FFA ppt.pptx

Fundus fluoroscein angiography of retina is an useful for imaging the retinal vasculature

1. Dr. G. Nageswar Rao ; MD Asso . Prof. Ophthalmology, KIMS Vitreo -retinal surgeon Fundus fluorescein angiography

2. What is fluorescence ???

3. LUMINESCENCE & fluorescence Luminescence :- Emission of light from any source other than high temperature It occurs when energy in the form of electromagnetic radiation is absorbed and then re-emitted at another frequency Fluorescence :- luminescence that is maintained only by continuous excitation

4. Understanding fluorescence Fluorescent chemical absorbs Radiant energy release Free electron Jump to higher level Becomes unstable Returns To Lower level Emit energy Luminescence/fluorescence

5. 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

6. Therefore , it helps : In clinical diagnosis to determine extent of damage To formulate treatment strategy for choroidal and retinal disease To monitor result of treatment

7. Indications of FFA Retinal vascular disorders Macular disorders Choroidal disorders Optic nerve disorders retinal vascular malformation and tumor

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

9. 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 1 st trimester)

10. Adverse effects MILD MODERATE SEVERE Staining of skin, sclera and mucous membrane Nausea and vomiting Respiratory- laryngeal edema , bhroncospasm Stained secretion Tear, saliva Vasovagal response Circulatory shock, MI, cardiac arrest Vision tinged with yellow urticaria Generalized convulsion Orange-yellow urine fainting Skin necrosis Skin flushing, tingling lips pruritus

11. PROCEDURE 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

12. 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.

13. CIRCULATION OF DYE Dye injected from peripheral vein venous circulation heart arterial system INTERNAL CAROTID ARTERY Ophthalmic artery Short posterior ciliary artery) Central retinal ( choroidal circulation.) ( retinal circulation) N.B. The choroidal filling is 1 second prior to the retinal filling.

14. what is normal angiography?

15. Two types of circulation in fundus A.Choroidal circulation - choriocapillaries are fenestrated -so allows dye to diffuse freely BUT, - outer blood-retinal barrier in RPE don’t let dye to reach retina B.Retinal circulation - endothelial cells of retinal blood vessels joined by tight junctions (inner blood retinal barrier) - prevents leakage of dye from vessels

16. Phases of angiogram A) Choroidal (pre-arterial) B) Arterial C) Arteriovenous (capillary) D) Venous and E) Late(elimination) Patchy filling No leakage No complication WHY ???

17. Prearterial / choroidal phase 8-12 seconds after dye injection Initial patchy filling followed by diffuse filling No dye has entered retinal circulation

18. Arterial phase Shows arterial filling Continuation of choroidal filling 1 second after choridal phase

19. Arterio -venous phase(capillary phase) Complete filling of arteries and capillaries Early laminar flow to veins Dye seen along lateral wall of veins

20. Early venous phase Arteries and capillaries completely filled Marked lamellar venous flow

21. Mid-venous phase Some veins completely filled Some shows marked laminar flow

22. Late venous phase All veins completely filled Arteries begin to empty

23. Late/elimination phase Elimination of dye from choroidal and retinal circulation Staining of disc – normal In 5-10 minutes fluorescein absent from angiogram And from body in several hours

24. Fovea in FFA Appears dark AVASCULARITY IN FAZ BLOCKAGE OF CHOROIDAL FLUORESCENCE INCREASED XANTHOPHYLL PIGMENTS LARGER RPE CELLS WITH MORE MELANIN

25. Hypofluorescence (black) patch Hyperfluorescence (white) patch

26. FFA interpretation flow chart F luorescein angiogram Normal Abnormal Artifact Hyperfluorescence Hypofluorescence Leakage Pooling Staining Window Blocked Nonfilling defect filling

27. hyperflourescence Greater level of fluorescence than would be found in normal angiogram Occur due to: -window defect - increased accumulation of dye leakage pooling staining

28. examples Papilledema Abnormal choroidal vasculature(CNV) Breaking of inner blood retinal barrier( cystoid macular oedema ) Abnormal retinal or disc vasculature(retinal neovascularization ) Proliferative Diabetic Retinopathy(NVD,NVE)

29. Flower petal appearance CME papilloedema

30. Neovascularization at disc(NVD) Neovascularization elsewhere (NVE) PROLIFERATIVE DIABETIC RETINOPATHY

31. pooling Accumulation of fluorescein in anatomical space Due to breakdown of outer blood retinal barrier

32. CENTRAL SEROUS RETINOPATHY PED

33. staining Accumulation of fluorescence within a tissue Due to prolonged dye retention Minimum hyperfluorescence in early and midphase which increases in late phase Can be seen in normal as well as pathologically altered tissue

34. examples RETINAL non- cystoid macular oedema Perivascular staining SUB RETINAL Drusens Sclera Lamina cribrosa scars

35. Drusens in ARMD

36. hypofluorescence Reduction or absence of fluorescein Two causes BLOCKED FLUORESCENCE VASCULAR FILLING DEFECTS

37. BLOCKED FLUORESCENCE Optical obstruction (masking) of normal density of fluorescein Caused by lesions anterior to retina

38. examples Pre-retinal lesions eg. vitreous opacity,preretinal haemorrhage block all fluorescence Deep retinal lesions eg. intraretinal haemorrhage and hard exudates block only capillary fluorescence Increased density of RPE eg. congenital hypertrophy Choroidal lesions eg.naevus

39. RPE hypertrophy Retrohyaloid haemorrhage

40. Filling defects Inadequate perfusion of tissue with resultant low fluorescein content

41. examples vascular occlusion of choroidal circulation or retinal arteries,veins and capillaries Loss of vascular bed eg.severe myopic degeneration – choroideremia Emboli arteriosclerosis

42. CRAO CRVO

43. Zonula occludents open up normal Endothelial cell is lost Pores in endothelial cells

44. PERIVASCULITIS

45. DIABETIC MICROANEURYSM

46. PROLIFERATED RETINAL VESSELS

47. RETINAL PIGMENT EPITHELIUM Normal RPE is tight zonula occludens seal portion of all the intercellular spaces of the pigment epithelial monolayer.

48. Cental serous chorioretinopathy Type I

49. Haemorrhagic PED in wet ARMD

50. summary Even today FFA, has its position in the diagnosis of retinal diseases Normal retinal vessels will not leak dye Hypofluorescence – blocked/filling defect always match with red free fundus photo Hyperfluorescence – leakage of dye from abnormal vasculature/collection of the dye into an extracellular space Wide field angiogram – recent advancement

51. THANK YOU