Fundus fluoroscein angiography of retina is an useful for imaging the retinal vasculature

1. D R . G . N A G E S W AR R A O ; M D
A S S O . P R O F. O P H T H A L M O L O G Y, K I M S
V I T R E O - R E T I N A L S U R G E O N
Fundus fluorescein angiography

2. What is fluorescence ???

3. LUMINESCENCE & fluorescence
 Luminescence:- Emission of light from any source
other than high temperature
 It occurs when energy in the form of electromagnetic
radiation is absorbed and then re-emitted at another
frequency
 Fluorescence:- luminescence that is maintained
only by continuous excitation

4. Understanding fluorescence
Fluorescent
chemical
absorbs
Radiant
energy
release
Free
electron
Jump
to
higher
level
Becomes
unstable
Returns
To
Lower
level
Emit
energy
Luminescence
/fluorescence

6. 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

7. Therefore ,
it helps :
 In clinical diagnosis
 to determine extent of damage
 To formulate treatment strategy for choroidal and
retinal disease
 To monitor result of treatment

8. Indications
of FFA
Macular
disorders

9. Retinal diseases
1) Diabetic retinopathy
2) Retinal vein occlusions
3) Retinal artery occlusion
4) Retinal vasculitis
5) Coats disease
6) Familial exudative
vitreoretinopathy
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. 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)

11. Adverse effects
MILD MODERATE SEVERE
Staining of skin,
sclera and
mucous
membrane
Nausea and
vomiting
Respiratory-
laryngeal edema
,bhroncospasm
Stained secretion
Tear, saliva
Vasovagal
response
Circulatory
shock, MI,
cardiac arrest
Vision tinged
with yellow
urticaria Generalized
convulsion
Orange-yellow
urine
fainting Skin necrosis
Skin flushing,
tingling lips
pruritus

12. PROCEDURE
Patient is informed of the normal procedures, the side effects and
the adverse reactions.
Dilating the pupil
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

13. 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
(choroidal circulation.) ( retinal circulation)
N.B. The choroidal filling is 1 second prior to the retinal filling.

16. what is normal angiography?

17. Two 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

18. Phases of angiogram
A) Choroidal (pre-arterial)
B) Arterial
C)
iovenous(capillary)
D) Venous and
E) Late(elimination)
Patchy filling
No leakage
No complication
WHY
???

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

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

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

23. Early venous phase
 Arteries and capillaries
completely filled
 Marked lamellar venous
flow

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

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

26. Late/elimination phase
 Elimination of dye from
choroidal and retinal
circulation
 Staining of disc – normal
 In 5-10 minutes
fluorescein absent from
angiogram
 And from body in several
hours

27. Fovea in FFA
 Appears dark
AVASCULARI
TY IN FAZ
BLOCKAGE OF
CHOROIDAL
FLUORESCENCE
INCREASED
XANTHOPHYL
L PIGMENTS
LARGER RPE
CELLS WITH
MORE
MELANIN

28. Hypofluorescenc
e (black) patch
Hyperfluorescen
ce (white) patch

29. FFA interpretation flow chart
Fluorescein angiogram
Normal Abnormal Artifact
Hyperfluorescence Hypofluorescence
Leakage Pooling Staining Window Blocked Nonfilling
defect filling

30. hyperflourescence
 Greater level of fluorescence than would be found in
normal angiogram
 Occur due to:
-window defect
-increased accumulation of dye
leakage
pooling
staining

31. examples
 Papilledema
 Abnormal choroidal vasculature(CNV)
 Breaking of inner blood retinal barrier(cystoid macular
oedema)
 Abnormal retinal or disc vasculature(retinal
neovascularization)
 Proliferative Diabetic Retinopathy(NVD,NVE)

32. Flower petal appearance
CME
papilloedema

33. Neovascularization at disc(NVD)
Neovascularization elsewhere (NVE)

34. pooling
 Accumulation of fluorescein in anatomical space
 Due to breakdown of outer blood retinal barrier

35. CENTRAL SEROUS
RETINOPATHY
PED

36. staining
 Accumulation of fluorescence within a tissue
 Due to prolonged dye retention
 Minimum hyperfluorescence in early and midphase
which increases in late phase
 Can be seen in normal as well as pathologically
altered tissue

37. examples
RETINAL
a. non-cystoid macular
oedema
b. Perivascular staining
SUB RETINAL
a. Drusens
b. Sclera
c. Lamina cribrosa
d. scars

38. Drusens in ARMD

39. hypofluorescence
 Reduction or absence of fluorescein
 Two causes
BLOCKED
FLUORESCENCE
VASCULAR
FILLING
DEFECTS

40. BLOCKED FLUORESCENCE
 Optical obstruction (masking) of normal density of
fluorescein
 Caused by lesions anterior to retina

41. examples
 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

42. RPE
hypertrophy
Retrohyaloid haemorrhage

43. Filling defects
 Inadequate perfusion of tissue with resultant low
fluorescein content

44. examples
 vascular occlusion of choroidal circulation or
retinal arteries,veins and capillaries
 Loss of vascular bed eg.severe myopic degeneration
– choroideremia
 Emboli
 arteriosclerosis

45. CRAO
CRVO

46. Zonula occludents open up
normal
Endothelial cell is lost
Pores in endothelial cells

47. PERIVASCULITIS

48. DIABETIC
MICROANEURYSM

49. PROLIFERATED
RETINAL VESSELS

50. RETINAL PIGMENT EPITHELIUM
 Normal RPE is tight
 zonula occludens seal portion of all the
intercellular spaces of the pigment epithelial
monolayer.

52. Cental serous
chorioretinopathy Type I

53. Haemorrhagic PED
in wet ARMD

54. summary
 Even today FFA, has its position in the diagnosis of
retinal diseases
 Normal retinal vessels will not leak dye
 Hypofluorescence –
blocked/filling defect
always match with red free fundus photo
 Hyperfluorescence – leakage of dye from
abnormal vasculature/collection of the dye into an
extracellular space
 Wide field angiogram – recent advancement

55. THANK YOU