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Corneal Infarction Following Foam Sclerotherapy. John Koziarski, MD Family Surgical Veins Battle Creek, MI. Financial Disclosures. I will be discussing the off-label use of medications. 2005 25 Year old Female. 6 yr history of pain, heaviness, aching since pregnancy 6 years prior - PowerPoint PPT Presentation
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John Koziarski, MDFamily Surgical Veins
Battle Creek, MI
I will be discussing the off-labeluse of medications
2005 25 Year old Female
6 yr history of pain, heaviness, aching since pregnancy 6 years prior
No significant PMH
No hx of migraines
Ultrasound Exam
Bilat GSV refluxBilat SSV refluvIncompetent
Cockett perforator right leg
Bilat deep system insufficiency
TreatmentSurgical
Sclerotherapy
Thermal ablation bilat GSV and bilat SSV
Ligation incompetent Cockett perforator
Multiple sessions with 0.66% Polidocanol liquid
2009Over the previous 1 yr UltrasoundIncreasing pain and
aching and swelling left leg despite compression stockings
5-6 mm reticular veins over thighs, 2-3 mm varicosities legs
No evidence of bilat GSV of bilat SSS
No neovascularity or refluxing acc veins
3 incompetent perforators left thigh/leg
Bilat deep system reflux
TreatmentChemoablation Perf Sclerotherapy
Superficial Varicosites3 perforators left
thigh/leg treated0.5 ml of 2% STS/
CO2 foam (1:4)Perivenous
injection of NS to compress vein
Perforators closedNo complications
Jan 2010 Treatment of superficial varicosities
Left thigh2 ml 0.2% liquid STS4 ml 0.4% STS/CO2
foam (1:4)Stocking appliedPt went to work (in
another physician’s office)
30 min post injection 60 min post injectionCalled office c/o
blurred vision left eye
Reassured that visual disturbances can happen and should resolve.
Said she would lie down for a while at work.
Called office againStill blurred vision
left eyeNow pain in right
eye (10/10) and blurred vision rt eye
NauseaBP 90/60 HR 70
SaO2 97%
To ERChief Complaint Diagnostic Work UpBlurred vision left
eye resolvedStill had pain IN her
rt eye and decreased vision
HeadacheChest pain/pressureNauseaNo focal neurologic
deficit
EKGTroponinCXRMRI BrainMRA/MRV brain
All Normal
ER DispositionTreated DischargedDilaudidZofranImitrex
No real improvement in pain, but nausea improved
Vicodin, ZofranF/U Family Dr in
am
24 hours post injectionFamily Physician OphthamologistMain complaint
right eye pain and vision loss
Some chest pain/pressure
Did not “seem” like a migraine
Later- CT scan chest- No PE
Vision right- 20/100 left- 20/20
Retina normalIOP normalRt cornea “ground
glass” appearanceIschemic?
Right Eye Left Eye
Cornea
TreatmentEye patchDrops
6 WeeksCornea HealedVisual acuity normalSome light sensitivity
Further WorkupTransthoracic Echo
Small PFO
TEE with bubble studyNo PFO
TCD with bubble studyNo PFO
Further WorkupNeurologist• Hypercoagulable w/u• Negative
• Repeat MRI (Jun 2010)• Normal
• Repeat MRI (Dec 2010)• Normal
Frequency of Visual Disturbances (VD) after Foam Sclerotherapy of 1.4%
Could be “positive” or “negative” or both50% headacheOther Sx included nausea, photophobia,
chest pressure, and parathesias.18/20 pts with sx had Diffusion-Weighted
MRIAll were normal. 5 had Non specific
White Matter lesions
Hypothesizes that endothelin-1, released from the treated vessel endothelium, may be the mediator
VD can occur with liquid or foam, though more frequent with foam (Guex et al Dermatol Surg 2005)
Endothelin-1 has been associated with retinal vasospasm, migraine with aura, and bronchconstriction
CorneaNo blood supplyReceives O2 and nutrients from tears and
aqueous humorEndothelin-1 has been found in the
Epithelium and tears (Lu et al.Exp Biol Med 2001)
Effects on Cornea are not well understood. May effect cell growth and apoptosis, and may promote corneal healing. (Salvatore, et al. J of Ophth 2010)
Summary
30 yr old female, no history of migraine, underwent foam sclerotherapy of reticular veins with 4 ml of 0.4% STS/CO2 foam and 2 ml 0.2% STS liquid
Experienced what seemed to be “typical” visual disturbances, but with the addition of corneal injury
Etiology is unclear