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   Table of Contents      
ORIGINAL ARTICLE
Year : 1982  |  Volume : 30  |  Issue : 3  |  Page : 143-146

Role of intravitreal injections of distilled water, air and urokinase in the management of recurrent vitreous haemorrhage


Department of Ophthalmology and Department of Biophysics, Post Graduates Institute of Medical Education and Research. Chandigarh, India

Correspondence Address:
P R Chattopadhyay
Department of Ophthalmoi'gy, North Bengal Medical College Sushrutanagar-Daneeiing, West Bengal-734432
India
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Source of Support: None, Conflict of Interest: None


PMID: 7174058

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How to cite this article:
Chattopadhyay P R, Jain I S, Dhir S P, Sharma R R. Role of intravitreal injections of distilled water, air and urokinase in the management of recurrent vitreous haemorrhage. Indian J Ophthalmol 1982;30:143-6

How to cite this URL:
Chattopadhyay P R, Jain I S, Dhir S P, Sharma R R. Role of intravitreal injections of distilled water, air and urokinase in the management of recurrent vitreous haemorrhage. Indian J Ophthalmol [serial online] 1982 [cited 2020 Apr 5];30:143-6. Available from: http://www.ijo.in/text.asp?1982/30/3/143/28194

Table 1

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Table 1

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Dramatic loss of vision following vitreous haemorrhage is alarming to the patient. Management of vitreous haemorrhage has always been problematic with unpredictable outcome. At present there is no safe and reliable mode of therapy. The natural resolu­tion of the vitreous haemorrhage takes from weeks to years. Usually the first uncompli­cated haemorrhage is readily absorbed without any residual changes in the vitreous and retina Subsequent haemorrhages take much longer time to absorb and leave behind considerable permanent damage to the vitreous and retina. The major challenge to an ophthalmologist lies in the management of a case of recurrent vitreous haemorrhage. Various forms o empirical therapies including intraocular injection of hyaluronidase[1] intravitreal injections of alpha-chymotrypsin[2], air and urokinase[4]4, and vitreous replacement in desperate cases with human vitreous[5], normal saline, lyophilized vitreous[6], silicone fluids or liquid silicone[7],[8] have been tried.

We undertook an experimental study to understand the mechanics involved in absorp­tion of simulated recurrent vitreous haemorr­hage (SRVH). As it is not possible to pro­duce controlled vitreous haemorrhage in ex­perimental animals, vitreous haemorrhage was simulated by injecting whole blood tagged, with Cr.51 into the vitreous.

The results of various modes of therapy (injections of distilled water, air and urokinase into the vitreous) have been evaluated.


  Materials and methods Top


Albino rabbits 1-1/2 kg. body weight were used. Thirty rabbits were divided into 5 groups (A,B,C,D and E) of 6 rabbits in each group. SRVH was produced by injection of Cr.[5] tagged blood into the vitreous[3].

Group A : 0.1 ml. of tagged blood was injected intravitreally on Ist, 8th and 16th day. Oblique and ophthalmoscopic examina­tions were carried out bi-weekly. Residual activity in situ was monitored by external counting biweekly for one month after 3rd simulated haemorrhage.

Group B, C and D : On the 3rd day after third simulated vitreous haemorrhage 0.1 ml. of sterile distilled water, sterile air and sterile urokinase was injected intravitreally in groups B, C and D respectively. Observations were continued as mentioned earlier.

Group E : Two rabbits of each were injec­ted with 0.1 ml. of distilled water, air and urokinase into the normal vitreous. Clinical examination was carried out for one month.

Radioactive counting : A collimated Nal (TI) crystal scintillation was used bi-weekly for external counting for one month according to the procedure adopted by Jain et al.[3]

Clinical examination : It was carried out bi weekly with loupe and ophthalmoscope.


  Observations Top


Cr.51 counting [Table - 1] : It was found that on an average it took 13.1 days for 50 per cent absorption with group A (Control), 3.5 days with Group B (distilled water), 6.36 days with group C (air) and 2.53 days with group D (urokinase). Thus 50 per cent absorption rate was 5.67 times faster with urokinase injection, 3.76 times with distilled water injection and 2.01 times with air injec­tion. Further follow up of these rabbits for 75 per cent absorption revealed that average time taken was 28.4 days with group A, 10.83 days with Group B, 17.96 days with Group C and 7.27 days with Group D. Thus 75 per cent absorption rate was 3.9 times faster with group D, 2.62 times with Group B and 1.58 times with Group C. The efficacy of various modes of therapy declined some what as more period elapsed. So, differences in the absorp­tion of whole blood (Group A) as compared to the groups B (distilled water), C (air) and D (urokinase) were statistically highly significant at P<0.001 level for both 50 per cent and 75 per cent absorption.

Clinical study-Oblique and ophthalmoscopic examination : For the first 4-5 days after first simulated haemorrhage, blood was in a localised clump with clear cut border. Then general turbidity of the vitreous was noticed around the blood clump. The hypera­emia of the iris in all cases within 2-3 days after first haemorrhage was also observed, subsequently, it became pale grey. On the 8th day, soon after 2nd simulated haemorrhage new blood was made out through hazy media in all cases. On the 16th day, soon after 3rd simulated haemorrhage, no new blood was made out. On 27-30th day after third simulated haemorrhage, faint glow of the fundi and slight clearance of the vitreous started in the periphery of the lower quadrant. Many bands, floating opacities and multiple fibrous tracts at the site of injection were seen. Details of the fundi could not be made out up to the 30th day of follow up. Grey colour of the iris was uncharged throughout.

In cases of distilled water injection on the 3rd day after 3rd simulated vitreous haemorr­hage, faint glow of the fundi was seen and clearing of the vitreous started on 8-13th day after 3rd simulated haemorrhage at the peri­phery of the lower quadrant. Fibrous tracts at the site of injection, bands and opacities in the vitreous were less in number. Outline of the blood vessels and disc were noted quite clearly on 25-30th day after 3rd simulated haemorrhage. Gray colour of the iris remained the same.

In the rabbits in which air was injected on the 3rd day after 3rd simulated haemorrhage, faint glow of the fundi was observed and clearance of the vitreous started from 15-20 days after 3rd haemorrhage at the periphery of the lower quadrant. Multiple opacities, bands and fibrous tracts at the site of injection were seen but less than that of the control (Group A). Faint outlines of the blood vessels at the periphery were made out and in the central area only glow was seen but details could not be made out on 25-30th day after 3rd simulated vitreous haemorrhage. Iris remained grey in colour.

In the rabbits where urokinase was injected on the 3rd day after 3rd simulated haemorr­hage, fundal glow and clearance of the vitreous were seen on 4-7th day after 3rd haemorrhage in the lower part of the periphery. Fibrous tracts at the site of injection, bands and opacities were least apparent in these animals. On the 25-30th day after 3rd simulated vitreous haemorrhage, outline of the disc and the blood vessels were easily made out although reasona­ble remnants of the residual vitreous opacities persisted. Fundus glow was much brighter and haziness of the media was markedly less in comparison with the other groups. Iris colour remained grey.

In the rabbits where distilled water, air and urokinase were injected into the normal vitreous, transient hyperaemia was seen in all the rabbits in the first 2-3 days, thereafter, it became normal. Fibrous tracts at the site of injection and pockets of liquefaction of the vitreous were present only in the rabbits where distilled water and air were injected. But animals where urokinase was injected, transient generalised mild haziness of the fundi was noted in the first 2-3 days followed by complete clearance of the fundi.


  Discussion Top


The radio-active study and the clinical exa­mination with ophthalmoscope have made it possible to register the progress of absorption of blood in repeated simulated vitreous haemorrhage. It had been found that before injection of any agent (distilled water, air or urokinase) rate of absorption of blood was similar in all animals of various groups (control, A; distilled water, B; Air, C Urokinases, D). But onset of the peripheral clearance of the fundi and the fluidity of the vitreous occurred in 4-7 days with urokinase, 8-13 days with distilled water, 15-20 days with air and 28-30 days in control group (Group A). This observation led us to postulate that urokinase, distilled water and air help in absorption of repeated simulated haemorrhage possibly acting by liquefaction of the vitreous thereby hastening the absorption of the blood[3],[10],[11],[12]. In addition, urokinase being a fibrinolytic agent and plasminogen activator, it helps in rapid resolution of the vitreous haemorrhage as compared to the other groups.

Statistically, differences of absorption of whole blood of control group as compared to the groups with urokinase, distilled water and air were highly significant, p<0.001 for both 50 per cent and 75 percent absorption. With radioisotope study for 75 percent absorption, average time required was 7.27 days with urokinase, 10.83 days with distilled water,

17.96 days with air and 28.4 per cent days with distilled water, 17.96 days with air and 28.4 per cent days with control group after 3rd simulated vitreous haemorrhage.


  Summary Top


An experimental model for S.V.R.H. was produced by repeated injections 0.1 ml of Cr51 labeled whole blood intravitreally. Therapeutic efficacy of intravitreal injections of distilled water, air and urokinase in the management of recurrent vitreous haemorrhage are studied in albino rabbits' eyes. To pro­vide a base line, deleterious effects of these injections alone had been studied also in normal rabbits.

 
  References Top

1.
Sallmao, L.V., 1948,, Amer. J. Ophthalmol 31, 90.  Back to cited text no. 1
    
2.
Paul, S.D. and Ahuja, O.P., 1963., Brit. J. Ophthalmol. 47: 673.  Back to cited text no. 2
    
3.
Jain I.S., Singla, R.K., Sharma R.R. and Gupta, S.D. 1972 Ind. J. Ophthalmol. 20: 95.  Back to cited text no. 3
    
4.
Dugmore, W.N. and Raichand, M., 1973., Amer. J. Ophthalmol. 75, 779.  Back to cited text no. 4
    
5.
Cutler, N.L., 1946, AMA Arch. Ophthalmol. 35: 615.  Back to cited text no. 5
    
6.
Stobbe, J.A., and Keeny, A.H., 1960., Arch. Ophthalmol. (Chicago), 64: 571.  Back to cited text no. 6
    
7.
Armaly, M.F., 1962., Arch. Ophthalmol. (Chicago) 68 : 390.  Back to cited text no. 7
    
8.
Horven, I., 1964., Acta. Ophthalmol. (Kobenh­ avn), 42: 608 and 800.  Back to cited text no. 8
    
9.
Greer, D.F., Benson W.E. and Spalter H.F., 1968., Arch Ophthalmol. 79, 755.  Back to cited text no. 9
    
10.
Benson, W.E., and Spalter, H.F., 1971, Sur. Ophthalmol. 15: 297.  Back to cited text no. 10
    
11.
Oksala, A., and Ahlas, A., 1962 , Quoted by Cibis, P,A., Survey of Ophthalmol. 9, 610:611.  Back to cited text no. 11
    
12.
Cibis, P.A., 1964., Survey of Ophthalmol. 9: 610.  Back to cited text no. 12
    


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