staining the vitreous with kenalog

One of the trickiest parts of an anterior vitrectomy is seeing the vitreous.

You can often see the nearly invisible vitreous strands pushing another structure aside or detect that the vitreous has occluded an I/A aspiration port. However directly seeing the vitreous is difficult. Scott Burk at Cincinatti Eye helped to solve this problem with his description of using Kenalog (off label) to stain vitreous that had prolapsed into the anterior chamber (ref below). As Kenalog is not approved by the FDA for this indication and as some retinal surgeons have had sterile and even infectious endophthalmitis from using Kenalog its use is controversial. However it is a very useful adjunct to anterior vitrectomy. For more detail on vitrectomy pls see: http://www.medrounds.org/cataract-surgery-greenhorns/2005/10/chapter-5-managing-surgical.html or the section in this blog.

Dr Burk described a process to wash the preservative off of the Kenalog to use in the anterior chamber. His process dilutes the 40mg/ml Kenalog 10:1 and washes off the preservative with a filter. I have summarizied the steps of his technique below and show the technique in the video. Please keep in mind that this is not approved by the FDA for this technique and does carry some risk of TASS (sterile anterior chamber inflamation) and of endophthalmitis.   you can also use the preservative free kenalog which is now available and dilute it 10:1 which although more expensive is easier and is approved for intraocular use.

Preparing the Kenalog Stain

• TB syringe to withdrawn 0.2 ml of well shaken Kenalog (40mg/ml)
• Remove the needle and replace with a 5 (or 22) micron syringe filter (Sherwood Medical)
• Force the suspension through the filter and discard the preservative filled vehicle
• The Kenalog will be trapped on the syringe side of the filter
• Transfer the filter to a 5 ml syringe filled with balanced salt solution (BSS)
• Gently force the BSS through the filter to further rinse out preservative
• Repeat rinsing a few times
• Place a 22 gauge needle on the distal end of the filter
• Draw 2 ml of BSS into the syringe through the filter to resuspend the Kenalog
• The Kenalog (now without preservative and dilute 10:1) will stain vitreous strands white

one of the nice things about the kenalog stain is that you can better understand the fluid dynamics of vitreous removal.  you can see the vitreous streaming around the cutter with a leaking wound.  you can see the vitreous heading better toward the cutter if you hold the cutter low and the irrigation cannula high.  here is a video showing these principles. 

References

Burk SE, Da Mata AP, Snyder ME, Schneider S, Osher RH, Cionni RJ. Visualizing vitreous using Kenalog suspension J Cataract Refract Surg. 2003 Apr;29(4):645-51

Burk, SE, Question 32: When and How Do I Stain the Vitreous With Intracameral Kenalog? from Chang DF, Oetting TA, Kim T, Curbside Consultations in Anterior Segment Surgery, Slack Inc, Thorofare NJ, 2007.

learning phaco chop

         Photo credit Jeff Gentner  /  AP

Shirley and Stan White's son, Andrew White, died in his sleep on Feb. 12, 2008, while taking a Seroquel, a powerful antipsychotic prescribed as a sleep aid. Shirley White holds a box of her son's prescription medication is photo taken in the their son's bedroom in Cross Lanes, W. Va.

Antipsychotic Prescribed as Sleeping Pill by Matthew Herper, Forbes September 2004

"When AstraZeneca introduced the schizophrenia drug Seroquel in 1997, it was a dud. The London-based drug giant had no experience selling psychiatric drugs, and its then small sales force couldn't compete with the might of Eli Lilly and Johnson & Johnson, which ruled the market for antipsychotic medicines."

AND

"Henry Nasrallah, a psychiatrist who is the associate dean of the University of Cincinnati School of Medicine, says he has prescribed Seroquel as a sleep aid for patients who also suffer from other mental disorders. "A lot of our patients beg us for sleep," says Nasrallah. "And if we are going to give them something for sleep, we want to give them a mild, not harmful, drug that seems to help both their sleep and their depression or anxiety."

---

Since the writing of Herper's 2004 article, Seroquel grew into a blockbuster antipsychotic that continues to be prescribed off-label for insomnia. The drug is connected to veterans dying in their sleep. Often prescribed to vets for insomnia and PTSD, the antipsychotic gained momentum the last 7 years, with increased sales and prescriptions.

The doctor quoted in the 2004 article above, psychiatrist Henry Nasrallah, is a doctor whose hand is heavily in the pharmaceutical paid speaker cookie jar. Nasrallah receives income from AstraZeneca, Pfizer and Johnson and Johnson, which could be a conflict of interest, when speaking about Benedryl vs. Seroquel as he did back in 2004.

It's incredible this story can be written again today, 7 years later. Since then AstraZeneca was fined $520 million dollars for illegal marketing of Seroquel, entered a CIA (Corporate Integrity Agreement) with the Dept of Justice, and internal documents have been exposed detailing AstraZeneca insiders as knowing the antipsychotic had metabolic possibilities, with weight gain and diabetes.

Seroquel lawsuits totalled 26,000 and some remain to be heard in court while others have an unsettled case, where the plaintiffs are waiting for actual settlement numbers, and even information packets. Bloomberg reported cases settled in August 2010 and those plaintiffs have yet to see a dime of settlement money, though the general consensus is about $10,000 per person, for a lifetime body damage of diabetes.

The drug is in multiple trials in the XR version for a multitude of indications.

There are some people who tout atypicals as wonder drugs, and some might say they "work". For those who say that, I say listen to those who this drug in particular has injured. Those are the ones paving the way to AstraZeneca's Golden Wonder Drug blockbuster bank account, the drug that has become the multi-purpose antipsychotic and the one with dangerous side effects....yet where are the funtioning Schizophrenics or patients who suffer with psychosis? what are they saying about this drug's usefulness?

When does America stop tolerating paid pharma doctors and researchers? What will the next 7 years bring? how many more lawsuits or deaths?