USED IN OPHTHALMOLOGY

Indra P SharmaMaster of Clinical Optometry (Year I)Amity Medical School

FLUORESCEIN STAIN

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

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Contents1. An overview- Introduction

2. Properties of sodium fluorescein

3. Indication of use

4. Contraindication, side effects and comtamination

5. Conculsion

6. Reference

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An overview

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Introduction –Sodium Fluorescein

Fluorescein is a synthetic organic compound available as a dark orange/ yellow water-soluble dibasic dye of xanthine series.

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Soduim Fluorescein - one of the most useful and most commonly used diagnostic agents (stains) in ophthalmology and optometry.

Fluorescein – Historical Perspective

Baeyer(1871): First fluorescein dye was made.

M Straub (1888) : First used fluorescein for vital staining of the eye.

Burk (1910): First used fluorescein to detect retinal disease

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Properties of fluorescein

A yellow water-soluble dibasic dye of xanthine series

Orange red in powder and yellow in solution.

Chemical formula: C2H12O5Na

Molecular weight: 376.27 Solubility : 50% (in water at

15 C)

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

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The fluorescent light appears yellow green in blue light.

The flourescence increases with greater concentration upto 0.001% and greater pH upto 8.

Important 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

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Preparation for tropical ocular use

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Available forms

Can be applied to eye

Topically in form of solution

By Fluorescein impregnated filter paper strips (developed by kimura)

Injectable form for IV use

Indication for use

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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 tonometry Seidel's test- Detection of site of

perforation/bleb Lacrimal testing ( Tear flim breakup time

(TBUT), Jone dye test, Fluorescein dye disappreance test(FDDT)

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1.Assessment of ocular surface integrity

Frequently used to detect lesions of ocular surface owing 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

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How does staining take place?

Any break in epithelium

Penetration of Fluorescein in adjoining bowman’s & stromal layer

Dye makes contact with an alkaline interstitial fluid

Fluid turns bright green owing to its PH indicator properties & depending to extent of lesion

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Staining of corneal infiltrate

Corneal abrasionSharma IP Conjunctival lesion

2. Seidel's test

Detection of site of perforation/bleb

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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

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Stained eye with contact lens

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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 betweenAnatomical and functionaloutflow problems-JONES DYE TEST

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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.

Procedure1.Anaesthetic & fluorescein instilled in conjuntival

sac2.With Cobalt blue filter,brightest illumination and

prism advanced until touches apex of cornea3.A pattern of 2 semicircles one above ,other below

the horizontal midline

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B. Intravenous indication 1. Fluorescein angiography

About 10 ml of a 5% solution injected in antecubital vein

The dye normally appears in central retinal artery in 10– 15 sec

Shows 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.

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Clinical photographs after fluorescein angiographySharma IP

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

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Ophthalmic Research Intraocular dynamic studies

[fluorometry] Tear film drainage studies Penetration to anterior segment

structures

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Side effects Topical - unconsciousness & hypertensive

reactions Rare side effects.

IV inj. – with increased concentration adverse effects in about 10% of patients receiving IV inj.

Less frequently – respiratory effects like laryngeal or pulmonary edema

Cardiovascular toxicity in form of severe hypotension and shock

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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

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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.

Pseudomonas aeruginosa – most dangerous microorganism with which fluorescein eyedrops are inclined to become invaded.

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Contd... Phenylmercuric acetate or nitrate in

0.002% -Best bactericide for preserving

fluorescein 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.

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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.

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ReferenceBooks Donald S. Fong,Drugs in Ophthalmology,,2006, Springer-

Verlag Berlin Heidelberg Graham Hopkins and Richard Pearson, Ophthalmic Drugs,

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

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Tashi Delek

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