Fluorescein Stain

Fluorescein stain used in Ophthalmology

1. Used in OPhthalmology Indra P Sharma Master of Clinical Optometry ( Y ear I ) Amity Medical School FLUORESCEIN STAIN

2. Objective To understand the biochemical properties, indication and contraindication of fluorescein stain ophthalmology . Sharma IP

3. Contents An overview- Introduction Properties of sodium fluorescein Indication of use Contraindication, side effects and comtamination Conculsion Reference Sharma IP

4. An overview Sharma IP

5. Introduction –Sodium Fluorescein Fluorescein is a synthetic organic compound available as a dark orange/ yellow water-soluble dibasic dye of xanthine series . Sharma IP Soduim Fluorescein - o ne of the most useful and most commonly used diagnostic agents (stains) in ophthalmology and optometry.

6. Fluorescein – Histor ical Perspective Baeyer(1871): F irst f luorescein dye was made . M Straub ( 1888 ) : First used fluorescein for vital staining of th e eye. Burk ( 1 910 ) : First used fluorescein to detect retinal disease Sharma IP

7. Properties of fluorescein A yellow water-soluble dibasic dye of xanthine series Orange red in powder and yellow in solution . Chemical formula: C 2 H 12 O 5 Na Molecular weight: 376.27 Solubility : 50% (in water at 15 C)

8. Optimum condition for observation of fluorescein For dilute concentrations of fluorescein in an aqueous solution Peak absorption: wavelength between 485 and 500 nm Peak emission: wavelength between 525 and 530nm Sharma IP The fluorescent light appears yellow green in blue light. The flourescence increases with greater concentration upto 0.001% and greater pH upto 8 .

9. I mportant clinical characterstics Stains epithelial defects bright green Diffuses into intercellular space Will not stain devitalized Tear film appears yellow orange Can exhibit pseudoflare, Fischer Schweitzer mosaic Promotes growth of pseudomonas aeruginosa in solution Will stain soft contact lens Sharma IP

10. P reparation for tropical ocular use Sharma IP

11. Available forms Can be applied to eye Topically in form of solution By Fluorescein impregnated filter paper strips (dev eloped b y kimura ) Injectable form for IV use

12. Indication for use Sharma IP

13. A. Topical Indication Assessment of ocular surface integrity - Detection of defects in corneal epithelium Fitting assessment of rigid contact lens . Applanation tonometry - Goldmann tonometer /Perkins hand-held tonomet ry Seidel's test - Detection of site of perforation/bleb Lacrimal testing ( Tear flim breakup time (TBUT), Jone dye test, Fluorescein dye disappreance test(FDDT) Sharma IP

14. 1. Assessment of ocular surface integrity Frequently used to detect lesions of ocular surface o wing to its high degree of ionization , it neither penetrates the intact corneal epithelium nor forms a firm bond with any vital tissue . Instillation of dye in cul-de-sac allows determination of corneal & conjunctival lesions such as abrasions ulcers& edema & aids in detection of foreign bodies . Epithelial defect appears as vivid green fluorescence Sharma IP

15. How does staining take place? Sharma IP

16. Staining of corneal infiltrate Corneal abrasion Sharma IP Conjunctival lesion

17. 2. Seidel's test Detection of site of perforation/bleb Sharma IP

18. A major aid in fitting of RGP contact lenses is vital staining of tear film Observation of Fluorescein stained tear film with a cobalt filter of slit lamp allows determination of the fit of lens Useful in assessing the integrity of cornea in CL users as the dye can disclose areas where the CL disrupts the corneal epithelium 3. Contact lens fitting and management Sharma IP

19. Stained eye with contact lens Sharma IP

20. 5.Evaluation for dry eye & lacrimal system Topically applied Fluorescein –used to evaluate integrity of the precorneal tear film& patency of the lacrimal drainage system Assessment of TBUT Evaluating the EPIPHORA Assessment of FDDT To distinguish between Anatomical and functional outflow problems - JONES DYE TEST Sharma IP

21. 4.Applanation tonometry Important component in measuring IOP with Goldmann applanation tonometer Requires the meniscus of tear fluid surrounding the flattened corneal surface be sufficiently stained so that apex of the wedge shaped meniscus is visible . Procedure 1.Anaesthetic & fluorescein instilled in conjuntival sac 2.With Cobalt blue filter,brightest illumination and prism advanced until touches apex of cornea 3.A pattern of 2 semicircles one above ,other below the horizontal midline Sharma IP

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23. B. Intravenous indication 1. Fluorescein angiography About 10 ml of a 5% sol ution injected in antecubital vein The dye normally appears in central retinal artery in 10– 15 sec S hows retinal blood vessels in high contrast Non vascularised , pigmented retinal & subretinal lesions appear as dark areas against the green fluorescing background Proven helpful in diagnosis of a variety of pathological conditions of fundus ,various macular lesions , choroidopathy , diabetic retinopathy etc . Sharma IP

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25. Clinical photographs after fluorescein angiography Sharma IP

26. 2.Iris Angiography IV inj. Dye first appears in radial vessels at betn 9-20 secs Amount of iris pigmentation and the pattern of its distribution compared with normal iris angiogram Sharma IP

27. Ophthalmic Research Intraocular dynamic studies [ fluorometry ] Tear film drainage studies Penetration to anterior segment structures Sharma IP

28. Side effects Topical - unconsciousness & hypertensive r eactions Rare side effects. IV inj. – with increased concentration a dverse effects in about 10% of patients receiving IV inj. Less frequently – resp iratory effects like laryngeal or pulmonary edema Cardiovascular toxicity in form of severe hypotension and shock Sharma IP

29. Contraindication Hypersensitivity to active ingredents or any other components Family and personal allergic history Not used over soft contact lens. SCL – avoided for few hrs. of fluorescein instillation Sharma IP

30. Contamination of fluorescein Contamination of fluorescein eyedrops is a serious risk - even greater than that encountered with the majority of other eyedrops . As these individual drops are liable to become infected with bacteria and, at the same time, are frequently used on damaged tissue that is prone to infection, very great care must be taken in their use . Ps eudomonas aeruginosa – most dangerou s microorganism with which fluorescein eyedrops are inclined to become invaded. Sharma IP

31. Contd... Phenylmercuric acetate or nitrate in 0.002% - B est bactericide for preserving f luorescein drops , and this is effective against Pseudomonas, given adequate contact time . However, the safest method is sterile single-dose units or sterile fluorescein -impregnated paper strips, both are readily available and to be highly recommended. Sharma IP

32. Conclusion Fluorescein stain is a very useful diagnostic agents in ophthalmic clinical practise and has many applications. The use of diagnostic dyes represents one of the most efficient, objective, non-invasive, and directly visible means we have of identifying and tracking ocular structures at the cellular level . Every optometrist must understand the proper use of its clinical application, contraindication and side effects in clinical use. Sharma IP

33. Reference Books Donald S. Fong , Drugs in Ophthalmology , , 2006 , Springer- Verlag Berlin Heidelberg Graham Hopkins and Richard Pearson, Ophthalmic D rugs , 2007 , Butterworth Heineman Elsevier. 5th Ed10:149-154 Brain Duvall, Ophthalmic medication and Pharmacology , SLACK incorporated 2nd Ed. P.H.O’Connor Davies, The Action and Uses of Ophthalmic Drugs ,1994, Jaypee Brothers. 3rd Ed. 9:148-153 Websites www. emedicine.medscape.com www.rootatlas.com en.wikipedia.org www.google.com/imghp Sharma IP

34. Tashi Delek Sharma IP