1. بسم الله الرحمن الرحيم Fluorescein & ICG Angiography F. Kianersi MD
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2. .
Sodium fluorescein (C20H10Na2) is a highly water-soluble complex organic molecule with a molecular weight of

3. Excitation of fluorescein occurs when it is
exposed to Blue wave-lengths between
465 and nm, resulting in emission of
Yellow-Green frequencies (520 to 530 nm).

4. The excited Fluorescein within the Vessels and extra-cellular spaces emits Yellow-Green Fluorescent Light, which is recorded on the Photographic film.

5. Route & Dose of Administration
5 CC of 10% Sodium Fluorescein solution is routinely given IV at the start of the procedure.
The Fluorescein dye is injected rapidly into an Antecubital Vein.

6. Fluorescein first appears in the eye as faint patchy regions of fluorescence in the Choroid approximately 12 to 15 seconds following IV administration.

7. Normal Angiogram

8. Background Choroidal Flush
The flow is directed toward the Choriocapillaris, the filling of which is called the Background Choroidal Flush.

9. Arterial Phase
Fluorescein dye is seen within the arterioles 1 second of the Choroidal flash.

10. Laminar Venous Phase (Early A-V Phase)
As blood-borne dye crosses the capillary network and enters the venous system, a columnar appearance to the veins initially is observed.

11. Full Venous Phase (Late A-V Phase)
As more fluorescein enters the veins, they fill totally.

12. Late Phase
This phase shows the eventual fate of the dye.

13. Evaluation of Fluorescein Angiography
Hypo-Fluorescence
Hyper-Fluorescence

14. Hypo-Fluorescence
Vascular Filling Defect
Blockage

15. Hypo-Fluorescence 1. Vascular Filling Defect
Carotid Artery
Ophthamic Artery
Retinal Vessels
Capillary Bed
Vessels of Optic Nerve
Choroid

16. Occlusion of the Carotid
Vascular Filling Defect
Occlusion of the Carotid

17. Vascular Filling Defect CRAO
(Retinal Vessels)
CRAO

18. Vascular Filling Defect BRAO
(Retinal Vessels)
BRAO

19. Vascular Filling Defect CRVO
(Retinal Vessels)
CRVO

20. Vascular Filling Defect
(Capillary Bed)
Diabetes

21. Vascular Filling Defect
(Capillary Bed)
Cotton Wool Spot

22. Hypo-Fluorescence 2. Blockage
Pre-Retinal
Intra-Retinal
Sub-Retinal
Different Deposits

23. Blockage
(Pre-Retinal)
Opacities of the Refractive Media and Vitreous

24. Pre-Retinal Hemorrhages
Blockage
(Pre-Retinal)
Pre-Retinal Hemorrhages

25. Blockage
(Pre-Retinal)
Melanocytoma

26. Blockage
(Intra-Retinal)
Hemorrhage ,

27. ,
Blockage
(Intra-Retinal Pigment)
RPE Hyperplasia

28. Blockage
(Sub-Retinal)
Hemorrhage

29. Blockage
(Sub-Retinal Pigment)
(Choroidal Nevus)

30. Blockage
(Sub-Retinal)
Inflammation
(Toxoplasmosis)

31. Blockage
(Sub-Retinal)
Fluid
(CSR)

32. Best Vitelliform Degeneration
Blockage
(Different Deposits)
Best Vitelliform Degeneration

33. Hyper-Fluorescence
Window Defect of RPE
Leakage
Anomalous Vessels

34. Hyper-Fluorescence
Window Defect of RPE

35. Window Defect of the RPE
(Decreased Pigment in the RPE)
Degenerative Myopia

36. Window Defect of the RPE
(Decreased Pigment in the RPE)
Albinism

37. Window Defect of the RPE
(Atrophy of the RPE)
Geographic, or Areolar Atrophy

38. Window Defect of the RPE
Angioid Streaks

39. Window Defect of the RPE
(Toxic Damage)
Bull's Eye Maculopathy
(Chloroquine)

40. Window Defect of the RPE
(Trauma)
Choroidal Ruptures

41. Hyper-Fluorescence
Anomalous Vessels
Choroid
Retina
Optic Nerve Head

42. Anomalous Vessels
(Choroid)
CNV

43. Anomalous Vessels
(Choroid)
Choroidal Tumor (Melanoma)

44. Anomalous Vessels
(Retina)
Coats' Disease

45. Anomalous Vessels (Retina) Collateral Vessels
Venous-Venous Anastomotic

46. Anomalous Vessels
(Retina)
(Parafoveal Telangiectasis)

47. Anomalous Vessels
(Retina)
Tumor Vessels
(Capillary Hemangiomas)

48. Hyper-Fluorescence Leakage Into Tissue Staining In a Preformed Space
Pooling

49. Leakage Into Tissue (Staining)

50. Leakage Into Tissue (Staining)
Drusen

51. Leakage Into Tissue (Staining)
Optic Disk & Sclera

52. Leakage Into Tissue (Staining)
Schar Tissue
(Serpiginous Choroidopathy)

53. Leakage Into Tissue (Staining)
Vessel Walls

54. Leakage in a Preformed Space (Pooling)

55. Leakage in a Preformed Space (Pooling)
CSR

56. Leakage in a Preformed Space (Pooling)
RPE Detachment (PED)

57. Leakage in a Preformed Space (Pooling)
Inflammatory Serous Detachment
(Harada Disease)

58. Retinal Leakage
Cystoid Edema
Non-Cystoid Edema

59. Cystoid Retinal Leakage

60. Cystoid Retinal Leakage
Retinal Teleangiectasia
(Juxta-Foveal Retinal Teleangiectasia)

61. Cystoid Retinal Leakage
Microaneurysms
(Leber's Miliary Aneurysms)

62. Cystoid Retinal Leakage
Diabetic Retinopathy

63. Cystoid Retinal Leakage
Venous Occlusion
(BRVO)

64. Cystoid Retinal Leakage
Venous Occlusion
(Non-Ischemic CRVO)

65. Non-Cystoid Retinal Leakage

66. Non-Cystoid Retinal Leakage
Arterial Hypertension

67. Non-Cystoid Retinal Leakage
Vasa-Occlusive Retinal disease
(BRVO)

68. Non-Cystoid Retinal Leakage
Diabetic Retinopathy

69. The light used for F/A is absorbed by the RPE, and thus can not take imaging of the Choroidal circulation.

70. ICG Angiography

71. ICG Angiography
Indocyanine green (ICG) is a tricarbocyanine dye that absorbs Infra-Red (non-visible) light.
ICG is almost 98% plasma protein bound.
This high degree of protein binding results in the tendency for ICG to remain intravascular.

72. ICG Angiography
The Infra-Red wavelenths have the ability to penetrate the retinal layers, enables imaging of the choroidal circulation below the RPE.
Thus the image usually take through pigmentation, fluid, or blood in the back of the eye.

73. ICG enhanced imaging of the choroid for,
Ischemic diseases,
Tumors,
Idiopathic syndromes, and
Inflammatory diseases.

74. Choroidal Malignant Melanoma

75. Choroidal Hemangiomas

76. Birdshot Chorioretinopathy

77. Harada's disease

78. The most practical clinical application of the ICG/A has been in those patients with ARMD.
ICG/A unique properties mean that areas of CNV beneath Blood, Exudate, or Pigment Epithelial Detachment (PED) can be imaged more readily.

79. Sub-Retinal Hemorrhage & CNV

80. PED & CNV

81. PED & CNV

82. Hemorrhagic PED & CNV

86. ICG/A complements F/A, which captures blood flow above the RPE.
Although ICG/A is not a replacement for F/A, it provides adjunctive information which assists in defining the Choroidal circulatory involvement in Retinal pathology.

87. F/A & ICG/A are valuable adjunct to diagnosis that supports and enhances, but does Not Replace, standard Clinical Examination.

88. THANK YOU