were probably not related to this complication. The singular aspect of this case was the severity of the bleeding, and its extraocular extension.
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