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.

Reposting this here from Optimal for Tim Bennett. Thanks again for digging up an article regarding this.

Steve

The cause could be a couple of things that you've probably already considered:

Yellow/brunescent cataract that absorbs the excitation light

AV malformation at the injection site that prevents delays normal flow to the eye.

I've seen both of these situations on rare occasions. SOunds like you've ruled those out.

One other cause was reported in the literature by Larry Merin several years ago, related to low blood pressure in a patient experiencing vaso-vagal symtoms. We had it happen once. The patient didn't faint but their BP dropped real low & our only clue was the lack of dye in the retinal vasculature. The docs were confused, but I grabbed the JOP from the shelf & showed them Larry's article. Sure enough it was the same thing.

Just one more possibility to consider. I've attached a pdf of Larry's article for review. Let us know if you get to the bottom of the mystery.

Steve

Patients vein was good... no visible problems during the push, no swelling, no complains of pain.  Got to be about 45 -50 seconds in and still nothing on screen (that's when you get that feeling coming over you that something is not right). Camera was functioning fine, all the filters were working, etc. Still no dye visible after a couple minutes. Patient only commented about slight discomfort, not the typical pain level we see with extravs.

Talked with Doc, talked with patient, decided to inject again. The second time worked fine. Then as patient was going back to doc after FA, I looked at their arm and there was lovely, bright yellow circular stain about the size of a half dollar right at the first injection sight.

 I guess if you are in this career long enough, you'll experience one of these patients eventually.

Gary

This is always the imager's nightmare, isn't it?

Years ago I had a patient. about 36, seemingly healthy, who started to have intermittent episodes of vision loss, and occasional vertigo on quickly standing or shifting position.  BP was within the normal range.  On fundus exam, everything looked normal and the neuro-ophthalmoloigst he had been referred to ordered a fluorescein. 

An absolutely normal, good injection at the left antecubital vein was done, tourniquet removed appropriately, all settings on camera frantically checked, and finally just a bare hint of dye showed up at about 48 seconds!  20 minutes later, fluorescence could still be visualized, more than normal.

After MUCH discussion and speculation by physicians and imagers alike, the patient had a left brachial angiogram - which lead to a carotid angiogram! 

The patient had a vascular abnormality of his left brachial vascular tree - actually a "pouch" under his armpit and it was speculated that the dye got to that pouch and just pooled, tiny amounts escaping occasionally. Similar abnormalities (on a smaller scale) were found in his neck and helped explain his symptoms.

A fluorescein angiogram, injection site right antecubital vein, was done the next week and the arm to retina time was normal, and his both retinas presented with normal findings.

There was nothing in this patient's medical history to indicate that he had such congenital  vascular abnormalities.  The human body is fascinating - and we can never presume anything!

Paula