Fluorescence dye allergy
Question:
2/10/2020
A 70 year-old female with wet macular degeneration, about 10 years ago received fluorescence, indocyanine green for an ocular procedure. She developed pruritus and dyspnea after receiving the dyes and was treated with Benadryl and improved. The ophthalmologist would like her to get one of these dyes as an IV for an ocular procedure and requested testing for any of the dyes. Please advise if any testing is available or any other alternatives to the dyes.
Answer:
Indocyanine green dye has been used for more than 50 years in human diagnostic testing. Adverse events are very rare and serious reactions are probably less than 0.05% (1). A review of 11, 898 fluorescent angiograms made the following recommendation…”Prophylactic treatment, fluorescein desensitization or oral fluorescein angiography should be considered in highârisk patients. Safe guards should be in place to manage potential serious adverse reactions. Other imaging techniques, like optical coherence tomography, should be considered as an alternative in selected cases.” (2). The paper did not provide any specifics on prophylaxis or desensitization. I could not find any specific recommendations in the medical literature. Optical coherence tomography angiography apparently obviates the need for the dye, but I do not know how readily available this technique may be (3).
In summary, I suggest that you ask about the potential use of ‘optical coherence tomography’ in lieu of a fluorescent dye study. If that is not an option, it would seem reasonable to perform percutaneous testing with the dye and a histamine control. I would test myself of staff volunteers to reduce the likelihood of an irritation response. I would also consider 1:100 and 1:10 v/v dilutions and perform intradermal testing. If all of the testing is negative, then I would suggest pretreating the patient similar to individuals with a history of radiocontrast sensitivity, i.e. oral prednisone 50 mg 13, 7 and 1 hour before the procedure and H1 inhibitor diphenhydramine 50 mg 1 hour before the procedure. The accuracy of skin testing or value of pretreatment for fluorescence dye reaction is not defined in the medical literature.
1. Hope-Ross, Monique, et al. "Adverse reactions due to indocyanine green." Ophthalmology 101.3 (1994): 529-533.
2. Kwan, Anthony SL, et al. "Fluorescein angiography and adverse drug reactions revisited: the Lions Eye experience." Clinical & experimental ophthalmology 34.1 (2006): 33-38.
3. Spaide, Richard F., et al. "Optical coherence tomography angiography." Progress in retinal and eye research 64 (2018): 1-55.
I hope this information is of help to you and your practice.
All my best.
Dennis K. Ledford, MD, FAAAAI