What you mean I’m going to look yellow – Fluorescein Angiography Nimesh Patel, OD 1. Fluorescein angiography (FA) is an excellent diagnostic tool used in the management of patients. The goal of this lecture is to provide practitioners regarding: a. b. c. d. 2. What is involved with FAs, injection, medication, and emergency Reasons for ordering an FA Interpreting the FA Treatments of conditions showing up on the FA The procedure a. Can be performed with and without a fundus camera. If performed without a fundus camera (i.e. with BIO) it is called fluorescein angioscopy. i. Camera must have 1. Excitation filter – Kodak wratten 47 – 490nm 2. Barrier filter – Kodak wratten G15 – 530nm ii. High speed 200 – 400 ASA black and white film recommended – or digital capture b. Sodium fluorescein for intervenous injection. Available in 5, 10, and 25% i. 5ml of 10% is injected into the arm venous system rapidly ii. or 3ml of 25% is injected – with dense media opacities c. photographs are taken at 4 sec intervals 5 to 25 sec after the dye is injected i. late stage photos are taken at 10 min or 20 min. 3. Complications from the dye a. Side effects i. Red after image ii. Discoloration of urine and skin b. Mild complications i. Nausea and vomiting ii. Allergic reaction – flushing, itching, hives, sneezing c. Serious complications i. Syncope ii. Laryngeal edema iii. Anaphylactic shock d. Importance to be CRP and/or ACLS certified 4. Stages of the normal angiogram a. Pre – arterial phases i. Filling of the choroidal vessels b. Arterial phase i. 4 seconds later ii. From the first appearance of dye in the arteries to when the arteries completely fill the arteries. c. Arteriovenous (capillary) phase i. Complete filling of the arteries and capillaries ii. Early lamellar flow in the veins d. Venous phase i. Venous filling and arterial emptying ii. Can be split into early, mid and late stages 5. Conditions requiring the use of FA (will present video of these conditions and their FAs) a. Branch Retinal Vein Occlusion i. Is the second most common retinal vascular ii. Superior arcade is most commonly affected iii. Cystoid macula edema is not uncommon with increased bleeding and inflammation. b. Cystoid macula edema (CME) i. CME appears as macular hyperfluorescence that increases in the late stages to eventually have a petaloid appearance. ii. Treatment of CME depends on the etiology of the condition. Usually systemic and topical NSAIDs are utilized. iii. If the CME is secondary to a branch retinal vein occlusion then guidelines set by the Branch Retinal Vein Study Group are used c. Diabetic retinopathy i. It is recommended that all diabetic patients with reduced acuity not correctable with lenses have a FA ii. FA of CSME involves leakage within 500 microns of the macula, or 1500 microns of leakage within 1500 of the macula iii. Treatment usually follows as recommended by the Early Treatment Diabetic Retinopathy Study Group and Diabetic Retinopathy Study Group. d. Age related macular degeneration i. Any suspicion of choroidal neovascular membrane should have a FA. ii. FA of CNV usually shows up as hyperfluorescence in the prearterial phase, as the choroid fills iii. The CNV becomes more diffuse as the procedure continues iv. Treatment of CNV includes PDT, and as recommended by Macular Photocoagulation Study Group e. Idiopathic Central Serous Chorioretinopathy i. ICSC or CSC is diagnosed based on FA appearance. ii. A classic smoke stack FA is seen typically iii. Treatment usually involves monitoring the patient as prognosis without treatment is excellent. f. Iris Neovascularization i. Iris neo can be noted on patients with and without retinal complications ii. FA can be used to rule out tufts in the iris if you are suspecting early neovascularization.