RETINAL IMAGING AND FLUORESCEIN ANGIOGRAPHY

*Choroid *Retina *Optic nerve RETINAL ANATOMY *Choroid *Retina *Optic nerve Choroid is vascular layer between sclera and retina Retina is clear nerve tissue Optic nerve head seen in fundus and travels thru optic chiasm to visual cortex where vision is processed by brain

Retinal Vasculature Central retinal artery Branch retinal arteries Arterioles Capillaries Venules Branch retinal veins Central retinal vein Central retinal artery supplies retina with blood containing oxygen, comes from heart Capillaries are network joining arterioles to venules Venules, BRV’s and CRV join to return blood back to heart

Reasons for physician wanting FA Macular degeneration To determine if exudative and what is the best treatment protocol Histoplasmosis To assess choroidal neovascularization CME To assess leakage, typical flower petal pattern White Dot Syndromes APMPPE (Acute posterior multifocal placoid pigment epitheliopathy MEWDS multiple evanescent white dot syndrome PIC punctate inner choroidopathy Panuveitis Diffuse subretinal fibrosis

Reason for physician ordering FA Vascular CRAO BRAO CRVO BRVO HTN Diabetes Nonproliferative diabetic retinopathy Diabetic macular edema Ischemia Proliferative diabetic retinopathy

Setting up FA *Schedule if possible *Eat prior to procedure (reduces chance of nausea and vomiting) *Should be well hydrated (optimizes vein access) *Optimal dilation with 1% Tropicamide and 2.5% phenylephrine (x 2 sometimes) *Informed consent

Color Photos F1 and F2

Mosaic

Seven Standard Fields

Red Free Photos Green filter

Set up 5cc Fluorescein Sodium 10% or 2cc Fluorescein Sodium 25% use filter needle if in glass ampule IV kit Tourniquet Alcohol wipes Gauze Tape Bandage 23 or 25 G butterfly needle Gloves

Starting Angiogram Filter in place (exciter only on our Topcon 50DX)

Position patient

Start timer and injection

Start photographing One photo taken as soon as dye is completely injected to let physician know injection time. Take one photo every second for approx 40-45 seconds. Photograph fellow eye. Photograph both eyes at around one minute. (End of early phase).

Angiogram continued After one minute pictures, patient gets break Sit back Remove needle Many times this is about when adverse effects occur Mid-phase pictures at 3 minutes Late phase pictures at 5-15 minutes, depends on pathology, will need to adjust flash.

Early phase: Choroidal/Arterial Choroidal Flush ~10 seconds Choroidal flush occurs 10 seconds post injection on average Choriocapillaris leaks dye into extravascular space Cilioretinal artery will fill

Early phase: arterial Artery fills 1-2 seconds after Average arm to eye 12 seconds Delayed arm to eye can mean: -carotid disease -heart disease -PVD(peripheral vascular dx)

Early phase: arteriovenous phase Complete filling of retinal capillary bed Veins begin to fill First fill along vein wall (laminar flow)

Laminar flow

Early Phase: venous phase Complete filling of veins Best time to view perifoveal capillaries

Mid phase 2-4 minutes after injection Veins and arteries equal Diminished brightness Dye removed from bloodstream Dye removed from bloodstream by kidneys

Late phase: Five to fifteen minutes post injection Elimination of dye from retina And choroidal vasculature Disc staining Other areas of hyperfluorescence

Risks of Fluorescein injection Extravasation of dye into tissues Small butterfly needles helpful due to blood being injected first. If dyes gets into tissues stop ASAP If happens, use ice and beware of necrosis and phlebitis. Educate patient

Flushing Nausea Vomiting Usually occurs at one minute mark Dependent on amount of dye, speed of injection and possibly concentration 25% Advise patient to eat and be hydrated prior to procedure If happens, advise deep breaths and reassure that it will pass quickly Have basket available “just in case” Phenergan can be used if they have had in past and physician determines FA essential to diagnosis and treatment

Vasovagal response Happens usually due to anxiety Be ready for them to pass out Frequently happens in younger patients

Hives Liquid Benadryl Make sure patient knows that they need to let you know of this or any other reaction so it can be documented in medical record and taken into account if they need another FA in future.

Bronchospasm Laryngeal edema Liquid Benadryl Epipen Document in medical record

Anaphylaxis Epipen Crash cart Physician in area whenever FA is done

Hypotension Syncope Seizures MI/cardiac arrest CVA Need for physician and emergency medical equipment/crash cart available Call for code Call 911 Epinephrine Corticosteroids

Abnormalities of Angiogram Hypofluorescence *Reduction or absence of normal fluorescence due to blockage such as blood or abnormalities in choroidal or retinal perfusion. (occlusion or ischemia)

Abnormalities of Angiogram Hyperfluorescence Increased transmission or abnormal presence of dye. Autofluorescence hyperfluorescence in absence of dye (optic nerve head drusen) Pseudofluorescence usually found in old filters that need replacement Transmission defect absence of pigment allowing choroidal fluorescence to be seen (window defect)

Transmission defect

Hyperfluorescence Leakage due to extravasation of dye due to DME, CME, CSR. Occurs with neovascularization from PDR and AMD

Staining Late hyperfluorescence from dye accumulation. Occurs with drusen, chorioretinal scar, optic nerve. Visible where there is reduction/absence of RPE.

Pooling Accumulation within distinct space such as CSR or serous detachment

Improving Images Focus ocular eyepiece. Place white paper in front of lens to focus reticle. Turn eyepiece to high plus power. Relax eyes by focusing on distance for few seconds to decrease accommodation. Focus with both eyes open to prevent accommodation. Turn toward plano and stop when reticle is just in focus. Repeat several times. Check it every time you use camera, especially if sharing camera with other staff members. Position patient properly with chin and forehead placed correctly Pull focusing knob toward you, slowly turn away until image just in focus.

Artifacts

Iris

Blink

Dust

Pathology

Cotton wool spots

Exudate Blot hemes

Microaneurysms

Intraretinal microvascular abnormalities (IRMA)

IRMA

IRMA

Retinal neovascularization

Neovascularization

Neovascularization

Rubeosis/neovascularization of iris (NVI)

Preretinal hemorrhage from PDR

Ischemia

Crossing changes/AV nicking

Crossing changes

Venous Beading in diabetic retinopathy Also enlarged foveal avascular zone

Venous beading

Cystoid Macular Edema

Retinitis pigmentosa

White dot syndrome: Acute posterior multifocal placoid pigment epitheliopathy (APMPPE)

APMPPE Red Free

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CRAO with Cilioretinal artery

CRAO with Cilioretinal artery

CRAO with PDR (1 minute post injection)

Choroidal folds

Choroidal folds red free

Choroidal folds FA late

Kissing choroidals (Choroidal hemorrhage)

Kissing Choroidals

Kissing choroidals

Diabetic papillopathy

Diabetic papillopathy red free

Central Serous Retinopathy

CNVM with histoplasmosis

CNVM Histo FA