Corneal infarction following foam sclerotherapy
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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

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Corneal Infarction Following Foam Sclerotherapy

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Corneal infarction following foam sclerotherapy

Corneal InfarctionFollowing Foam Sclerotherapy

John Koziarski, MD

Family Surgical Veins

Battle Creek, MI


Financial disclosures

FinancialDisclosures

I will be discussing the off-label

use of medications


2005 25 year old female

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

Ultrasound Exam

  • Bilat GSV reflux

  • Bilat SSV refluv

  • Incompetent Cockett perforator right leg

  • Bilat deep system insufficiency


Treatment

Treatment

Surgical

Sclerotherapy

  • Thermal ablation bilat GSV and bilat SSV

  • Ligation incompetent Cockett perforator

  • Multiple sessions with 0.66% Polidocanol liquid


Corneal infarction following foam sclerotherapy

2009

Over the previous 1 yr

Ultrasound

  • Increasing 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


Treatment1

Treatment

Chemoablation Perf

Sclerotherapy Superficial Varicosites

  • 3 perforators left thigh/leg treated

  • 0.5 ml of 2% STS/ CO2 foam (1:4)

  • Perivenous injection of NS to compress vein

  • Perforators closed

  • No complications


Jan 2010

Jan 2010

Treatment of superficial varicosities

  • Left thigh

  • 2 ml 0.2% liquid STS

  • 4 ml 0.4% STS/CO2 foam (1:4)

  • Stocking applied

  • Pt went to work (in another physician’s office)


Corneal infarction following foam sclerotherapy

30 min post injection

60 min post injection

  • Called 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 again

  • Still blurred vision left eye

  • Now pain in right eye (10/10) and blurred vision rt eye

  • Nausea

  • BP 90/60 HR 70 SaO2 97%


To er

To ER

Chief Complaint

Diagnostic Work Up

  • Blurred vision left eye resolved

  • Still had pain IN her rt eye and decreased vision

  • Headache

  • Chest pain/pressure

  • Nausea

  • No focal neurologic deficit

  • EKG

  • Troponin

  • CXR

  • MRI Brain

  • MRA/MRV brain

  • All Normal


Er disposition

ER Disposition

Treated

Discharged

  • Dilaudid

  • Zofran

  • Imitrex

  • No real improvement in pain, but nausea improved

  • Vicodin, Zofran

  • F/U Family Dr in am


24 hours post injection

24 hours post injection

Family Physician

Ophthamologist

  • Main 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 normal

  • IOP normal

  • Rt cornea “ground glass” appearance

  • Ischemic?


Right eye left eye

Right Eye Left Eye


Cornea

Cornea


Treatment2

Treatment

  • Eye patch

  • Drops

  • 6 Weeks

  • Cornea Healed

  • Visual acuity normal

  • Some light sensitivity


Further workup

Further Workup

  • Transthoracic Echo

    • Small PFO

  • TEE with bubble study

    • No PFO

  • TCD with bubble study

    • No PFO


Further workup1

Further Workup

Neurologist

  • Hypercoagulable w/u

    • Negative

  • Repeat MRI (Jun 2010)

    • Normal

  • Repeat MRI (Dec 2010)

    • Normal


Corneal infarction following foam sclerotherapy

  • Frequency of Visual Disturbances (VD) after Foam Sclerotherapy of 1.4%

  • Could be “positive” or “negative” or both

  • 50% headache

  • Other Sx included nausea, photophobia, chest pressure, and parathesias.

  • 18/20 pts with sx had Diffusion-Weighted MRI

  • All were normal. 5 had Non specific White Matter lesions


Corneal infarction following foam sclerotherapy

  • 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


Cornea1

Cornea

  • No blood supply

  • Receives O2 and nutrients from tears and aqueous humor

  • Endothelin-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

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


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