Journal of Pediatric Ophthalmology and Strabismus

Original Article 

Induction of Posterior Vitreous Detachment in Pediatric Vitrectomy by Preoperative Intravitreal Injection of Tissue Plasminogen Activator

Chih-Chun Chuang, MD; San-Ni Chen, MD

Abstract

Purpose:

To report the efficacy of intravitreal injection of tissue plasminogen activator (tPA) with or without autoserum in induction of posterior vitreous detachment (PVD) in pediatric vitrectomy.

Methods:

Retrospective, interventional case series of pediatric patients receiving intravitreal injection of tPA preoperatively to facilitate PVD in vitrectomy from January 2011 to December 2014 at the Changhua Christian Hospital, Taiwan. All patients received intravitreal injections of 25 µg of tPA 3 days before vitrectomy. For cases without preexisting vitreous hemorrhage, 0.1 mL of intravitreal autologous serum was co-administered. Main outcome measures included successful rate of posterior vitreous detachment in vitrectomy, visual outcome, and related ocular complications.

Results:

Four boys and 2 girls were included. Ages ranged from 39 weeks' postmenstrual age to 8 years. The indications for vitrectomy were traumatic macular hole (cases 1 and 2); premacular hemorrhage secondary to retinopathy of prematurity (case 3); abusive head trauma with premacular hemorrhage, subinternal limiting membrane hemorrhage, and macular hole (case 4); trauma with dense vitreous hemorrhage (case 5); and vitreous hemorrhage with unknown cause (case 6). Successful PVD was induced intraoperatively in all cases and the macular hole was closed successfully in 3 of 3 cases (cases 1, 2, and 4). No surgical complications were noted. Visual outcome improved in all 3 eyes with checkable preoperative visual acuity (cases 1, 2, and 6).

Conclusions:

Intravitreal injection of tPA 3 days before vitrectomy may be a helpful adjunct to induce pediatric PVD.

[J Pediatr Ophthalmol Strabismus. 2016;53(2):113–118.]

Abstract

Purpose:

To report the efficacy of intravitreal injection of tissue plasminogen activator (tPA) with or without autoserum in induction of posterior vitreous detachment (PVD) in pediatric vitrectomy.

Methods:

Retrospective, interventional case series of pediatric patients receiving intravitreal injection of tPA preoperatively to facilitate PVD in vitrectomy from January 2011 to December 2014 at the Changhua Christian Hospital, Taiwan. All patients received intravitreal injections of 25 µg of tPA 3 days before vitrectomy. For cases without preexisting vitreous hemorrhage, 0.1 mL of intravitreal autologous serum was co-administered. Main outcome measures included successful rate of posterior vitreous detachment in vitrectomy, visual outcome, and related ocular complications.

Results:

Four boys and 2 girls were included. Ages ranged from 39 weeks' postmenstrual age to 8 years. The indications for vitrectomy were traumatic macular hole (cases 1 and 2); premacular hemorrhage secondary to retinopathy of prematurity (case 3); abusive head trauma with premacular hemorrhage, subinternal limiting membrane hemorrhage, and macular hole (case 4); trauma with dense vitreous hemorrhage (case 5); and vitreous hemorrhage with unknown cause (case 6). Successful PVD was induced intraoperatively in all cases and the macular hole was closed successfully in 3 of 3 cases (cases 1, 2, and 4). No surgical complications were noted. Visual outcome improved in all 3 eyes with checkable preoperative visual acuity (cases 1, 2, and 6).

Conclusions:

Intravitreal injection of tPA 3 days before vitrectomy may be a helpful adjunct to induce pediatric PVD.

[J Pediatr Ophthalmol Strabismus. 2016;53(2):113–118.]

Introduction

Creating a complete posterior vitreous detachment (PVD) is important to manage vitreoretinal disorders including macular hole, vitreomacular traction, proliferative diabetic retinopathy, and proliferative vitreoretinopathy. In most patients, PVD can usually be induced by active aspiration of the vitreous gel from the nasal retina around the optic disc. With the assistance of triamcinolone acetonide, a better visualization of the vitreous can be achieved, which facilitates and ensures complete separation of the vitreous cortex from the retina.1 However, to induce an atraumatic PVD is particularly challenging in young children whose posterior hyaloid is tightly attached to the retina.2 Despite the improvement of instruments and techniques for vitreoretinal surgery in recent years, surgical removal of the vitreous cortex still carries the great risk of retinal tear or retinal detachment.3 Enzymatic vitreolysis thus may offer a less traumatic way for inducing PVD, especially in pediatric patients.4,5

Tissue plasminogen activator (tPA) is an enzyme that catalyzes the conversion of plasminogen to plasmin. Because plasminogen is rich in serum, we hypothesize that co-administration of tPA and autologous serum in the vitreous cavity may generate plasmin locally and facilitate the enzymatic cleavage of posterior hyaloid from the retina. For eyes with preexisting vitreous hemorrhage, injection of tPA alone may induce PVD. In this study, we review our clinical results of six pediatric cases to see whether intravitreal injection of tPA along with autologous serum in eyes without preexisting vitreous hemorrhage and intravitreal injection of tPA in eyes with preexisting vitreous hemorrhage preoperatively may help PVD induction during vitrectomy.

Patients and Methods

A retrospective chart review was done of pediatric patients who received intravitreal injection of tPA and autologous serum to induce PVD 3 days before vitrectomy from January 2011 to December 2014 at Changhua Christian Hospital, Taiwan. The study was approved by the institutional review board of Changhua Christian Hospital. Patients younger than 10 years who had undergone intravitreal injection of tPA with or without autologous serum 3 days before vitrectomy were included. All patients underwent a complete ophthalmologic evaluation, including slit-lamp examination, indirect ophthalmoscopy, intraocular pressure measurement, and visual acuity. Optical coherence tomography was performed in some cases. Data extracted from the chart included the age and gender of the patient, the presence of retinal pathologic features, preoperative visual condition, postoperative visual condition, surgical methods, complications, and length of follow-up.

Informed consent was obtained before performing the procedures. For preparation of autologous serum, 5 to 10 mL of blood was taken by venipuncture. The blood was allowed to clot for 15 minutes at room temperature. After centrifugation at 2,500 revolutions per minute for 15 minutes, the serum was extracted. Twenty-five micrograms of tPA (Actilyse; Boehringer Ingelheim, Ingelheim am Rhein, Germany) and 0.1 mL of autologous serum were injected through the pars plana with a 30-gauge needle under sterile conditions in clinic. Antibiotic drops were given for 3 days after the injection. Three days after intravitreal injection, each patient had 23-gauge vitrectomy under general anesthesia. All surgeries were performed by one experienced surgeon (S-NC). After core vitrectomy, PVD was induced with a vacuum of 300 mm Hg at the nasal aspect of the optic disc. A PVD was considered to be present if a Weiss ring was seen to be freely detached from the retina.

Results

Four boys and 2 girls were included. Ages ranged from 39 weeks' postmenstrual age to 8 years. The indications for pars plana vitrectomy were traumatic macular hole (cases 1 and 2); retinopathy of prematurity with vitreous hemorrhage (case 3); abusive head trauma with premacular, subinternal limiting membrane hemorrhage and macular hole (case 4); traumatic dense vitreous hemorrhage (case 5); and dense vitreous hemorrhage without known cause (case 6). The patient data are shown in Table 1. All patients received intravitreal injection of 25 µg of tPA 3 days before vitrectomy. For cases without preexisting vitreous hemorrhage (cases 1 and 2), 0.1 mL of intravitreal autologous serum was co-administered. All cases had PVD induced successfully with a vacuum of 300 mm Hg during vitrectomy. A Weiss ring was observed as freely detached from the retina intraoperatively in all cases.


Patient Characteristics

Table 1:

Patient Characteristics

The follow-up period ranged from 12 to 45 months. The final visual acuity improved in 3 cases (cases 1, 2, and 6) and could not be checked preoperatively in the other patients. The macular hole was closed successfully in 3 of 3 cases (cases 1, 2, and 4) (Figures 12).


(A) Before vitrectomy, a giant macular hole and retinal pigment epithelium alteration around the fovea in the left eye were noted in case 1. (B) After vitrectomy, visual acuity improved from counting fingers to 20/200 and the macular hole was closed.

Figure 1.

(A) Before vitrectomy, a giant macular hole and retinal pigment epithelium alteration around the fovea in the left eye were noted in case 1. (B) After vitrectomy, visual acuity improved from counting fingers to 20/200 and the macular hole was closed.


(A) Before vitrectomy, indirect funduscopy and optical coherence tomography in the right eye revealed a macular hole in case 2. (B) After vitrectomy, the visual acuity recovered to 20/50 and the macular hole was closed.

Figure 2.

(A) Before vitrectomy, indirect funduscopy and optical coherence tomography in the right eye revealed a macular hole in case 2. (B) After vitrectomy, the visual acuity recovered to 20/50 and the macular hole was closed.

No complications occurred with the use of tPA and autologous serum in this cohort of patients. No surgical complications were noted. There was no evidence of retinal toxicity related to tPA injection or postoperative increase in intraocular pressure. In addition, no intraretinal or vitreous bleeding was observed, and postoperative anterior segment inflammation was minimal.

Discussion

The induction of PVD is difficult in children. Because of the strong adherence between the vitreous and retina in children, mechanical peeling of the vitreous is likely to be lamellar and tends not to result in complete vitreous removal. PVD is important in vitreomacular surgeries.6 Therefore, how to detach the posterior vitreous without trauma to the retina is a major but challenging goal in pediatric vitrectomy.

Enzymatic adjuncts that can create an atraumatic and complete vitreoretinal separation are considered a good choice before pediatric vitrectomy. Sebag proposed a classification of the enzymatic adjuncts based on the biologic effect on the vitreous, including “liquefactants” that refer to the ability to liquefy vitreous and “interfactants” that cause disruption of the vitreoretinal interface.7 A purely liquefactant compound, such as hyaluronidase, results in vitreous liquefaction without PVD formation due to the absence of an interfactant effect.7,8 Chondroitinase and dispase are examples of interfactants. Although chondroitinase breaks down chondroitin sulfate, its ability to induce PVD is inconsistent.9 Dispase cleaves collagen type IV and fibronectin to induce PVD in animal and human cadaveric eyes,10,11 but its harmful effects on retinal vessels and diminution of electroretinogram amplitude precludes clinical use.12–14 On the other hand, plasmin, which is a nonspecific serine protease,15 has both interfactant and liquefactant properties.7 The hydrolysis of laminin and fibronectin by plasmin enzyme spontaneously creates a PVD or allows for a relatively atraumatic peeling of the posterior hyaloid from the retinal surface.16

Plasmin has been used in humans most commonly in the form of autologous plasmin enzyme.17 Before ocular administration, inactive human plasminogen isolated from blood requires conversion in vitro to enzymatically active plasmin by streptokinase.18 However, autologous plasmin enzyme is relatively unstable19; the isolation of autologous plasmin is also a costly and time-consuming process, and the necessary facilities are not readily available everywhere. Hesse et al. thus applied cryopexy followed by intravitreal injection of tPA in rabbit eyes to induce PVD: by temporally breaking down the blood retinal barrier with cryotherapy, plasminogen activator from the blood was able to influx into the vitreous cavity, which was then converted to plasmin, resulting in the subsequent induction of PVD.20

More recently, microplasmin (ocriplasmin), a biologically produced recombinant enzyme, has been evaluated in Phase II19,21 and Phase III randomized controlled trials.4 Ocriplasmin has a smaller molecular mass (28 vs 88 kDa) than human plasmin22,23 and theoretically penetrates the vitreoretinal interface more effectively than human plasmin.24 Ocriplasmin also has a half-life in blood several times longer than human plasmin25 and is therefore able to more effectively induce vitreous liquefaction and separation from the retina. Unfortunately, ocriplasmin is expensive and is not covered by the national health insurance in Taiwan.

Autologous plasmin enzyme has been used as an adjunct to pediatric vitrectomy in a variety of clinical conditions, such as traumatic macular hole,26,27 congenital x-linked retinoschisis,28 and stage 5 retinopathy of prematurity.29,30 In addition to direct injection of purified plasmin into the vitreous cavity,17,31–35 several methods have been previously used to achieve sufficient plasmin concentration in the vitreous, including injection of tPA in proliferative diabetic retinopathy36 and cryopexy followed by tPA injection.20 In the former method, plasminogen was present in the vitreous cavity because of the loss of the blood–retinal barrier in eyes with proliferative diabetic retinopathy; in the latter method, cryopexy induced the breakdown of the blood–retinal barrier with a subsequent influx of plasminogen into the vitreous cavity. In proliferative diabetic retinopathy, the use of 25 µg of tPA by intravitreal injection 15 minutes before vitrectomy did not improve the results of the number of perioperative iatrogenic tears, the gain in visual acuity, and the reattachment rate of tractional retinal detachments.36 The failure could be attributed to a short delay between tPA injection and beginning of surgery, an insufficient dose, or an insufficient quantity of plasminogen in the vitreous at the beginning of the intervention.36 We hypothesized that 3 days in our series was a long enough time interval to make tPA and autoserum to produce plasmin.

In our series, we used the co-administration of both autologous serum and tPA in eyes without vitreous hemorrhage and only injected tPA in eyes with preoperative vitreous hemorrhage 3 days before vitrectomy in 6 consecutive pediatric patients. We did not inject autologous serum in eyes with preexisting vitreous hemorrhage because we hypothesized that it contained plasminogen in vitreous hemorrhage. PVD was successfully induced in every eye. A Weiss ring was visualized intraoperatively in all cases. Three of 3 patients had macular hole closure after surgery, and all patients with dense vitreous hemorrhage had the vitreous hemorrhage removed without any complications related to the PVD procedures. The outcomes of our study indicate that intravitreal tPA in the presence of serum could probably produce a sufficient amount of plasmin to cleave the vitreoretinal interface by converting plasminogen in serum to plasmin. Further studies are required to validate this preliminary study.

It has been reported that retinal toxicity has followed intravitreal tPA.37–39 Endophthalmitis from intravitreal injection of tPA and autologous serum is another possible complication. However, even though we did not observe any related complications in our study, these complications may still be a major concern.

The limitations of this study include the small case number and its retrospective nature. There was no retrospective control group in this study because this method was used in all pediatric vitrectomy cases. There was no direct evidence to quantify increased plasmin levels in the vitreous after intravitreal injection of tPA and autologous serum.

Intravitreal tPA in the presence of intravitreal serum, either co-administered or preexisting within the vitreous cavity, is an alternative approach to help induce PVD in pediatric vitrectomy. No prior pre-clinical or clinical studies have tested this approach. This was a hypothesis-driven approach sought by the authors. This is a preliminary study and further studies are required prior to definitive recommendations.

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Patient Characteristics

CaseAgeGenderEyeBasic Data and Eye FindingsSurgical MethodsPreoperative Visual ConditionPostoperative Visual Condition and Eye FindingsFollow-up (mo)
16 (y)MOSTraumatic MHPPV, ICG-assisted ILM peeling and 13% C3F8BCVA: counting fingersBCVA: 20/200; MH was closed; RPE alteration around fovea12
28 (y)MODTraumatic MHPPV, ICG-assisted ILM peeling and 13% C3F8BCVA: 20/100BCVA: 20/50; MH was closed; ring-shaped fibrosis around the fovea13
339 weeks' PMAFOSPrematurity (GA: 28 weeks, BBW: 1,120 g, ROP stage 3, zone I s/p IVI bevacizumab); dense VHPPV and peripheral retinal photocoagulationUncheckedBCVA: 20/50; AR: −9.50/−2.50 × 0; tessellated fundus45
46 (mo)FOSAbusive head trauma, premacular hemorrhage, sub-ILM hemorrhage, and MHPPV, ICG-assisted ILM peeling and 30% SF6UncheckedAR: −9.50/−3.00 × 46; tessellated fundus27
51 (y)MODTrauma with dense VH; Berlin's edemaPPVUncheckedBCVA: 20/200; AR: −1.25/−0.75 × 165; macular RPE atrophy, disc mild pallor, and mild esotropia34
62 (y)MOSDense VH; unknown causePPVBCVA: counting fingersBCVA: 20/200; AR: −12.00/−2.50 × 13; tessellated fundus and esotropia37
Authors

From the Department of Ophthalmology, Changhua Christian Hospital, Changhua City, Taiwan (C-CC, S-NC); the School of Medicine, Chung-Shan Medical University, Taichung, Taiwan (C-CC, S-NC); and the School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan (S-NC).

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: San-Ni Chen, MD, Department of Ophthalmology, Changhua Christian Hospital, 135 Nanhsiao Street, Changhua, Taiwan. E-mail: 108562@cch.org.tw

Received: January 14, 2015
Accepted: January 01, 2016

10.3928/01913913-20160209-01

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