John Koziarski, MDFamily Surgical Veins

Battle Creek, MI

I will be discussing the off-labeluse of medications

2005 25 Year old Female

6 yr history of pain, heaviness, aching since pregnancy 6 years prior

No significant PMH

No hx of migraines

Ultrasound Exam

Bilat GSV refluxBilat SSV refluvIncompetent

Cockett perforator right leg

Bilat deep system insufficiency

TreatmentSurgical

Sclerotherapy

Thermal ablation bilat GSV and bilat SSV

Ligation incompetent Cockett perforator

Multiple sessions with 0.66% Polidocanol liquid

2009Over the previous 1 yr UltrasoundIncreasing pain and

aching and swelling left leg despite compression stockings

5-6 mm reticular veins over thighs, 2-3 mm varicosities legs

No evidence of bilat GSV of bilat SSS

No neovascularity or refluxing acc veins

3 incompetent perforators left thigh/leg

Bilat deep system reflux

TreatmentChemoablation Perf Sclerotherapy

Superficial Varicosites3 perforators left

thigh/leg treated0.5 ml of 2% STS/

CO2 foam (1:4)Perivenous

injection of NS to compress vein

Perforators closedNo complications

Jan 2010 Treatment of superficial varicosities

Left thigh2 ml 0.2% liquid STS4 ml 0.4% STS/CO2

foam (1:4)Stocking appliedPt went to work (in

another physician’s office)

30 min post injection 60 min post injectionCalled office c/o

blurred vision left eye

Reassured that visual disturbances can happen and should resolve.

Said she would lie down for a while at work.

Called office againStill blurred vision

left eyeNow pain in right

eye (10/10) and blurred vision rt eye

NauseaBP 90/60 HR 70

SaO2 97%

To ERChief Complaint Diagnostic Work UpBlurred vision left

eye resolvedStill had pain IN her

rt eye and decreased vision

HeadacheChest pain/pressureNauseaNo focal neurologic

deficit

EKGTroponinCXRMRI BrainMRA/MRV brain

All Normal

ER DispositionTreated DischargedDilaudidZofranImitrex

No real improvement in pain, but nausea improved

Vicodin, ZofranF/U Family Dr in

am

24 hours post injectionFamily Physician OphthamologistMain complaint

right eye pain and vision loss

Some chest pain/pressure

Did not “seem” like a migraine

Later- CT scan chest- No PE

Vision right- 20/100 left- 20/20

Retina normalIOP normalRt cornea “ground

glass” appearanceIschemic?

Right Eye Left Eye

Cornea

TreatmentEye patchDrops

6 WeeksCornea HealedVisual acuity normalSome light sensitivity

Further WorkupTransthoracic Echo

Small PFO

TEE with bubble studyNo PFO

TCD with bubble studyNo PFO

Further WorkupNeurologist• Hypercoagulable w/u• Negative

• Repeat MRI (Jun 2010)• Normal

• Repeat MRI (Dec 2010)• Normal

Frequency of Visual Disturbances (VD) after Foam Sclerotherapy of 1.4%

Could be “positive” or “negative” or both50% headacheOther Sx included nausea, photophobia,

chest pressure, and parathesias.18/20 pts with sx had Diffusion-Weighted

MRIAll were normal. 5 had Non specific

White Matter lesions

Hypothesizes that endothelin-1, released from the treated vessel endothelium, may be the mediator

VD can occur with liquid or foam, though more frequent with foam (Guex et al Dermatol Surg 2005)

Endothelin-1 has been associated with retinal vasospasm, migraine with aura, and bronchconstriction

CorneaNo blood supplyReceives O2 and nutrients from tears and

aqueous humorEndothelin-1 has been found in the

Epithelium and tears (Lu et al.Exp Biol Med 2001)

Effects on Cornea are not well understood. May effect cell growth and apoptosis, and may promote corneal healing. (Salvatore, et al. J of Ophth 2010)

Summary

30 yr old female, no history of migraine, underwent foam sclerotherapy of reticular veins with 4 ml of 0.4% STS/CO2 foam and 2 ml 0.2% STS liquid

Experienced what seemed to be “typical” visual disturbances, but with the addition of corneal injury

Etiology is unclear