Fibrinolytic Therapy with Low-Dose Recombinant Tissue Plasminogen Activator in Retinal Vein Occlusion

Abstract

Fibrinolytic therapy aimed at early restoration of blood flow appears to be a promising therapeutic approach in haemorrhagic retinopathy. The risk of bleeding complications, a major problem with fibrinolysis, can be reduced by the use of low-dose thrombolytic regimens. In our study, 14 patients with ischaemic central (CRVO) or branch (BRVO) retinal vein occlusion who presented with severe visual loss and recent onset of symptoms were treated with a low dose (50 mg) of recombinant tissue plasminogen activator (rt-PA) and intravenous heparin. In 10 of 14 patients (7 CRVO, 3 BRVO), an increase in visual acuity of one line or more on the logarithmic visual acuity chart was noted and in 8 patients (6 CRVO, 2 BRVO) a reduction of areas of capillary non-perfusion was observed, suggesting that a restoration of retinal capillary blood flow can be achieved if fibrinolysis is initiated in the early phase of haemorrhagic retinopathy. In view of the poor prognosis in the natural course of haemorrhagic retinopathy and the potential haemorrhagic risk in fibrinolysis, the use of low-dose rt-PA appears to constitute an encouraging approach in the management of this disease.

Visual Outcome after Treatment with Low-Dose Recombinant Tissue Plasminogen Activator or Hemodilution in Ischemic Central Retinal Vein Occlusion

“…In another study, a more favorable outcome after treatment of CRVO and branch retinal vein occlusion with streptokinase in comparison to anticoagulant therapy with heparin was observed [25]. Moreover, several investigators have reported on a beneficial effect of rtPA in the management of CRVO and branch retinal vein occlusion, but the numbers of patients enrolled in these studies were small [21, 22, 24, 30], and most investigators administered higher doses of rtPA (70 mg) in a nonfrontloaded manner, followed by continuous intravenous heparinization over a maximum period of 72 h. A large body of evidence for the effectiveness of rtPA in retinal vein occlusion, however, has been provided by several experimental studies [31, 32]. …”

“…Moreover, the spectrum of indications for thrombolytic drugs such as streptokinase or recombinant tissue plasminogen activator (rtPA) comprises lung embolism, ischemic stroke, deep-vein thrombosis and acute arterial occlusions of the lower limbs [17, 18, 19, 20]. In contrast, the use of thrombolytic agents in retinal vessel occlusion is in its infancy, although several studies have indicated that fibrinolysis may be associated with a better visual prognosis in CRVO [21, 22, 23, 24, 25]. Since, basically, it is of some concern that the systemic administration of fibrinolytic agents carries a risk of bleeding, the choice of an appropriate intravenous thrombolytic therapy in a non-life-threatening situation should be based on minimizing the probability of potential complications.…”

Central Retinal Vein Occlusion and Nonarteritic Ischemic Optic Neuropathy in 2 Patients with Mild Iron Deficiency Anemia

“…In view of the progression of the CRVO and the rapid deterioration in visual acuity, fibrinolytic treatment was started on day 8 [3]. We administered 50 mg of recombinant tissue plasminogen activator intravenously over a period of 60 min.…”

Retinal Venous Occlusions: Diagnosis and Choice of Treatments

“…Recombinant tissue plasminogen activator (rtPA) is a synthetic fibrinolytic agent that converts plasminogen to plasmin and destabilizes intravascular thrombi. rtPA, as therapy against CRVO, has been administered by several routes: systemic [13,14], intravitreal [15,16,17], and by endovascular cannulation of retinal vessels either through a neuroradiological or a vitreoretinal approach, and delivery of minute quantities of rtPA directly to the occluded vessels to release the suspected thrombus [18,20,21]. …”