Hemorrhagic ocular complications associated with the use of systemic thrombolytic agents

Outcomes in Patients with Suprachoroidal Hemorrhage After Anterior Segment Surgery

Objective

The purpose of the current study is to report outcomes of suprachoroidal hemorrhage (SCH) after anterior segment surgery at a single institution, and to identify clinical features associated with visual prognosis.

Methods and Analysis

Retrospective consecutive case series of patients with SCH occurring after anterior segment surgery.

Results

The study includes 112 eyes of 112 patients between 2014 and 2020. There were 76 cases of non-appositional SCH versus 36 cases of appositional SCH. The mean presenting visual acuity for patients with non-appositional versus appositional SCH was 2.03 logMAR (SD 0.78) versus 2.39 logMAR (SD 0.43), respectively. Visual acuity outcomes generally remained poor at last follow-up: 64 (58%) patients had a visual acuity (VA) of ≤ 20/200, including 19 (17%) with light perception (LP), and 11 (10%) with no light perception (NLP). Regarding management of non-appositional versus appositional SCH, observation was selected in 46 (61%) vs 12 (33%), delayed drainage in 14 (18%) vs 15 (42%), delayed pars plana vitrectomy in 16 (21%) vs 13 (36%), and VA at last follow-up was 1.2 versus 1.86 logMAR (p=0.002). In patients that were observed, both appositional SCH (p=0.01) and duration of apposition (p=0.04) were correlated with worse outcome.

Conclusion

Appositional SCH was associated with poorer visual outcomes compared to non-appositional SCH. Observation remains a reasonable management strategy for non-appositional SCH.

Massive Spontaneous Suprachoroidal Hemorrhage in a Patient With Type 1 Chronic Myeloid Leukemia and Lymphoplasmacytic Lymphoma: Case Report and Review of the Literature

Purpose:

This work reports a rare case of spontaneous suprachoroidal hemorrhage (SSCH) and summarizes the literature on its treatment options and outcomes.

Methods:

A case report and comprehensive literature review are presented on the medical and surgical management of SSCH on PubMed from 1998 to 2021.

Results:

The literature search revealed 58 studies, 33 of which included 52 eyes of 47 patients. Surgical treatment typically consisted of choroidal drainage with posterior sclerotomies combined with pars plana vitrectomy and silicone oil placement. Medical therapy involved intraocular pressure control with laser peripheral iridotomy and topical, oral, and intravenous medication.

Conclusions:

In cases of SSCH, conservative management and a prompt workup should be initiated to identify the cause before proceeding with surgery. If the initial workup does not reveal a cause, medical and surgical treatments are both viable and the decision is at the discretion of the treating physician.

Displaced Orbital Fractures with Concurrent Orbital Compartment Syndrome: A Case-Based Systematic Review

Orbital compartment syndrome (OCS) is an emergency that complicates intra-orbital, retrobulbar hemorrhage in most cases. Bony orbital decompression is an effective treatment for OCS, and displaced orbital fractures are protective. Nevertheless, in rare cases, OCS occurs despite a displaced orbital fracture. The aim of the current review is to present its pathophysiology and management based on what is published in the medical literature, and our center's experience. A systematic review of literature was conducted through PubMed, Medline, Embase, and Cochrane from inception through February 2021. The following search query was used: "orbital fracture" and "trauma" and "orbital compartment syndrome." Studies tackling the pathophysiology and management of concurrent displaced orbital fracture with OCS were included and a cohort of patients was constituted. A cohort of 18 cases reported in the literature were included (49.3 ± 30.6 years, 50% M). Given that OCS occurs with or without orbital fracture, pathophysiology of OCS is mostly explained by the division of the orbital fat into many compartments, due to the presence of Koorneef's fibrous septa. Management of OCS in such circumstances consisted of inferior-lateral canthotomy and cantholysis in 50% of cases, subperiosteal drainage with myringotomy in 22.2% of cases, subperiosteal drainage in 16.7% of cases, and complete lateral cantholysis in 16.7% of cases. Two cases who presented to our tertiary care center were also added to this review. Physicians should be aware that OCS can occur even with displaced fractures of the orbital cavity. When clinical suspicion is present, an emergent management is needed.

Orbital Compartment Syndrome: An Update With Review Of The Literature

Orbital compartment syndrome (OCS) is a potentially blinding condition characterized by a rapid increase in intra-orbital pressure. OCS is most commonly seen in the context of intra-orbital hemorrhage secondary to either trauma or surgery. A review of the literature indicates that better visual outcomes are achieved when interventions occur within the first 2 hrs. There are reports of visual recovery after a delay in management and consideration should be given to intervention even when presentation is delayed. Reported interventions include: lateral canthotomy with cantholysis, bony orbital decompression and treatment of the underlying cause.

Idiopathic Bilateral Suprachoroidal Haemorrhage: A Rare Case Presentation

55-year-old male presented with sudden onset painful diminution of vision in both eyes. On local examination, his visual acuity was FC at 2 metres in right eye and FC at 1 m in left eye. The IOP in right eye was 46 mm Hg and 44 mm Hg in left eye. The patient was admitted and started on injection mannitol, oral syrup glycerol, and oral acetazolamide. Locally, timolol maleate and brimonidine were also started. The next day, his IOP was 17 mm Hg bilaterally but his visual acuity deteriorated to FC 1 m in right eye and hand movement in left eye with inaccurate projection of rays in both eyes. USG B-scan was performed which revealed bilateral choroidal detachment. The echotexture of fluid was suggestive of haemorrhage. As the IOP was controlled, systemic hyperosmotic/antiglaucoma agents were withdrawn in stepwise fashion over next two days. The patient was started on oral prednisolone. At 2 weeks, the visual acuity in both eyes was only perception of light, with inaccurate PR. IOP was 10 mm Hg in both eyes. USG B-scan revealed resorption of the hemorrhage, with partial resolution of the choroidal detachment. The final BCVA was 6/18 and 6/12 in right and left eye.

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

Purpose—

To critically review and evaluate the science behind individual eligibility criteria (indication/inclusion and contraindications/exclusion criteria) for intravenous recombinant tissue-type plasminogen activator (alteplase) treatment in acute ischemic stroke. This will allow us to better inform stroke providers of quantitative and qualitative risks associated with alteplase administration under selected commonly and uncommonly encountered clinical circumstances and to identify future research priorities concerning these eligibility criteria, which could potentially expand the safe and judicious use of alteplase and improve outcomes after stroke.

Methods—

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council’s Scientific Statement Oversight Committee and the American Heart Association’s Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge and, when appropriate, formulated recommendations using standard American Heart Association criteria. All members of the writing group had the opportunity to comment on and approved the final version of this document. The document underwent extensive American Heart Association internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee.

Results—

After a review of the current literature, it was clearly evident that the levels of evidence supporting individual exclusion criteria for intravenous alteplase vary widely. Several exclusionary criteria have already undergone extensive scientific study such as the clear benefit of alteplase treatment in elderly stroke patients, those with severe stroke, those with diabetes mellitus and hyperglycemia, and those with minor early ischemic changes evident on computed tomography. Some exclusions such as recent intracranial surgery are likely based on common sense and sound judgment and are unlikely to ever be subjected to a randomized, clinical trial to evaluate safety. Most other contraindications or warnings range somewhere in between. However, the differential impact of each exclusion criterion varies not only with the evidence base behind it but also with the frequency of the exclusion within the stroke population, the probability of coexistence of multiple exclusion factors in a single patient, and the variation in practice among treating clinicians.

Management of airway compromise following thyroid cyst hemorrhage after thrombolytic therapy

The risk of hemorrhage after therapeutic administration of tissue plasminogen activator (tPA) is well known. Cases of postadministration hemorrhage have been reported within many organ systems. We present a case of a 62-year-old female with undiagnosed thyroid goiter who received tPA for acute ischemic stroke and developed acute airway compromise. The surgical airway response team was called due to inability to ventilate or intubate. An incision into the mass during attempted tracheotomy released colloid and blood, decompressing the airway and facilitating ventilation and intubation. Hemithyroidectomy for mass removal was delayed for 3 days to allow normalization of post-tPA coagulopathy.

The impact of suction drainage on orbital compartment syndrome after craniofacial surgery

PURPOSE

Postoperative orbital compartment syndrome is a potentially blinding complication of surgery in the orbital region. We describe the technique of orbital drain placement as a method of preventing vision loss resulting from orbital compartment syndrome.

METHODS

We present a retrospective case series of 29 patients who underwent orbital fracture, facial fracture, and orbital implant removal from 7/4/2008 to 5/3/2013 by the same craniofacial surgeon. An orbital drain was placed in each patient. The drainage was recorded daily until drain removal. Criteria for removal included less than or equal to 5 mL of drainage in 24 hours.

RESULTS

Of the 29 patients included in this study, 21 were men and 8 were women. Ages ranged from 17 to 67 years. The postoperative drainage ranged from less than 1 mL to 71 mL of serosanguinous fluid. All drains were removed between the first and sixth postoperative days. No postoperative visual loss, infections, or additional antibiotics were recorded with follow-up reaching as far as 40 months.

CONCLUSIONS

Postoperative orbital compartment syndrome is a dangerous complication of surgery in the orbital region. Its rapid onset necessitates immediate intervention to prevent permanent vision loss. Morphologic changes to the optic nerve as well as reductions in electroretinogram a- and b-wave amplitudes have been demonstrated with as little as 7 mL of fluid accumulation. Intraoperative orbital drain placement should be considered in all patients undergoing surgery in the orbital region as a preventative measure.

Nontraumatic orbital hemorrhage

Nontraumatic orbital hemorrhage (NTOH) is uncommon. I summarize the published reports of NTOH and offer a classification based on anatomic and etiologic factors. Anatomic patterns of NTOH include diffuse intraorbital hemorrhage, "encysted" hemorrhage (hematic cyst), subperiosteal hemorrhage, hemorrhage in relation to extraocular muscles, and hemorrhage in relation to orbital floor implants. Etiologic factors include vascular malformations and lesions, increased venous pressure, bleeding disorders, infection and inflammation, and neoplastic and nonneoplastic orbital lesions. The majority of NTOH patients can be managed conservatively, but some will have visual compromise and may require operative intervention. Some will suffer permanent visual loss, but a large majority have a good visual outcome.

Lingual Haematoma due to Tenecteplase in a Patient with Acute Myocardial Infarction

The use of intravenous thrombolytic agents has revolutionised the treatment of acute myocardial infarction. However, the improvement in mortality rate achieved with these drugs is tempered by the risk of serious bleeding complications, including intracranial haemorrhage. Tenecteplase is a genetically engineered mutant tissue plasminogen activator. Haemorrhagic complications of tissue plasminogen activator (tPA) are well known. Compared to other tPAs, tenecteplase use leads to lower rates of bleeding complications. Here, we report a case of unusual site of spontaneous bleeding, intralingual haematoma during tenecteplase therapy following acute myocardial infarction, which caused significant upper airway obstruction and required tracheotomy to maintain the patient's airway. Clinical dilemmas related to securing the airway or reversing the effects of tissue plasminogen activator are discussed.

Postoperative choroidal hemorrhage shows elevated concentration of tissue plasminogen activator

PURPOSE

The purpose of this study was to report the levels of tissue plasminogen activator in liquefied suprachoroidal hemorrhage.

METHODS

An interventional case report of a 61-year-old woman who underwent drainage sclerotomy for choroidal hemorrhage.

RESULTS

A 61-year-old pseudophakic woman underwent pars plana vitrectomy and fluid-gas exchange for retinal detachment in her right eye and developed postoperative serous choroidal detachments with large hemorrhages. Drainage sclerotomy was performed 18 days after the initial development of suprachoroidal hemorrhage. Sample of the liquefied hemorrhage and serum sample collected during sclerotomy were tested for tissue plasminogen activator levels using the antibody tissue plasminogen activator-enzyme immunoassay test. Hemorrhage tissue plasminogen activator levels were three times the levels present in the serum.

CONCLUSION

Tissue plasminogen activator may be involved in the process of suprachoroidal hemorrhage liquefaction.

Vitreo-retinal hemorrhage after thrombolysis in a patient with acute ischemic stroke: a case report

PURPOSE

Bleeding is the major side effect of thrombolysis with alteplase (tissue plasminogen activator, t-PA) used for the treatment of acute ischemic stroke. Life-threatening intracranial, retroperitoneal, gastrointestinal, respiratory, and genitourinary bleeding can occur with the use of t-PA. Vitreo-retinal bleeding in the context of acute ischemic stroke treatment has not been reported in the literature before and therefore is not posed as a potential risk during decision making. Here we describe the first reported case of vitreo-retinal hemorrhage due to alteplase administration in a patient with acute ischemic stroke.

SUMMARY

An 84-year-old white male presented to the emergency room with complaints of right arm and leg weakness. The onset of symptoms was approximately 30 min prior to presentation to the emergency room. After ruling out contraindications including the presence of hemorrhage on head CT scan, patient was administered alteplase within 2 hours of symptom onset. Four hours after the administration of alteplase, the patient developed right-sided vision changes. A repeat CT scan demonstrated a newly developed right intraocular hemorrhage. Throughout the hospital course, patient's neurological status improved, but he continued to have right-sided visual loss.

CONCLUSION

Clinicians should be aware of the potential for ocular hemorrhage especially in high-risk patients. The likelihood of a subsequent vision-loss needs to be therefore discussed with the patient and family in such situations.

Orbital compartment syndrome following aneurysm surgery

Orbital compartment syndrome (OCS) is a rare cause of blindness following intracranial surgery. We report a patient with OCS following intracranial cerebrovascular surgery precipitated by severe straining. OCS occurred due to a rapid increase in intraorbital pressure within the rigid confines of the orbit causing hypoperfusion of critical neural structures, which resulted in visual loss and a complete external ophthalmoplegia. Treatment involved urgent surgical soft tissue decompression of the orbit, corticosteroids and osmotic agents. It is important to consider OCS as a cause of blindness in the neurosurgical postoperative setting as without rapid treatment this condition has a very poor prognosis.

Non-steroidal drug-induced glaucoma

Numerous systemically used drugs are involved in drug-induced glaucoma. Most reported cases of non-steroidal drug-induced glaucoma are closed-angle glaucoma (CAG). Indeed, many routinely used drugs that have sympathomimetic or parasympatholytic properties can cause pupillary block CAG in individuals with narrow iridocorneal angle. The resulting acute glaucoma occurs much more commonly unilaterally and only rarely bilaterally. CAG secondary to sulfa drugs is a bilateral non-pupillary block type and is due to forward movement of iris-lens diaphragm, which occurs in individuals with narrow or open iridocorneal angle. A few agents, including antineoplastics, may induce open-angle glaucoma. In conclusion, the majority of cases with glaucoma secondary to non-steroidal medications are of the pupillary block closed-angle type and preventable if the at-risk patients are recognized and treated prophylactically.

A spontaneous suprachoroidal haemorrhage: a case report

Introduction

We present a case of spontaneous suprachoroidal haemorrhage in a patient taking Warfarin. This is only the second case reported of a patient whose anticoagulation was within the therapeutic range.

Case presentation

An 84 year old white male with a history of end stage atrophic age related macular degeneration presented with angle closure glaucoma. The patient was taking warfarin and had a therapeutic International Normalized Ratio (INR). Ultrasound examination revealed a spontaneous suprachoroidal haemorrhage.

Conclusion

Anticoagulation is common in those with cardiovascular disease, which increases the risk of haemorrhagic complications. These patients are also more likely to suffer from age related macular degeneration. Suprachoroidal haemorrhage should be considered in such patients presenting with suspicious signs and a low threshold should be had for investigating for this condition in such circumstances. Early detection may reduce the morbidity.

Intraocular pressure change in orbital disease

Intraocular pressure change has been found concurrent with many orbital pathologies, particularly those involving proptosis. The objective of this review is to offer an inclusive classification of orbital disease-related intraocular pressure change, not only for oculoplastics and glaucoma specialists, but also for general ophthalmologists. Various orbital conditions associated with increased intraocular pressure and glaucoma are comprehensively summarized, and pathophysiology, clinical manifestations, and treatment options of these diseases are discussed. Graves disease, arterio-venous shunts, trauma, and orbital neoplasia, and other common conditions are discussed in detail; less frequent syndromes such as orbitocraniofacial deformities, phakomatoses, and mucopolysaccharidoses are included for the sake of comprehensiveness, but discussed less extensively.

Orbital compartment syndrome: the ophthalmic surgical emergency

Orbital compartment syndrome is an uncommon, ophthalmic surgical emergency characterized by an acute rise in orbital pressure. When intraorbital tension rises, damage to ocular and other intraorbital structures, including irreversible blindness, may occur if not promptly treated. The diagnosis of orbital compartment syndrome is completely clinical and early recognition and emergent orbital decompression (even prior to imaging) is essential in preventing permanent vision loss. Lateral canthotomy and inferior cantholysis remain the mainstays of management. More extensive incision of the orbital septum and orbital bony decompression may be necessary in unresponsive cases. This review discusses the various etiologies and mechanisms resulting in orbital compartment syndrome, clinical features, imaging findings, treatment, and prognosis.

Spontaneous suprachoroidal hemorrhage associated with age-related macular degeneration and anticoagulation therapy

Suprachoroidal hemorrhage is a rare but dreadful event. We report the case of an 86-year-old man with age-related macular degeneration (ARMD) in both eyes. He had been receiving anticoagulation therapy for several years for systemic disease. He presented with severe headache and intractable pain in his right eye. Vision was no light perception, and the intraocular pressure was 50 mmHg in the right eye despite maximal antiglaucoma medications. Slit-lamp and B-scan examination disclosed suprachoroidal hemorrhage in the right eye. Nine days later, he underwent choroidal drainage, which only relieved the symptoms for 1 day. Suprachoroidal hemorrhage recurred and evisceration was performed. This case illustrates how ARMD with anticoagulation therapy could cause spontaneous suprachoroidal hemorrhage. Therefore, anticoagulants should be meticulously prescribed with prothrombin time monitored regularly in ARMD patients.

Biochemical and enzymatic properties of a novel marine fibrinolytic enzyme from Urechis unicinctus

A novel potent protease, Urechis unicinctus fibrinolytic enzyme (UFE), was first discovered by our laboratory. In this study, we further investigated the enzymatic properties and dynamic parameters of UFE. As a low molecular weight protein, UFE appeared to be very stable to heat and pH. When the temperature was <50 degrees C, the remnant enzyme activity remained almost unchanged, but when the temperature was raised to 60 degrees C the remnant enzyme activity began to decrease rapidly. UFE was quite stable in a pH range of 3.0-12.0, especially at slightly alkaline pH values. Mn(2+), Cu(2+), and Fe(2+) ions were activators of UFE, whereas Fe(3+) and Ag(+) ions were inhibitors. Fe(2+) ion along with Fe(3+) ion might regulate UFE activity in vivo. The optimum pH and temperature of UFE were about 8.0 and 50 degrees C, respectively. When using casein as substrate and a substrate concentration <0.1% casein (w/v), the reaction velocity was increased with substrate concentration. Also when using casein as substrate, the determined K(m) and V(max) of UFE were 0.5298 mg/mL and 3.0845 mol of L-tyrosine equivalent, respectively. Our systematic research results are significant when UFE is applied for medical and industrial purposes.

Idiopathic orbital hemorrhage related to the inferior rectus muscle: a rare cause for acute-onset diplopia and unilateral proptosis

PURPOSE

To report 6 patients with spontaneous orbital hemorrhage in relation to the inferior rectus muscle.

DESIGN

Retrospective observational case series.

PARTICIPANTS

Six patients with acute onset orbital pain, diplopia, and proptosis referred to the orbital clinic at the Royal Victorian Eye and Ear Hospital, January 1995 through December 2004.

METHODS

Review of clinical history, imaging studies, and follow-up.

MAIN OUTCOME MEASURES

Resolution of proptosis and diplopia and imaging studies of the orbit, including computed tomography (CT), magnetic resonance imaging (MRI), or both.

RESULTS

Six patients (4 men, 2 women; mean age, 68 years) were referred with acute onset of unilateral proptosis and diplopia. None of the patients had a history of bleeding disorder. Visual acuity and intraocular pressure were normal; 3 patients showed marked limitation in upgaze on the affected side. Imaging studies of the orbit by CT, MRI, or both showed inferior orbital hemorrhage either within (4 patients) or adjacent to (2 patients) the inferior rectus muscle, possibly within the muscular sheath. Symptoms resolved completely in all but 1 patient, who had persistent diplopia in extreme upgaze. Follow-up CT, MRI, or both showed complete resolution in 3 patients and mild persistent inferior rectus muscle thickening in 2 patients.

CONCLUSIONS

Acute onset proptosis and diplopia may be secondary to spontaneous orbital hemorrhage within the inferior rectus muscle or its sheath with no other orbital or systemic pathologic features. Symptoms resolved spontaneously over the course of days to weeks, and orbital imaging showed complete resolution or mild persistent enlargement of the muscle without significant symptoms.

Massive spontaneous choroidal hemorrhage

PURPOSE

To describe the course, management, and prognosis of massive spontaneous choroidal hemorrhage.

METHODS

The presenting visual acuity, ocular findings, duration to surgical intervention, and outcomes of five patients were retrospectively reviewed.

RESULTS

Five eyes from four patients (median age, 80 years; range, 66-85 years) were studied. The patients were observed from 4 to 72 months (median, 33 months). Three patients were on anticoagulation therapy with warfarin; one patient had bilateral involvement with no history of anticoagulation therapy. Three patients were hypertensive, and three of the four had been diagnosed with age-related macular degeneration. Four eyes underwent choroidal drainage procedures, and one was observed. In all patients whose choroids were drained, the final vision was no light perception.

CONCLUSIONS

Massive spontaneous choroidal hemorrhage may be associated with hypertension, systemic anticoagulation, advanced age, and age-related macular degeneration. Final visual acuities are generally poor.

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.

Massive choroidal hemorrhage associated with low molecular weight heparin therapy

An 84-year-old woman with unstable angina pectoris was treated with subcutaneous enoxaparine (Clexane) for several days before presenting with severe pain and decreased vision in her left eye. The intraocular pressure was 70 mmHg, and fundus examination showed a pigmented choroidal lesion and associated choroidal and retinal detachment. Ultrasonography was consistent with choroidal hemorrhage, and she was diagnosed as having acute glaucoma secondary to massive subchoroidal hemorrhage. Medical control of the intraocular pressure resulted in a significant clinical improvement. Intraocular hemorrhage and angle-closure glaucoma are rare and previously unreported complications in patients treated with low molecular weight heparin. It is important to be aware of this ocular complication as these drugs are so often used.

Spontaneous retrobulbar hemorrhage in type IV Ehlers-Danlos syndrome

PURPOSE

To describe a case of spontaneous retrobulbar hemorrhage in type IV Ehlers-Danlos syndrome, a disorder characterized by vascular fragility and associated severe bleeding problems.

METHODS

Observational case report. Spontaneous unilateral retrobulbar hemorrhage in a 22-year-old man with type IV Ehlers-Danlos syndrome was documented by clinical and radiographic examination.

RESULTS

The retrobulbar hemorrhage was self-limited and resolved without visual sequelae.

CONCLUSION

Spontaneous retrobulbar hemorrhage should be recognized as part of the spectrum of type IV Ehlers-Danlos syndrome, and clinicians must be alert to diagnosis and treatment of this vision-threatening problem.

Airway compromise secondary to lingual hematoma complicating administration of tissue plasminogen activator for acute ischemic stroke

Hemorrhagic complications of tissue plasminogen activator (tPA) are well known. We report a case of a lingual hematoma that developed after tPA administration for an acute ischemic stroke that necessitated orotracheal intubation to maintain the patient's airway. This case demonstrates the need for thorough preadministration physical examination, as well as careful monitoring during infusion and after administration of this potent therapeutic agent.

Orbital compression syndrome after orbital extravasation of X-ray contrast material

PURPOSE

To report the orbital compression syndrome after orbital extravasation of x-ray contrast material during catheterization of the left middle meningeal artery.

METHODS

Case report.

RESULTS

A 61-year-old woman had profound loss of vision, pain, and proptosis of her left eye immediately after catheterization of the left middle meningeal artery. Computed tomography (CT) revealed that contrast material had extravasated into the orbit. Her symptoms improved with lateral canthotomy and cantholysis and resolved totally within 24 hours without the need for an orbital surgical procedure to remove the contrast material.

CONCLUSION

This report describes an unusual cause of the orbital compression syndrome.

Spontaneous suprachoroidal haemorrhage in a patient receiving low-molecular-weight heparin (fraxiparine) therapy

Spontaneous suprachoroidal bleeding is a rare event. Of the six previously reported cases, five had identifiable mechanisms for the development of choroidal bleeding in addition to concurrent systemic anticoagulation/thrombolytic therapy. We report a case of spontaneous suprachoroidal haemorrhage in a patient who received subcutaneous low-molecular-weight heparin therapy but without any identifiable ocular condition predisposing to choroidal bleeding.

Suprachoroidal hemorrhage

Suprachoroidal hemorrhage is a feared complication of all types of intraocular surgery. Although rare, it is typically associated with severe visual disability, and this has prompted efforts to better understand the pathogenesis of this condition, to identify the patients at risk for this event, and to improve treatment of patients who develop this condition either intraoperatively or postoperatively. Controversy still exists regarding the best course of treatment for these patients. Although the introduction of perfluorocarbon liquids as a surgical adjunct during vitrectomy surgery may assist in the removal of suprachoroidal hemorrhage, the visual outcomes still remain disappointing.