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.