[optimal] No infiltration...no Fluorescein
- From: "Egnatz, Thomas James" <tegnatz@xxxxxxxxx>
- To: optimal@xxxxxxxxxxxxx
- Date: Wed, 09 Oct 2013 08:11:32 -0400
Interesting posts on no dye getting to the retina. Let me add a few
(including little dye getting to the eye) and summarize in most likely
to least likely (in my experience):
1. Camera glitch. My digital system is mounted on a Topcon 50-DX: B+W
camera on the top port and color on the back port. Protocol is to
shoot the color, then select "Mono" on the monitor, which switches the
"capture" port to the B+W camera, dial in the the green filter, shoot
the redfree, dial out the green filter to "N", press the "Ex" button
which inserts the exciter filter and take one control photo (the
barrier filter automatically clicks at at the moment of exposure). On
the average patient with clear media, the control photo is pure black;
if there is a cataract or exudates (or fluorescein on the cornea) a
muddy image will be apparent. Then click "Start" on the monitor, and
the timer will start with the next flash.
Then find a vein, do the injection, start shooting pictures 8 seconds
after the start of the injection. Maybe six times in the last four
years I glance at the monitor and no dye images at 20-30-35 seconds
("Does your arm burn"?..."No"). What's going on???? And I look at the
Topcon control panel and the "LOWER" light is on, so I am getting a
flawless angiogram on the color back, and all the images on the monitor
are pure black. Switching to "UPPER" immediately shows a dye image
with every flash. (If you are getting muddy images, but no dye images,
this is not the problem).
I don't think I hit the "Lower" switch by mistake (there is a "Beep"
when it is switched). It seems the switch times out and switches
itself, or it switches itself when it gets a little extraneous
electrical impulse, like when the table height is adjusted (though it
has not switched when I purposely tried to test it adjusting the
table). My stereo retinal camera takes a blank image every time the
table is adjusted, so I delete 4 or 5 black images before I save the
file.
2. Tight sleeve or collar. This is sort of obvious, but winter in the
Midwest is coming. So I will see overweight diabetic patients in too
small sweatshirts that I will roll up to get to the AC vein. And it is
a tight as a blood pressure cuff. "Let's just take that arm out of the
sleeve"...80% of the female patients: "I'm not wearing a shirt (or a
bra)". (Lady, just because you came to the eye doctor doesn't
mean you are going to get out of here without getting a shot!).
Dye gets "stuck" in arm. Low cardiac output (and sometimes tight
sleeve). Hold arm up after injection and the dye comes in all of
sudden.
Armrest, or lack thereof. My armrest is 7 inches high, not above the
level of the heart but it helps. One office I did angiography at had
the patient grip the edge of the table, the nurse injected the back of
the hand. This added 5-8 seconds to the circulation time in most
patients.
3. Painless perivascular leakage. About 20 years ago there was a JOPS
cover story on this. (The JOPS search function is not available, so I
cannot link to it). I have seen it few times, generally the patient's
arms are black and blue because they bruise so easily. 20-40 seconds
and very little dye ("Does your arm burn?"..."No"). Turn on the light, and
there is what looks like a bad extravasation. The veins are so porous
that the dye just seeps out, but no burning.
4. Vasovagal syncope. Larry Merin had a JOPS article about 20 years
ago. The patient fainted at the camera but stayed in the chin rest
with eyes open, blood pressure dropped significantly, very slow
circulation, slow choroidal perfusion.
5. Venous malformation (loop to nowhere). This is the first I have
heard of it, but it seem a plausible explanation.
6. Oops, missed the carotid! Not sure which retina book I read this
in, but the theory was a bolus of dye might act in a laminar fashion,
i.e. travel along the walls of the vessels but miss the carotid artery
and therefore not get to the head and the eyes.
I had a young, healthy male patient where we had a good, fast
injection. No tight sleeve or collar, but it didn't get to the eye for
about one minute, and then it seemed to be the recirculation phase,
i.e. the dye went through the body twice before it showed up in the
eye. Only remember it happening in that one patient.
Tom
Quoting Hasan Omairah <shagroon@xxxxxxxxxxx>:
It happened to
me twice so far. Both were females, diabetics, and had weight problem.
We don't use
butterfly needles anymore -quite rarely I guess - instead a nurse inserts an
angio-cath. On both cases the line was in place and there were no sign of
leakage or extravasation. Both patients had fairly good media, with
nicely dilated
pupils, their cooperation and fixation was very good though, nevertheless No
dye was visible during any stage, and I had to check the camera in-between
phases just to make sure all are OK. I used a drop from what was left
in the FA
ampule, one a small piece of tissue, and another drop from
Benoxinate/fluorescein
on another piece of tissue, had it in-front of the camera and took
few shots; still both fluoresce, therefore I knew the filter,
barrier, camera and flash are fine, the culprit was something else!
We have seen
the patients on intervals of (1wk, 1month, 3months, and 1 year) post
injection,
and they didn't complain of any pain, skin necrosis, or any other sign of
extravasation, but strangely both experienced discoloration of their
urine, and
the discoloration lasted over one day, which I believe was consistent
with the
dye being pushed in ok. No skin discoloration on or near the
injection site, no swelling, or anything that is abnormal!
In our practice
we use AK-Fluor - fluorescein injection 10% for so many years and we
didn't have
any problem with its stability, and both of these cases were from two
different
batches. Still; normal FA's were obtained from both batches on
different patients.
Nothing we
can think of explained why no dye was visible.
Hasan
,-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-,
, Hasan Omairah AAS COT OCT-C CRA
, Department of Ophthalmology MBC (97)
, King Faisal Specialist Hospital & Research Center
, PO Box 3354
, Riyadh, 11211
, Saudi Arabia
,--------------
, Mobile-Pager within KFSH 44345
, +966 11-557-6131(work)
, +966 11 442-4975 (fax)
, -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-,
"True wisdom comes to each of us when we realize how little we
understand about life, ourselves, and the world around us" -Socrates
Subject: [optimal] No infiltration...no Fluorescein
Date: Tue, 8 Oct 2013 09:39:57 -0400
From: slusk@xxxxxxxxxxxxx
To: optimal@xxxxxxxxxxxxx
No infiltration...no Fluorescein
Has anyone ever experienced a phenomenon where an FA injection did
not infiltrate, or at least we did not have any indication of
infiltration, and no dye infuses into the retinal blood vessels? All
camera functions we're verified and set correctly and the Color
fundus and redfree images we're good.
Just curious.
Thanks
Steve Lusk, CRA
Vistar Eye Center Retina Consultants
5296 Peters Creek Road
Roanoke, VA 24019
Phone: (540) 342-3400 ext. 4731
Fax: (540) 362-1155
slusk@xxxxxxxxxxxxx
www.vistareye.com
T
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