fundus fluoroscein angiography

FUNDUS FLUORESCEIN ANGIOGRAPHY

FLUORESCENCE :- Property of the certain molecules to emit light energy of longer wave length when stimulated by a shorter wavelength.

Absorbs light in the blue range peaking at 465-490 nm Emits light of yellow-green range of visible

spectrum peaking at 520-530nm.

PRINCIPLE

EXCITATION AND EMISSION

SODIUM FLUORESCEIN Diabasic Acid, Yellow Red in color. Stable, Highly Water Soluble & Pharmacologically

inert. Low Molecular Weight 376.27 D Fluoresces at Blood pH Peak absorption 465 – 490 nm Peak emission 520 – 530 nm 80% bound to plasma protein and also with RBC Can’t pass through tight retinal barriers so allows

study of retinal circulation

within 24 hours

Mainly –urine ( yellow orange coloration) Small amount-bile

Some absorbed by kidney

Skin staining may remain up to 24 hours

Urine discoloration –24-36 hours

CLEARANCE

10 % Solution of 5 ml25% Solution of 3 ml (for opaque media)

Solution above 25% precipitates.

DOSAGE

Peripheral vein

venous circulation

heart

arterial system

INTERNAL CAROTID ARTERY

Ophthalmic artery

Short posterior ciliary artery Central retinal Artery (choroidal circulation) (retinal circulation)

CIRCULATION

TECHNIQUE

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)

PROCEDURE

5ml of 10% or 3ml of 25% NAF injected through the anticubital vein

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

Prearterial phase (choroidal phase) Arterial phase Arterio -venous phase Venous phase early venous mid venous late venous Late phase

PHASES OF NORMAL ANGIOGRAM

10 -12 seconds

Initially patchy filling diffuse filling dye leaks from choriocapillaris

no dye reaches retinal arteries

Cilioretinal artery if present fills in this phase

CHOROIDAL PHASE

CHOROIDAL PHASE

ARTERIAL PHASE

ARTERIO-VENOUS PHASE

EARLY VENOUS PHASE

MID VENOUS PHASE

MID VENOUS LATE VENOUS

LATE PHASE ( ELIMINATION PHASE)

Gradual elimination of dye from choroidal and the retinal circulation

Staining of disc :- normal

After 30 seconds of injection first high concentration flush of fluoroscein begins to empty and Recirculation phase follows.

Vessels completely empty of fluoroscein in approx 10 minutes.

PHASE TIME ( IN Secs)

Injection 0

Choroidal phase 10

Arterial 10-12

Arterio venous 13

Early venous 14-15

Mid venous 16-17

Late venous 18-20

Late ( elimination) 5 MINS

Angiogram

Normal Abnormal Artifact

Hyperfluorescence Hypofluoresence

INTERPRETATION

HYPERFLUORESCENCE – an area of abnormally high fluorescence due to increase density of dye molecule

HYPOFLUORESCENCE - an area of abnormally poor fluorescence

TERMINOLOGIES

PSEUDOFLUORESCENCE - Non fluorescent light passes through entire filter system. - Decreased contrast and resolutionConditions: Any light colored fundus change e.g.ScleraScar tissueMyelinated nerve fibreForeign Body

innate property of fluorescence in certain ocular tissue

fluorescence without dye

Optic nerve head drusen & astrocytic hamartoma

AUTOFLUORESCENCE

Optic Nerve Head Drusen

Microaneurysm, Telengiectasia Anastomosis

Retinal Abnormal Vessels in DR

Retinal Neovascularization

Tumor: Choroidal Hemangioma

PE Window Defect

SUBRETINAL NEOVASCULARIZATION

Late Extravascular Hyperfluorescence Considered Normal

Fluorosence of Disc margins from surrounding capillaries

Fluorosence of lamina cribrosa

Fluorosence of Sclera at disc margin if RPE terminates away from disc as in Optic crescent

Fluoresence of Sclera if RPE is lightly pigmented.

Vitreous

DISC

CYSTOID MACULAR EDEMA

NON CYSTOID

PERIVASCULAR STAINING

POOLING –

accumulation of dye in closed space e.g. RPE detachment, CSR

SUB-RETINAL SPACE SUB RPE SPACE Early hyperfluorescence early hyperfluorescence increase in size & intensity increase intensity only e.g. CSR,CNVM e.g. PED

CENTRAL SEROUS CHORIORETINOPATHY

SUBRETINAL NEOVASCULARIZATION

PED

STAINING

Refers to leakage of fluoroscein into tissue or material

Must be contrasted from Pooling

Rule out which tissue involved: RPE Bruch’s Memb Choroid Sclera

STAINING

Blockage

Pre Retinal Haemorrhage

Intra Retinal Hhg

Sub retinal Hhg

RPE Hypertrophy

Vascular Filling Defect

BRVO

Evaluation of vascular integrity of retinal & choroidal vessels

Disease process affecting macula

Integrity of the Blood Ocular Barrier. - outer blood retinal barrier breaks in :- CSR - inner blood retinal barrier breaks in:-NVD ,NVE

USES

Determining the extent of damage

Formulating the treatment strategy for retinal & choroidal disease.

Monitoring the result of treatment.

MILD MODERATE SEVEREStaining of skin, sclera and mucous membrane

Nausea ,vomiting laryngeal edema bronchospasm

Stained secretion Tear, saliva

Vasovagal response

Circulatory shock, MI, cardiac arrest

Orange-yellow urine urticaria Generalized convulsion

Skin flushing, tingling lips, pruritus

fainting Skin necrosis

periphlebitis

COMPLICATIONS

CONTRAINDICATION

ABSOLUTE1) known allergy2) H/O adverse reaction in past.

Asthma

Hay fever

Renal failure

Hepatic failure

Pregnancy ( especially 1st trimester)

RELATIVE

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