2. RETINAL IMAGING AND FLUORESCEIN ANGIOGRAPHY

3. *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

5. 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

6. 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

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

8. 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

10. Color Photos F1 and F2

11. Mosaic

12. Seven Standard Fields

13. Red Free Photos
Green filter

14. 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

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

16. Position patient

17. Start timer and injection

18. 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 seconds.
Photograph fellow eye.
Photograph both eyes at around one minute. (End of early phase).

19. 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.

20. 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

21. 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)

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

23. Laminar flow

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

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

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

27. 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

29. 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

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

31. 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.

32. Bronchospasm Laryngeal edema
Liquid Benadryl
Epipen
Document in medical record

33. Anaphylaxis
Epipen
Crash cart
Physician in area whenever FA is done

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

35. 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)

36. 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)

37. Transmission defect

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

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

40. Pooling
Accumulation within distinct space such as CSR or serous detachment

41. 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.

42. Artifacts

43. Iris

44. Blink

45. Dust

46. Pathology

47. Cotton wool spots

48. Exudate Blot hemes

49. Microaneurysms

50. Intraretinal microvascular abnormalities (IRMA)

51. IRMA

52. IRMA

53. Retinal neovascularization

54. Neovascularization

55. Neovascularization

56. Rubeosis/neovascularization of iris (NVI)

57. Preretinal hemorrhage from PDR

58. Ischemia

59. Crossing changes/AV nicking

60. Crossing changes

61. Venous Beading in diabetic retinopathy
Also enlarged foveal avascular zone

62. Venous beading

63. Cystoid Macular Edema

64. Retinitis pigmentosa

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

66. APMPPE Red Free

67. ??????

68. CRAO with Cilioretinal artery

69. CRAO with Cilioretinal artery

70. CRAO with PDR (1 minute post injection)

71. Choroidal folds

72. Choroidal folds red free

73. Choroidal folds FA late

74. Kissing choroidals (Choroidal hemorrhage)

75. Kissing Choroidals

76. Kissing choroidals

77. Diabetic papillopathy

78. Diabetic papillopathy red free

79. Central Serous Retinopathy

80. CNVM with histoplasmosis

81. CNVM Histo FA