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Case report: extravasation of lipiodol — A complication of dacryocystography
Clinical Radiology' (1994) 49, 217-218
Case Report: Extravasation of LipiodolA Complication of Dacryocystography D. C. M A N S F I E L D , S. M. ZEKI and J. R. MACKENZIE*
Departments of Ophthalmology" and *Radiology, Royal Hospitalfor Sick Children, Yorkhill, Glasgow We describe the occurrence of a significant cosmetic blemish in the cheek of a young girl which was caused by extravasation of'Lipiodol' from the lacrimal canaliculus. Erythema and swelling lasted for several months before resolving completely. This complication has not been reported in the English literature before. Mansfield, D.C., Zeki, S.M. & Mackenzie, J.R. (1994). Clinical Radiology 49, 217-218. Case Report: Extravasation of Lipiodol - A Complication of Dacryocystography
Dacryocystography is usually a simple atraumatic procedure. Radiographs demonstrate those parts of the lacrimal passage which are patent, provided that sufficient contrast medium is retained in the lumen, and that the contrast medium is sufficiently radio-opaque. Iodinated oil such as 'Lipiodol' (May and Baker) has been considered the best contrast medium for this purpose, superior to water-based media such as 'Iohexol' (Nycomed) in its viscosity and radio-opacity [1]. We report a case of extravasation of Lipiodol from the lower canaliculus into the subcutaneous tissues of the cheek of a child, causing localized chronic inflammation. CASE REPORT A 489 girl was referred to the ophthalmology clinic because of constant epiphora of the left eye for 4 months. Both eyes were otherwise
Fig. 1 - Left dacryocystogram: Lipiodol in the soft tissues below the left orbital rim, at the time of injection. Correspondence to: Dr J. R u t h Mackenzie, Department of Radiology, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ.
normal; so too were the lacrimal puncta and the positions of the eyelids. She did not have distension of the lacrimal sac, nor was there a history suggestive of acute or chronic dacryocystitis. Dacryocystography was performed under general anaesthesia to investigate her unexplained epiphora. The p u n c t u m o f the left lower eyelid was enlarged with a Nenleship's puncture dilator. A fine and flexible plastic tube was introduced into t h e lower canaliculus and no more than about 0.5 ml of Lipiodol was injected. It was apparent immediately that the medium had passed out of the lacrimal canaliculus into the subcutaneous tissues, so the injection was halted. Extravasation of the contrast medium was confirmed radiologically (Fig. 1). The patient developed red discolouration of the skin o f the upper part of the left cheek, with slight swelling of the tissue, during the next few days. These symptoms were still apparent when she attended the clinic 11 weeks later. In the affected area cutaneous blood vessels were telangiectatic. The girl had no significant discomfort. Radiography during this visit showed the Lipiodol lingering in the soft tissues below the orbital rim, some of the contrast medium appeared to be draining into tiny lymphatics (Fig. 2). No attempt was made to remove the Lipiodol. Six m o n t h s later she was reviewed: no cosmetic blemish remained. She had no epiphora. M u c h less contrast medium was visible with X-rays.
Fig. 2 - Orbital X-ray, postero-anterior view, 11 weeks after t h e dacryocystogram. Some of the remaining Lipiodol is within small lymphatics.
218
CLINICAL RADIOLOGY
DISCUSSION This patient suffered an unsightly cosmetic blemish because of extravasation of a small volume of Lipiodol during dacryocystography. No active treatment was recommended, and the erythema and swelling gradually resolved without residue. We suspect that both extravasation and a hypersensitivity reaction may be required to produce the clinical picture we have described, though we have not tried to confirm hypersensitivity in our patient. In the great majority of cases extravasation of Lipiodol during lymphangiography causes no symptoms [2], but occasional reactions to extravasated iodinated oil have been reported both in lymphangiography [3] and orbitography [4]. A history of hypersensitivity to iodinecontaining compounds should prompt one to avoid Lipiodol for dacryocystography. Only one account of dacryocystography discusses extravasation [5]: it occurred 13 times in a series of 2300 dacryocystograms, but it rarely caused a rash. Possible risk factors mentioned in that account were anatomical anomalies of the canaliculus, diverticulum, ectasia and scar. The authors suggest irrigation o f the canaliculus with sterile saline so that sudden pain and swelling would warn of extravasation prior to injection of contrast medium. We use brief general anaesthesia when performing dacryocystography on infants and young children. This facilitates the procedure, but it may be a risk factor
because it prevents feedback about pain from trauma to the canaliculus and from extravasation. We also stress the need to inspect punctum dilators and probes before use for the presence of sharp barbs. In the event of a reaction to extravasation, symptoms may resolve quicker if a water-based contrast medium is used, rather than iodinated oil. We have used 'Iohexol' for recent dacryocystograms in children. The resolution achieved is satisfactory, but if higher resolution is required this may be achieved by digital subtraction techniques, which are equally applicable to either type of medium [6].
REFERENCES 1 Munk, PL, Burhenne LW, Buffam FV, Nugent RA, Linn DT. Dacryocystography: comparison of water-soluble and oil-based contrast agents. Radiology 1989; 173:827-830. 2 MacDonald JS. Lymphography. In: Ansell G & Wilkins RA, eds. Complications in diagnostic imaging, 2nd ed. Oxford: Blackwell Scientific Publications, 1987:Ch. 20. 3 Redman HC. Dermatitis as a complication of lymphangiography. Radiology 1966;86:323-326. 4 Eifrig DE. Lipid granuloma of the orbit. Archives of Ophthalmology 1968;798:163-165. 5 Radnot M, Gall J. Die R6ntgendiagnostik der Triinenableitenden Wege. Budapest: Akad6miai Kiad6, 1966. 6 Galloway JE, Kavic TA, Ratio GT. Digital subtraction macrodacryocystography: a new method of lacrimal system imaging. Ophthalmology 1984;91:956-962.
Case Report: Extravasation of LipiodolA Complication of Dacryocystography D. C. M A N S F I E L D , S. M. ZEKI and J. R. MACKENZIE*
Departments of Ophthalmology" and *Radiology, Royal Hospitalfor Sick Children, Yorkhill, Glasgow We describe the occurrence of a significant cosmetic blemish in the cheek of a young girl which was caused by extravasation of'Lipiodol' from the lacrimal canaliculus. Erythema and swelling lasted for several months before resolving completely. This complication has not been reported in the English literature before. Mansfield, D.C., Zeki, S.M. & Mackenzie, J.R. (1994). Clinical Radiology 49, 217-218. Case Report: Extravasation of Lipiodol - A Complication of Dacryocystography
Dacryocystography is usually a simple atraumatic procedure. Radiographs demonstrate those parts of the lacrimal passage which are patent, provided that sufficient contrast medium is retained in the lumen, and that the contrast medium is sufficiently radio-opaque. Iodinated oil such as 'Lipiodol' (May and Baker) has been considered the best contrast medium for this purpose, superior to water-based media such as 'Iohexol' (Nycomed) in its viscosity and radio-opacity [1]. We report a case of extravasation of Lipiodol from the lower canaliculus into the subcutaneous tissues of the cheek of a child, causing localized chronic inflammation. CASE REPORT A 489 girl was referred to the ophthalmology clinic because of constant epiphora of the left eye for 4 months. Both eyes were otherwise
Fig. 1 - Left dacryocystogram: Lipiodol in the soft tissues below the left orbital rim, at the time of injection. Correspondence to: Dr J. R u t h Mackenzie, Department of Radiology, Royal Hospital for Sick Children, Yorkhill, Glasgow G3 8SJ.
normal; so too were the lacrimal puncta and the positions of the eyelids. She did not have distension of the lacrimal sac, nor was there a history suggestive of acute or chronic dacryocystitis. Dacryocystography was performed under general anaesthesia to investigate her unexplained epiphora. The p u n c t u m o f the left lower eyelid was enlarged with a Nenleship's puncture dilator. A fine and flexible plastic tube was introduced into t h e lower canaliculus and no more than about 0.5 ml of Lipiodol was injected. It was apparent immediately that the medium had passed out of the lacrimal canaliculus into the subcutaneous tissues, so the injection was halted. Extravasation of the contrast medium was confirmed radiologically (Fig. 1). The patient developed red discolouration of the skin o f the upper part of the left cheek, with slight swelling of the tissue, during the next few days. These symptoms were still apparent when she attended the clinic 11 weeks later. In the affected area cutaneous blood vessels were telangiectatic. The girl had no significant discomfort. Radiography during this visit showed the Lipiodol lingering in the soft tissues below the orbital rim, some of the contrast medium appeared to be draining into tiny lymphatics (Fig. 2). No attempt was made to remove the Lipiodol. Six m o n t h s later she was reviewed: no cosmetic blemish remained. She had no epiphora. M u c h less contrast medium was visible with X-rays.
Fig. 2 - Orbital X-ray, postero-anterior view, 11 weeks after t h e dacryocystogram. Some of the remaining Lipiodol is within small lymphatics.
218
CLINICAL RADIOLOGY
DISCUSSION This patient suffered an unsightly cosmetic blemish because of extravasation of a small volume of Lipiodol during dacryocystography. No active treatment was recommended, and the erythema and swelling gradually resolved without residue. We suspect that both extravasation and a hypersensitivity reaction may be required to produce the clinical picture we have described, though we have not tried to confirm hypersensitivity in our patient. In the great majority of cases extravasation of Lipiodol during lymphangiography causes no symptoms [2], but occasional reactions to extravasated iodinated oil have been reported both in lymphangiography [3] and orbitography [4]. A history of hypersensitivity to iodinecontaining compounds should prompt one to avoid Lipiodol for dacryocystography. Only one account of dacryocystography discusses extravasation [5]: it occurred 13 times in a series of 2300 dacryocystograms, but it rarely caused a rash. Possible risk factors mentioned in that account were anatomical anomalies of the canaliculus, diverticulum, ectasia and scar. The authors suggest irrigation o f the canaliculus with sterile saline so that sudden pain and swelling would warn of extravasation prior to injection of contrast medium. We use brief general anaesthesia when performing dacryocystography on infants and young children. This facilitates the procedure, but it may be a risk factor
because it prevents feedback about pain from trauma to the canaliculus and from extravasation. We also stress the need to inspect punctum dilators and probes before use for the presence of sharp barbs. In the event of a reaction to extravasation, symptoms may resolve quicker if a water-based contrast medium is used, rather than iodinated oil. We have used 'Iohexol' for recent dacryocystograms in children. The resolution achieved is satisfactory, but if higher resolution is required this may be achieved by digital subtraction techniques, which are equally applicable to either type of medium [6].
REFERENCES 1 Munk, PL, Burhenne LW, Buffam FV, Nugent RA, Linn DT. Dacryocystography: comparison of water-soluble and oil-based contrast agents. Radiology 1989; 173:827-830. 2 MacDonald JS. Lymphography. In: Ansell G & Wilkins RA, eds. Complications in diagnostic imaging, 2nd ed. Oxford: Blackwell Scientific Publications, 1987:Ch. 20. 3 Redman HC. Dermatitis as a complication of lymphangiography. Radiology 1966;86:323-326. 4 Eifrig DE. Lipid granuloma of the orbit. Archives of Ophthalmology 1968;798:163-165. 5 Radnot M, Gall J. Die R6ntgendiagnostik der Triinenableitenden Wege. Budapest: Akad6miai Kiad6, 1966. 6 Galloway JE, Kavic TA, Ratio GT. Digital subtraction macrodacryocystography: a new method of lacrimal system imaging. Ophthalmology 1984;91:956-962.