Introduction

Fundus fluorescein angiography (FFA) and indocyanine green angiography (ICGA) are the gold standard tests to detect posterior segment inflammatory involvement. Adverse events (AEs) reported with FFA range from mild, including nausea, vomiting, extravasation, sneezing, pruritus; to moderate, namely rash/urticaria, syncope/dizziness/hypotension, angioedema, dyspnoea; to severe, including anaphylaxis/bronchospasm, myocardial infarction and seizure [1, 2]. ICGA is rarely associated with nausea and vomiting, more commonly with urticarial/hives, hypotension and vasovagal reaction/syncope [1, 2]. Based on these findings, the use of FFA/ICGA in children and young people (CYP) has been limited by safety concerns. Although reports indicate the safety of angiographic procedures in CYP (Table 1), further evidence is required to confirm it, as larger numbers are needed to explore rare events. In addition, similar information regarding ICGA in CYP is needed. Here we report our experience with AEs associated with angiographic procedures in CYP.

Table 1 Studies reporting adverse effects following fluorescein and/or indocyanine angiography in paediatric population by year and performed procedure.
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Methods

Prospective evaluation of CYP age 5–17 years undergoing outpatient oral or intravenous (IV) FFA and/or ICGA without general anaesthesia between January 2015 and December 2017 at Moorfields Eye Hospital, London, UK (Trust Service Evaluation CA15/ONSP/23). All patients signed a consent form. Electronic medical records were prospectively compiled to identify AEs within 24 h from the procedure with an observation of 60 min. Data recorded included demographics and clinical indications.

The protocol for performing FFA/ICGA in CYP is included as Supplementary information.

Results

One hundred and fourteen consecutive CYP were included (median age 11.5 years; 55 (48.2%) female, 59 (51.8%) male). Eighty-two (71.9%) received IV fluorescein, 10 (8.8%) oral fluorescein and 22 (19.3%) ICGA. Most common clinical indications include uveitis (43.0%), with intermediate and posterior uveitis accounting for 13.1% and 12.3%, respectively; Coats disease (12.3%), familiar exudative vitreoretinopathy (8.9%), unknown macular lesions (7.9%), incontinentia pigmenti (4.4%) and abnormal retinal vessels (3.5%). During/after IV FFA, 26 (31.7%) CYP experienced one or more AEs. In 25 (96.1%), AEs were mild, including nausea, vomiting, itchy skin, hot flush and extravasation. One patient (3.8%) had bronchial spasm as a severe adverse reaction. Following oral FFA, 1 patient (10%) had vomiting. Following ICGA, 1 patient (4.5%) developed itchy skin and hot flushes. AEs are described in Table 2.

Table 2 Adverse events following angiographic procedures.
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Discussion

Our study showed that mild AEs can happen after FFA and ICGA, and they appear to be more common after IV FFA compared to oral FFA (31.7% vs 10%, respectively). These findings are in contradiction to previous publications which reported no AEs after FFA/ICGA (Table 1). Although AEs appear less common after oral administration of fluorescein compared to IV, data cannot be compared given the different sizes of the samples (also the lack of serious AEs after ICGA is likely due to the small number of the sample). However, the authors believe that, considering the inferior angiographic details, oral administration cannot be considered the route of choice [3].

Strengths of this study include the inclusion of consecutive patients and the relatively large sample size, allowing detection of serious AEs to be added to the existing paediatric literature. However, the sample size is not large enough to inform practice.