gyanus FFA

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Slide 1: 

FUNDUS FLUORESECENCE ANGIOGRAM Dr Gyanendra Lamichhane Lumbini Eye Institute Bhairahawa ,Nepal

References : 

References 1) Fluorescence angiography –a users manual by Gass JDM 2) Clinical ophthalmology –J. J. Kanski 6th edition 3) Medline plus article on FFA updated on 2007/10/6 4) Digital angiography in Ophthalmology by John Whipwell 5) Duanes Ophthalmology CD ROM 2005-2006 6) FFA monogram AAO series 2005-2006

COVERAGE : 

COVERAGE 1) What is FFA? 2) Principal of FFA 3) Dye used in FFA 4) Flow chart of FFA 5) Purpose 6) Indications 7) Contraindications 8) Complications 9) Technique 10) Phases 11)Interpretation flow chart 12) terminologies 13) Abnormal fluorescence

What is FFA? : 

What is FFA? It is a test which allows the blood vessels in the back of the eye to be photographed as the flourescein dye is injected into the blood stream via the vein in the arm.

Slide 5: 

Principal of FFA (a brief introduction)

Principal of FFA : 

Principal of FFA Fluorescence is the property of the certain molecules to emit light energy of longer wave length when stimulated by a shorter wavelength. . The dye absorbs light in the blue range of the visible spectrum peaking at 480-530nm and emits light of yellow-green range of visible spectrum peaking at 520-530nm.

Slide 7: 

Excitation and emission

Slide 9: 

light ( camera flash light) blue filter blue light stimulate fluorescein in retinal and choroidal circulation fluorescein molecule become more energetic rise to higher energy orbital and become more unstable emit green light , become more stable and return back to original orbital green filter stimulate photographic film

Dyes used in angiography : 

Dyes used in angiography Sodium Fluorescein Indocyanine Green

Sodium fluorescein : 

Sodium fluorescein An organic vegetable dye. First synthesized by Von Bayer in 1871 Molecular weight 376 Dalton. advantage- can’t pass through tight retinal barriers so allows study of retinal circulation disadvantage- can’t study choroidal circulation

Properties of NAF : 

Properties of NAF Non expensive, non toxic , highly fluorescent that can be used safely with most people. It fluoresces effectively at normal blood ph level(7.37-7.45) 80% bound to plasma protein and also with RBC Rapid diffusion High solubility in water.

Clearance of NAF : 

Clearance of NAF Usually cleared within 24 hours. Mainly –urine ( yellow orange coloration) clinical application false positive benedict test , so informed not to change dose of insulin Small amount-bile Some absorbed by kidney Skin staining may remain up to 24 hours Urine discoloration –24-36 hours.

Indocyanin Green : 

Indocyanin Green Green dye that fluoresces with invisible infrared light. It specially useful for studying the deeper choroidal circulation. Safe for general use and less toxic than sodium flourescein. Needs special type of fundus camera.

Purpose of FFA : 

Purpose of FFA 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

So …. : 

So …. It helps 1) the clinical diagnosis. 2) determining the extent of damage 3) formulating the treatment strategy for retinal and choroidal disease. 4) in monitoring the result of treatment.

INDICATIONS : 

INDICATIONS 1) Retinal vascular disorders 2) Macular disorders 3) Retinal vascular malformation and tumors 4) Choroidal disease 5) Optic nerve disease

FFA in Retinal disease : 

FFA in Retinal disease 1) Diabetic retinopathy 2) Retinal vein occlusions 3) Retinal artery occlusion 4) Retinal vasculitis 5) Coats disease 6) Familial exudative vitreoretinopathy

FFA in macular diseases : 

FFA in 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

Retinal vascular malformation and tumors : 

Retinal vascular malformation 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

FFA in choroidal lesion : 

FFA in choroidal lesion 1) Choroidal neovascular membrane (CNV) 2) Hemangioma 3) Nevus 4) Melanoma 5) Choroiditis 6) Metastasis 7) MEWDS 8) APMPPE 9) Choroidal folds

FFA in optic nerve disease : 

FFA in optic nerve disease 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

Contraindications : 

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)

Complications of FFA : 

Complications of FFA

FFA techniques : 

FFA techniques 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

Slide 28: 

wait for 10 – 12 seconds( 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.

Circulation of NAF : 

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.

Phases of normal angiogram : 

Phases of normal angiogram Prearterial phase (choroidal phase) Arterial phase Arterio -venous phase Venous phase early venous mid venous late venous Late phase

Choroidal Phase : 

Choroidal Phase 10 -12 seconds after dye injected Initially patchy filling followed by the diffuse filling as the dye leaks from the choriocapillaries. no dye has reached the retinal arteries. Cilioretinal artery if present fills in this phase

Arterial phase : 

Arterial phase Starting of arterial filling and continuation of choroidal filling 1 second after choroidal phase

Arteriovenous phase(capillary phase) : 

Arteriovenous phase(capillary phase) Complete filling of the retinal arteries and capillaries. early laminar flow of the veins so dyes seen along lateral wall

Venous phase : 

Venous phase Early venous phase. mid venous phase. Late venous phase

Early venous phase : 

Early venous phase

Mid venous phase : 

Mid venous phase Some veins are completely filled Some shows marked laminar flow

Slide 40: 

Late venous phase all veins are completely filled and the arteries beginning to empty.

Late phase( Elimination phase) : 

Late phase( Elimination phase) Gradual elimination of dye from the choroidal and the retinal circulation. Staining of the disc is the normal finding. Any areas of late hyper fluorescence suggest an abnormality . fluorescence is absent from angiogram after 5-10 minutes and is usually totally eliminated from the body within several hours

Fluorescein in foveal region : 

Fluorescein in foveal region Dark appearance why? i) Avascularity in the FAZ ii) Blockage of the choroidal flourescein because of a) increased amount of xanthophyll pigments at fovea b) melanin in RPE and are larger

FFA interpretation flow chart : 

FFA interpretation flow chart fluorescein angiogram normal abnormal artifact hyperfluorescence hypofluorescence Leakage pooling staining window blocked nonfilling defect

Terminologies : 

Terminologies Fluorescence- ability of a compound to absorb light of shorter wavelength and emit light of longer wavelength with in a very short interval hyperfluorescence – an area of abnormally high fluorescence due to increase density of dye molecule hypofluorescence - an area of abnormally poor fluorescence autofluorescence – an inherent property of a lesion to spontaneously fluoresce even in absence of dye ( observed before injection of the dye)

Slide 48: 

Control photograph –photo taken before dye given to detect autofluorescence arm retina circulation time- from dye injection to first appearance in retinal arteries( 10-12 secs) 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 hyperfluorescence due to RPE atrophy

Slide 49: 

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

Abnormal fluorescein : 

Abnormal fluorescein Hyperfluorescence (white lesion) Hypofluorescence ( black lesion) Autofluorescence

Hyperfluorescence : 

Hyperfluorescence 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. APMPPE, Serpiginous Choroiditis inflammation of RPE depigmentation and atrophy of RPE

Window defect : 

Window defect RPE atrophy (bull’s eye maculopathy )

Slide 53: 

Pooling( accumulation of dye in a closed space) sub-retinal space sub RPE space -Early hyperfluorescence early hyperfluorescence -increase in size ,intensity increase intensity only e.g. CSR e.g. PED

Pooling of dye : 

Pooling of dye CSR( sub RETINAL space)

Slide 55: 

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

FFA in central serous retinopathy : 

FFA in central serous retinopathy

Slide 60: 

Leakage ( frank hyperfluorescence that increase in size and intensity ) 1) abnormal choroidal vasculature CNV 2) breaking of inner blood-retinal barrier Cystoid macular edema- flower Patel 3) abnormal retinal or disc vasculature NVD, NVE Staining ( hyperfluorescence that is minimum in early and mid phase and increasing in late phase) due to prolonged dye retention e.g. drusen

Slide 61: 

Causes of hyperfluorescence Leakage of dye Prolonged dye retention ( staining ) Into sensory retina (Cystoid macular edema) From new vessels (choroidal neovascularization Associated with drusen

Focal exudative : 

Focal exudative Circumscribed retinal thickening Associated complete or incomplete circinate hard exudates Focal leakage on FA

Diffuse exudative : 

Diffuse exudative Diffuse retinal thickening Obliteration of landmark leads to localization of FOVEA difficult Generalized leakage on FA

Cystoid macular edema : 

Cystoid macular edema

Hypofluorescence : 

Hypofluorescence Blockage Filling defect 1)Retinal fluorescence 1) vascular occlusion vitreous opacity ( choroidal, retinal artery pre-retinal hge vein or capillary) 2 background choroidal fluorescence 2) loss of vascular bed sub retinal hge choroidermia increased RPE density myopia choroidal naevi

BRVO : 

BRVO

Macula appears relatively normal dark blot hemorrhage Capillary non-perfusion on FA Enlargement of the FAZ

Eales disease( peripheral ischemia) : 

Eales disease( peripheral ischemia)

Limitations of FFA : 

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.e.g. polycythemia weldenstrom macroglobulenaemia binding of fluorescein with excess Hb or protein Lack of freely circulating molecule

autofluorescence : 

autofluorescence innate property of fluorescein in certain ocular tissue fluorescein without dye it is exhibited by crystalline lens, basement membrane, myelinated nerve fibers, melanin granules ,certain lipids

Autofluorescence : 

Autofluorescence

Stepwise approach to reporting FFA : 

Stepwise approach to reporting FFA 1) Comment on red free photograph 2) Is the abnormality black or white? 3) Indicate the phase of angiogram 4) Indicate any characteristic feature as smoke stag 5) Are the retinal vessels filling normally? 6) Indicate any change in area or intensity of fluorescence N.B : patient’s history and clinical co relation should always be done before drawing conclusion from the FFA

FFA Vs ICG : 

FFA Vs ICG

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