Fundus Fluorescein Angiography

PHYSICAL PRINCIPLES
Luminescence- Emission of light from any source other then high temp.

Fluorescence- luminescence maintained only by continuous excitation. (stop as soon as exciting stimulus withdrawn)

FFA
PURPOSE

Evaluate, Diagnose -Retinal, Choroidal vascular & Macular diseases Guide - for laser treatment Monitor-effect of treatment

 1871-Adolf Baeyer-first to synthesize dye Na. Fluorescien 1910-Burke examine the Retina & choroid after administration of fluorescien in coffee 1925-Nordenson fundus camera 1961-Novotny & Alvis- First Successful FFA in human.

HISTORY

TECHNIQUE
seated in front of fundus camera Color & Red-free image is capture Fluorescein dye 5ml of 10% or 3ml 25%(for opaque media) injected. Images taken approx 1-sec intervals ,5-12 sec after inj. After transit phase photograph in one eye control picture of opposite eye.

 Flourescene enters in the eye through ophthalmic artery Passing into the choroidal circulation.post ciliary A. Retina-central retinal a.

PHASES OF ANGIOGRAM
Choroidal (10-12 sec) Arterial (1-3 sec) A-V (capillary) Venous (20-25 sec) Recirculation(30 sec ) Late phase(10 min)

CHOROIDAL (PRE-ARTERIAL) PHASE

Early choroidal fluo is faint patchy & irregularchoroidal flush Area of filling & nonfilling distinct patchy choroidal filling Cilioretinal a. fills

ARTERIAL PHASE
Filling of CRA.

 Dye from smaller venules enter the vein along their wall-laminar flow Dye sticks to the wall of vein At the junction of two vein ,inner lamina of each merge creating a trilaminar flow

EARLY A-V PHASE

A-V PHASE
Dye completely fill the lumen of vein Perifoveal capillary network best visualized (dye max concentration) Fovea appears hypofluo.

RECIRCULATION PHASE
Begins about 30 sec of dye inj Dye in lower concentration

LATE PHASE
Vessels are empty(10 min after inj) Diffuse background fluo (d/t staining of bruchs memb. choroid & sclera ) Large vessels seen in silhouette against this background Disc remain hyperfluo in late film (staining)

WATERSHED ZONE
Post ciliary a. supply the lat. & medial halves of disc & choroid Four (sometime 6-7) post ciliary vein (vertex vein) drain into sup. & inf ophthalmic veins quadrantric pattern Segmental drainage exists vertical & horizontal watershed FA-patchy choroidal filling

DARK APPEARANCE OF FOVEA

Avascularity of FAZ Blockage of choroidal flurescene (xanthophyll) Blockage of choroidal flurescene (larger RPE , more melanin)

ABNORMAL FLUORESCENCE
d/t LEAKAGE (a) Abnormal choro.vasculatureCNV Early lacy filling pattern which increase in size & intensity

b)(Breakdown of inner retinal barrier-CME Beginning of A-V phase which increase in size and intensity Flower-petal pattern (late phase)

(c) Abnormal retinal or disc vasculaturePDR

HYPERFLUORENSCENCE D/T POOLING

Dye in anatomical space d/t breakdown of outer retinal barrier(RPE tight jn) (a) In the sub-retinal spaceEarly hyperfluo which increase in size and intensity-CSR

CSR

(b) In the sub-RPE space- PED early hyperfluo which increases in intensity but not in size

STAINING
Attachment of the dye molecule to tissue May be seen in late phase of angiogram It occur in normal structure (sclera) or pathological states (Scar ,drusen) Margins do not go beyond

TRANSMISSION (WINDOW) DEFECT

Seen focal RPE atrophy Or absence Unmasking of normal choroidal fluo. Early hyper-fluo. Increases in intensity & then fades in late phase without changing size or shape

CAUSES OF HYPOFLUORESCENCE
Reduction or absence of fluo. (a) Blockage(masking)-retinal / choroidal (b) Filling defects

BLOCKAGE OF RETINAL FLUORESCENCE

1-vit.opacities & Preretinal lesion-blood -Block all fluo. 2 deep retinal lesions intra-retinal hage & HE -Block only capillary fluo. Sparing large retinal vessels

BLOCKAGE OF CHOROIDAL FLUORESCENCE

1-sub-retinal/ Sub-RPE lesion-blood 2-incease density of RPE- congenital hypertrophy of RPE 3- choroidal lesion -naevi

FILLING DEFECTS
1-Vascular occlusion-prevent access dye to the tissue Occlusion may choroidal circulation / retinal a./r.vein/capillaries(capillary drop out) 2 loss of vascular bed-severe myopic deg or choroideremia