The Open Ophthalmology Journal




ISSN: 1874-3641 ― Volume 14, 2020

Intracameral Recombinant Tissue Plasminogen Activator for Refractory Glaucoma Secondary to a Fungal Corneal Abscess



L. Jay Katz*, Oana Stirbu, Garth Willis, Parul Ichhpujani
Wills Eye Institute, 840 Walnut Street, Philadelphia, USA

Abstract

We present a 78-year-old patient who developed refractory glaucoma following a fungal infection of the corneal incision after cataract extraction with posterior chamber intraocular lens implantation. An anterior chamber injection of 0.1 ml recombinant tissue plasminogen activator (25 mcg/0.1 mL) was performed to improve the trabecular meshwork outflow facility compromised secondary to fibrin blockade. The intraocular pressure dropped dramatically from 48 mmHg to 10 mmHg postoperatively, negating the need for glaucoma surgery.



Article Information


Identifiers and Pagination:

Year: 2009
Volume: 3
First Page: 75
Last Page: 76
Publisher Id: TOOPHTJ-3-75
DOI: 10.2174/1874364100903010075

Article History:

Received Date: 11/6/2009
Revision Received Date: 23/7/2009
Acceptance Date: 31/8/2009
Electronic publication date: 25/9/2009
Collection year: 2009

© Katzet al.; Licensee Bentham Open.

open-access license: This is an open access article licensed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted, non-commercial use, distribution and reproduction in any medium, provided the work is properly cited.


* Address correspondence to this author at the Glaucoma service, Wills Eye Institute, 840 Walnut Street, Philadelphia, USA; Tel: 215-285-8148; Fax: 215- 928-3903; E-mail: ljk22222@aol.com





INTRODUCTION

Recombinant tissue plasminogen activator (rTPA) in ophthalmology has been used in the treatment of hyphema [1Laatikainen L, Mattila J. The use of tissue plasminogen activator in posttraumatic hyphema Graefes Arch Clin Exp Ophthalmol 1996; 234: 67-8.] and fibrin formation after cataract surgery [2Wedrich A, Menapace R, Ries E, et al. Intracameral tissue plasminogen activator to treat severe fibrinous effusion after cataract surgery J Cataract Refract Surg 1997; 23: 873-7., 3Klais CM, Hattenbach LO, Steinkamp GWK, et al. Intraocular recombinant tissue plasminogen activator fibrinolysis of fibrin formation after cataract surgery in children J Cataract Refract Surg 1999; 25: 357- 61.].In glaucoma surgery, rTPA has been used for tube shunt occlusion, bleb failure and fibrin effusion [4Zalta AH, Sweeney CP, Zalta AK, Kaufman AH. Intracameral tissue plasminogen activator use in a large series of eyes with valved glaucoma drainage implants Arch Ophthalmol 2002; 120: 1487-93., 5Lundy DC, Sidoti P, Winarko T, et al. Intracameral tissue plasminogen activator after glaucoma surgery. Indications, effectiveness, and complications. Ophthalmology ions; 103: 274-82.].

We present a case of refractory glaucoma following a fungal infection of a corneal incision after cataract extraction that was successfully treated with intracameral injection of rTPA.

CASE REPORT

A 78-year-old Caucasian female presented with a red painful left eye at her 1 month postoperative visit after uneventful cataract extraction with posterior chamber intraocular lens implantation. The visual acuity (VA) was 20/20 in right eye (OD), 20/70 in left eye (OS), and the intraocular pressure (IOP) was 14 mmHg in OD and 20 mmHg in OS. Slit lamp examination of the OS revealed a corneal ulcer measuring 1.5mm horizontally and 6 mm vertically corresponding to the temporal clear corneal incision, a deep anterior chamber with 1+ flare and a posterior chamber implant in the capsular bag.

Treatment was started with topical fortified vancomycin 25 mg/mL and tobramycin 15 mg/mL hourly, scopolamine TID and oral moxifloxacin 400 mg daily. In the following days, the ulcer extended vertically to 7 mm, a hypopyon formed, a fibrin clot grew to fill the anterior chamber and the IOP rose to 24 mmHg. Corneal scrapings showed fungal elements and treatment was changed to oral voriconazole 200 mg BID, topical voriconazole 1% hourly, topical moxifloxacin 0.5% every 2 hours and continued with oral moxifloxacin. The vision in the OS dropped precipitously to counting fingers at 3ft on day 2 to hand motion on day 3. On day 4, the patient was hospitalized with an IOP of 41 mmHg, more fibrin and a larger hypopyon. Microbiology reported growth of methicillin resistant staphylococcus aureus(MRSA) sensitive to vancomycin and the treatment was changed to fortified vancomycin and voriconazole hourly, dorzolamide-timolol fixed combination BID, brimonidine TID, atropine and oral acetazolamide sequel 500 mg BID, voriconazole and moxifloxacin. Despite the intensive topical treatment and intravenous mannitol, the IOP fluctuated in the range of 40-57 mmHg. After informed consent, the patient agreed to the use of rTPA, which was prepared by the hospital pharmacy staff from lyophilized recombinant tPA (Activase, Genetech Inc, San Francisco). An anterior chamber injection of 0.1 ml rTPA (25 mcg/0.1 mL) preceded by aspiration of 0.08 ml of aqueous humor, was performed to clear the fibrin (Fig 1A). On postoperative day 4, slit lamp examination showed no change in the ulcer margins and a shallow anterior chamber with hyphema covering the hypopyon (Fig 1B). IOP in OS was 10 mmHg with only brimonidine TID. On postoperative day 15, the patient’s VA was CF at 1ft, slit lamp examination revealed a markedly retracted fibrin clot with traces of blood, no hyphema, minimal hypopyon and an IOP of 18 mmHg without glaucoma medication (Fig. 1C). At follow-up visits (week 3, week 5, week 8, week 12), the IOP had a favorable evolution (16, 15, 12, 31 and 18 mmHg, respectively) with brimonidine.

Fig. (1)

(A) Slit lamp photograph 2 hours post rTPA injection showing fibrin clot retraction superiorly (white arrow) and marked conjunctival congestion and chemosis. (B) Slit lamp photograph on day 4 post intracameral rTPA showing shallow anterior chamber, hyphema overlying the hypopyon (white arrow) and no progression of the corneal abscess. (C) Slit lamp photograph on day 15 post intracameral rTPA showing markedly reduced fibrin clot with minimal hypopyon.



DISCUSSION

Though acute inflammation within the eye may reduce aqueous secretion and lower the intraocular pressure, inflammatory material, consisting of white blood cells, macrophages and proteins, may obstruct the trabecular meshwork [5Lundy DC, Sidoti P, Winarko T, et al. Intracameral tissue plasminogen activator after glaucoma surgery. Indications, effectiveness, and complications. Ophthalmology ions; 103: 274-82.]. Additionally, inflammatory scarring may lead to peripheral anterior synechiae resulting in angle-closure glaucoma. In this case the secondary glaucoma was thought to be due to the inflammatory debris blocking the outflow of aqueous through the trabecular meshwork.

A surgical approach such as a trabeculectomy or tube shunt with an infectious corneal ulcer is not ideal for fear of intraocular extension of the infection, further intraocular inflammation or bleeding. A cyclodestructive procedure such as laser cyclophotocoagulation would encourage further inflammation and may lead to phthisis in this clinical setting. Therefore, the minimally invasive technique of rTPA injection became the favored initial approach to lower theIOP by dissolution of the fibrin clot. The effect of rTPA on the fibrin clot was seen in the next two hours but as a minor complication, a minimal hyphema covered the hypopyon. Nevertheless, the hyphema completely disappeared in 10 days and there was no further bleeding.

rTPA is a genetically cloned serine protease that works by converting plasminogen into plasmin. It promotes degradation of the fibrin only at the clot surface and it is not associated with systemic fibrinolysis. rTPA has been effectively used in the past in traumatic hyphema [1Laatikainen L, Mattila J. The use of tissue plasminogen activator in posttraumatic hyphema Graefes Arch Clin Exp Ophthalmol 1996; 234: 67-8.], fibrinous effusion after cataract surgery in adults [2Wedrich A, Menapace R, Ries E, et al. Intracameral tissue plasminogen activator to treat severe fibrinous effusion after cataract surgery J Cataract Refract Surg 1997; 23: 873-7.], severe post cataract fibrinous membrane in pediatric groups [3Klais CM, Hattenbach LO, Steinkamp GWK, et al. Intraocular recombinant tissue plasminogen activator fibrinolysis of fibrin formation after cataract surgery in children J Cataract Refract Surg 1999; 25: 357- 61.], glaucoma surgery [4Zalta AH, Sweeney CP, Zalta AK, Kaufman AH. Intracameral tissue plasminogen activator use in a large series of eyes with valved glaucoma drainage implants Arch Ophthalmol 2002; 120: 1487-93., 5 Lundy DC, Sidoti P, Winarko T, et al. Intracameral tissue plasminogen activator after glaucoma surgery. Indications, effectiveness, and complications. Ophthalmology ions; 103: 274-82.] and subretinal hemorrhage [6Hattenbach LO, Klais C, Koch FH, et al. Intravitreous injection of tissue plasminogen activator and gas in the treatment of submacular hemorrhage under various conditions Ophthalmology 2001; 108: 1485-92.]. The response to rTPA may have been coincident with an improving clinical course and unrelated to the drug. The potential complications related to the use of rTPA are corneal edema and anterior chamber turbidity, which results from immediate fibrinolysis products [5Lundy DC, Sidoti P, Winarko T, et al. Intracameral tissue plasminogen activator after glaucoma surgery. Indications, effectiveness, and complications. Ophthalmology ions; 103: 274-82.].

In conclusion, in markedly inflamed eyes with a fibrin blockade of aqueous outflow, the use of intracameral rTPA should be considered to lower IOP in eyes resistant to topical and systemic medications.

REFERENCES

[1] Laatikainen L, Mattila J. The use of tissue plasminogen activator in posttraumatic hyphema Graefes Arch Clin Exp Ophthalmol 1996; 234: 67-8.
[2] Wedrich A, Menapace R, Ries E, et al. Intracameral tissue plasminogen activator to treat severe fibrinous effusion after cataract surgery J Cataract Refract Surg 1997; 23: 873-7.
[3] Klais CM, Hattenbach LO, Steinkamp GWK, et al. Intraocular recombinant tissue plasminogen activator fibrinolysis of fibrin formation after cataract surgery in children J Cataract Refract Surg 1999; 25: 357- 61.
[4] Zalta AH, Sweeney CP, Zalta AK, Kaufman AH. Intracameral tissue plasminogen activator use in a large series of eyes with valved glaucoma drainage implants Arch Ophthalmol 2002; 120: 1487-93.
[5] Lundy DC, Sidoti P, Winarko T, et al. Intracameral tissue plasminogen activator after glaucoma surgery. Indications, effectiveness, and complications. Ophthalmology ions; 103: 274-82.
[6] Hattenbach LO, Klais C, Koch FH, et al. Intravitreous injection of tissue plasminogen activator and gas in the treatment of submacular hemorrhage under various conditions Ophthalmology 2001; 108: 1485-92.
Track Your Manuscript:


Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

"The widest possible diffusion of information is critical for the advancement of science. In this perspective, open access journals are instrumental in fostering researches and achievements."


Alessandro Laviano
(Sapienza - University of Rome, Italy)

"Open access journals are very useful for all scientists as they can have quick information in the different fields of science."


Philippe Hernigou
(Paris University, France)

"There are many scientists who can not afford the rather expensive subscriptions to scientific journals. Open access journals offer a good alternative for free access to good quality scientific information."


Fidel Toldrá
(Instituto de Agroquimica y Tecnologia de Alimentos, Spain)

"Open access journals have become a fundamental tool for students, researchers, patients and the general public. Many people from institutions which do not have library or cannot afford to subscribe scientific journals benefit of them on a daily basis. The articles are among the best and cover most scientific areas."


M. Bendandi
(University Clinic of Navarre, Spain)

"These journals provide researchers with a platform for rapid, open access scientific communication. The articles are of high quality and broad scope."


Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

"Open Access journals offer an innovative and efficient way of publication for academics and professionals in a wide range of disciplines. The papers published are of high quality after rigorous peer review and they are Indexed in: major international databases. I read Open Access journals to keep abreast of the recent development in my field of study."


Daniel Shek
(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


Browse Contents



Table of Contents


Webmaster Contact: info@benthamopen.net
Copyright © 2020 Bentham Open