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High Injection Pressure During Intralesional Injection of Corticosteroids Into Capillary Hemangiomas
James E. Egbert, MD;
Saurav Paul, PhD;
W. Keith Engel, MD;
C. Gail Summers, MD
Arch Ophthalmol. 2001;119:677-683.
ABSTRACT
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Background Intralesional injection of corticosteroids is an effective treatment
for tumors of the head and neck. Complications are rare but include permanent
loss of vision. We designed a study to investigate the mechanism for this
complication.
Methods Three fellowship-trained pediatric ophthalmologists participated in
the study in a nonmasked fashion. Four patients received 5 separate treatment
sessions of an intralesional injection of a 50-50 mixture of triamcinolone
diacetate (40 mg/mL) and betamethasone sodium phosphate and betamethasone
acetate (6 mg/mL) into capillary hemangiomas. Injection pressure was obtained
in real time using a cannula designed for this purpose. Maximum pressure,
mean pressure, and volume of corticosteroid were measured from each injection.
Results A total of 71 injections (range, 8-33 injections per patient) was performed.
The total volume of corticosteroid ranged from 0.9 to 2.1 mL. In 63 of 71
injections, the maximum pressure exceeded 100 mm Hg (range, 18.65-842.18 mm
Hg). Each surgeon produced injection pressures greater than the systemic arterial
pressures of each patient.
Conclusions Injection pressures exceeding the systemic arterial pressures routinely
occur during intralesional injections of corticosteroids into capillary hemangiomas.
Experienced surgeons participating in a nonmasked protocol were unable to
prevent high injection pressures of corticosteroid. A sufficient volume of
corticosteroid injected at high injection pressure would account for the embolization
of corticosteroid particles into the ocular circulation from retrograde arterial
flow. We recommend limiting the volume of corticosteroid and performing indirect
ophthalmoscopy on all patients receiving injections of long-acting corticosteroids
into the orbit and periorbital soft tissue.
INTRODUCTION
INTRALESIONAL injection of corticosteroids is an effective treatment
for a variety of benign and malignant proliferations in the head and neck
regions. These disorders include chalazion, capillary hemangiomas, histiocytosis,
nasal polyps, chronic nasal turbinate inflammation, and postrhinoplasty scarring.1-6
Unfortunately, intralesional injection of corticosteroid in the head and neck
area can result in ocular embolization with permanent loss of vision.7-16
The mechanism for this complication has been hypothesized to be retrograde
flow of injected drug from the target tissue into the ophthalmic artery proximal
to the central retinal artery.
Ocular embolization from retrograde flow during injection of corticosteroids
into capillary hemangiomas has been previously demonstrated in humans.16 For retrograde flow to occur, the injection pressure
of corticosteroid would need to exceed the systemic arterial pressure.
The mechanism of ocular embolization from retrograde flow during intralesional
injections of corticosteroids has not been studied. The absence of an acceptable
animal model for capillary hemangiomas and lack of a device to measure in
situ pressure and drug volume applied during intralesional injection of corticosteroids
have prevented in vivo studies.
We have designed a custom device that allows simultaneous measurement
of injection pressure and volume for use during intralesional injection of
medications.17 The accuracy of this device
has been verified by studies with an animal model simulating capillary hemangioma.17-18 The purpose of this article is to
report the frequent occurrence of high injection pressures during intralesional
injection of corticosteroids into capillary hemangiomas. The critical role
of high injection pressure in causing retrograde flow of drug and the conditions
under which retrograde flow of drug can lead to ocular embolization with possible
blindness are examined. Also outlined are methods to reduce the occurrence
of this complication and treatment to minimize associated vision loss.
METHODS
MEDICATION
The corticosteroid drug used in this study was a 50-50 mixture of (1)
triamcinolone diacetate (40 mg/mL Aristocort Forte; Fujisawa Pharmaceutical
Co, Deerfield, Ill) and (2) betamethasone sodium phosphate and betamethasone
acetate (6 mg/mL Celestone Soluspan; Schering Co, Kenilworth, NJ). A sterile
suspension of this medication comes as micronized glucocorticoids suspended
in an aqueous medium. The particle size distribution of this medication is
74% between 1 and 5 µm, 13% between 5 and 10 µm, 4% between 10
and 15 µm, 2% between 15 and 20 µm, and 7% for a greater than
20-µm diameter. The viscosity of the mixture was measured using a cone-and-plate
viscometer. At shear strain rates greater than 1.0 s-1, the
viscosity was found to remain constant at 0.0017 Pa s (pascal-second).17 The density of the mixture was 1.0 g/mL-1.
INSTRUMENTATION
The pressure produced during injection of corticosteroid was estimated
by means of a specially designed cannula (Figure 1).18 The cannula was connected
to a 3-mL nonpyrogenic disposable syringe (Monoject; Sherwood Medical, St
Louis, Mo) filled with corticosteroid. The cannula was a standard 21-gauge
stainless steel tube, 3.82 cm long, with a nominal internal diameter of 0.05
cm, and a sharp beveled tip at its distal end. The cannula was made with side
ports for piezometric tappings at 2 sites along the length of the tube. The
tissue pressure, "P3", was calculated from pressures "P1"
and "P2" measured at these 2 side ports. The flow of the drug mixture
in the syringe-cannula injection system was modeled as a steady-state laminar
flow of homogeneous particulate suspension. The relationship between pressure
drop and flow rate was established from the Poiseuille law in conjunction
with the Bernoulli theorem. Under in vivo conditions of injection, the backpressure
P3 existing in the tissue at the site of injection was taken to
be the same as the pressure at the outlet tip of the cannula. The tissue equilibrium
pressure was the value of P3 when flow rate just exceeded zero
at the start of the injection.
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Figure 1. The injection cannula. The pressure
measured at the side ports P1 and P2 were used to calculate
the pressure P3 at the tip of the cannula, and the flow rate during
injection.
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The pressure signal was acquired and measured using techniques validated
in vitro and in vivo.17-18 In
brief, the side ports of the cannula were connected to the transducers by
polyethylene tubing filled with water to maintain fluid coupling. The pressure
transducers were connected to a signal-conditioning amplifier (model 563HL;
Ectron Co, San Diego, Calif) and the calibrated signal was acquired digitally
into the computer at a sampling frequency of 10 Hz. The signal-conditioning
amplifier and the analog-to-digital acquisition system were configured to
allow pressure measurements at a digital resolution of 0.488 mm Hg. The data
acquisition, processing, and on-line computer display were achieved by software
developed using LabVIEW (National Instruments, Austin, Tex) programming language.
DATA ANALYSIS
Uncertainty analysis of this method of measuring pressure revealed that
the system had a standard error of 2.1 mm Hg.17
A 95% confidence interval was thereby established by setting the minimum differential
pressure at 4.2 mm Hg.19 Consequently, the
injection start time (ts) was determined at the instant that (1)
the differential pressure between side ports (P1-P2
) was greater than 4.2 mm Hg, and (2) the rate change of the side port pressure,
dP1/dt, is greater than 0. The end of injection(te)
was defined as the time when (1) the differential pressure between side ports
(P1-P2) is less than 4.2 mm Hg, (2) the rate change
of side port pressure dP1/dt is less than 0, and (3) the acceleration
of side port pressure d2P1/dt2 is equal to
0. The duration of injection, defined as the time interval (te-ts), was used to calculate the time-averaged values of the injection
pressure P3 and of the flow rate. For each injection, the maximum
pressure and the amount of medication delivered were measured. The volume
of drug injected was computed from the integral of the volumetric flow rate
during injection time.
PROTOCOL
Board-certified ophthalmologists in the Minneapolis area who had pediatric
ophthalmology fellowship training were invited to participate in this study.
All were experienced with intralesional injection of steroids for the treatment
of periocular hemangiomas. All patients received a verbal and written explanation
of the research protocol, which was approved by the institutional review board
at the University of Minnesota, Minneapolis. Each patient received 1 drop
of 1% cyclopentolate in both eyes approximately 20 minutes before surgery.
Injections were performed under general anesthesia. Patients with presumed
subcutaneous capillary hemangioma without cutaneous involvement received an
incisional biopsy to confirm the diagnosis. Indirect ophthalmoscopy was performed
prior to injection of corticosteroids to confirm clear visualization of the
fundus. While an assistant visualized the optic nerve and macula ipsilateral
to the capillary hemangioma, the surgeon inserted the cannula into the capillary
hemangioma. The syringe plunger was withdrawn, and the syringe was examined
for the presence of blood. If blood was seen aspirating into the syringe,
the needle was withdrawn and repositioned. After the syringe plunger was withdrawn,
the pressure was allowed to attain a quasi–steady state before pressure
was applied to the syringe plunger to inject the drug. The number of injections
and the amount of drug delivered into the tissue at each site was determined
by the surgeon's preference. The infusion rate was dependent on the surgeon's
manual injection of the medication. A conscious effort was made to provide
a slow and steady injection of the steroid.
During the injection, a real time graph displaying the pressures measured
at side ports P1 and P2, as well as the estimated pressure
P3 was viewed by an assistant. If the pressure exceeded 100 mm
Hg during the injection, the surgeon was immediately informed. The operating
surgeon then discontinued the injection. No patches or pressure was applied
to the operative site.
RESULTS
Three pediatric ophthalmologists performed injections during the study.
Four patients were studied, 2 patients received a single treatment session,
and 2 patients received 2 treatment sessions. All sessions were included in
the study except for the second session of a single patient. This omission
occurred because of a conflict in scheduling the computer system.
A typical waveform generated during injection is shown in Figure 2. The data for each patient are presented in Table 1,
Table 2, Table 3,
Table 4, and
Table 5.
A total of 71 injections was performed, and only 8 were at pressures less
than 100 mm Hg. The maximum pressures ranged from 18.65 mm Hg to 842.18 mm
Hg. All 3 pediatric ophthalmologists produced pressures greater than the systemic
arterial pressure of each patient. No reduction of ocular circulation or emboli
was observed during or following the injections.
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Figure 2. Pressure waveforms. Typical waveforms
of measured pressures at the side ports P1 and P2. Included
in the figure is the tip-of-the cannula waveform P3 calculated
from P1 and P2. The solid line indicates P1;
the dashed line, P2 and the solid line with dots, P3.
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Table 1. Corticosteroid Injection: Case 1
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Table 2. Corticosteroid Injection: Case 2
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Table 3. Corticosteroid Injection: Case 3
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Table 4. Corticosteroid Injection: Case 3
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Table 5. Corticosteroid Injection: Case 4
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CASE 1
A healthy 4-week-old girl had a cutaneous and subcutaneous capillary
hemangioma of the temporal third of the right upper eyelid and superior temporal
quadrant of the orbit. During the next 4 weeks, the capillary hemangioma completely
obstructed the pupil. At 8 weeks of age, the patient received a total of 1.34
mL of corticosteroid injected at 8 separate sites (Table 1). The maximum pressure during the injections ranged from
36.24 mm Hg to 490.80 mm Hg. Only 3 of the 8 injections were performed with
a maximum injection pressure of less than 100 mm Hg. The visual axis cleared
within 2 weeks following injection. At 19 months of age, the visual acuity
was equal, alignment was orthophoric, and no anisometropic refractive error
was present.
CASE 2
A healthy 4-month-old infant had a subcutaneous lesion of the left superior
nasal orbit that produced a bluish tinge to the overlying skin. At 6 months
of age, the medial aspect of the left upper eyelid was encroaching the pupil,
and the left eye had amblyopia due to 4.5 diopters (D) of astigmatism. At
that time, the patient underwent an incisional biopsy revealing a capillary
hemangioma, for which she received an injection of 1.09 mL of corticosteroids
divided into 9 separate sites (Table 2). The maximum pressure during each injection ranged from 18.65 mm Hg to 649.60
mm Hg. Four of the 9 injections were performed with a maximum injection pressure
of less than 100 mm Hg. Following injection of corticosteroid, the visual
axis cleared, but 4 D of astigmatism remained. Two months later, the patient
received a second intralesional injection of corticosteroid without pressure
recording. At 27 months of age, the visual acuity was 20/30 in each eye, with
1.75 D of astigmatism in the left eye.
CASE 3
A healthy 2-month-old boy was referred for evaluation of a swelling
of the nasal portion of the left upper eyelid. A subcutaneous mass creating
a blue coloration to the skin was present. At 3 months of age, amblyopia was
present, owing to 6.50 D of astigmatism. He underwent an incisional biopsy
demonstrating a capillary hemangioma, and received an injection of 0.94 mL
of corticosteroid divided into 8 different sites (Table 3). The maximum pressure during each injection ranged from
51.49 to 383.25 mm Hg. Only 1 of the 8 injections was performed with an injection
pressure less than 100 mm Hg. During the next 2 months, a small decrease in
the size of the capillary hemangioma occurred, but the refractive error did
not change. At 7 months of age, 1.55 mL of corticosteroid was injected into
the capillary hemangioma using 13 separate injections (Table 4). The maximum pressure during each injection ranged from
195.20 mm Hg to 405.60 mm Hg. At 33 months of age, the visual acuity was equal,
and 4.5 D of astigmatism in the left eye remained. The capillary hemangioma
was present but reduced in size.
CASE 4
A healthy infant girl was noted to have a right superior nasal orbital
mass at 1.5 months of age. At 3 months of age, the pupil was partially obstructed
by a subcutaneous mass, producing a bluish tinge to the overlying skin. Examination
of an incisional biopsy specimen confirmed a capillary hemangioma, and injections
of 2.11 mL of corticosteroid divided into 33 different sites were performed
(Table 4). The maximum pressure
of each injection ranged from 149.0 mm Hg to 842.2 mm Hg. None of the 33 injections
was performed at a maximum injection pressure of less than 100 mm Hg. At 7
months of age, the visual acuity was equal, and the capillary hemangioma had
decreased in size.
COMMENT
Three experienced, fellowship-trained, nonmasked pediatric ophthalmologists
(J.E.E., W.K.E., and C.G.S.) routinely performed injections of corticosteroids
into capillary hemangiomas at pressures greater than the systemic arterial
pressures of the infants. This occurred despite each surgeon attempting to
use the least amount of pressure necessary, and stopping the injection when
told by the computer operator when injection pressures reached 100 mm Hg.
The injection pressures we have measured are sufficient to cause retrograde
flow into the orbital circulation. Retrograde flow is a necessary but not
a sufficient condition to cause ocular embolization. In the presence of high
injection pressure, ocular embolization can occur if a sufficient volume of
a drug is injected into the vasculature. None of the study patients receiving
intralesional injections of corticosteroid had any retinal complications.
We deduce that the lack of ocular embolization, despite frequent high injection
pressures, was owing to the limited total and individual injection volume
delivered.
Two necessary conditions for ocular embolization are retrograde flow,
and a sufficient volume of corticosteroid delivered during an intralesional
injection. Retrograde flow can occur when the corticosteroid is injected either
into a terminal artery that feeds the capillary hemangioma, into the capillary
bed, or into the interstitial space of the capillary hemangioma. When the
drug is injected directly into a terminal artery, retrograde flow will occur
if the pressure of the injected corticosteroid exceeds the systolic arterial
pressure and frictional losses owing to viscous flow of drug in the artery.
Arterial pressure in mature infants averages 70/50 mm Hg and gradually increases
with age.20 The pressure drop due to the viscous
flow of the drug within the arteriole can be approximated using the Poiseuille
law.17-18,21-22
Using the axial distance of the medial orbit (4.5 cm) and a lumen diameter
of 0.05 cm for an arteriole,23 the mean pressure
drop from the eyelid to the apex of the orbit, at a mean flow rate of 4 mL/min,
is 23 mm Hg. When the drug is injected into a terminal artery, the drug will
predominantly flow in the direction of least resistance. The resistance to
fluid flow in a terminal artery is much less than the resistance in capillaries.24-25
Retrograde flow of the drug from the eyelid toward the apex of the orbit
could, therefore, occur if the surgeon inadvertently injects corticosteroids
into an arteriole at pressures exceeding the systemic arterial pressure. Retrograde
flow into an arteriole can also occur if the medication is injected at high
pressures into a capillary bed. The particle size distribution of the corticosteroid
drug used in this study, namely, a 50-50 mixture of triamcinolone diacetate
and betamethasone sodium phosphate and betamethasone acetate, has been shown
to remain unchanged for the short durations of injection.26
With the drug particle size predominantly smaller than the capillary diameter,
retrograde flow can also occur if the medication is injected at high pressures
into a capillary bed. When drugs are injected at pressures exceeding the arterial
pressure, then, under the assumptions of uniform hydraulic conductivity of
the drug within the tissue, the amount of drug flowing in the arterial and
the venous directions will be directly proportional to the pressure gradients
in the respective direction.27-28
For instance, in an infant with an arterial pressure of 70/50 mm Hg and a
venous pressure of 10 mm Hg, injecting the drug at a pressure of 100 mm Hg
midway between the artery and the vein will cause the flow to occur in the
ratio of 0.48:1.00 in the arterial and venous direction. That is, 33% of the
injected drug will flow in the retrograde direction. The percentage of drug
displaced in the arterial direction will increase with increasing injection
pressure. Thus, percentages will be 43% at 200 mm Hg, 46% at 300 mm Hg, and
they will asymptotically be 50% of the injected volume at very high injection
pressures. In reality, the assumption of uniform hydraulic conductivity in
tissues is, however, not strictly correct. Even in normal tissue, variability
of the vessel size and distribution in the terminal vascular beds are known
to cause appreciable changes in pressure gradients.24-25
Under pathological conditions, the morphological changes that occur in tissues
and microvascular structures generally accentuate such inhomogeneities.29-31 This is especially
true for capillary hemangiomas. Histopathological and ultrastructural examinations
have revealed that capillary hemangiomas have areas of large vascular spaces
with few endothelial cells, along with areas of densely packed endothelial
cells and fibrous tissues with much less vasculature.32-35
This is further complicated by the possible vasoconstrictive effects of corticosteroids
on vascular beds.36-37 As a result,
the pressure drop at a distance from the injection site within a capillary
hemangioma cannot be accurately determined a priori to allow a margin of safety
from overpressurization during injection of corticosteroids.
Retrograde flow alone is not sufficient to cause ocular embolization.
For ocular embolization of corticosteroid during injection, the medication
has to gain access to the ophthalmic artery proximal to the central retinal
artery. This happens only when the following 2 conditions are met in sequential
order: (1) high injection pressure necessary to cause retrograde flow of drug
is established and (2) a sufficient volume of drug is injected at such high
pressures. While high injection pressure occurs frequently, the volume of
the drug necessary to cause embolization of the ocular circulation depends
on a number of factors, including the proximity of the injection site from
the ophthalmic artery proximal to the central retinal artery. For a feeder
vessel from the ophthalmic artery arising just proximal to the central retinal
artery and without branches, the minimum volume of drug necessary to cause
embolization would be the amount needed to fill the arteriole. Using typical
dimensions of an arteriole, as before (lumen diameter of 0.05 cm and axial
distance of 4.5 cm for the medial orbit), the required volume is only 0.01
mL.23 The arterial network of the orbit is,
however, complex, with many branches emanating from the ophthalmic artery.38 Calculating the volume of drug necessary for ocular
embolization would require the formidable task of knowing the exact location
of the injection site, its proximity to the feeder vessel, and the size, number,
and distribution of the branching arterioles between the injection site and
the ophthalmic artery adjacent to the central retinal artery.
The total volume of corticosteroid injected into a capillary hemangioma
also determines whether ocular embolization occurs when the drug is delivered
into the interstitial space within the tumor. For injections into the interstitium
of the capillary hemangioma, fluid flow is significantly limited by the resistance
offered by the surrounding normal tissue39
and the lack of a functioning lymphatic drainage system.40
Continued injection of the drug beyond the capacity of the extracellular space
displaces the corticosteroid into venules and arterioles. At injection pressures
higher than the systemic arterial pressure, this results in retrograde flow
of the drug into arteries. The volume of the extracellular space within a
tumor is, however, not known a priori. For solid tumors, the vascular space
can range from 1% to 20% of the total volume.41-42
Capillary hemangiomas are vascular tumors, and the interstitium and vasculature
should be expected to occupy a higher percentage of the tumor volume. Assuming
a value of 30%, the total volume of drug that can be safely injected into
a capillary hemangioma sized 3 x 2 x 1.5 cm (ellipsoid volume,
4.7 mL) is just 1.4 mL.
Other investigators have argued that the injection pressure can be maintained
within safe limits by using a large-capacity syringe and small bore cannula.43 Using Pascal's law, Bullock et al,43
concluded that ocular explosions occurring from inadvertent high-pressure
intraocular injection of anesthetic agents can be prevented with a sufficiently
large syringe. Unfortunately, this will not prevent injection pressures from
exceeding the systolic pressure of infants during intralesional injection
into capillary hemangiomas. Pascal's law states that pressure is inversely
proportional to the cross-sectional area for any applied force. Accordingly,
the digital force applied to the plunger of a large-capacity syringe will
generate a lower pressure due to its increased cross-sectional area. The maximum
force normally observed for a 3-point (palmar) pinch force is 11.4 kg for
male adults, and 7.7 kg for female adults between ages 25 and 60 years.44 Using an unusually large syringe to inject 1 to 2
mL of drug, such as a 50-mL syringe with a plunger diameter of 2.5 cm, the
corresponding pressures developed under hydrostatic condition are 1730 mm
Hg and 1168 mm Hg, respectively, for male and female adults. Despite being
lower than the reported values of 3000 mm Hg necessary to cause scleral rupture,45-46 these pressures are much higher than
the pressure necessary to cause retrograde flow of drug into the ophthalmic
artery.
Unfortunately, using a small-bore needle will not prevent high injection
pressures. During injection of the drug, pressure losses occur from hydrodynamic
effects of viscous flow within the cannula. Using the law of Poiseuille, the
pressure drop due to viscous effects in the 21-gauge cannula is less than
21 mm Hg at a flow rate of 4 mL/min-1. Reducing the lumen diameter
of the cannula by a factor of 2, as in the case of a 25-gauge cannula, can
increase the pressure drop by 16 mm Hg to 336 mm Hg. Subtracting this pressure
drop from the maximum pressure that can be exerted to a 50-mL syringe by female
adults using a 3-point pinch force, a pressure of 832 mm Hg can still be obtained
at the tip of the cannula. Clearly, such injection pressure far exceeds the
systolic pressure in tissues.
The use of a large syringe and small needle will not prevent the surgeon
who uses the least amount of pressure applied to the syringe from exceeding
the systolic arterial pressure. Viscosity of the steroid medication increases
at low flow rates and dramatically decreases with increasing flow.17 As a result, the resistance to flow of the medication
through a needle is typically 10 times greater during initiation of the injection
than when flow is established. Therefore, the surgeon needs to apply 10 times
the amount of pressure to initiate flow than is necessary to maintain it.
This higher initial pressure is directly transmitted to the tissue. The smaller
the needle, the greater is the initial pressure transmitted to the tissues.
We have shown that a sufficient pressure is used during injection of
corticosteroids into capillary hemangiomas to cause retrograde arterial flow.
Our findings of routine high injection pressures of corticosteroids into capillary
hemangiomas have direct implications to all physicians injecting corticosteroids
into the orbital and periorbital regions. Surgeons cannot prevent high injection
pressures by adjusting the size of the syringe or needle used during injection.
Since high injection pressures will occur, limiting the volume of the corticosteroid,
avoiding a direct intra-arterial injection, and avoiding placement of force
to the treated tumor are the most important variables a surgeon can control.
The following steps can be taken to minimize the risk of embolization of corticosteroids
into the ocular circulation: (1) Before each injection of corticosteroid into
the lesion, aspiration into the syringe should be performed to detect the
presence of arterial blood. If blood is aspirated into the syringe, the cannula
should be withdrawn and repositioned. If injections are performed without
general anesthesia, steps to prevent movement of the needle tip during the
time from aspiration to the end of injection are important. (2) Multiple areas
of the capillary hemangioma should be treated with small volumes of corticosteroid.
We agree with previous investigators12 that
individual treatment sites receive 0.1 mL of medication. (3) The total volume
of corticosteroid injected during the entire treatment session should be limited.
We have found that total volumes of 0.8 mL to 1.5 mL were sufficient to cause
shrinkage of periocular tumors between 4 mL and 8 mL in volume. (4) Because
none of these efforts can completely prevent the occurrence of ocular embolization,
we recommend indirect ophthalmoscopy be used during or immediately after treatment
of lesions in the eyelid and orbital region. (5) Pressure to the tumor should
not be applied, and a pressure patch should not be used, since these will
increase the intratumor pressure and may dislodge corticosteroid into the
arterial circulation. The child should not lay or sleep in a way such that
the weight of the head is transmitted to the treated tumor. We recommend that
a shield be placed for 24 hours around the tumor to prevent inadvertent pressure
to the lesion.
Indirect ophthalmoscopy at the time of injection can immediately diagnose
embolization of the ocular circulation. Embolization of the ophthalmic artery
will result in a diffuse whitening of the retina and attenuation of blood
perfusion in retinal arterioles. Embolization of the central retinal artery
will produce the above effects, plus a "cherry" red spot in the fovea. Embolization
distal to the central retinal artery will result in white glistening steroid
particles visible in the retinal arterioles. In case of embolization of the
ocular circulation, normal vision can be partially or fully salvaged with
rapid treatment.16 This is essential since
occlusion of the ocular circulation for more than 90 minutes results in necrosis
of the retina.47 Treatment of ocular embolization
involves the rapid reduction of intraocular pressure to promote dislodging
the embolus into more peripheral branches of ocular circulation. This can
be immediately performed by placing a needle or sharp cutting blade into the
anterior chamber to decompress the intraocular pressure. In the absence of
expertise, equipment, or restraint of the child to perform a mechanical decompression
of the eye, massage of the eye can result in lowering of the intraocular pressure.
Administration of carbonic anhydrase inhibitor and carbogen may also be used
to treat ocular embolization of retinal arteries.
Several treatment modalities for capillary hemangioma exist.48 It is not the intention of this study to dissuade
physicians from using intralesional injection of corticosteroids to treat
capillary hemangiomas. Intralesional injection of corticosteroids into capillary
hemangiomas can result in rapid clearing of the visual axis, resolution of
induced astigmatism, and reduced amblyogenic potential.2
Many ophthalmologists commonly use this modality as the treatment of choice
for capillary hemangiomas causing amblyopia.49-51
Ocular embolization is a rare complication probably because most physicians
avoid an intra-arterial injection by aspiration before injection and limit
the total and individual volume delivered per injection.52-53
Nevertheless, high injection pressures generated during injection increase
the risk for retrograde flow and possible ocular embolization. Indirect ophthalmoscopy,
during or after injections into the orbit and periorbital soft tissues, allows
surgeons to immediately diagnose and treat this rare but serious complication.
AUTHOR INFORMATION
Accepted for publication December 1, 2000.
This study was supported by an unrestricted grant to the Department
of Ophthalmology, University of Minnesota, Minneapolis, from Research to Prevent
Blindness Inc, New York, NY.
Corresponding author and reprints: James E. Egbert, MD, 440 Davis
Ct, Suite 1911, San Francisco, CA 94111-2455.
From the Departments of Ophthalmology (Drs Egbert, Engel, and Summers),
Biomedical Engineering (Dr Paul), Otolaryngology (Dr Paul), and Pediatrics
(Dr Summers), University of Minnesota, Minneapolis.
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