DEXAMETHASONE INTRAVITREAL IMPLANT COMPLICATIONS INCLUDING VITREOUS HEMORRHAGE AND HYPOTONY

PURPOSE

To describe cases of visually significant vitreous hemorrhage (VH) following dexamethasone intravitreal implant in our practice and present two cases that required surgical intervention and a case of VH and hypotony following dexamethasone implant. An injection technique that may minimize the incidence of these complications is described and illustrated.

METHODS

Retrospective case series.

RESULTS

The overall incidence of VH was 1.7% (8 of 467 injections) and those that required surgical intervention was 0.4% (2/467) over a 10-year period, from June 2010 to June 2020 ( Table 1 ). Overall, 75% (6 of 8) VH resolved spontaneously over time, without surgical intervention.

CONCLUSION

Nonclearing VH and hypotony are rare but serious complications of dexamethasone implant.

Ocular Syphilis Unmasked Following Bilateral Intravitreal Dexamethasone Implant (Ozurdex) Injection

Intraocular corticosteroids are used in ophthalmologic conditions such as macular edema secondary to vascular occlusions, diabetes, and uveitis. Infectious ocular diseases must be ruled out before intravitreal corticosteroid implantation. Here, the authors report a case that has been referred to their clinic for surgical treatment due to dense vitreous hemorrhage in the right eye after bilateral intravitreal dexamethasone implantation. As an intraoperative finding, diffuse changes in the color-like paleness of the retina as well as intraretinal white-colored deposits were observed. Serology tests were performed, and syphilis serology was positive. Intravenous penicillin provides resolution of inflammation. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:e77-e80.].

Bilateral Spontaneous Hyphema, Vitreous Hemorrhage, and Choroidal Detachment With Concurrent Dabigatran Etexilate Therapy

A 79-year-old woman was referred for rapid onset of painless bilateral vision loss. Anterior segment exams revealed bilateral spontaneous hyphema and fibrin accumulation. Observation of the posterior chamber by B-scan ultrasound showed vitreous hemorrhage and choroidal detachment bilaterally. No evidence of additional intraocular inflammation was present. Laboratory work-up for hematologic abnormalities was unremarkable. These hemorrhagic events were suspected to be a complication from taking the novel anticoagulant, dabigatran etexilate (Pradaxa; Boehringer, Ingelheim, Germany). She initially underwent non-surgical therapy, which included immediate cessation of dabigatran, and administration of topical and systemic steroids. The lack of response to medical therapy in the left eye led to surgical treatment of vitreous and persistent subcapsular hemorrhage via pars planar vitrectomy with capsulectomy.

A one-year follow-up study of ocular and systemic complications of intravitreal injection of bevacizumab (Avastin)

OBJECTIVES

To report systemic and ocular complications within a year of intravitreal injection of bevacizumab (Avastin) in ocular neovascularisation.

METHODS

The quasi-experimental (randomized without control) study was carried out at the Eye Department of Abbasi Shaheed Hospital, Karachi, from July 2008 to June 2010. It comprised 150 patients selected from the outpatient department with ocular neovascularisation through non-probability purposive sampling. After detailed history and examination, the patients were counseled for intravitreal injection Avastin (bevacjzumab) which was injected into the vitreous cavity in sterile environment in the operation theatre using fully aseptic technique. The injection site was compressed for several seconds to avoid reflux when the needle was removed. Paracentesis was done following the injection as soon as possible. Patients were discharged on moxifloxcin eye drops and steroid antibiotic combination ointment at night time. They were followed up the very next day, after 2 weeks, 6 weeks, 3 months, 6 months and 1 year. Injection was repeated after 6 weeks if required and further repetition was done again after 6 weeks according to the need of the patient.

RESULTS

Of the 150 patients, 93 (62%) were males and 57 (38%) were females. Most commonly presenting age group was between 50-60 years (n=51; 34%) followed by 41-50 years (n=41; 27.4%). Most common indication for intravitreal injection Avastin (bevacizumab) was proliferative diabetic retinopathy in 134 (89.33%) patients, followed by age-related macular degeneration (wet type) in 5 (3.3%) patients. Most frequently presenting ocular complication was subconjunctival haemorrhage seen in 35 (23%) patients, followed by regurgitation of drug from the site of injection in 8 (5.3%) patients, transient rise of intraocular pressure in 7 (4.7%) patients, mild uveitiS in 4 (2.7%) patients, lens injury in 3 (2%) patients, conjunctival chemosis and iatrogenic vitreous haemorrhage in 1 (0.7%) patients. Among the systemic complications were acute rise of blood pressure in 4 (2.7%) patients, and mild irritation and allergic reaction on skin in 1 (0.7%) patient.

CONCLUSION

Avastin is generally a safe drug for treatment of ocular neovascularization. The complications reported were more associated with the technique of the procedure and not the drug itself and were easily manageable. Drug-related complications were limited, transient and easily managed with treatment.

Maintenance of Warfarin Anticoagulation for Patients Undergoing Vitreoretinal Surgery

OBJECTIVE

To evaluate the risk of hemorrhagic complications associated with vitreoretinal surgery in patients whose warfarin sodium therapy was continued throughout the surgical period.

METHODS

A review of 1737 records of patients undergoing pars plana vitrectomy was conducted. Inclusion criteria included patients receiving warfarin therapy whose international normalized ratios (INRs) were elevated above normal values on the day of surgery. Intraoperative and postoperative hemorrhagic complications were documented.

RESULTS

Fifty-four patients underwent 57 vitreoretinal surgical procedures with warfarin therapy and were divided into groups as follows: group S with INRs of 1.20 to 1.49, values considered subtherapeutic; group B with INRs of 1.50 to 1.99, values considered borderline therapeutic; group T with INRs of 2.00 to 2.49, values considered therapeutic; and group HT with INRs of 2.50 or greater, values considered highly therapeutic. No patients experienced anesthesia-related or intraoperative hemorrhagic complications. Two (7.7%) of 26 eyes in group S and 2 (16.7%) of 12 eyes in group HT experienced postoperative hemorrhages. All of the patients with vitreous hemorrhages had spontaneous clearing without additional treatment.

CONCLUSIONS

Many patients may safely undergo vitreoretinal surgery while maintaining therapeutic levels of warfarin anticoagulation. We experienced no intraoperative hemorrhagic complications; the 4 postoperative complications resolved spontaneously without persistent visual sequelae or the need for supplemental surgery.

Maintenance of warfarin anticoagulation for patients undergoing vitreoretinal surgery

PURPOSE

The purpose of this study was to evaluate the risk of hemorrhagic complications associated with vitreoretinal surgery in patients in whom warfarin therapy was continued throughout the surgical period.

METHODS

A review of 1,737 consecutive charts of patients undergoing pars plana vitrectomy was conducted. Inclusion criteria included patients on warfarin therapy whose international normalized ratio (INR) was elevated above normal on the day of vitreoretinal surgery. The occurrence of intraoperative and postoperative hemorrhagic complications was documented.

RESULTS

The retrospective review detected 54 patients who underwent 57 vitreoretinal surgical procedures while on warfarin therapy. Group S consisted of patients whose INR ranged from 1.2 to 1.49, values that were considered to be subtherapeutic. Group B had INR values ranging from 1.5 to 1.99, values that were considered to be borderline therapeutic. Group T had INRs ranging from 2.0 to 2.49, values that were considered therapeutic. Group HT had INRs of 2.5 or greater, values that were considered highly therapeutic. No patients experienced anesthesia-related or intraoperative hemorrhagic complications. Four procedures (7.0%) were complicated by postoperative hemorrhage. Two of 26 eyes (7.7%) in group S and two of 12 eyes (16.7%) in group HT experienced postoperative hemorrhages. All hemorrhagic complications cleared without additional therapy.

CONCLUSIONS

Our findings suggest that many patients may safely undergo vitreoretinal surgery while maintaining therapeutic levels of warfarin anticoagulation. We found no intraoperative hemorrhagic complications. Those hemorrhagic complications that occurred postoperatively resolved spontaneously without persistent visual sequelae or the need for supplemental surgery.

[Problems of perioperative period in patients with Steinert's myotonic dystrophy operated due to cataract]

Steinert's myotonic dystrophy is a genetically conditioned systemic disease with symptoms related to circulatory, respiratory, muscular, endocrine and mental disturbances. Most if not all of these patients develop lens opacification as a presenting symptom and need to undergo cataract surgery. Nevertheless, selection of a type of anaesthesia can arise to a problem in these patients because local anaesthesia can be insufficient whereas general endotracheal anaesthesia is known, to potentially provoke serious postoperative complications. In this contribution we discuss problems we faced during cataract surgery in three siblings affected by Steinert's myotonic dystrophy. Two of them were operated on in local anaesthesia and developed intraoperative problems related to sudden increase of intraocular pressure, bleeding and vitreous efflux. After receiving a thorough examination the youngest of the three was operated on under short acting general intravenous anaesthesia (propofol and/or benzodiazepines, piperidine derived opioids, non-polarizing paralytics). We conclude that short acting general intravenous anaesthesia can help in avoiding both, local ocular complications during surgery and problems in the postoperative period.

Acute bilateral vitreo-retinal hemorrhages following oxygen-ozone therapy for lumbar disk herniation

PURPOSE

To describe a case of acute bilateral intraocular hemorrhages occurring after injection of oxygen-ozone (O(2)O(3)) mixture.

DESIGN

Observational case report.

METHODS

A 45-year-old woman complained about acute bilateral visual loss after intradiscal and periganglionic injection of gas mixture (O(2)O(3)) for lumbar disk herniation. Detailed ophthalmologic examination; magnetic resonance imaging (MRI) of brain and spinal cord; and neodymium:yttrium-aluminum-garnet (Nd:YAG) laser membranotomy in the left eye was performed.

RESULTS

Ophthalmoscopy revealed a premacular hemorrhage involving the left macula. In the right eye multiple, flat, retinal hemorrhages around the optic disk and the posterior pole were observed. The MRI scan for intracranial hemorrhage was unremarkable. Drainage of the left premacular hemorrhage by pulsed Nd:YAG laser was obtained a few weeks later.

CONCLUSIONS

Retinal hemorrhages seem to be an uncommon but significant complication of intradiscal O(2)O(3) infiltration, and we suggest that it should be carefully considered when recommending this procedure.

[Heterochromia of the Iris after t-PA and Gas Injection of Sulfur Fluoride]

BACKGROUND

Are changes in iris colour and retinal pigment epithelium after t-PA and gas injection and subsequent vitreous haemorrhage caused by blood cells, or is this a toxic effect?

CASE

A 81-year old female presented for vitrectomy with a persistent vitreous haemorrhage two months after t-PA and gas injection because of subretinal macular haemorrhage. Sonographic control revealed attached retina. The examination disclosed a new heterochromia of the iris with a change from blue to green-brown. A discrete anterior chamber flare and blood cells were found. Subsequent vitrectomy revealed a thick, rubber-like haemorrhage in the vitreous with suspect pigmentation. A change in retinal pigmentation was also evident.

CONCLUSION

The cause for the heterochromia and the change in pigmentation of the retinal pigment epithelium remained unclear. It may have been a consequence of the persistent bleeding with iron apposition on the iris. A toxic effect of t-PA has to be discussed which led to the alteration in pigmentation.

The effects of aspirin and warfarin therapy on haemorrhage in vitreoretinal surgery

BACKGROUND

No substantial recommendations exist regarding the management of anticoagulant drugs prior to ocular surgery. Stopping anticoagulation can cause fatal emboli, but sight-threatening bleeds may occur if anticoagulation is continued. We examined the effects of anticoagulation on vitreoretinal surgery.

METHODS

Clinical details were prospectively entered on a database. The anticoagulant status of 541 consecutive patients undergoing vitreoretinal surgery was recorded.

RESULTS

Sixty patients in the study were taking aspirin and seven were taking warfarin. There were 11 cases of choroidal haemorrhage, one of which involved a warfarin user. Of 325 retinal detachment repairs, 21 (6.5%) had preoperative vitreous haemorrhages. Two of these patients were on aspirin and two were on warfarin. Sixty-six vitrectomies were performed for diabetic vitreous haemorrhages, of which nine re-bled postoperatively. One of these patients was taking warfarin. The association of warfarin with bleeding was statistically significant (relative risk 6.185).

CONCLUSION

Anticoagulation had no effect on the number of significant perioperative (choroidal) haemorrhages. Aspirin had little effect on bleeding during vitreoretinal surgery. Warfarin, however, was associated with bleeding complications. We suggest that aspirin should not be stopped prior to surgery. Warfarin may be stopped if the patient's thromboembolic risk is low.

Intravitreal gas injection for the treatment of experimental vitreous hemorrhage in rabbits

PURPOSE

To determine the effectiveness of intravitreous gas injection in the management and clearing of experimental vitreous hemorrhage.

METHODS

A total of ten New Zealand white rabbits received an injection of 0.4 ml of autologous blood into the vitreous of the right eye. After 24 hours of the vitreous hemorrhage simulation, six eyes were randomly assigned for treatment with na intravitreous injection of 0.2 ml of 100% perfluoropropane gas (C3F8) (group A), while four eyes received a control injection of an equivalent volume of balanced salt solution (group B). The persistence of vitreous opacification, which was graded at pre-established time points during 32 days of follow-up, was evaluated on the basis of visibility of retinal details in each of the four quadrants.

RESULTS

In the gas-treated group (A), a partial view of the retina in the four quadrants was possible at 15 days, while at 32 days, the vitreous cavity was completely free of blood in all eyes, allowing unobstructed observation of the fundus. No retinal details could be observed in the control group after 32 days of follow-up.

CONCLUSIONS

Gas injection proved effective in the treatment of experimental vitreous hemorrhage. It was significantly better than the injection of balanced salt solution, according to criteria of extension, intensity, and clearing time. Its technical facility, lack of complications, and low cost encourage additional research into gas injection to add knowledge to this initial study and to clarify its potential usefulness to treat persistent vitreous hemorrhage as well as to elucidate some unique pathophysiology features of blood catabolism in the vitreous.

Studies of Ocular Complications of AIDS Research Group. The AIDS Clinical Trials Group. The ganciclovir implant plus oral ganciclovir versus parenteral cidofovir for the treatment of cytomegalovirus retinitis in patients with acquired immunodeficiency syndrome: The Ganciclovir Cidofovir Cytomegalovirus Retinitis Trial

PURPOSE

To compare the regimen of the ganciclovir implant plus oral ganciclovir to one of intravenous cidofovir for the treatment of cytomegalovirus retinitis.

METHODS

Sixty-one patients with acquired immunodeficiency syndrome and cytomegalovirus retinitis were randomized either to the regimen of the ganciclovir implant plus oral ganciclovir, 1 gm three times daily, or intravenous cidofovir, 5 mg/kg once weekly for two doses, followed by 5 mg/kg every other week.

RESULTS

Mortality was similar between the two treatment groups. Mortality rates were 0.41 per person-year in patients assigned to the ganciclovir regimen and 0.49 per person-year in patients assigned to cidofovir (P =.59). Ocular outcomes were similar between the two groups. Retinitis progression occurred at a rate of 0.67 per person-year in the ganciclovir group and 0.71 per person-year in the cidofovir group (P =.72). A loss of visual acuity of 15 letters or more occurred at a rate of 0.78 per person-year in the ganciclovir group and 0.47 per person-year in the cidofovir group (P =.28). The rate of loss of visual field was 7 degrees per month in the ganciclovir group and 2 degrees per month in the cidofovir group (P =.048). Vitreous hemorrhage was more common in the ganciclovir implant group (0.13 per person-year) than in the cidofovir group (no cases, P =.014), whereas uveitis appeared to be more common in the cidofovir group (0.35 per person-year) than in the ganciclovir group (0.09 per person-year, P =.066). Nephrotoxicity (serum creatinine 1.6 mg/dL or greater) occurred at a rate of 0.18 per person-year in the ganciclovir group and 0.48 per person-year in the cidofovir group (P =.10).

CONCLUSIONS

Although the small number of patients in this study limits definitive interpretation, these data suggest that in the era of highly active antiretroviral therapy, the regimens of the ganciclovir implant plus oral ganciclovir and of intravenous cidofovir are similar for controlling cytomegalovirus retinitis and preventing visual loss but have different side effects.

Relationship between anticoagulant medication and massive intraocular hemorrhage in age-related macular degeneration

BACKGROUND

A massive intraocular hemorrhage in the course of age-related macular degeneration (AMD) is a devastating event. We set out to determine the role of anticoagulant therapy prescribed for vascular or cardiac indications in the development of a massive hemorrhage.

METHODS

A retrospective case-controlled study was conducted of 50 cases of age-related macular degeneration complicated by massive subretinal and vitreous hemorrhage. The control group consisted of 50 cases of AMD with small subretinal hemorrhage.

RESULTS

There was a significant difference in the use of anticoagulant medication (warfarin sodium) between the groups. The difference in the use of antiplatelet medication (aspirin) between the groups was not significant. A patient with a massive intraocular hemorrhage and AMD is 11.6 times more likely to use anticoagulant medication. It appeared that more than 50% of the patients in the massive hemorrhage group were allowed to stop the anticoagulant medication.

CONCLUSION

Anticoagulant medication poses a significant risk in the development of a massive intraocular hemorrhage in patients with exudative AMD. Antiplatelet medication poses a less significant risk. Physicians prescribing anticoagulant medication should be informed about the macular status of the patient. the In case of neovascular AMD, anticoagulant medication should be prescribed only for absolute systemic indications.

Inadvertent topical exposure to isocyanates caused damage to the entire eyeball

Isocyanates are part of a group of important chemicals necessary in the production of adhesives, synthetic rubbers, and a variety of plastics. They are known to have minimal toxic effects when administered locally. However, we experienced a case of damage involving the entire eyeball in a person who accidentally exposed his eye to isocyanates. The patient presented with inflamed conjunctiva, and shrunken cornea and sclera, with focal atrophic changes in the iris. The lens and vitreous were opacified. After removal of the lens and vitreous, there were large areas of atrophic retina and areas of retinal necrosis with holes. We found that locally absorbed isocyanates can cause damage to the entire eyeball. Therefore, we recommend that if there is any evidence of isocyanate penetration, early vitrectomy should be performed to help in determining the extent of retina damage and to decrease the amount of toxic substance in the vitreous.

Vitreous hemorrhage after intravitreal tissue plasminogen activator (t-PA) and pneumatic displacement of submacular hemorrhage

PURPOSE

To report the immediate complication of dense vitreous hemorrhage after intravitreal injection of tissue plasminogen activator and gas for treatment of two cases of sudden submacular hemorrhage associated with retinal arterial macroaneurysm.

METHODS

Case reports.

RESULTS

Two patients, a 67-year-old woman and a 92-year-old man, presented with sudden vision loss related to submacular hemorrhage from a retinal macroaneurysm. Tissue plasminogen activator at a dose of 50 microg to 75 microg and a sulfur hexafluoride (SF(6)) gas bubble were injected intravitreally under local anesthesia. Dense vitreous hemorrhage was noted on the first postoperative day in both cases, which subsequently required pars plana vitrectomy removal.

CONCLUSION

Sudden severe vitreous hemorrhage may be an immediate complication after intravitreal injection of tissue plasminogen activator and gas for treatment of submacular hemorrhage associated with retinal arterial macroaneurysm.

Diabeteslike proliferative retinal changes in galactose-fed dogs

OBJECTIVE

To determine whether diabeteslike lesions associated with the proliferative stage of diabetic retinopathy develop in galactose-fed dogs, since studies designed to define the complex biochemical effects of prolonged hyperglycemia on retinal vessels have been hampered by the lack of an animal model that mirrors both the early and advanced stages of diabetic retinopathy.

METHODS

Eyes from 9-month-old male beagles fed a daily diet containing either 30% nonnutrient filler (control diet) or 30% galactose (galactose diet) for up to 84 months were enucleated and histologically examined.

RESULTS

Retinal vessel changes associated with the proliferative stage were observed in two of nine galactose-fed dogs while the remainder demonstrated retinal changes that included the appearance of microaneurysms, acellular capillary beds associated with areas of nonperfusion, and intraretinal microvascular abnormalities. Proliferative changes were evidenced by the formation of preretinal fibrous membranes and the appearance of fibrovascular membranes on the retinal surface and on the posterior hyaloid membrane. No retinal lesions were observed in similar dogs fed a control diet for up to 84 months.

CONCLUSION

The galactose-fed dog appears to be the first animal model that can develop diabeteslike retinal vessel changes associated with both the early and advanced stages of retinopathy, including the proliferative stage.

Terson's syndrome in a patient with acute promyelocytic leukemia on all-trans retinoic acid treatment

The syndrome of vitreous hemorrhage in association with any form of intracranial bleeding is known as Terson's syndrome. Acute promyelocytic leukemia (APL) constitutes 5% to 15% of cases of acute nonlymphocytic leukemias, in which hemorrhagic diathesis often occurs and results in a rapid fatal outcome. In this report we describe a patient with APL who developed cerebral bleeding in association with bilateral subhyaloid and vitreous hemorrhages consistent with Terson's syndrome while she was on all-trans retinoic acid induction therapy.

The effect of tissue plasminogen activator on retinal bleeding

Tissue plasminogen activator is a potent thrombolytic agent that recently has been used to treat postvitrectomy fibrin formation. However, a recent report noted anterior and posterior segment bleeding following intracameral tissue plasminogen activator injection. In this study, we performed lensectomy and vitrectomy in 20 rabbits. A retinal blood vessel was incised to stimulate intraocular hemorrhage; bleeding was controlled and vitreous hemorrhage aspirated. Postoperatively, one eye received a 0.1-mL injection of tissue plasminogen activator (25 micrograms); the other received balanced salt solution. The eyes receiving tissue plasminogen activator had a 28% incidence of increased anterior chamber blood and a 61% incidence of increased intravitreal blood. There was no evidence of postinjection bleeding in eyes receiving balanced salt solution. Most cases of bleeding occurred within 24 hours of tissue plasminogen activator injection. Administration of tissue plasminogen activator in the setting of segmented blood vessels may lead to intraocular hemorrhage.

[Comparative studies in chronic ocular chalcosis]

Seven eyes containing a copper foreign body for a period from 8 months to 2.5 years were studied histopathologically. Foreign bodies, containing 99% copper, were in all eyes, encapsulated and located in the anterior vitreous. Characteristic features were: formation of foreign body granuloma, especially in later stages, marked fibroblastic proliferation in the vitreous with traction retinal detachment, choroidal effusion with fibrosis and foci of chronic nongranulomatous inflammation in cyclitic membranes, iris, ciliary body and sclera. Copper could be identified by rubeanic acid and rhodanine stainings in the fibrous capsule around foreign body in all eyes, in the lens capsule in one eye and in macrophages in the vitreous and retina in 2 eyes. In eyes with intravitreal haemorrhage macrophages contained also haemosiderin.