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FFA Dr Md Afzal Mahfuzullah
Fundus Fluorescein Angiography (FFA) provides detailed information about the retinal and choroidal circulation. It reveals inflammatory changes, lesions, neovascularization, fluid accumulation, and other abnormalities not visible on standard examination. FFA uses sodium fluorescein dye and filters to produce images of the retinal vasculature and detect leakage or blockages. Areas of hyperfluorescence indicate leakage or pooling of dye, while hypofluorescence shows blocked fluorescence from materials obstructing the view. FFA is useful for diagnosing and monitoring many retinal diseases.
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- 1. Fundus Fluorescein Angiography Dr MdAfzal Mahfuzullah MCPS,FCPS,Felow Vitreo-Retina Retina Specialist & Surgeon Bangabandhu Sheikh Mujib Medical University
- 2. WHY FFA Toconfirms the elements already revealed by clinical examination. Flow characteristics in the blood vessels as the dye reaches and circulates through the retina and choroid. Gives a clear picture of the retinal vessels and assessment of their functional integrity. To monitor the disease intensity and impact of therapy. Provides guidance for application of focal laser in photocoagulation therapy. To detect the leakages without clinical manifestation of edema
- 3. What are theinformations we get from FFA FFA reveals: Inflammatory status of retinal and choroidal blood vessels. Localization of intra retinal lesions e.g. depth of pathological involvement in DR. CNV Neovascularisation in disc or retina
- 4. FFA reveals: Cont Subretinal fluid status Cystoid macular edema Intraretinal/ preretinal haemorrhages Optic nerve disorders RPE integrity and disorders Choroidal neovessels and chorioretinal atrophy
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- 6. BASIC PRINCIPLES: Basedon luminescence and fluorescence. Luminescence – is the emission of light from any source other than high temperature. Fluorescence is luminescence that is maintained only by continuous excitation. Excitation occurs at one wave length and immediate emission occurs through a longer wave length.
- 7. FLUORESCENCE Refers tofluorescein sodium (C20H10Na2O5) A brown or orange red crystalline substance, alkaline in nature. MW- 376 dalton Readily diffuses through body fluids and choriocapillaries but does not diffuse through vascular endothelial cells and RPE (Blood retina barriers)
- 8. OPTICAL PRINCIPLE Absorbsblue light (465- 490nm ) and Emits yellow-green light (520- 530nm) Metabolized by liver and exerted by kidney
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- 10. Blood supply toretina
- 11. Layers & bloodsupply
- 12. GENERAL PRINICIPLES OFFFA Fluorescein • 85% bound to serum proteins • 15% unbound ‘free’ fluorescein • Impermeable to fluorescein Outer blood-retinal barrier (zonula occludens) • Impermeable to fluorescein Choriocapillaris Permeable only to ‘free’ fluoresce Inner blood-retinal barrier (retinal capillaries)
- 13. Circulation of NaF Dyeinjected from peripheral vein Venous circulation Heart Arterial system INTERNAL CAROTID ARTERY Ophthalmic artery Short posterior ciliary artery) Central retinal artery (choroidal circulation.) ( retinal circulation) N.B. The choroidal filling is 1 second prior to the retinal filling.
- 14. ANGIOGRAPHIC PHASES Fiveangiographic phases: • Pre arterial (Choroidal 9-15 seconds) • Arterial • Arteriovenous(capillary) • Venous • Recirculation
- 15. Basic anatomy : The inner retina contains the retinal blood vessels. The larger vessels in the Nerve fiber layer. The retinal capillaries in the Inner nuclear layer. Both are impermeable to dye. The outer retina is primarily interstitial space of the retina, where hemorrhages, edematous fluid and hard exudates accumulate. In normal conditions this layer does contain NaF as because of RPE tight junctions(Outer BRB) Large choroidal vessels do not leake NaF but choriocapillaris does leak.
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- 17. PRE-ARTERIAL/ CHOROIDAL PHASE Choroidal flush Patchy Choroidal filling because of lobular arrangements of choriocapillaris 10-12 sec in young 12-15 sec in old Cilioretinal artery fills at the same time with choroid circulation Macula remains dark due to tall RPE and more pigments.
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- 23. ABNORMAL ANGIOGRAPHIC FINDINGS Hypofluorescence: Filling defect Blocking defect Hyperfluorescence : Window defect Leakage Pooling Staining
- 24. Hypofluorescence Blocked fluorescence(Transmission defects- blood, pigment, hard exudates etc) Vascular filling defects (Circulation abnormality) Blocked Retinal fluorescence 1. Arterial segment material 2. Vitreous material 3. Inner retinal material Blocked choroidal fluorescence 1. Deep retinal material 2. Subretinal material 3. Sub RPE material 4. Choroidal material
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- 26. Hyperfluorescence Anomalous vessels Choroid Retina Optic nerve head Subretinalneovasculari- zation Tumor vessels Chorioretinal anastomosis Vascular tortuosities Dilation and shunts Anastomosis Neovascularization Aneurysms Teleangiectasia Tumor vessels Hamatoma Neovascularization Tortuosity Dilation Hamatoma Tumor vessels
- 27. Hyper- fluorescence In a preformed space(pooling) Into tissue (staining) Retinal Subretinal Retina Subretinal Cystoid edema Detachment of the pigment epithelium Detachment of the sensory retina noncystoid edema e.g.dursen
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- 29. Fluorescence without the administration of fluorescein Autofluorescence Pseudofluorescence Drusenof the optic nerve head Hamatoma Scleral exudate Myelinate nerve Fibers, optic nerve drusen Scar tissue Foreign body
- 30. Causes of darkappearance of fovea -Avascularity • Increased density of xanthophyll • Large RPE cells with more melanin -Blockage of background choroidal fluorescence by:
- 31. Causes of Hyperfluorescence RPE‘ window’ defect RPE atrophy (bull’s eye maculopathy Pooling of dye Under RPE (pigment epithelial detachment) Under sensory retina (central serous retinopathy)
- 32. Causes of Hyperfluorescence Leakageof dye Prolonged dye retention ( staining ) Into sensory retina (cystoid macular oedema) From new vessels (choroidal neovascularization Associated with drusen
- 33. Vascular occlusion Capillary non-perfusion (venousocclusion) Loss of vascular tissue Choroideremia or high myopia Causes of Hypofluorescence
- 34. BRVO- HYPO F-BLOCKED F
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- 36. SUB HYLOID. Hge/PRERETINAL Hge HYPO F- BLOCKED
- 37. STARGARDT'S DISEASE Fundusflavimaculatus:(Stargardt disease (STGD) is the most common childhood recessively inherited macular dystrophy. Blocked the choroidal fluorescence, so fundus background looks black.
- 38. AION – HYPOF OF DISC
- 39. Red-free Fundus photos Normalappearance Autofluorescence
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- 41. ARMD - HYPER-STAINING
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- 43. DIABETIC RETINOPATHY Diabetic retinopathygives a combination of both hyper/ hypofluorescence. Several pathologies are seen in this frame:
- 44. DIABETIC RETINOPATHY Hypofluorescence: Retinalhaemorrhage (1) Ischaemia (2). Hyperfluorescence: microaneurysms (3) and neovascularization (4) In addition, there are IRMA (5) between the retinal artery and vein and venous beading (6)
- 45. DIABETIC MACULOPATHY TREATEDWITH LASER
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- 48. CENTRAL SEROUS RETINOPATHY POOLING/HYPER F Late phase of FFA shows a spot of pigment epithelium leakage has enlarged & fuzzy,in this case there is pooling of fluorescein under the detched retina
- 49. HYPER F- WINDOW/POOLING EFFECT Fundus photography shows PED & late phase of angiogram showing the corresponding well defined hyperfluorescent lesion
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- 52. 1) Does notpermit 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.
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