basics , principle, mechanism of fluorescence and auto fluorescence with pictures of high quality, detailed diseases description with photographs of early and late phases of angiography

1. LUMINESCENCE
• Emission of visible light
• Absorbs energy in the form of electromagnetic radiation
• Free electrons are elevated into higher energy states - unstable -
decay of into their lower energy states
• Decay occurs in the visible spectrum - luminescence.
• Luminescence is always a shift from a shorter to longer wavelength

2. FLUORESCENCE
• Luminescence maintained by continuous excitation
• No afterglow
• Sodium fluorescein – absorbs 465-490 nm (blue) and fluoresces 520–
530 (green–yellow)
• 80% of fluorescein bound to protein 20% remains free in the blood
• blue filter shields out all other light but blue excitation light
• green–yellow filter allows the fluorescent light but keeps out blue

3. PSEUDOFLUORESCENCE
• Penetration of non-fluorescent blue light through yellow-green filter
• Can confuse interpretation
• Causes decreased contrast and resolution
• White or yellowish-white areas of the fundus - hard exudates
• Excitation (blue) and barrier (green–yellow) filters sh’d be carefully
matched

5. FLUORESCEIN SOLUTION
• Sodium fluorescein
• orange-red crystalline hydrocarbon (C20H12O5Na)
• Low molecular weight (376.27 Da)
• Does’nt diffuse through retinal endothelium or pigment epithelium.
• Vials of 10 mL 5% or 5 mL 10% or 3 mL 25% fluorescein
• Greater the volume - longer the injection time
• Smaller the volume - more fluorescein remains in venous dead space

6. Side-effects and Complications
• Eliminated by liver and kidneys within 24 hours, traces found for a
week
• Retention - if renal function is impaired
• Skin has a yellowish tinge for few hours
• Urine has a yellow–orange color for most a day
• Extravasation – painful, Necrosis and sloughing may occur rarely
Superficial phlebitis

7. • Nausea – Vomiting
• Subcutaneous granuloma
• Toxic neuritis
• Vasovagal attacks, Shock and syncope (more severe vasovagal)
• Anaphylaxis (hives and itching, laryngeal edema, bronchospasm,
tachycardia)
• Neurologic problems (tonic–clonic seizures)
• Thrombophlebitis
• Pyrexia

8. CONTRAINDICATIONS
• Known hypersensitivity Absolute
• Renal failure
• Some companies specify that beta-blocker treatment
• No established contraindications in pregnancy ?
• coagulopathies, impaired blood or lymphatic circulation (post-
mastectomy)
• Dehydrated or underweight
• juvenile asthmatics

9. Checklist for Fluorescein Angiography
• Written informed consent
• Dilated pupil
• Fluorescein solution, scalp-vein needle, and syringe
• Input patient identification and demographic data in database
• Position patient for alignment, focus, and comfort

10. Injecting the Fluorescein
• Color fundus and red-free image of each macula taken
• Timer started at starting of injection
• Rapid injection delivers a high concentration - better photographs
• First photo - at about 10 seconds, then, rapidly at intervals of 2
seconds, until all veins and arteries are full
• Latestage angiographs at 5 minutes and 10 minutes

11. INTERPRETATION
• Vitreous - clear and nonfluorescent
• Opacities - block the fluorescence – hypofluorescence
• Preretinal area
• ERM
• hemorrhage
• Sensory retina devided into:
• Inner vascular half - from ILM to the INL
• outer avascular half - OPL to Rods and cones

12. • OPL - primary interstitial space in the retina
• RPE prevents fluorescein leakage and blocks choroidal fluorescence.
• Choroid supplied in lobules - patchy filling
MCULA
• Stellate appearance of CME - oblique GCL
• Dark appearance of the macula
Xanthophyll, more melanin in RPE,
FAZ (400–500 mm)

13. Normal Fluorescein Angiogram
• Early choroidal fluorescence 10 – 12s in young, 12 – 15s in older
• faint, patchy, and irregularly scattered - choroidal flush
• Most of the disc is fed by the ciliary system - fluoresces
simultaneously with choroid
• Cilioretinal artery
• RA -1–3 seconds after choroidal fluorescence

15. • Veins 1 – 2s after RA - laminar flow
• In the next 5–10 seconds - complete fluorescence of the retinal veins.
• healthy disc contains many capillaries - fairly hyperfluorescent

16. • “peak” phase – 20 –25s - Perifoveal capillary net - seen best in young
• 30s after injection, flush of begins to empty

17. • 3–5 minutes after injection, vasculatures begin to empty and become
gray - completely empty in approximately 10 minutes

18. ABNORMAL FLUORESCEIN ANGIOGRAM
Hypofluorescence
• blocked fluorescence - masked, obscured, or negative fluorescence or
transmission decrease
• The further the opacification is in front, the less it will block and the
more it will affect the overall quality

19. Preretinal hemorrhage causing hypofluorescent blockage of all
retinal and choroidal fluorescence

20. Intraretinal hemorrhages causing hypofluorescent blockage

21. Subretinal hemorrhage causing hypofluorescence, specifically,
blockage of choroidal fluorescence

22. Hypertrophy of the retinal pigment epithelium.

23. Choroidal nevus hypofluorescent blockage

24. Optic pit and sensory macula detachment

25. • Vascular Filling Defect

26. Retinal branch vein occlusion

27. Branch retinal artery occlusion

28. Occlusion of the posterior ciliary artery gives rise to hypofluorescence
due to nonfilling of the affected segment of the choroid

29. Choroideremia: total loss of retinal pigment epithelium (RPE) and
choriocapillaris with much of the large choroidal vasculature remaining

30. Choroidal hypoperfusion caused by photodynamic therapy with
verteporfin

31. Abnormal Hyperfluorescence
• Preinjection fluorescence
• Autofluorescence and Pseudofluorescence
• Transmitted fluorescence
• appears with normal choriocapillaris – reduced or loss of RPE
(window defect)
• Abnormal vessels
• Leakage

32. Autofluorescence
• Crystalline Lens
• Corneal epithelium and endothelium
• Drusen
• Lipofuschin pigment in RPE

33. Autofluorescence of optic nerve drusen

34. • A-V phase angiogram - multiple leakages - multifocal CSR
• Hypoautofluorescence (arrows) corresponding to the focal leaks on
FFA are made out on fundus autofluorescence
• Drusen - hyperautofluorescent

35. • Neurosensory detachment at the fovea - chronic CSR
• Autofluorescence - speckled autofluorescence oval area of RPE
atrophy
• A-V phase angiogram - leakage

36. • Multiple atrophic patches
• Autofluorescence - Hypoautofluorescent spots - RPE atrophic patches
• angiogram - pinpoint leakage superonasal to the fovea, RPE atrophic
patches are seen

37. Transmitted fluorescence due to congenital absence of pigment in the
retinal pigment epithelium is seen in patients with albinism

38. Abnormal retinal vascular fluorescence: retinal vascular
microaneurysms, telangiectasis, and anastomoses

39. Abnormal retinal vessels: retinal neovascularization due to
proliferative diabetic retinopathy

40. • Dirty-gray membrane, small subretinal hemorrhage
• A-V phase of angiogram - fine, lacy, irregular hyperfluorescence
corresponding to a patch of subretinal NVM
• Late phase of angiogram – leakage of these vessels into the
subpigment epithelial and subretinal spaces

41. • dirty-gray membrane noted in the inferotemporal portion of the macula
• Early A-V phase - a lacy, irregular, nodular area of hyperfluorescence
• Late phase - leakage from the patch of subretinal neovascularization

42. • choroidal hemangioma
• A-V phase of angiogram - prominent hyperfluorescence in this area
demonstrating the tumor vessels
• Late phase - marked leakage in this area.

43. cystoid retinal edema

44. noncystoid edema
generalized leakage in the distribution of the blocked branch vein
leakage is not yet severe enough to form clearly defined cystic spaces.

45. When a large retinal vessel (artery or vein) traverses a CNP area,
ischemic retinal factors act adversely on the endothelium and cause it
to leak. This is called perivascular staining. also occurs with traction or
inflammation.

46. subretinal pooling: central serous chorioretinopathy

47. leakage from the choroid due to a retinal pigment epithelial (RPE) rip.

48. pooling (or staining) of large drusen
The larger the drusen, the more similar they are to pigment epithelial
detachments, and therefore the more likely it is that they will show
pooling of fluorescein (or staining of the drusen material)