Tissue plasminogen activator-assisted vitrectomy in the early treatment of acute massive suprachoroidal hemorrhage complicating cataract surgery.

Dear Editor, I am Dr. Zhao PQ, from the Department of Ophthalmology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China. I write to present a case report of tissue plasminogen activator (tPA)-assisted vitrectomy in the early treatment of acute massive suprachoroidal hemorrhage (SCH) complicating cataract surgery. SCH is a vision-threatening complication associated with certain surgical procedures, such as cataract extraction, glaucoma filtering surgery, retinal detachment repair, and penetrating trauma. Generally, SCH has a guarded prognosis and poor visual outcome. Surgical drainage is a topic of much controversy. A suggested time for surgical drainage is 1014d when the hemorrhagic clot begins to liquefy. However, if adequate thrombolysis can be achieved earlier, retinal complications may be prevented or reduced. Previously, several reports have been published about tPA in the treatment of vitreoretinal diseases. However, no reports were about tPA assisted vitrectomy in the management of acute massive SCH complicating cataract surgery. Here we present a patient with massive SCH during cataract surgery who underwent an early successful tPA-assisted vitrectomy and attained good visual outcome. It may be the earliest drainage of the clot by recombinant tPA (r-tPA) in SCH after cataract extraction surgery up to our knowledge. A 73-year-old male underwent phacoemulsification surgery for cataract of right eye in other hospital. SCH was complicated during the surgery with ruptured posterior capsule. Four days after surgery, the patient was referred to our clinic with visual acuity of light perception (suspected) in right eye. The right eye was aphakia with a few lens cortex residue and massive SCH (Figure 1A). The intraocular pressure (IOP) was 20 mm Hg. Ultrasound scan further showed kissing choroidal detachment of all the four quadrants (Figure 1B). He had a history of hypertension but with a normal blood pressure at the time of examination. The patient was scheduled for r-tPA suprachoroidal cavity injection the following day. r-tPA (alteplase, 10 μg/0.2 mL) was injected into each quadrant of the suprachoroidal space (Figure 2A). The next day, sclerotomy 5 mm behind the limbus were created in four quadrants to drain the liquefied hemorrhage with the anterior chamber maintainer placed at the limbus (Figure 2B). We chose the location where the choroid detached most and the direction of microvitreoretinal (MVR) blade was oblique. Standard three-port vitrectomy was performed after drainage at the same session. The residual cortex was firstly removed by lensectomy (Figure 2C). Vitrectomy, liquid gas exchange combined with C3F8 tamponade were performed later. The next day after PPV, 2 mm hyphema was noticed, but the IOP remained normal (Figure 2D). The hyphema was spontaneously absorbed 6d later. During the follow up, the choroid was attached. Secondary IOL was implanted 10mo later (Figure 2E, 2F). Best corrected vision was 30/60. The actual incidence of SCH during or after cataract surgery is somewhat difficult to reliably estimate. The advent of tPA asssited vitrectomy in suprachoroidal hemorrhage