1) Fluorescein angiography (FA) is a useful tool for diagnosing and monitoring retinopathy of prematurity (ROP). It allows for more accurate staging of acute ROP and detection of plus disease compared to color fundus photography alone. 2) FA is valuable for evaluating peripheral avascular retina and abnormal vasculature during follow-up after ROP regression or anti-VEGF treatment. It can detect persistent avascular areas and vascular abnormalities not visible on exam. 3) FA may help identify occult neovascularization and guide treatment decisions for ROP recurrence or persistent peripheral avascular retina. It provides important information on vascular changes over time.

1. FFA IN ROP
BENEFITS & LIMITATIONS
Gazi University, School of Medicine, Ankara, Turkey
sengulozdek@gmail.com
sozdek@gazi.edu.tr
QOIC Feb 2021

2. ROP
• Vasoproliferative
disease of retina
in prematures
• BIO is the major
tool for
screening

3. Problems in ROP screening
• Shortage of trained experts
• Telemedicine may help
• Wide-field imaging devices for babies

4. Role of Digital Imaging for
Diagnosis of Acute ROP
• Advantage over BIO?
• CF pictures allow more
accurate comparison
for follow up
• Zone/plus
determination better

5. Role of FA for ROP
• FA is a perfect tool to demonstrate
the vascular pathologies
• Acute disease
• Follow up of regression
• Reactivation

6. FA technical issues
• Bedside /OR
• Topical anesthesia
/ GA
• 1ml/kg 10%Na
Fluorescite

7. 1. Role of FA
for Diagnosis of Acute ROP
• Determination of stage 2-3 (NV)
• Pre plus-Plus disease
• Capillary loss posterior to the ridge
• Choroidal circulation abnormalities
• Macular changes: FAZ absence

8. Zone-Stage
• Allows more objective
assessment of
disease for stage 3
and zone 1

9. Influence of FA on the
Diagnosis and Management of ROP
Ophthalmology, 2015, Klufas et al
Addition of FA to CFP
• 9 ROP experts (16 CP and 16 CP+FA pairs)
• Improvement in sensitivity for diagnosis of stage 3 or
worse disease (39.8% vs. 74.1%)
• Increased sensitivity of diagnosis of stage 2 or
worse, pre- plus or worse, and type-2 ROP or worse.
• Improved intergrader agreement for diagnosis of
treatment-requiring ROP.

10. FA in APROP-OIR
Capillary nonperfusion areas posterior to the ridge
A. Vinekar et al.

11. Oxygen induced retinopathy

12. Choroidal Circulation in ROP
• Choroid has the
potential to play a major
role in maintaining the
retina until the retinal
vasculature fully
develops.
• Choroid filling
abnormalities (linear not
lobular)

13. FA Findings in Macula
No FAZ

14. 2. Role of FA during follow up
• To evaluate retinal vascular morphology
following Anti-VEGF injections
• Persistent Peripheral Avascular Retina
(PPAR)
• Abnormal branching, loops, anastomosis,
finger like peripheral vessels
• Evaluation of recurrences (NV, leakage)

15. GA: 26 wk, BW: 640 gr
APROP
Treated with Lucentis at 34wk

16. Presence of peripheral persistent avascular areas (PPAR)
and leakage from primary and secondary ridge
4y/o, Right Eye: BCVA: 20/80

17. Presence of PPAR and leakage from the primary ridge
4y/o, Left Eye: BCVA: 20/80

18. FA in Natural disease
vs Post Anti-VEGF
• PMA>60wk,
• Spontaneously regressed vs IVB
• NV: ophthalmoscopic vs FA
• NV in FA in 30.0% of IVB and 37.5% of
spontaneous group (then lasered)
• Occult NV (visible only with FA): 40%
Fluorescein Angiography in Retinopathy of Prematurity- Comparison of Infants Treated with
Bevacizumab to Those with Spontaneous Regression. Ophthalmol Retina-2019, Mansukhani et al.

19. 20y/o, M,
GA: 27 wk, BW: 1100gr
• Followed in USA for ROP since birth
• Previous patching treatments for amblyopia and
strabismus (No treatment for ROP)
• Laser PC for lattice degenerations in both eyes.
• Came for a control visit (asymptomatic)
• BCVA: 20/25 (myopia) OU

22. SAN DIEGO-ASRS

23. FFA SAN DIEGO-ASRS

25. 360
360 PERIPHERAL LPC

26. No problem since 6 years

27. 34wk, 2400gr,
OIR with severe plus disease
IVB at 38wk, Now 60wk
Previous macular edema resembling macular hole

30. OCT: macular atrophy

31. Persistent Peripheral
Avascular Retina (PPAR)
• Natural disease process
• Following Anti-VEGF injections
• Late recurrences

32. PPAR

33. PPAR

34. Finger like branching vessels

35. PPAR & Finger like branching vessels
28mo old premature following anti-VEGF injection

36. 2y/o after Anti-VEGF
FA: Peripheral vascular
anastomosis

37. Vascular anastomosis, loops

38. Peripheral leakage following
anti-VEGF treatment of ROP
18mo old

40. When to treat PPAR?
• Controversial issue
• PPAR is treated with laser when vessels do
not extend into zone 3 by 60 weeks post-
menstrual age (PMA).

41. 23wk, 540gr,
Type 1 ROP (zone 1) at 37 wk
• Bilateral Eylea injection

42. 5 days after injection

43. 11 mo old, OD: -7.50 -2.00x90

44. 11mo old, OS: -9.00 -1.50x54

45. FA, RE: Avascular Zone 2, Abnormal branching
anastomozing peripheral vessels

46. FA, LE: Avascular Zone 2, Finger like peripheral
vessels, leakage.

47. GAAM Sonrası
Tedavi
LPC to both eyes

48. Persistent vascular tortuocity

50. GA: 28 wk, BW: 7300 gr,
APROP,
Treated with Eylea at 34wk

51. 2y/o, FA

52. FA in ROP
Take-home messages
• More reliable tool for diagnosing stage 3
and plus disease in acute ROP
• Very crutial for follow up of PPAR after
regression (antiVEGF treatment)
• Very important tool to detect reactivation
and to determine laser treatment

54. Thank you
sozdek@gazi.edu.tr
www.sengulozdek.com
Thanks to my Co-workers
Dr. Emine A. Sukgen, Dr. H. Tuba
Atalay
H. Baran Özdemir