What are the contraindications to fluorescein eye stain?

Contraindications to Fluorescein Eye Stain

Fluorescein eye staining has few absolute contraindications, with the primary contraindication being a known history of anaphylactic reaction to fluorescein. 1 While fluorescein 2% eye drops are generally considered safe and are universally used in clinical practice, they can rarely cause severe systemic reactions including anaphylaxis in susceptible individuals.

Contraindications and Precautions

• Absolute contraindication:

  • Known history of anaphylactic reaction to fluorescein 1
  • Previous severe hypersensitivity reaction to fluorescein

• Relative contraindications/Use with caution:

  • History of multiple drug allergies or brittle asthma 1
  • History of anaphylaxis to other allergens (increased risk)
  • Active inflammatory eye disease (may cause exacerbated local reactions) 2

Safe Application Method

When fluorescein eye staining is indicated and no contraindications exist:

1. Use a fluorescein strip moistened with sterile nonpreserved saline
2. Apply to the inferior tarsal conjunctiva 3
3. Allow patient to blink several times to distribute the dye
4. Examine using a cobalt blue filter on the slit lamp
5. Wait approximately 2 minutes for optimal visualization 3, 4

Important Considerations

• Avoid fluorescein-anesthetic combination drops for tear break-up time testing, as the anesthetic may affect test results 3
• Evaluate tear break-up time before instillation of any eye drops and before eyelid manipulation 3
• For enhanced visualization, a yellow filter can be used in conjunction with the cobalt blue filter 3
• Be aware that mild fluorescein staining can be observed in normal eyes and may be more prominent in the morning 3, 5

Risk Management for Patients with Potential Hypersensitivity

For patients with a history of multiple allergies or previous mild reactions:

• Have emergency medications readily available (epinephrine, antihistamines, corticosteroids)
• Consider having an intravenous line in place before administration
• Monitor the patient closely for at least 30 minutes after administration
• Consider alternative diagnostic approaches such as lissamine green dye, which causes less ocular irritation than rose bengal 3, 4

Recognizing Adverse Reactions

Adverse reactions to fluorescein may include:

• Local reactions: burning sensation, tearing, conjunctival chemosis and injection 2
• Systemic reactions: nausea, vomiting, hypotension, bronchospasm, urticaria
• Severe reactions: anaphylaxis (extremely rare with topical application) 6, 1

Clinical Pitfalls to Avoid

• Don't assume that topical fluorescein is completely safe in all patients - while systemic reactions are extremely rare with topical application, they can occur 1
• Don't use fluorescein-anesthetic combinations for tear break-up time assessment 3
• Don't interpret staining patterns in isolation - consider the full clinical picture 4
• Don't forget that eyes with active inflammatory diseases may have exaggerated local reactions to fluorescein 2