ABSTRACT
BACKGROUND: Inadvertent intra-arterial injection of sclerosants is an uncommon adverse event of both ultrasound-guided and direct vision sclerotherapy. This complication can result in significant tissue or limb loss and significant long-term morbidity. OBJECTIVES: To provide recommendations for diagnosis and immediate management of an unintentional intra-arterial injection of sclerosing agents. METHODS: An international and multidisciplinary expert panel representing the endorsing societies and relevant specialities reviewed the published biomedical, scientific and legal literature and developed the consensus-based recommendations. RESULTS: Actual and suspected cases of an intra-arterial sclerosant injection should be immediately transferred to a facility with a vascular/interventional unit. Digital Subtraction Angiography (DSA) is the key investigation to confirm the diagnosis and help select the appropriate intra-arterial therapy for tissue ischaemia. Emergency endovascular intervention will be required to manage the risk of major limb ischaemia. This includes intra-arterial administration of vasodilators to reduce vasospasm, and anticoagulants and thrombolytic agents to mitigate thrombosis. Mechanical thrombectomy, other endovascular interventions and even open surgery may be required. Lumbar sympathetic block may be considered but has a high risk of bleeding. Systemic anti-inflammatory agents, anticoagulants, and platelet inhibitors and modifiers would complement the intra-arterial endovascular procedures. For risk of minor ischaemia, systemic oral anti-inflammatory agents, anticoagulants, vasodilators and antiplatelet treatments are recommended. CONCLUSION: Inadvertent intra-arterial injection is an adverse event of both ultrasound-guided and direct vision sclerotherapy. Medical practitioners performing sclerotherapy must ensure completion of a course of formal training (specialty or subspecialty training, or equivalent recognition) in the management of venous and lymphatic disorders (phlebology), and be personally proficient in the use of duplex ultrasound in vascular (both arterial and venous) applications, to diagnose and provide image guidance to venous procedure. Expertise in diagnosis and immediate management of an intra-arterial injection is essential for all practitioners performing sclerotherapy.
ABSTRACT
PURPOSE: To determine etiological factors in the development of, as well as anatomic success rate and visual outcome of a large consecutive series of macular hole surgeries. METHODS: Retrospective analysis of 300 consecutive cases of macular hole surgery by a single surgeon (RDB) between 1999 and 2003. Patients' medical and surgical histories were recorded and analysed for factors involved in aetiology and visual outcome. RESULTS: There were 8 (4.12%) women, on tamoxifen in the study, two of these women had bilateral macular holes. When this study prevalence of tamoxifen therapy (4.12%) was compared to the estimated percentage of women in the same age group in the Australian population on tamoxifen (0.82%), a statistically significant difference (p value 0.0001) was found. Analysis of the number of bilateral holes in the tamoxifen group compared to the non-tamoxifen group was suggestive of an increased incidence of bilateral holes but not to a significantly significant degree. CONCLUSION: Whilst no published reports link tamoxifen and macular holes, this may be due to the low incidence of the condition. Our study demonstrates a strong link between tamoxifen use and macular holes. Patients being commenced on tamoxifen should be advised of possible ocular complications and receive prompt ophthalmic review if symptoms develop.
