1. FUNDUS FLUORESCEIN ANGIOGRAPHY
NISHITA AFRIN
B.OPTOM
3rd batch
ICO,CU

2. INTRODUCTION
Fluorescein angiography
refers to photographing fluorescein dye in the retinal vasculature following intravenous injection of fluorescein solution

3. FLUORESCENCE C20H12O5 Refers to fluorescein sodium (C20H10Na2O5)
A brown or ornge red crystalline substance, alkaline in nature
First synthesized in 1871 in Germany by Von Bayer

5. CONTINUE… Metabolized by liver and exerted by kidney
Absorbs blue light (490nm ) and emits yellow-green light (530nm)
Metabolized by liver and exerted by kidney

6. HAZARDS OF FLUORESCEIN DYE
Reletively safe drug
Temporary tan skin coloration
Urine discoloration
Transient nausea and vomiting
More severe : hives ,asthmatic symptoms and laryngeal edema

7. CONTINUE… Myocardial infraction Respiratory and Cardiac arrest
Syncope , anaphylactic reaction to fluorescein
Myocardial infraction
Respiratory and Cardiac arrest

8. INDOCYANINE GREEN Binds to plasma protein, confined to vascular system
Cyanine dye
Binds to plasma protein, confined to vascular system
Molecular wt. 775 dalton
Half life – dalton
Remove from circulation by the liver to bile juice

9. Absorbs 600 nm -900 nm and emits 750 nm to 950 nm

10. General Principles of ICG Angiography
1. Binding
98% bound to proteins
Less leakage from choriocapillaris
2. Fluorescence
Much less than fluorescein
Excitation peak 800 nm
Emission at 835 nm
3. Filters
Infrared barrier and excitation
4. Safer than fluorescein

11. Side effects of ICG… Sore throats and hot flashes Anaphylactic shock
Risk in pregnancy
Sore throats and hot flashes
Anaphylactic shock
Hypotension
Trachycardia
Dyspnea and Urticaria

12. CLINICAL USE OF FLUORESCENCE DYE
Clinical use Research Care -treatment protocol for retinal diseases - to understand retinal and choroidal leisons . E.g. Age related macular degeneration, diabetic retinopathy ,retinal detachment…

13. Anatomic Considerations

14. FFA

15. General principles of FA
Fluorescein
85% bound to serum proteins
15% unbound ‘free’ fluorescein
Inner blood-retinal barrier
(retinal capillaries)
Impermeable to fluorescein
Outer blood-retinal
barrier (zonula occludens)
Impermeable to fluorescein
Choriocapillaris
Permeable only to ‘free’ fluorescein

18. OPTICAL PRINCIPLE

19. Filters
1.Blue excitation filter
2.Yellow-green filter

20. PROCEDURE… Pupils should well dialed
Patient seat infront of the camera
Red free photographs taken
Dye injected in the forearm or anticubital vein
Photographs with fluorescein
- 1 sec interval between 5 and 25 secs
- late photographs after mins

21. Syringe with NaF
Insertion of needle containing
Retractable needle with catheter system
Mild hematoma

22. Angiographic phases: Five angiographic phases:
Pre arterial (choroidal 9-15 seconds)
Arterial
Arteriovenous(capillary)
Venous
Recirculation

24. Circulation of NaF Dye injected 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.

25. 1-Choroidal flush
2-Arterial phase

26. 3-Arteriovenous phase

27. 4-Venous phase
Mid Phase Late Phase

28. Interpretation of FA

29. Red-free fundus photos
Normal appearance Autofluorescence

30. Abnormal angiographic findings
Hypofluorescence:
Filling defect
Blocking defect
Hyperfluorescence :
window defect
Leakage
Pooling
Staining

31. Subretinal neovasculari-
zation
Choroid
Tumor vessels
Chorioretinal anastomosis
Vascular tortuosities
Dilation and shunts
Anastomosis
Neovascularization
Hyperfluorescence
Anomalous vessels
Aneurysms
Retina
Teleangiectasia
Tumor vessels
Hamatoma
Neovascularization
Tortuosity
Optic nerve
head
Dilation
Hamatoma
Tumor vessels

32. Retinal
Cystoid edema
In a preformed
space (pooling)
Subretinal
Detachment of
the pigment
epithelium
Hyper-
fluorescence
Leakage
Detachment of
the sensory
retina
Retina
noncystoid
edema
Into tissue
(staining)
Subretinal
e.g.dursen

33. Fibers, optic nerve drusen
Drusen of the optic
nerve head
Autofluorescence
Fluorescence
without the
administration
of fluorescein
Hamatoma
Scleral exudate
Scar tissue
Pseudofluorescence
Foreign body
Myelinate nerve
Fibers, optic nerve drusen

34. Causes of dark appearance of fovea
Avascularity
Blockage of background
choroidal fluorescence by:
Increased density of xanthophyll
Large RPE cells with more
melanin

35. Causes of hyperfluorescence
RPE ‘ window’ defect
Pooling of dye
RPE atrophy
(bull’s eye maculopathy
Under RPE
(pigment epithelial detachment)
Under sensory retina
(central serous retinopathy)

36. Causes of hyperfluorescence
Leakage of dye
Prolonged dye retention
( staining )
Into sensory retina
(cystoid macular oedema)
From new vessels
(choroidal neovascularization
Associated with drusen

37. Capillary non-perfusion
Causes of hypofluorescence
Vascular occlusion
Loss of vascular tissue
Capillary non-perfusion
(venous occlusion)
Choroideremia or high myopia

38. Red-free fundus photos
Normal appearance Autofluorescence

39. Autofluorescence

40. Macular hole

41. CHOROIDAL NAEVUS

42. DIABETIC MACULOPATHY TREATED WITH LASER

43. BACKGROUND DIABETIC RETINOPATHY

44. CENTRAL SEROUS RETINOPATHY

45. PROLIFERATIVE DIABETIC RETINOPATHY (early venous phase)

46. Stargardt's Disease

47. DIABETIC AND HYPERTENSIVE RETINOPATHY

48. Limitations of FFA
1) Does not permit 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.e.g.
polycythemia
weldenstrom macroglobulenaemia
binding of fluorescein with excess Hb or protein
Lack of freely circulating molecule

49. THANKS TO ALL