[optimal] Re: No infiltration...no Fluorescein
- From: "Bennett, Timothy" <tbennett1@xxxxxxxxxxx>
- To: "'optimal@xxxxxxxxxxxxx'" <optimal@xxxxxxxxxxxxx>
- Date: Wed, 9 Oct 2013 12:40:03 +0000
Both of the mentioned JOP articles can be found here:
http://www.opsweb.org/forums/posts.asp?topic=657644&;
tim
-----Original Message-----
From: optimal-bounce@xxxxxxxxxxxxx [mailto:optimal-bounce@xxxxxxxxxxxxx] On
Behalf Of Egnatz, Thomas James
Sent: Wednesday, October 09, 2013 8:12 AM
To: optimal@xxxxxxxxxxxxx
Subject: [optimal] No infiltration...no Fluorescein
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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