Abstract
Purpose
To report an alternative technique of fundus fluorescein angiography using percutaneous endoscopic gastrostomy (PEG).
Methods
A case series from a single center.
Results
Two bed-bound children on tracheostomy received 10% fluorescein sodium via PEG to diagnose their retinal condition. The dye appeared at 5 min after administration and stayed in the retinal circulation past 30 min. Good quality fluorescein angiograms were obtained in all cases. There were no safety issues in these two children.
Conclusions and Importance
Retinal angiography with fluorescein dye administered via percutaneous endoscopic gastrostomy may represent a suitable alternative to currently used intravenous and oral fluorescein angiography.
Keywords: Fundus fluorescein angiography, Percutaneous endoscopic gastrostomy, Retina
1. Introduction
Fundus fluorescein angiography has been one of the longest-used diagnostic modality in retinal and choroidal disease.1 It involves intravenous injection of fluorescein, after which fundus images are obtained. An alternative to intravenous injection of fluorescein is oral fluorescein angiography.2 It has been used in cases in which intravenous injection is difficult to perform or is refused by patients for various reasons. This practice has been available for both adult and pediatric patients.3,4
Percutaneous endoscopic gastrostomy (PEG), developed in the 1880s, is a recommended procedure for patients who require enteral access for more than 4–6 weeks.5 Apart from drainage and decompression, a PEG-tube can serve as a vehicle for liquid feeding formulas, fluids and/or liquid medications into the stomach.6 The substances injected to the PEG-tube bypasses upper gastrointestinal tract, including the pharynx and the esophagus.
Bed-bound ventilated patients on enteral feeding who have difficult venous access and are in need of retinal angiography represent a different challenge. Inability to swallow disqualifies them for oral dye administration. Herein, we present an enteral alternative in scenarios in which neither intravenous nor oral dye administration is a possibility.
2. Methods
FFA was performed in two mechanically ventilated children at Danat Al Emarat hospital in Abu Dhabi, UAE. Informed consent was obtained from parents of both children. The report was approved by the Research and Ethics Committee of the Moorfields Eye Hospitals UAE (#REC/2022/P36).
We used a wireless hand-held retinal camera with built-in LED screen (Visunex, San Ramon, CA, U.S.A.). The first step was insertion of an eyelid speculum, followed by application of a coupling gel to the cornea and placement of a hand-held camera on the cornea to capture the digital images from both eyes. The yellow filter lens was changed in order to switch the light source to blue light. This was followed by intra-PEG administration of fluorescein sodium 10% at a dose of 0.1 mL/kg body weight via Luer-lock (Fig. 1) and isotonic saline flush under a close monitoring by an anesthetist. Images were captured as soon as the dye appeared in the circulation (Video). The camera alternated between the eyes so as to capture all phases of dye transit in either eye.
Fig. 1.
Case 1 showing edematous extremity with difficult venous access (left panel) and percutaneous endoscopic gastrostomy (PEG) for parenteral nutrition (right panel).
The following are the supplementary data related to this article:
This video shows administration of fluorescein dye via percutaneous endoscopic gastrostomy (PEG) tube and capturing of retinal angiograms.2
3. Results
3.1. Case 1
A newborn baby with a missense homozygous variant in the ZNF699 zinc finger gene on chromosome 19p13 causing a syndrome known as “Developmental delay with gastrointestinal, cardiovascular, genitourinary, and skeletal abnormalities” (DEGCAGS syndrome) had retinal pigment epithelial mottling on dilated fundus examination. The first appearance of fluorescein dye was universally noted after 5.05 min. The peak fluorescence followed, and the dye was present past 30 min following administration. There was a diffuse hyperfluorescence corresponding to the pigment mottling noted on fundus examination but no leakage of dye. The retinal vasculature was clearly visible along with details of vessel bifurcation (Fig. 2 upper panels).
Fig. 2.
Fundus fluorescein angiography (FFA) of the case 1 (upper panels) showing diffuse hyperfluorescence corresponding to retinal pigment epithelium mottling on clinical exam but no focal lesions or dye leakage. FFA of case 2 shows retinal vessel tortuosity in the right eye (lower left panel) and dysplastic retinal vessels with no dye leakage (lower right panel).
3.2. Case 2
A 3-year-old boy diagnosed with DiGeorge syndrome underwent pars plana vitrectomy for vitreous hemorrhage after which retinal vascular dysplasia was diagnosed. In search for the cause of bleeding FFA was ordered. As the peripheral veins were inaccessible, parenteral administration of dye via gastric feeder device was successfully performed. The dye appeared after 5 min and was still detectable after 30 min from administration (Fig. 2 lower panels). The quality of images was satisfactory for clinical decision-making showing no neovascularization or leaking vessels.7
4. Discussion
This report presents a novel approach to obtain fundus fluorescein angiogram in handicapped, bed-ridden patients on mechanical ventilation, inability or refusal of venous access. It focuses on the technique more than detailed clinical description of cases. The technique uses PEG-tube for systemic dye entry and subsequent capture of fundus images and retinal angiography using a hand-held retinal camera.
Parallel to oral administration of fluorescein, we expect delayed appearance of the dye in the retinal circulation due to dye absorption from the gastrointestinal system.8 However, unlike oral administration, fluorescein injected to the PEG-tube bypasses the upper gastrointestinal tract including the pharynx and the esophagus, thereby changing both pharmacokinetics and pharmacodynamics of the process.
Both patients tolerated the procedure very well. The procedures were uneventful with no allergic reaction, change in respiratory parameters or change in subsequent feeding. However, this pilot report is not proving safety of the procedure. Significantly more observation is needed to prove safety, similar to safety data collection following introduction of oral fluorescein angiography.
Possible indications for PEG-FFA include cases with significant worsening of ocular conditions detected by bedside examination for both verbal and non-verbal patients. These include suspected endophthalmitis, uveitis, primary or metastatic cancers or retinal/vitreous hemorrhage. While the indications for this approach are rare we believe that having an ability to diagnose this population is extremely important.
In summary, in mechanically ventilated patients with poor venous access, fundus fluorescein angiography can be performed using fluorescein dye administration via PEG-tube.
Patient consent
Consent to publish this case report has been obtained from the patient(s) in writing.
Authorship
All authors attest that they meet the current ICMJE criteria for Authorship.
Declaration of competing interest
None.
Acknowledgements
None.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.ajoc.2023.101832.
Appendix A. Supplementary data
The following are the Supplementary data to this article:
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
This video shows administration of fluorescein dye via percutaneous endoscopic gastrostomy (PEG) tube and capturing of retinal angiograms.2