Dr. Vijay jr-3 at department of ophthalmology , MLB medical college jhansi

1. Dr. Vijay pratap singh
Dept. of Ophthalmology
M.L.B.M.C, Jhansi

2. What is F.F.A?
 fundus fluorescein angiography (FFA) is a
technique for examining the circulation of
the retina and choroid (parts of the fundus) by using a
iv fluorescent dye and a specialized angiographic
camera.

3. What is fluorescence
Free
electron
fluorescence
Radiant
energy
Fluorescent
chemical
ReleaseAbsorbs
Emit
energy
Jump
to
higher
level
 Becomes
unstable
Returns
To
Lower
level

4. Dye used in FFA
 Refers to fluorescein sodium (C20H10Na2O5).
 First synthesized in 1871 in Germany by Von Bayer.
 A brown or orange-red crystalline substance, alkaline in nature.
 Stable, Highly Water Soluble & Pharmacologically inert.
 Fluoresces at Blood Ph.
 80% bound to plasma protein and also with RBC.
 Absorbs blue light (490nm ) and emits yellow-green light
(530nm).
 Metabolized by liver and exerted by kidney

5. Purpose of FFA
 Studying the normal physiology of the retinal and
choroidal circulation,as well as disease process affecting
the macula
 Evaluation of the vascular integrity of the retinal and
choroidal vessels
 Check the integrity of the blood ocular barrier.
- outer blood retinal barrier breaks in CSR
- inner blood retinal barrier breaks in NVD,NVE

6. Therefore ,FFA helps
 In clinical diagnosis of choroidal and retinal disease
 To determine extent of damage.
 To formulate treatment strategy.
 To monitor result of treatment.

7. Indications of FFA
 Indications
of FFA
Retinal vascular
malformation and
tumor
Retinal
vascular
disorders
Macular
disorders
Choroidal
disorders
Optic
nerve
disorders

8. Retinal vascular disorder, malformation
and tumors
1) Diabetic retinopathy.
2) Retinal vein occlusions.
3) Retinal artery occlusion.
4) Retinal vasculitis.
5) Coats disease.
6) Familial exudative vitreoretinopathy.
7) Capillary hemangioma of retina.
8) Cavernous hemangioma of retina.
9) Retinal AV malformation.
10) Congenital tortuosity of retinal vasculature.
11) Congenital hypertrophy of RPE.
12) Angioid streaks.
13) Astrocytic hamartoma.

9. Macular diseases
1) Central serous retinopathy
2) RPE detachment
3) Cystoid macular edema
4) Macular hole
5) ARMD
6) Cone rod dystrophy
7) Epiretinal membrane
8) Vitiliform dystrophies
9) Stargardts dystrophy

10. Choroidal lesions
1) Choroidal neovascular membrane (CNV)
2) Hemangioma
3) Nevus
4) Melanoma
5) Choroiditis
6) Metastasis
7) Choroidal folds

11. Optic nerve disorders
1) Optic atrophy
2) Papilloedema
3) Ischemic optic neuropathy
4) Optic disc pit
5) Optic disc drusen
6) Optic disc hemangioma
7) Melanocytoma
8) Myelinated nerve fibers

12. Contraindications
ABSOLUTE
1) known allergy to iodine containing compounds.
2) H/O adverse reaction to FFA in the past.
RELATIVE
1) Asthma
2) Hay fever
3) Renal failure
4) Hepatic failure
5) Pregnancy ( especially 1st trimester)

13. PROCEDUREPatient is informed of the normal procedures, the side effects and the adverse
reactions.
Dilating the pupil of pt. and Made to sit comfortable
3-4 red free photographs taken. (control photographs)
5ml of 10% or 3ml of 25% NAF injected through the anticubital vein
wait for 10 – 12 seconds( normal arm-retina time)
Photos are taken at 1 second interval for 10 seconds
Then every 2 seconds interval for 30 seconds
Late photographs are usually taken after 3 ,5 and 10 minutes.

14. CIRCULATION OF DYE
Dye injected from peripheral vein
venous circulation
heart
arterial system
INTERNAL CAROTID ARTERY
Ophthalmic artery
Short posterior ciliary artery) Central retinal A.
(choroidal circulation.) ( retinal circulation)

15. Types of circulation in fundus
A.Choroidal
circulation
-choriocapillaries are
fenestrated
-so allows dye to
diffuse freely
BUT,
-outer blood-retinal
barrier in RPE don’t
let dye to reach
retina
B.Retinal circulation
-endothelial cells of
retinal blood vessels
joined by tight
junctions (inner
blood retinal barrier)
-prevents leakage of
dye from vessels

16. Phases of angiogram
A) Choroidal (pre-arterial) -
B) Arterial
C) Arteriovenous(capillary)
D) Venous and
E) Recirculation (elimination)-
Patchy filling
No leakage
No complication

18. 1.Prearterial/choroidal phase
 8-12 seconds after dye
injection
 Initial patchy filling
followed by diffuse
filling
 No dye has entered
retinal circulation

19. 2.Arterial phase
 Shows arterial filling
 Continuation of
choroidal filling
 1 second after
choridal phase

20. 3.Arterio-venous phase(capillary phase)
 Complete filling of
arteries and capillaries
 Early laminar flow to
veins
 Dye seen along lateral
wall of veins

21. 4.Venous phase
 Early venous phase
-Arteries and
capillaries
completely filled
-Marked lamellar
venous flow

22.  Mid-venous phase
-Some veins
completely filled
-Some shows
marked laminar
flow

23. Late venous phase
 All veins
completely filled
 Arteries begin to
empty

24. 5.Late/elimination phase-
 Elimination of dye
from choroidal and
retinal circulation
 Staining of disc –
normal
 In 5-10 minutes
fluorescein absent
from angiogram

25. FFA interpretation
FFA should be
Normal Abnormal Artifact
Hyperfluorescence Hypofluorescence
Leakage Pooling Staining Window Blocked Non
filling defect filling
d/t increased accumulation of dye

26. Window defect-
 Defect in RPE – increased
transmission of choroidal
fluorescence.
 Sharply defined
hyperfluorescence
area. Window defect- large
Macular hole

27. Increased accumulation of dye
 LEAKAGE
 Papilledema
 CNV
 Breaking of inner blood
retinal barrier(CME)
 Retinal
neovascularization
 Proliferative Diabetic
Retinopathy(NVD,NVE)

28. CME
CME on OCT CME on FFA

29. NVD & NVE in PDR

30. POOLING
1. In sub Retinal space
- As in CSR
2. In sub RPE space
- As in PED

31.  STAINING -Accumulation of fluorescence within a tissue
-Due to prolonged dye retention
-Can be seen in normal as well as pathologically
altered tissue
RETINAL
a. Non-cystoid macular
oedema
b. Perivascular staining
SUB RETINAL
A. Drusens
B. Sclera
C. Lamina cribrosa
D. Scars
Examples are-
ARMD

32. Hypofluorescence
 Reduction or absence of
fluorescein
 Two causes-
1. BLOCKED
FLUORESCENCE
2. VASCULAR
FILLING DEFECTS
A. Optical obstruction (masking)
of normal density of fluorescein.
B. Caused by lesions anterior to
retina
A. Inadequate perfusion of tissue
with resultant low fluorescein
content

33. BLOCKED FLUORESCENCE EXAMPLES ARE
 Pre-retinal lesions eg.vitreous
opacity,preretinal
haemorrhage block all
fluorescence
 Deep retinal lesions
eg.intraretinal haemorrhage
and hard exudates block only
capillary fluorescence
 Increased density of RPE
eg.congenital hypertrophy
 Choroidal lesions eg.naevus
RPE hypertrophy

34. Examples of Filling defects-
 Avascular occlusion of choroidal circulation or
retinal arteries,veins and capillaries
 Loss of vascular bed eg.severe myopic degeneration –
choroideremia
 Emboli
 arteriosclerosis

35. CRAO CRVO

36. Fovea in FFA(FAZ)
 Appears dark
d/t
AVASCULARITY
in fovea
BLOCKAGE OF
CHOROIDAL
FLUORESCENCE
INCREASED
XANTHOPHYL
PIGMENTS
LARGER RPE
CELLS WITH
MORE
MELANIN

37. Autofluorescence
Fluorescence
without the
administration
of fluorescein
Pseudofluorescence
-Drusen of the
optic
nerve head
-Hamatoma
-Scleral exudate
-Scar tissue
-Foreign body
-Myelinate nerve
Fibers, optic nerve
drusen

38. Complications of FFA
MILD
Staining of skin,
sclera and mucous
membrane
Stained secretion
Tear, saliva
Vision tinged with
yellow
Orange-yellow
urine
Skin flushing,
tingling lips
pruritis
MODERATE
Vasovagal response
Utricaria
Fainting
Periphlebitis
Nausea and
vomiting
SEVERE
Respiratory-
laryngeal edema
,bhroncospasm
Circulatory shock,
MI, cardiac arrest
Generalized
convulsion
Skin necrosis

39. Limitations of FFA
1) Does not permit study of choroidal circulation details due to
a) melanin in RPE
b) low mol wt of fluorescein
2) More adverse reaction
3) Inability to obtain angiogram in patient with excess hemoglobin
or serum protein.e.g.
- polycythemia
-weldenstrom macroglobulenaemia
bcz binding of fluorescein with excess Hb or protein so ,Lack
of freely circulating molecule

40. OPHTHALMIC ULTRASOUND
What is ultrasonography?
- Non-invasive imaging by
using ultrasonic wave
(Piezoelectric Effect)
- 1942 – Neurologist Karl
Dussik is credited with
being the first to
use sonography for
medical diagnoses

41. Frequency uses in ocular scan
 Low frequency (3-5 MHz)
Use for orbital tissue pathology
 Medium frequency (7- 10 MHz)
Retina , vitreous, and optic nerve pathology
 High frequency (30-50 MHz)
For Ant. Chamber pathology

42. Type of scan
 A-Scan (by using
single beam)
 B-Scan (by using
multiple baem)

43. A-scan

44. B-scan
 Baum and Greenwood in 1950’s
developed B scan
 Mainly 3 types of probe position-
A)Transverse section
B) Longitudinal section
C)Axial section

47. A)Transverse section

50. FEATURES CHOROID
DETACHMENT
RETINAL
DETACHMENT
PVD
SHAPE DOME LINEAR V/U -
LOCATION PERIPHERY VARIABLE VARIABLE
ATTACHMENT
TO ONH
NO YES VARIABLE
OTHER
FINDINGS
KISSING
CHOROIDALS
FOLDS,BREAKS,
PVR CHANGES
PROMINENT
INFERIORLY
A SCAN SPIKE % 90-100 80-100 40-90
MOBILITY MINIMAL MODERATE MARKED
AFTER
MOVEMENT
- MINIMAL MARKED