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Physicians must prepare for possible anaphylaxis during fluorescein angiography

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WAIKOLOA, Hawaii — Physicians must prepare for the relatively uncommon complication of anaphylaxis during fluorescein angiography to avoid potentially life-threatening consequences, a presenter said at Retina 2008.

"We all know that fluorescein angiography is not without complications," Sharon Fekrat, MD, FACS, said.

"Anaphylaxis is actually relatively uncommon, but the allergic reactions that do happen can be life-threatening and they do require immediate attention and expertise of a trained physician. You can't just not have an MD physician in the office at the time of fluorescein angiography and rely on 9-1-1."

Of 1,400 patients who underwent fluorescein angiography in a Duke University satellite office, only four, or 0.02%, had anaphylactic reactions, Dr. Fekrat said. But in a show of hands, about half of the physicians in the audience said they had experience with anaphylaxis during a fluorescein angiography exam.

Dr. Fekrat presented four cases and described the symptoms of each that led her to diagnose anaphylaxis and begin administration of epinephrine. Patients must have involvement in two systems, such as gastrointestinal tract and skin. Symptoms can include vomiting, coughing, nausea, swelling of the mouth or throat and hives, but Dr. Fekrat emphasized that hives are not always present.

"You have to do a lot of decision-making," she said. "We do know that anaphylaxis can be very rapid and can be unpredictable."

When anaphylaxis is diagnosed, epinephrine, the "treatment of choice," must be administered within 30 minutes for most effective treatment, she explained. If symptoms do not show signs of improvement within 5 to 10 minutes, Dr. Fekrat said the patient can receive another dose of epinephrine.

"Relying on 9-1-1 to go ahead and treat your anaphylaxis is not always wise," she added, because not all emergency medical technicians are authorized to carry or administer epinephrine and they may not arrive in time.

Because anaphylaxis can be bi-phasic, Dr. Fekrat said patients should always be taken to the emergency room for further observation and treatment, if needed.

All of these factors contribute to Dr. Fekrat's conclusion that fluorescein angiography should not be performed without an MD in the office, she said.

"Optometrists are attempting to expand the scope of their practice," Dr. Fekrat said. "And now, in North Carolina, they are able to do fluorescein angiography in their office."