Intra-operative fluorescein videoangiography-related nephrotoxicity in intracranial aneurysm surgery: Single center, observational cohort study.

OBJECTIVES: Intra-operative fluorescein video angiography (FL-VA) has been given increasing attention recently and several studies reported its high utility in neurovascular surgery. The aim of this study was to evaluate the safety of FL-VA in a prospective, single-center cohort of patients operated due to cerebral aneurysms. PATIENTS AND METHODS: This is an observational cohort study including 150 patients operated due to intracranial aneurysms. The study group consisted of 70 consecutive patients operated with the use of fluorescein video angiography. Post-operative acute kidney injury (AKI) occurrence as well as systemic adverse reactions were reported and further compared with 80 matched controls where FL-VA was not used. Statistical analysis was performed using non-parametric tests (Fisher's exact test). RESULTS: Post-operative AKI was observed in 17,1% of patients in the study group with only half presenting with acute functional impairment. All of these patients presented initially due to aneurysm rupture. Pre-existing renal dysfunction and hypertension occurred in 16,7% and 33,3%, respectively. No systemic complications following FL-VA were reported. When compared to matched controls, no statistically significant difference regarding AKI occurrence was observed between these two patient populations. CONCLUSION: Intra-operative fluorescein video angiography proved to have a good safety profile in our cohort. The results of this study suggest that post-operative acute kidney injury observed in patients with subarachnoid hemorrhage is not related to fluorescein use.

Can sodium fluorescein cause contrast-induced nephropathy?

BACKGROUND: Contrast-induced nephropathy (CIN) is a common cause of acute kidney injury (AKI), and can be diagnosed when the etiology of AKI is unclear other than via a contrast agent. Fluorescent angiography (FAG) with fluorescein sodium dye is generally considered to be safe for patients with kidney diseases. However, it remains unresolved whether or not FAG can induce CIN. METHODS: Patients from two tertiary hospitals who underwent FAG and had serum creatinine results within 4 weeks before FAG and 3 days after FAG between 2001 and 2017 were retrieved. Cases with concurrent iodinated contrast imaging or undergoing dialysis were excluded from the analysis. CIN was defined by two criteria: CIN criteria as >0.5 mg/dL or >25% increase in serum creatinine (sCr) level within 3 days after FAG, and contrast-induced acute kidney injury (CIAKI) criteria as ≥0.3 mg/dL increase within 2 days or ≥50% increase within 7 days after FAG. RESULTS: A total of 979 patients were screened, and we found 124 patients with AKI after FAG. After excluding 32 patients with clear causes of AKI other than FAG, the incidence rates of CIN were 7.3% by CIN criteria and 6.4% by CIAKI criteria. CIN incidence had a U-shaped distribution according to chronic kidney disease (CKD) stages in CIN criteria, while linear association between CIN incidence and CKD stages were found in CIAKI criteria. Kaplan-Meier curves showed the CIN group was significantly associated with end-stage renal disease (ESRD) progression (log-rank P < 0.001, in both CIN criteria and CIAKI criteria), and adjusted hazard ratios by multivariable Cox regression were 2.23 [95% confidence interval (CI) 1.468-3.378] in CIN criteria and 2.17 (95% CI 1.462-3.232) in CIAKI criteria. CONCLUSIONS: According to CIN and CIAKI criteria, FAG may cause CIN and appeared to be a possible risk factor for ESRD progression. However, CIN or CIAKI criteria themselves may overestimate AKI and require meticulous attention to the interpretation of results.

Fluorescein-guided surgery for spinal gliomas: Analysis of 220 consecutive cases.

OBJECTIVE: Sodium fluorescein (FL) is widely used as a fluorescent tracer for brain tumor resection. However, FL-guided resection of spinal gliomas has been reported only occasionally. To evaluate the safety, characteristics, and usefulness of FL-guided surgery in the resection of spinal glioma. METHODS: Between January 2015 and December 2018, 220 consecutive patients with 227 spinal gliomas underwent FL-guided resection using the Zeiss Pentero 900 surgical microscope with an integrated YELLOW 560 filter. FL evaluation and clinical outcomes were analyzed. RESULTS: No FL-related complications occurred in this series. Entire tumor fluorescence was observed in 161 (70.93%) gliomas, nodular fluorescence in 46 (20.26%) tumors, and no fluorescence in 20 (8.81%) tumors. The intraoperative fluorescence of 217 (95.59%) gliomas was highly correlated with preoperative contrast-enhancing magnetic resonance imaging, except in eight ependymomas, one pilocytic astrocytoma, and one diffuse midline glioma. Gross-total resection was achieved in 78.85% (179/227) of spinal gliomas, including 94.30% (149/158) ependymal tumors and 43.48% (30/69) astrocytic and oligodendroglial tumors. At the final clinical follow-up, the spinal function of 75 (33.04%) patients showed significant improvement, 105 (46.26%) showed stabilization, and 47 (20.70%) showed deterioration. CONCLUSION: FL is a safe and useful real-time tool that could enhance tumor borders or residual tumors and hence increase the gross-total resection rate in cases with contrast-enhanced tumors.

Eyeliner Induces Tear Film Instability and Meibomian Gland Dysfunction.

PURPOSE: To compare the degree of tear film instability and severity of meibomian gland dysfunction between subjects who use eyeliner and those who do not use eyeliner. METHODS: This cross-sectional study included 42 healthy volunteer women who had no dry eye symptoms (Ocular Surface Disease Index score < 13) and aged between 18 and 40 years. The subjects were classified into 2 groups: an eyeliner-use group (EL: regularly used eyeliner ≥3 d/wk and continuously used ≥6 mo) and a noneyeliner-use group as controls. A questionnaire for ocular surface symptoms using a visual analog scale was administered. Then, a number of eye tests were performed [grading of conjunctival inflammation, fluorescein tear breakup time, ocular surface fluorescein staining, Schirmer I, evaluation of meibomian gland (MG) function, detection of eyelid margin abnormalities, and Demodex detection]. RESULTS: Tear breakup time was significantly lower in the EL group compared with controls (3.0 ± 1.9 vs. 5.8 ± 2.1 s, P < 0.001). MG grading was significantly higher in the EL group than in controls (P = 0.004); higher grade (grades 2-3) was found in 85.7% of EL and 47.6% of controls. Meiboscore was also higher in EL than in controls (P = 0.001). Regarding the morphological changes in lid margin, only telangiectasia was detected significantly more in EL (28.6%) compared with controls (4.8%) (P = 0.041). Conjunctival inflammation was observed 4 times more in EL (66.7%) than in controls (14.3%), P = 0.001. Other outcomes included ocular surface symptoms and fluorescein staining scores, and Schirmer I and Demodex detection were not significantly different between both groups. CONCLUSIONS: The regular use of eyeliner induces tear film instability and MG dysfunction.

Systemic reaction to and interference with urine protein measurements after intravenous fluorescein injection.

BACKGROUND: Fluorescein angiography is an important and frequently used diagnostic tool in ophthalmological practice. In this case report we describe a patient who experienced an anaphylactic reaction after the injection of fluorescein. Furthermore, we report an interference with laboratory testing by fluorescein in this patient and summarize the literature on this topic. CASE PRESENTATION: An 86-year old Caucasian woman undergoing fluorescein angiography due to suspected peripapillary neovascularizations collapsed after the injection of fluorescein. The patient developed an anaphylactic reaction. With fluid resuscitation and oxygen therapy, the patient regained consciousness after a few minutes. The patient was admitted to the geriatric ward for observation, and routine blood and urine tests were performed. Urine protein concentration appeared to be falsely increased as a consequence of disturbance of the laboratory analysis by the presence of fluorescein. CONCLUSIONS: Serious complications can occur with fluorescein angiography, such as an anaphylactic reaction. In the case of anaphylaxis appropriate supportive measures including the use of oxygen and epinephrine (e.g. EpiPen), should be available to prevent morbidity and mortality from this test. Furthermore, these potential complications should be taken into consideration when choosing the healthcare setting for fluorescein angiography, such as the immediate availability of an acute medical team. Several studies have demonstrated the interference of laboratory analyses by fluorescein. The majority of these studies were published 10 to 30 years ago. By presenting this case, the authors hope to bring renewed attention to this phenomenon among clinicians, as falsely increased or decreased laboratory values can result in unnecessary diagnostics and/or therapy.

Extracapsular dissection in peripheral nerve schwannoma surgery using bright light and fluorescein sodium visualization: case series.

BACKGROUND: Schwannomas are the most frequent peripheral nerve sheath tumors and are treated by surgical resection when symptomatic. Tumor removal is performed by intraneural dissection and enucleation. In order to safely remove the tumor from the nerve, the use of sodium fluorescein has recently been proposed to distinguish the tumor from the adjacent normal nerve fibers, before incision of the tumor pseudocapsule and during intraneural tumor dissection. METHODS: We report a consecutive case series of 5 peripheral nerve schwannomas operated in 4 patients, in which we evaluate the usefulness of sodium fluorescein compared to usual visual landmarks, at each step of the surgical procedure. RESULTS: After exposition of the schwannoma, sodium fluorescein helped with the localization of intracapsular en passant nerve fascicles in only one case. Hence, the definition of a safe entry zone for capsular incision relied mainly on nerve monitoring and direct visualization of en passant nerve fascicles under microscope. During intraneural dissection, there was a sharp contrast between the fluorescent tumor and the non-fluorescent adjacent pseudocapsule in most cases but the colorimetric variation between tumor and normal tissue induced by fluorescence did not outperform the natural contrast between the yellow true capsule and the gray-red layers of the pseudocapsule. CONCLUSION: Based on these results, we consider that the limited additional value of sodium fluorescein in primary peripheral nerve schwannoma surgery does not warrant its use in daily clinical practice. Additional studies are needed to assess its usefulness during the surgery of recurrences and tumors which are intertwined with several fascicles of origin such as neurofibromas.

How Safe is the Use of Intrathecal Fluorescein? An Experimental Study.

AIM: To investigate the effects of fluorescein-sodium on neural tissues. MATERIAL AND METHODS: Twenty-one Wistar rats were randomly divided into three experimental groups: control (group 1) and fluorescein-sodium groups with different doses (groups 2 and 3). In the control group, craniectomy following with durotomy was performed with the help of a loupe microscope, and a dry sponge was overlayed to the brain tissue. In the study groups, the open dura was covered with a sponge soaked with 0.02 mg (group 2) and with 0.2 mg (group 3) fluorescein sodium following craniectomy. Three weeks postoperatively, rats were sacrificed for the histopathologic evaluations. RESULTS: Fluorescein-induced apoptosis occurs in a dose-dependent manner in rats' neurons. It was determined that neuron and neuroglial cell TUNEL staining was statistically different among the three groups (p < 0.001). Our results indicated that fluorescein induces apoptosis, resulting in increased nuclear factor kappa beta (NF-kß) expression in a dose-dependent manner. CONCLUSION: Fluorescein sodium is used frequently during surgery for CSF fistulas. However, information in the literature about its safety is insufficient. Our study holds promise for the development of new studies on the reliability of this agent.

Adverse reactions to fluorescein angiography: A comprehensive review of the literature.

We reviewed literature on adverse reactions to intravenous fluorescein angiography using PubMed and found 78 articles in English from 1961 to 2017. The reported rates of adverse reactions were overall 0.083-21.69%, separated into mild (1.24-17.65%), moderate (0.2-6%), and severe (0.04-0.59%). There were 1:100,000 to 1:220,000 deaths. Fluorescein concentration, volume injected, speed of injection, temperature, and contaminants were not correlated with the incidence of reactions. Patient characteristics including other comorbid diseases, allergy history, age, race, and gender showed only an increased rate of reaction in patients with a history of reaction to fluorescein. Although a number of studies examine techniques to reduce adverse reactions to intravenous fluorescein angiography, to date, the only proven method is reviewing allergy history, specifically a history of previous reaction to fluorescein.

Dacryocystosclerotherapy as an alternative to dacryocystectomy.

Purpose: The aim of this study was to perform a histopathological assessment of the efficacy of sclerosing agents in dacryocystosclerotherapy (DCST) and to evaluate its role as an alternative to dacryocystectomy (DCT) in a specific group of patients. Methods: Thirteen lacrimal drainage systems of 10 patients with primary acquired nasolacrimal duct obstruction (PANDO) were studied. All patients were awaiting a DCT, indications being repeated attacks of dacryocystitis with severe systemic or ocular co-morbidities and/or refusal for a dacryocystorhinostomy. Fluorescent labelled sodium tetradecyl sulphate (SDS) or bleomycin were used as sclerosing agents for a DCST taking specific precautions. All patients underwent a DCT after 4 weeks and histopathological evaluation was performed to assess the changes and extent of DCST. Results: There were nine females and one male, and all patients were above the age of 60 years. Of the 13 lacrimal systems studied, the mean duration of PANDO was 1.3 years. All the patients had associated systemic and/or ocular co-morbidities. SDS and bleomycin were used in 6 and 7 lacrimal systems, respectively. The mean doses used for SDS and bleomycin were 0.26 and 0.31 cc, respectively. The post-injection phase was uneventful except for one patient who had a moderate inflammation, which resolved with low dose oral steroids. Histopathological features were more marked in the SDS group and included loss of epithelium, luminal closure, gross fibrosis across the lacrimal sac wall, congestion and hyalinization of blood vessels, and multiple areas of haemorrhages in the sac wall. Conclusions: DCST is a safe and effective alternative to DCT in very carefully selected patients. Histopathology demonstrates SDS to be more effective as compared to bleomycin.

Safety and feasibility of low-dose fluorescein-guided resection of glioblastoma.

OBJECTIVES: The extent of resection is an independent predictor of prognosis in patients with glioblastomas. Although fluorescein sodium may enhance intraoperative visualization of tumor margin and increase the extent of glioblastoma, the dose related anaphylactic reaction is still a major concern. In the present study, we used allergy skin testing to exclude the patients susceptible to anaphylaxis preoperatively, and then investigated the feasibility of low-dose fluorescein sodium to guide glioblastoma resection intraoperatively, thereby to improve the safety of fluorescein-guided glioma resection. PATIENTS AND METHODS: Patients with suspected glioblastoma based on brain MRI were subjected to allergy skin intradermal tests for fluorescein sodium preoperatively. Only those with negative allergy skin tests received intravenous injection of low dose fluorescein sodium (1-2 mg/kg) during microsurgical tumor resection under dedicated Yellow 560 filter. The degree of fluorescent staining was documented and the extent of resection was evaluated by MRI scan. RESULTS: One patient with positive allergy skin test was excluded from fluorescein sodium administration and no anaphylactic reaction was found during fluorescein sodium guided surgery in the patients who were negative for allergy skin tests. The low dose fluorescein sodium (1-2 mg/kg) could provide enough visualization of tumors with sufficient discrimination from surrounding normal brain tissue and improve the resection extent of glioblastoma. CONCLUSION: Preoperative allergy skin test is a useful method to exclude the patients susceptible to anaphylaxis, together with intraoperative low dose fluorescein sodium administration, may facilitate glioblastoma resection by fluorescence guidance while avoid safety concern of dose-related anaphylaxis.

Dynasore protects the ocular surface against damaging oxidative stress.

Water soluble "vital" dyes are commonly used clinically to evaluate health of the ocular surface; however, staining mechanisms remain poorly understood. Recent evidence suggests that sublethal damage stimulates vital dye uptake by individual living cells. Since cell damage can also stimulate reparative plasma membrane remodeling, we hypothesized that dye uptake occurs via endocytic vesicles. In support of this idea, we show here that application of oxidative stress to relatively undifferentiated monolayer cultures of human corneal epithelial cells stimulates both dye uptake and endocytosis, and that dye uptake is blocked by co-treatment with three different endocytosis inhibitors. Stress application to stratified and differentiated corneal epithelial cell cultures, which are a better model of the ocular surface, also stimulated dye uptake; however, endocytosis was not stimulated, and two of the endocytosis inhibitors did not block dye uptake. The exception was Dynasore and its more potent analogue Dyngo-4a, both small molecules developed to target dynamin family GTPases, but also having off-target effects on the plasma membrane. Significantly, while Dynasore blocked stress-stimulated dye uptake at the ocular surface of ex vivo mouse eyes when treatment was performed at the same time as eyes were stressed, it had no effect when used after stress was applied and the ocular surface was already damaged. Thus, Dynasore could not be working by inhibiting endocytosis. Employing cytotoxicity and western blotting assays, we went on to demonstrate an alternative mechanism. We show that Dynasore is remarkably protective of cells and their surface glycocalyx, preventing damage due to stress, and thus precluding dye entry. These unexpected and novel findings provide greater insight into the mechanisms of vital dye uptake and point the direction for future study. Significantly, they also suggest that Dynasore and its analogues might be used therapeutically to protect the ocular surface and to treat ocular surface disease.

Análise da microbiota em tonômetros de aplanação de Goldmann / Analysis of the microbiota in Goldmann applanation tonometers

RESUMO Objetivos: Analisar a prevalência da microbiota nos tonômetros de aplanação de Goldmann nos consultórios do SUS e definir o grau de contaminação dos tonômetros e a eficácia da assepsia do cone do tonômetro de aplanação. Métodos: Estudo transversal em que foi realizado a coleta de 60 "swabs", divididos nos três tonômetros de aplanação dos ambulatórios do SUS em dois momentos distintos. No primeiro realizou-se a coleta no início dos atendimentos e no segundo momento, a coleta foi realizada ao final de todos os atendimentos. Todos "swabs" foram colhidos no meio Stuart e foi realizada a cultura em meio de bactérias. Resultados: Das 60 amostras, apenas uma apresentou crescimento de agente patogênico, a Escherichia coli. Conclusão: Independente dos vários métodos que o oftalmologista escolher para realizar a assepsia, a mesma é imprescindível para a manutenção de uma boa saúde ocular do paciente, evitando assim a transmissão e propagação de patógenos por meio do exame oftalmológico e concluímos também que o método utilizado pelo nosso serviço parece ser eficaz nesta profilaxia.

ABSTRACT Objective: Analyze the microbiota prevalence in the Goldmann applanation tonometers in the clinic of the SUS to define the contamination of the tonometers and the efficacy of asepsis of the applanation tonometer cone. Methods: A cross-sectional study was carried out to collect 60 "swabs" divided into the three aplanation tonometers of SUS clinics at two different times. In the first one, the collection will be performed at the beginning of the visits and at the second moment, the collection will be performed at the end of all the visits. All swabs will be harvested in the Stuart medium and culture was carried to sow bacteria. Results: Of the 60 samples, only one showed pathogen growth, Escherichia coli. Conclusion: Regardless of the various ways the ophthalmologist chooses to perform asepsis, it is essential for the maintenance of good patient eye health, thus avoiding the transmission and propagation of pathogens through ophthalmologic examination, and we also conclude that the method used by our patient seems to be effective in this prophylaxis.

Fluorescein Staining of Intraocular Lenses.

BACKGROUND: Recent case reports have indicated that intraocular lenses may be discoloured by systemically or locally applied fluorescein. Since very few data are available on the susceptibility of intraocular lenses to fluorescein, an experimental survey on lens discolouration was performed. MATERIAL AND METHODS: Intraocular lenses fabricated from polmethylmethacrylate (PMMA), silicone, hydrophobic acrylic copolymers, and hydrophilic acrylic copolymers were exposed to 10% fluorescein. Staining effects were determined by standardised quantification of light transmission. RESULTS: Intraocular lenses fabricated from PMMA, silicone, or hydrophobic acrylic copolymer did not exhibit any measurable dye uptake after exposure to fluorescein. Intensive and rapid discolouration occurred in hydrophilic acrylic intraocular lenses. The transmission of blue light was reduced by 22% after 1 second and by 74% after 10 minutes of dye exposure. CONCLUSIONS: The results indicate that hydrophilic acrylic intraocular lenses develop rapid and intensive discolouration and reduced light transmission after exposure to fluorescein. Lenses fabricated from other materials (PMMA, silicone, hydrophobic acrylic copolymers) were not discoloured by fluorescein staining.

Anaphylactic Shock After Intravenous Fluorescein Administration for Intraoperative Cystoscopy.

BACKGROUND: Rates of administration of intravenous sodium fluorescein during cystoscopy have increased since indigotindisulfonate sodium was removed from the market in 2014. Although sodium fluorescein has been extensively evaluated and found to be safe, side effects including anaphylaxis have been observed, with an incidence between 0.05% and 1.0%. CASE: We present a case of anaphylactic shock after administration of intravenous sodium fluorescein for the assessment of ureteral efflux in a patient with a history of frequent severe allergic reactions undergoing urethral lysis and cystoscopy for urinary retention. Cardiopulmonary structure and function were evaluated and found to be normal. An elevated serum tryptase level was identified, indicating an anaphylactoid reaction. Timely recognition of symptoms associated with a severe allergic reaction in the setting of hemodynamic instability with prompt supportive and pharmacologic therapy was vital in the patient's recovery. CONCLUSION: Health care providers must be aware of this potential complication, especially in patients with a history of severe allergic reactions.

Effect of fluorescein angiography on renal functions in type 2 diabetes patients: A pilot study.

Fluorescein angiography (FA) is an important tool for the diagnosis and management of diabetic retinopathy. However, the safety of fluorescein sodium on renal functions is not fully understood. One hundred type 2 diabetes patients, within the Ophthalmology Outpatient Clinic at Alexandria Main University Hospital, Egypt, were enrolled in this prospective observational study to determine the safety of FA on renal function. Serum creatinine and cystatin C were measured pre- and 2 days post-FA. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) was measured pre- and 4 hours post-FA. Renal injury was defined as a 25% increase in serum creatinine, cystatin C, or uNGAL. The study included 71 females and 29 males, with a mean age of 55.73 ± 7.29 years. Baseline serum cystatin C and uNGAL were 0.89 ± 0.34 mg/L and 21.7 ± 2.39 ng/mL, respectively. Serum cystatin C and uNGAL significantly increased after FA to 0.95 ± 0.36 and 27 ± 2.81, respectively (P <0.001). Eleven patients (11%) experienced more than a 25% rise in serum cystatin C from baseline, whereas 40 patients (40%) experienced more than a 25% increase in uNGAL levels after FA. However, the mean serum creatinine level did not change significantly after FA (P = 0.061). Only one patient experienced more than a 25% rise in serum creatinine from baseline. FA showed a significant increase in early sensitive acute kidney injury biomarkers (as serum cystatin C and uNGAL) in substantial number of patients, suggesting but still not proving, a potential harmful effect of FA on kidney functions. These findings were not demonstrated using ordinary serum creatinine.

Safe intrathecal fluorescein use for identification of cerebrospinal fluid leaks: Case-report and perioperative algorithm description. / Uso seguro de fluoresceína intratecal en la localización de las fístulas de líquido cefalorraquídeo: descripción de un caso e implementación de un algoritmo perioperatorio.

Intrathecal injection of fluorescein is a method for repairing cerebrospinal fluid fistulas. The most frequent surgical procedure is endonasal endoscopy and the purpose of injecting this dye is to locate the fistula. The anaesthesiologists usually perform the puncture, therefore it is necessary to review this method and to specify some anaesthetic considerations such as correct dosing, safe management protocols and medical-legal aspects. In this case-report we describe the pre, intra and postoperative protocol of action implemented in our department that basically consists of: obtaining a specific consent, prior neurological/ophthalmologic assessment to rule out hypertension and brain damage, use of corticosteroids and previous antihistamines, choosing the correct dose and concentration of intrathecal sodium fluorescein (maximum 1ml at a concentration of 5% diluted in 9ml of cerebrospinal fluid) and close intra and postoperative monitoring.

Intraoperative Cystoscopic Evaluation of Ureteral Patency: A Randomized Controlled Trial.

OBJECTIVE: To compare different modalities to aid in the evaluation of intraoperative ureteral patency on cystoscopy in the postindigo carmine era. METHODS: In a randomized controlled trial, participants undergoing pelvic surgery were randomized into one of four groups: saline distention (control), 10% dextrose distention, oral phenazopyridine, or intravenous sodium fluorescein. Our primary outcome was visibility of the ureteral jets. Secondary outcomes included surgeon satisfaction; adverse reactions including allergies, urinary tract infections, urinary retention, cystoscopy times, and ureteral obstruction; and delayed diagnosis. Participants were followed for 6 weeks. A sample size of 176 participants was planned to demonstrate a 30% difference in the visibility scale. All analyses were performed in an intention-to-treat fashion. RESULTS: From February 25, 2015, through August 2015, 176 participants were enrolled; 174 completed the trial, and two did not undergo intervention. Forty-four participants were included in the phenazopyridine, dextrose, saline, and sodium fluorescein groups. Sodium fluorescein and 10% dextrose resulted in significantly improved visibility and satisfaction when compared with the control group (P<.001 and P=.004, respectively). Dextrose provided the highest satisfaction and phenazopyridine provided lowest, but visibility was not statistically different between the two groups (P=.101). Three ureteral obstructions were identified intraoperatively and none in the postoperative period. Mean total cystoscopy time varied between 4.0 and 4.8 minutes and postoperative urinary retention rate was 50% across all groups. Overall urinary tract infection rate was 24.1%, which was similar between interventions. There were no related adverse events. CONCLUSION: Compared with the control, 10% dextrose and sodium fluorescein resulted in improved visibility and provided significantly more satisfaction in the evaluation for ureteral patency with no considerable increase in operative time or morbidity. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, https://clinicaltrials.gov, NCT02476448.

Intravenous fluorescein angiography-associated adverse reactions.

OBJECTIVES: To assess (i) the adverse reactions (ARs) associated with intravenous fluorescein angiography (IVFA); (ii) the relationship between a known history of IVFA-associated AR and ARs on the subsequent IVFA test; and (iii) the dose-response relationship between intravenous sodium fluorescein (NaFl) injection and ARs associated with IVFA. DESIGN: Retrospective chart review. PARTICIPANTS: A total of 2247 patients with 3381 consecutive IVFAs between May 2013 and April 2014. METHODS: Fisher's exact tests or χ2 tests were used to compare the percentage difference of IVFA-associated ARs for different categorical variables. Logistic regressions were used to assess the relationship between a known history of IVFA-associated AR and any AR(s) on a subsequent IVFA test. RESULTS: The overall percentage for IVFA-associated ARs was 3.3%. Adjusted for age and sex, patients who had a previous IVFA-associated AR(s) were 6.2 times more likely (adjusted odds ratio 95% CI 3.4-11.2, p < 0.0001) to have an AR compared to those who did not. Among 17 patients who had 2 repeated IVFA tests and an AR on the first IVFA test, the rate of AR on the second test was lower in patients who received a reduced dosage of NaFl (n = 14) compared to those with the standard dosage (n = 3) (35.7% vs 66.7%); however, this finding was not statistically significant (p = 0.5368). CONCLUSIONS: The rate of IVFA-associated ARs in this study was low. Patients who had a known IVFA-associated AR were more likely to re-experience an AR on a subsequent test compared to those who did not. In addition, a reduced NaFl dose did not significantly reduce the chance of experiencing an AR on a subsequent test, which is likely because of the insufficient power of this comparison.

A lower dose of fluorescein sodium is more suitable for confocal laser endomicroscopy: a feasibility study.

BACKGROUND AND AIMS: Image quality can be guaranteed with the conventional dosage of fluorescein sodium in probe-based confocal laser endomicroscopy (pCLE). However, yellow discoloration of the skin seriously affects daily life and simultaneously increases the risk of adverse events such as allergic reactions. The aim of this study was to test whether a lower dosage of fluorescein sodium can provide satisfactory image quality and to compare the diagnostic accuracy of gastric intestinal metaplasia (GIM) through a randomized blind controlled trial. METHODS: Consecutive patients were randomly assigned to different doses of fluorescein sodium. Image quality was determined by the endoscopists' subjective assessments and signal-to-noise ratio (SNR) assessment systems. Skin discoloration was tested using a neonatal transcutaneous jaundice detector. In addition, consecutive patients with a known or suspected diagnosis of GIM were examined by pCLE with the lower dose and the traditional dose. RESULTS: Only 0.01 mL/kg dose of 10% fluorescein sodium led to a significant decrease in image quality (P < .05), and a dose of 0.02 mL/kg had the highest SNR value (P < .05). There were no significant differences in skin discoloration between the 0.01 mL/kg and 0.02 mL/kg doses (P = .148) and no statistical difference in the diagnostic accuracy of pCLE for GIM between the 0.02 mL/kg and 0.10 mL/kg doses (P > .05). The kappa values for the correlation between pCLE and histopathology were 0.867 (95% confidence interval, 0.782-0.952) and 0.891 (95% confidence interval, 0.811-0.971). CONCLUSIONS: The 0.02 mL/kg dose of 10% fluorescein sodium seems to be the best dose for pCLE in the upper GI tract, with comparable image quality with the conventional dose and insignificant skin discoloration. This dose is also very efficient for the diagnosis of GIM.