Fundus fluorescein angiography involves injecting a dye called sodium fluorescein intravenously and then photographing the retina as the dye circulates through the blood vessels. This allows visualization of the retinal and choroidal vasculature and detection of any abnormalities. The dye is absorbed by tissues and emits light at a higher wavelength when exposed to blue light, appearing green in the photographs. Areas of hypofluorescence or hyperfluorescence can indicate conditions like neovascularization or leakage. The angiogram proceeds through choroidal, arterial, venous, and late phases as the dye enters and clears from the blood vessels. While it provides valuable diagnostic information, limitations include inability to image the choroid directly and requirement for specialized

1. Fundus Flurescein Angiography
Punitha S.J., Boopathi Raja

2. INTRODUCTION
• Fluorescein angiography is an important invasive diagnostic tool for
posterior segment eye surgeons for the evaluation of the retina and choroid.
• Refers to photographing fluorescein dye in the retinal vasculature following
intravenous injection of fluorescein sodium.
• This photography can be performed with a fundus camera and either a
standard 35 mm camera back and films or video-based systems.

4. What is fluorescein ???
• Fluorescein (C20H12O5) refers to fluorescein sodium ( C20H10Na2O5)
• A brown or orange-red crystalline substance first synthesized in 1871 in
Germany by von Baeyer.
• It is highly water- soluble .
• Molecular weight of 376.27.
• Belongs to the group of triphenylmethane dyes.

5. Conti….
• It is the product of a reaction of phthalic acid anhydride and resorcinol in
which hot sulphuric acid is the catalyst.
• Available in topical solution form and as a mixture with corneal anesthetic, a
combination of benoxinate HCl.
• Also available in strip form for topical application to the cornea.
• Fluorescein solution is commercially available for injection as 10% and 25%
solution.

6. HISTORY OF EVOLUTION
Evaluation of fluorescein angiography has a unique and interesting aspect.
• In 1950, HaroldNovotny and Dr.David Alvis
• Novotny used the sodium fluorescein to determine the oxygen saturation into the
retinal arterioles for the first time for fluorescence observation.
• Meanwhile Dr. David Alvis used a mixed drop of it's own blood with sodium
fluorescein for fluorometric analysis.
“World’s first fluorescein angiography was done on Dr. David Alvis’s right eye”

7. Landmark work by Novotny and Alvis led
to evolution of fluorescein angiography….
• In April 1960, Miller and Chao, collaborators of Dr.Maumenae presented
their technique of fluorescein angiography .
• In 1969, Dr. F. Palomar presented the first article on fluorescein
angiography.
• Clinical works in Europe and USA , the better refinement of FA technique is
used for accurate and better assessment of various ocular pathologies.

8. In the present era of greater ophthalmological advances in the field of
diagnosis, surgical and laser management, fluorescein angiography is an
important diagnostic tool.
• There is a little difference between the Fundus Flurescein Examination
performed today and those performed when the procedure was in its infancy.

9. Recent advances in FA
• CUE wide field fluorescein angiography
• Digital video Angiography
• High speed fluorescein angiography
• 3D coor Doppler video angiography

10. PRINCIPLE
“Fluorescein dye absorbs light energy from a lower wave length and
emits at a higher wave length with fluorescence properties”.
• The absorption spectrum of fluorescein lies between 465 and 490 nm
(blue end of the visible spectrum).
• The emission spectrum lies between 520 and 530 nm ( green- yellow
area of the spectrum).

12. • On intravenous injection, 70 to 85 % of fluorescein molecules bind to serum
proteins,
• The remaining unbound component is responsible for fluorescence
displayed during angiography.
• The dye is excreted completely by the kidneys in 24 hours.

13. TECHNIQUE
A good quality angiogram requires adequate pupillary dilatation and clear
media.
Patient is explained about the procedure and an informed consent is taken.
Patient is seated in front of the camera comfortably and the sequence is as
follows:
• Color photograph of the fundus and red-free photograph.
• Securing an intravenous line.

14. • Fundus photograph with the exciter and barrier filters in place to look
for auto or pseudo fluorescence.
• Injection of fluorescein and switching on the timer.
• Photographs are taken 8 seconds after the beginning of the injection.
• Photographs at intervals of 11/2 to 2seconds.
• Late phase photographs at the end of 15 minutes.

16. SIDE EFFECTS AND
COMPLICATIONS OF FA
• Extravasations of the dye and local tissue necrosis.
• Nausea
• Vomiting
• Vasovagal attack (circulatory shock, myocardial infarction)
• Allergic reaction:
• Anaphylaxis
• Itching
• Hives
• Laryngeal edema
• Bronchospasm

17. Normal Fluorescein Angiogram
• Normal arm to retina time is 10 to 12 seconds.
• Fluorescein enters the eye through the ophthalmic artery, passing into the
choroidal circulation through the short posterior ciliary arteries and into the
retinal circulation through the central retinal artery.
• The inner blood retinal barrier is formed by the tight junctions of the
endothelium in the retinal vessels and the outer blood retinal barrier by the
retinal pigment epithelium; these barriers keep the fluorescein from
diffusing in to the vitreous cavity or subretinal space.
• The pigmented retinal pigment epithelium masks the choroidal fluorescence
during fluorescein angiography.

18. PHASES OF THE ANGIOGRAM
Choroidal
( pre- arterial)
Phase
Arterial Phase
Venous Phase
Arteriovenous
( capillary) Phase
Late Phase

19. 1. THE CHOROIDAL PHASE
• Also called pre-arterial phase.
• One to two seconds before the dye appears in the central retinal artery.
• Patchy filling of the choroid is obscured almost immediately as the
dye diffuse out of the choriocapillaries resulting in the choroidal flush.
• A cilioretinal artery, if present will fill at this time because it is derived
from the posterior ciliary circulation.

20. CHOROIDAL PHASE

21. 2.THE ARTERIAL PHASE
• Entry of the dye into the retinal arterioles

22. 3.THE ARTERIOVENOUS PHASE
• Also called capillary phase.
• Dye enters the venules after passing through the retinal capillaries.
• Early arteriovenous phase shows laminar flow in the veins.
• In the late arteriovenous phase, the veins are filled with the dye.

23. Early arteriovenous
phase of the FFA
showing laminar flow in
the veins
Arteriovenous phase
showing more
pronounced laminar
flow in the veins

24. 4. VENOUS PHASE
• Venous phase of the angiogram shows
loss of laminar flow and complete
filling of the veins.
• In the late venous phase the veins
appear brighter than the arterioles as
the concentration of the dye is more in
the venules than the arterioles.

25. 5.THE LATE PHASE
• Due to elimination of the dye on
recirculation, fluorescence within the
retinal vessels is faint; disc staining
may appear.
• Scleral staining appears as a diffuse
background fluorescence.

26. Absence of blood
vessel in the foveal
zone and increased
density of xanthophyll
at the five and taller
retinal pigment
epithelial cells at the
fovea block the
choroidal fluorescence
resulting in a dark
fovea on FA.

28. ABNORMAL ANGIOGRAM
Abnormalities in the angiogram are classified essentially as
Hyperfluorescene
Hypofluorescence

29. HYPOFLUORESCENCE
Reduction or absence of normal fluorescence.
This is caused by
• Blocked fluorescence
• Hypoperfusion/vascular filling defect

30. Blocked
Fluorescence
• Blood, pigment,educates can
block underlying fluorescence.
• Area of blocked fluorescence
corresponds to the area of the
lesion.
Preretinal haemorrhage Corresponding FFA
shows blood blocking
underlying retinal and
choroidal fluorescence

31. HYPOPERFUSION/VASCULAR
FILLING DEFECT
Hypofluroscence due to non
filling of the vasculature due to
vascular occlusion or loss of
vascular bed.
Hypofluroscence due to loss of capillary bed

32. HYPERFLUROSCENCE
• Pre-injection fluorescence-auto/pseudofluorescence
- Autofluorescence-fluorescent characteristic of an abnormal fundus
lesion.
• Astrocytoma, optic nerve head drusen.
- Pseudofluorescence-mismatched filters

33. • Transmitted fluorescence.
- Due to transmission of the
choroidal fluorescence due to loss
of RPE barrier.
• Leakage.
-Leakage of the dye in the
vitreous or subretinal space due to
loss of blood retinal barrier .
• Pooling.
- Accumulation of the dye
within a space.
Hyperfluorescent spots
temporal to macular
fading away in late
phase
Hyperfluoroscene due
to leakage.Indicative of
leakage in to the vitreous
from retinal
neovascularization
FFA in CSR showing
leakage of the dye into
the subretinal space

34. • Staining
-Accumulation of the dye into the tissue.

35. WINDOW DEFECT
• The well-defined subretinal hyperfluorescent
spot appears in choroidal phase, increasing
in intensity with pro-gression of the
angiogram and fades in the late phase with
emptying of the choroidal vessels.
• Size of the lesion remains same and there
are no fuzzy margins.

36. BASIC PRINCIPLES OF
ANGIOGRAPHY INTERPRETATION
HYPOFLUORESCENCE
• Blocked fluorescence
1. Hemorrhages
2. Exudates
3. Glial tissue
4. Retinal pigment
• Vascular filling defects
1. Emboli
2. Arteriosclerosis
3. Vascular non perfusion
4. Vascular occlusion
HYPERFLUORESCENE
• Abnormal vessels
1. Tortuosity and dilatation
2. Neovascularization
3. Aneurysms
4. Subretinal neovascularization
• Leakage
1. Papilledema
2. Cystoid edema
3. Subretinal neovascularization
4. Retinal neovascularization

38. STRENGTHS
• The procedure with the fluorescein
dye is very much protective
procedure with nausea.
• Rare infection due to its side
effects.

39. • It allows us to assess both the anatomy and function of the retinal
and choroidal vasculature in a minimally invasive manner.
• It has become a vital component in the diagnosis, treatment, and
management of vitreoretinal disorders.
• To precisely define the location of pathologic changes, such as
those in choroidal neovascular membranes, treatment can be
initiated for the pathologic condition while the unaffected areas are
preserved.

40. LIMITATIONS
• The major limitation of fluorescein angiography is its inability to
precisely image the choroidal circulation.
• Another limitation of fluorescein angiography is the fact that it is a
technically involved procedure, requiring precise photographic
equipment in addition to a well-trained photographer to produce
quality results.

41. • Quantification of macular edema is not possible with fluorescein
angiography and to a large extent, it has been replaced with ocular
coherence tomography in the management of certain diseases
such as
• diffuse diabetic macular edema,
• uveitic macular edema, and
• the Irvine-Gass syndrome.

42. REFERENCES:
• PRIMARY CARE OPTOMETRY.
- Theodore Grosvenor
• CLINICAL PROCEDURES IN OPTOMETRY.
- J.Boyd Eskridge, John F. Amos, Jimmy D.Bartlett
• FUNDUS FLURESCEINANGIOGRAPHY (MINI ATLAS )
- Ashok Gorg, Josè Maria Ruiz Moreno, João J Nassaralla.
Jr, Arturo Perez Arteaga

43. • Jeffrey L. Olson MD, Naresh Mandava MD.,Flurescein angiography,
in retinal imaging, 2006
• Delhi Eye Centre, super speciality eyecare
• https://youtu.be/7rdHTeq4BQE
• https://youtu.be/37y1X54o_1Y
• https://youtu.be/YtzcmBNJ3ko