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Ffa by suraj chhetri

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Ffa by suraj chhetri

  1. 1. FUNDUS FLUORESCEIN ANGIOGRAPHY SURAJ CHHETRI B.Optometry 16th batch Maharajgung medical campus , Nepal
  2. 2. PRESENTATION LAYOUT • Introduction to fluorescein • Basic principle of fluorescence • Some terminologies • Anatomical considerations • Indication and contraindication of FFA • Procedure of FFA • Normal phases of FFA • FFA interpretation • FFA Vs ICG • Phenomenon of FFA
  3. 3. INTRODUCTION OF FLUORESCEIN • Orange water soluble dye • When injected IV , it remains largely intravascular and circulates in blood stream • 70 – 85 % of fluorescein bind with blood serum albumin • Rest of remain free i.e unbound form • Sodium fluorescein : C20 H10 O5 Na2
  4. 4. CONTINUE… • Properties -Non-expensive -Non-toxic -Flouresces at blood PH level 7.37 – 7.45 -Rapid diffusion • Synthesized from the petroleum derivatives resorcinol and phthalic anhydride Chemically related to Phenolphthalein • Molecular weight : 376 daltons
  5. 5. BASIC PRINCIPLE OF FLUORESCENCE • Absorption followed by release of the radiant energy in the form of visible light • Fluorescent substance follows Stokes law Stokes law • Fluorescent substances absorbs light • Molecular excitation • Electrons elevated to higher less stable state  Returns to stable lower energy form  Releasing light of longer wavelength  FLUORESCENCE • Entire process – 10 – 8 sec.
  6. 6. BASIC PRINCIPLE OF FLUORESCENCE • Absorption spectrum of fluorescein – 465 to 490 nm • Excitation peak 490nm (blue part of spectrum ) • Emission spectrum of fluorescein – 520 to 530 nm • Emission peak 530 nm (green-yellow spectrum )
  7. 7. NOTE Absorbed radiant energy > emitted energy AND As energy – inversely proportional to –wavelength SO, λ of emitted wave > λ of absorbed wave
  8. 8. FILTERS FOR PROCEDURE • Two type • 1) blue barrier filter • 2) yellow green barrier filter • Blue barrier filter ensures that only the blue light enters the eye
  9. 9. • Yellow green barrier filter blocks the blue light reflects from the eye • It allows green light to pass through unimpaired, to be recorded on the film
  10. 10. TERMINOLOGIES  Fluorescence- ability of a compound to absorb light of shorter wavelength and emit light of longer wavelength with in a very short interval  Hyper-fluorescence – an area of abnormally high fluorescence due to increase density of dye molecule  Hypo-fluorescence - an area of abnormally poor fluorescence  Auto-fluorescence – an inherent property of a lesion to spontaneously fluoresce even in absence of dye ( observed before injection of the dye)
  11. 11.  Arm retina circulation time- from dye injection to first appearance in retinal arteries( 10-12 sec) Pooling- accumulation of dye in closed space .e.g. RPE detachment, CSR Leakage- dye escapes in open space e.g. vitreous space Window defect- type of early hyper-fluorescence due to RPE atrophy Control photograph –photo taken before dye given to detect auto-fluorescence
  12. 12. Staining- late hyperfluorescence due to adsorption of the dye by a tissue Blocked fluorescence – hypofluorescence occurs by masking underlying retinal and choroidal tissue by blood , pigment etc. Capillary nonperfusion – due to non filling of the retinal capillaries due to anatomical and function reasons Artifacts- undesirable shadows that are seen following the development of the film
  13. 13. ANATOMICAL CONSIDERATION • Major choroidal vessels are impermeable to both bound and unbound form of fluorescein BUT Choriocapillaries • Walls are extremely thin • Contains multiple fenestrations • Through which free molecules pass across Bruchs membrane Choriocapillaries and Bruchs membrane both permeable to free and bound fluorescein molecules
  14. 14. CONTINUE…. • Outer blood retinal barrier : tight junction between RPE cells prevent passage of fluorescein • Inner blood retinal barrier : tight junctins between endothelium cells of retinal blood vessels prevent passage of fluorescein • Fluorescein pass from choriocapillaries also passes through bruch’s membrane but it encounter with tight junction intracellular complex zonula occludens of RPE cells and prevent passage • Disruption of barrier leak both bound and free fluorescein molecules
  15. 15. BLOOD VESSLES IN RETINA • For FFA interpretation sensory retina divided into two layers 1. Inners vascular half ( ILM – INL )  Here retinal blood vessels located in two separate planes  large retinal arteries and veins located in nerve fiber layer  Retinal capillaries located in inner nuclear layer 2. Outer avascular half (OPL – RPE ) • when retina becomes edematous , • it is the layer that fluid accumulate causing the cystoid space
  16. 16. PURPOSE OF FULUROSCEIN ANGIOGRAPHY • 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
  17. 17. CONTINUE… • It helps in clinical diagnosis • To determine extent of damage • To formulate treatment strategy for choroidal and retinal disease • To monitor result of treatment
  18. 18. INDICATION OF FFA Retinal vascular malformation and tumors Retinal vascular disorders Macular disorders Choroidal disorders Optic nerve disorders
  19. 19. 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
  20. 20. Retinal vascular malformations and tumors 1) Capillary hemangioma of retina 2) Cavernous hemangioma of retina 3) Retinal AV malformation 4) Congenital tortuosity of retinal vasculature 5) Congenital hypertrophy of RPE 6) Angioid streaks 7) Astrocytic hamartoma
  21. 21. Choroidal lesions 1) Choroidal neovascular (CNV) 2) Hemangioma 3) Nevus 4) Melanoma 5) Choroiditis 6) Choroidal folds Optic nerve disorders 1) Optic atrophy 2) Papilloedema 3) Ischemic optic neuropathy 4) Optic disc pit 5) Optic disc drusen 6) Optic disc hemangioma 7) Melanocytoma 8) Myelinated nerve fibers
  22. 22. 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)
  23. 23. 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 utricaria Generalized convulsion Orange-yellow urine fainting Skin necrosis Skin flushing, tingling lips pruritis periphlebitis COMPLICATIONS
  24. 24. COMPICATIONS MANAGEMENT • Unavoidable minor side effects : treatment not needed • Temporary tan skin colour, Red after image from the photoflash and discoloration of the urine • Transient Nausea and vomiting (10%): treatment not needed • Vasovagal syncope (1%) :treatment not needed • In extreme bradycardia • IV atropine may be needed.
  25. 25. CONTINUE.. • Anaphylaxis such as bronchospasm, urticarial skin rash and hypotension (<1%). • Treatment is with chlorpheniramine (piriton) 10mg IV, hydrocortisone 100mg IV • Hypotension and Bronchospasm • oxygen and adrenaline 1ml of 1:1000 IM • Cardiac and respiratory arrest (<0.01%) • Treatment would involve cardiopulmonary resuscitation
  26. 26. EQUIPMENT AND MATERIALS NEEDED FOR ANGIOGRAPHY Fundus camera and auxilliary equipment Matched fluorescein filters ( barrier and exciter ) Digital photoprocessing unit ( computer based ) 23 gauge scalp vein needle 5 ml syringe 5 ml of 10% OR 3ml of 25 % fluorescein solution
  27. 27. 20 gauge , 1.5 inch needle to draw the dye Armrest for fluorescein injection Tourniquet Alcohol swabs Bandage Standard emergency equipment
  28. 28. 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
  29. 29. Wait for 8 seconds for young and 12 seconds for older patients ( 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.
  30. 30. 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)
  31. 31. NORMAL PHASES IN FFA •Early phase • Choroidal(prearterial) • Arterial • Arteriovenous (capillary) • Venous • Early • mid • Late •Mid phase •Late phase
  32. 32. CONTINUE… • Normally 10 -15 secs elapse between dye injection and arrival of dye in the short ciliary arteries • Choridal circulation preceeds retinal circulation by 1 Sec • Transit- if dye through the retinal circulation takes approximately 15- 20 secs
  33. 33. EARLY PHASE • Choroidal filling through the short ciliary arteries • Initial patchy filling of lobules followed by diffused blush as dye leaks out of choriocapillaries • Cilioretinal vessels and prelaminar vessels and prelaminar optic disc capilaries fill Choroidal ( prearterial ) phase
  34. 34. FACTS OF PATCHY CHOROIDAL FILLING • Choriocapillaries has number of lobules • The lobules fill independently from one another, • giving a transiently patched or blotched appearance
  35. 35. ARTERIAL PHASE • Begins with the first appearance of fluorescein in the arteries, and extends until the arteries are completely filled • Posterior pole fills with dye earlier than the periphery • Superior branches usually fill first
  36. 36. Arterial phase
  37. 37. ARTERIO-VENOUS PHASE(CAPILLARY PHASE) • Complete filling of retinal arteries and capillaries. • Early laminar flow in the veins in which dye is seen along the lateral wall of the vein • Choroidal fluorescence increases as free fluorescein continues to leak from the choriocapillaries
  38. 38. Arteriovenous phase
  39. 39. VENOUS PHASE • Gradually whole diameter of the veins is filled • Earliest seen in the peripapillary and macular region • Divided according to the venous filling and arterial emptying • Early • mid • Late
  40. 40. EARLY VENOUS PHASE • Arteries and capillaries are completely filled and marked lamellar venous flow
  41. 41. MID VENOUS PHASE • Some veins are completely filled • Some shows marked laminar flow
  42. 42. LATE VENOUS PHASE • All veins are completely filled and the arteries beginning to empty
  43. 43. MID PHASE • Known as recirculation phase • 2-4 min after injection • Veins and arteries remain roughly equal in brightness. • Intensity of fluorescein diminishes slowly as • flourescein is removed from the blood stream on the first pass through the kidneys.
  44. 44. LATE PHASE • After 10-15 minutes little dye remains in the blood stream • This phase demonstrates • Gradual elimination of the dye from the retinal and choroidal vasculature • staining of optic disc , sclera is normal finding • Any other hyperfluoresecence suggest the presence of abnormality
  45. 45. Late Phase
  46. 46. Phases of angiogram Time ( in seconds) Injection 0 Posterior ciliary artery 9.5 Choroidal phase 10 Arterial 10 - 12 Arterio venous 13 Early venous 14 - 15 Mid venous 16 -17 Late venous 18 – 20 Late ( elimination) 5 minutes
  47. 47. FLUORESCENCE IN FOVEAL REGION • Dark appearance WHY? i) Avascularity in the FAZ ii) Blockage of the choroidal flourescein because of • increased amount of xanthophyll pigments at fovea • melanin in RPE
  48. 48. NORMAL ANGIOGRAM • Patchy filling of choroid • Retinal blood vessels filling • Dark area of foveal avascular zone • But there is no hyper or hypofluroscence area • At the end of the transit phase, fluorescein dye remains in the choroid and sclera due to leakage from the choroidal vessels • A small amount of fluorescein also remains in the optic nerve head and retinal vessels, but there is no leakage • Any additional fluorescein in the eye should be regarded as pathologic
  49. 49. NORMAL ANGIOGRAM
  50. 50. STEPWISE APPROCH TO FFA • A fluorescein angiogram should be interpreted systematically to optimize diagnostic accuracy as follows:- • A ) Indicate whether images of right , left or both eyes have been taken. • B)comment on the red free images • C)indicate any delay in filling as well as hyper or hypo fluorescence • D)indicate any characteristic features such as a smoke –stack or lacy filling pattern. 54
  51. 51. FFA INTERPRETATION FLOW CHART Fluorescein angiogram Normal Abnormal Auto/pseudofluorescence Hyperfluorescence Hypofluorescence Leakage Pooling Staining Window Blocked Non defect filling
  52. 52. NOTE • Hyperfluorescence and hypofluorescence can alternate in same location • Especially in inflammatory disorder • 1st hypofluorescence due to retinal oedema • Later hyperfluorescence due to increased vascular permeability
  53. 53. AUTOFLUORESENCE • Emission of fluorescence light in the absent of fluorescein Example : optic nerve head drusen , astrocytic hematoma , myelinated nerve fibers Optic disc drusen Astrocytic hematoma
  54. 54. PSEUDOFLUORESCENCE • Occurs when nonfluorescence light passes through the entire filter system • Blue reflected light passes from green filter pseudofluorescence occurs • It decrease contrast aswell as resolution of image • To avoid pseudofluorescence filter combination to be sure that no significant overlap exists • Over the time filter alter the range of light transmission so should be change in certain time . Auther recommend about 5 year time to change filter
  55. 55. WINDOW DEFECT • Focal RPE atrophy • Unmasking of normal background of choroidal fluorescence • Characterized by early hyperfluorescence which increases in intensity then fade without changing shape and size e.g. inflammation of RPE atrophy of RPE , drusen
  56. 56. EXTRAVASCULAR LEAK • Pooling and staining in choroid • Cystoid edema and noncystoid edema in retina • Neovascularization , inflammation and tumor vessels in vitreous • Disc staining Cystoid oedema of macula
  57. 57. Pooling( accumulation of dye in a closed space) -Early hyperfluorescence sub-retinal space Early hyperfluorescence sub RPE space increase in size ,intensity increase intensity only e.g. CSR e.g. PED
  58. 58. POOLING OF DYE CSR( sub RETINAL space)PED( sub RPE space)
  59. 59. CSR increase in size and intensity
  60. 60. NVD NVE
  61. 61. 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
  62. 62. examples RETINAL a. non-cystoid macular oedema b. Perivascular staining SUB RETINAL  Drusens  Sclera  Lamina cribrosa  scars
  63. 63. Drusens in ARMD
  64. 64. LATE HYPERFLUROSCENCE ALONG THE EDGE OF GEORAPHIC SCAR
  65. 65. FOCAL EXUDATIVE • Circumscribed retinal thickening • Associated complete or incomplete circinate hard exudates • Focal leakage on FA
  66. 66. Optic Disc Swelling
  67. 67. HYPOFLURESCENCE • Reduction or absence of fluorescein • Two causes BLOCKED FLUORESCENCE VASCULAR FILLING DEFECTS
  68. 68. BLOCKED FLUORESCENCE • Optical obstruction (masking) of normal density of fluorescein • Caused by lesions anterior to retina • 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 EXAMPLE
  69. 69. FILING DEFECTS • Inadequate perfusion of tissue with resultant low fluorescein content • Avascular occlusion of choroidal circulation or retinal arteries,veins and capillaries • Loss of vascular bed eg.severe myopic degeneration – choroideremia • Emboli • arteriosclerosis EXAMPLE
  70. 70. CRAO CRVO
  71. 71. LIMITATIONS OF FFA 1) Does not permit study of choroidal circulation details due to a) melanin in RPE b) low mol. Wt. of fluorescein how to overcome ---- ICG 2) More adverse reaction 3) Inability to obtain angiogram in patient with excess hemoglobin or serum protein
  72. 72. INDOCAINE GREEN ANGIOGRAPHY • FFA excellent method for demonstrating retinal circulation. • But… • Not helpful in delineating choroidal circulation • ICG –of particular value in studying choroidal circulation , • Can be useful adjunct to FA in investigation of macular diseases.
  73. 73. FFA Vs ICG PARAMETERS FFA ICG 1) Dye used Sodium fluorescein Indocyanine green 2) Light used visible spectrum infrared 3) purpose study retinal vasculature Choroidal vasculature 4) Filter used Blue- green Infra-red 5) expense lower higher
  74. 74. PHENOMENON OF FFA • All the process of occurrence of hyper or hypo-fluorescence can be described under following 3 phenomenons A. OPTICAL PHENOMENON B .MECHANICAL PHENOMENON C. DYNAMIC PHENOMENON
  75. 75. OPTICAL PHENOMENON • Normal neurosensory retina is transparent • Normal RPE and Bruch’s Membrane are semitransparent • Hence, we can see choroidal fluorescence • BUT, this transparency can be pathologically increased or decreased
  76. 76. DECRESEING TRANSPARENCY • In case of blocked fluorescence , transparency is lost • SO, WE DO NOT SEE CHOROIDAL FLUORESCENCE
  77. 77. Accumulation of blood haemorrhage
  78. 78. RPE hypertrophy Choroidal naevus
  79. 79. INCRESING TRANSPARENCY • In case of staining due to drusens,angioid streaks ,scars and degenerative processes
  80. 80. Accumulation of drusens under RPE
  81. 81. MECHANICAL PHENOMENON • Related to adhesion of RPE to Bruch’s Membrane • RPE firmly attached to Bruch’s membrane by hemidesmosomes
  82. 82. Absence of hemidesmosomes RPE splits away from Bruch’s membrane Fluorescein stained fluid accumulate in between them eg. PIGMENT EPITHELIAL DETACHMENT
  83. 83. DYNAMIC PHENOMENON • Related to diffusion of fluorescein in ocular tissue • Determined by inner and outer blood retinal barrier I.E DIFFUSION BARRIER
  84. 84. RETINAL VESSELS • Normal retinal vessels do not leak fluorescein - due to zonula occludents in between endothelial cells • These zonula occludents open up during inflammatory process
  85. 85. Zonula occludents open up normal Endothelial cell is lost Pores in endothelial cells
  86. 86. PERIVASCULITIS
  87. 87. DIABETIC MICROANEURYSM
  88. 88. PROLIFERATED RETINAL VESSELS
  89. 89. RETINAL PIGMENT EPITHELIUM • Normal RPE is tight • zonula occludens seal portion of all the intercellular spaces of the pigment epithelial monolayer.
  90. 90. Cental serous chorioretinopathy
  91. 91. Haemorrhagic PED in wet ARMD
  92. 92. REFERENCES INTERNATE
  93. 93. •Thank you

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