Sequential treatment of central retinal vein occlusion with intravitreal tissue plasminogen activator and intravitreal triamcinolone

1 Ophthalmology, University of California at San Francisco, San Francisco, CA, USA

2 Ophthalmology, Kaiser Permanente, Hayward, CA, USA

Keywords: tissue plasminogen activator; central retinal vein occlusion; triamcinolone

Treatment for central retinal vein occlusion (CRVO) remains disappointing despite recently proposed intraocular surgical techniques.1,2 We previously introduced the use of intravitreal tissue plasminogen activator (TPA) for acute central retinal vein occlusion in 1999.3 Numerous investigators have confirmed its safety and suggested that it may have a beneficial role in the treatment of acute central retinal vein occlusion.4–7 Although some studies in rabbits suggest the rabbit retina is not permeable to TPA, investigators found the porcine retina was, in fact, permeable to TPA.8,9 Our clinical experience with intravitreal TPA in humans with CRVO and large submacular haemorrhages strongly suggests that intravitreal TPA does cross the human retina. Greenberg et al were the first to report the possible beneficial effect of intravitreal steroids on patients with chronic CRVO.10 This report describes a sequential treatment strategy for patients with CRVO who present early in the course of their disease and can be performed in the office while avoiding the risks of vitrectomy. It utilises intravitreal TPA in the acute phase of the vein occlusion to attempt clot lysis, and then treats any remaining vascular leakage with intravitreal triamcinolone.

Case report

A 59 year old obese, hypertensive flight instructor presented with a sudden decrease in vision for 7 days in the right eye. Vision was 20/400 right eye and 20/20 left eye. The patient was diagnosed with an acute CRVO in the right eye (fig 1A). The left eye was normal. After being advised of the risks and benefits, the patient elected to undergo intravitreal injection of TPA (75 μg). Thirteen days later, the patient noted marked improvement in vision with 20/60 vision. Thirty four days after the injection, the patient’s vision was 20/30 (Fig 1B).

Figure 1  (A) Fundus photograph shows an acute CRVO with dilated retinal veins, retinal haemorrhages, and retinal oedema. (B) Fundus appearance 1 month after intravitreal injection of tissue plasminogen activator. (C) Photograph of the same eye 5 months later.

Six months after intravitreal TPA injection, the vision remained 20/30, but the patient still complained of metamorphopsia and blurry vision despite resolution of other findings of CRVO (fig 1C). Fluorescein angiogram (FA) revealed persistent macular oedema (fig 2A). Optical coherence tomography (OCT) showed the foveal thickness to be 331 m with mild intraretinal oedema. After being advised of the risks and the benefits, the patient then underwent injection of intravitreal triamcinolone (4 mg).

Figure 2  (A) Fluorescein angiogram reveals persistent macular oedema and hyperfluorescence 6 months after intravitreal TPA injection. (B) Late frames show resolution of macular oedema 6 weeks after intravitreal triamcinolone.

Six weeks after the intravitreal triamcinolone, the FA returned to normal and OCT showed decreased foveal thickness from 331 μm to 291 μm. The patient reported a significant improvement in vision with decreased metamorphopsia. Vision was 20/25 with no late leakage on the fluorescein angiogram (fig 2B).

Comment

To our knowledge, this represents the first published case of CRVO treated sequentially with intravitreal TPA for the acute phase and intravitreal triamcinolone for the chronic phase. TPA is a drug that must be used early in the course of thrombus formation to be effective. We do not recommend its use for patients with chronic symptoms. Intravitreal steroids appear to decrease the blood-retinal barrier breakdown and macular oedema, but recurrent oedema may occur since the steroids do not appear to affect the thrombus itself.

References

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