Introduction To Introduction To Fluorescein AngiographyFluorescein Angiography

Saleh A. Al Amro, FRCS

Head of Retina – Vitreous Division

KSU

• Described in 1959 by MacLean and Maumenee

• IV FAA or oral FFA• Angiography or Angioscopy• Emergency kit

FFA

Characteristics of Fluorescein

• Nontoxic, inexpensive, safe• Alkaline solution• Highly fluorescent• Absorbs blue light (480-500 nm)• Emits yellow-green (500-600 nm [525 nm])• Effective at pH 7.37-7.45• Removal from blood by kidneys and liver within 24

hrs.

FFA

• Informed consent• Anticubital vein, 21 G needle• Rapid injection of 5 cc of 10% Na Fl, or 3 cc

of 25% solution – within 2 seconds• Flush with a saline solution• Early photos of 1 second. Take, OU • Stereoscopic FFA

FFA

During Pregnancy and Lactation

• Controversial• Fl. Crosses the placenta• Has been done in pregnancy

with no adverse effect• Do it when necessary

FFA

Hazards

• Minimal relatively safe drug• Use of dilating drops• Red after – images from the

photoflash• Temporary tan skin color• Fl. Urine discoloration• Interfere with serological tests

FFA

Hazards cont …

• 2-4% Transient nausea and occ. VOMITING

• Hives, asthmatic symptoms• Laryngeal edema• Rarely – Syncope, anaphylactic rxn,

MI, resp. or Cardiac arrest• Rx – oral or I.V. Benadryl or

Cortisone• A physician in the 1st few minutes

FFA

Anatomic and Physiologic Considerations

• Retinal B.V. , choricapillaris, large choroidal vessels

• Optic disc – normal fluorescent, no leakage

• Ciliary body leaks dye in A/C and vitreous

FFA

Anatomic and Physiologic Considerations

• Fovea to disc = 4 mm (15o)• FAZ – 25-1500 u (350 u)• Pigment filters – Melanin, xanthophyll,

lipofuscin• RPE – anatomic variations• Outer BRB, Bruch’s membrane• Inner BRB

FFA

Anatomic and Physiologic Considerations

• B.V. appears larger with FFA than with colors

• A major vein at the disc = 150 u• Capillary - free zone around arteries and

veins• Macula - Clinical (within temporal

arcades) - Anatomic (1500 u)

• Fovea (1500 u)

FFA

Angiographic Analysis

• Sequential• Anatomic• Morphologic• Be systematic – comment on the

choroid, retina, disc and macula

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Normal

• Arm-to-retina circulation time is 12-15 sec.• Five angiographic phases:

• Pre arterial• Arterial• Arteriovenous• Venous• Recirculation

FFA

Normal cont…

• Choroidal filling – segmental (patchy)• Laminar venous filling• Macular hypofluorescence • A-V Transit time up to 11 - 12 Sec.• Scleral staining• Disc fluorescence

FFA

Hyperfluorescence Hyperfluorescence

LeakLeak

Transmission increase Transmission increase

Abnormal vessels Abnormal vessels

LeakLeak

Pooling (in a space)Pooling (in a space)

Staining (in a tissue).Staining (in a tissue).

Pigment epithelial window defect Pigment epithelial window defect

Retinal Retinal

Subretinal Subretinal Tumors Tumors

Abnormal Vessels

Abnormal Vessels

Transmission increase

Transmission increase

Hyperfluorescence Hyperfluorescence LeakLeak

Pooling

(in a space)

Pooling

(in a space)

Staining

(in a tissue).

Staining

(in a tissue).

Retinal Retinal

Subretinal Subretinal

Retinal Retinal

Subretinal Subretinal

Cystoid edema Cystoid edema

Perivascular staining Perivascular staining

Retinal pigment epitheliumRetinal pigment epithelium

Noncystoid edema Noncystoid edema

DrusenDrusen

Scars Scars

Sclera Sclera

Lamina cribrosa Lamina cribrosa

Sensory retina detachmentSensory retina detachment

Hyperfluorescence Hyperfluorescence Transmission

Increase

Transmission

Increase

Pigment

Epithelial

Window

Defect

Pigment

Epithelial

Window

Defect

Atrophy Atrophy

Drusen Drusen

Hyperfluorescence Hyperfluorescence Abnormal

Vessels

Abnormal

Vessels

Retinal Retinal

Subretinal Subretinal

Tumors Tumors

Tortuosity and Dilation Tortuosity and Dilation

Neovascularization Neovascularization Aneurysms Aneurysms

Telangiectasias Telangiectasias

Shunts and collaterals Shunts and collaterals

Vessels in scar Vessels in scar

MacroaneurysmsMacroaneurysms

Neovascularization Neovascularization

Retinal Retinal

Subretinal Subretinal

Angioma Angioma

Retinoblastoma Retinoblastoma

MicroaneurysmsMicroaneurysms

Hemangioma Hemangioma Melanoma Melanoma MetastasesMetastases

Hypofluorescence Hypofluorescence

Transmission Decrease

(blocking effect)

Transmission Decrease

(blocking effect)

Filling defect

(delay and occlusion)

Filling defect

(delay and occlusion)

Hypofluorescence Hypofluorescence Transmissionc

Decrease (blocked)

TransmissioncDecrease (blocked)

Pigment Pigment

Exudates

Exudates

Edema and

transudate

Edema and

transudate

Other abnormal materials

Other abnormal materials

Melanin Melanin Hemoglobin Hemoglobin

Xanthophyll Xanthophyll

LipofuscinLipofuscin

HardHard

Soft Soft

Best`s disease Best`s disease Foreign bodyForeign body

Fundus flavimaculatusFundus flavimaculatus

Hypofluorescence

Hypofluorescence

Filling defect (delay and occlusion)

Filling defect (delay and occlusion)

Retinal Retinal

Subretinal Subretinal

Artery Artery

VeinVein

Capillary bed Capillary bed

Loss of tissueLoss of tissue

NonperfusionNonperfusion

DystrophiesDystrophies

DegenerationDegeneration

ChoroideremiaChoroideremia

Choroidal atrophy etc.Choroidal atrophy etc.

Myopia Myopia

Central areolar atrophy Central areolar atrophy

• Retinal vascular disorders• Macular disorders• Tumors• O.N. lesions• Other fundus lesions• Iris fluorescein angiography

FFA

Not all abnormal conditions of the ocular fundus will produce abnormal fluorescein angiograms.

FFA

Things to rememberThings to remember

Thank You For Your Attention!

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