Teguh Susilo

Introduction
Fluorescein
 From petroleum derivatives: phthalic anhydrate & resorcinol
 Highly fluorescent dye
 Fluorescein efficiency: 100%
 Absorbs: 485 nm – 500 nm (Blue-Green light)
 Emits: 520 nm – 530 nm (Yellow Green light)
 Dose:
 Average adult: 500mg: 2mL (25%) or 5 mL (10%)
 pH: 8.5
 Adjusted for small adult & children
Introduction
Sodium fluoresecein (C20H10O5Na2)
Introduction
 In the blood:
 80% → protein bound
 20% → free → to fluoresce
 Metabolized in: kidney
 Excreted by: kidney → urine
 Clears from the system within 24-48 hrs
 Avoid any blood work
 Faint yellow blush in the ptn’s skin for several hrs
following angiography
 Excreted in breastmilk
Adverse Effect
Mild
 Nausea & vomiting
 ±10%
 Usually no Tx needed
 Extravasation
 Painful (pH 8.5)
 Cold followed warm compress
 Subcutaneous granuloma
 Toxic neuritis
 Local necrosis
Adverse Effect
More severe (1%)
 Pruritus
 Urticaria
 Laryngeal oedema
 Brochospasm
 Syncope
 Anaphylaxis
0.02 %:
 AMI
 Cardiac arrest
Principle
1. Fluorescein can’t diffuse through the tight junction
 Inner blood retinal barrier: retinal blood vessel
endothelium
 Outer blood retinal barrier: RPE
2. There 2 circulation system within the fundus
 Choroidal circulation
 Fluorescein leaks our freely though the fenestrated CC →
bruch’s membrane
 Further diffusion block by RPE
 Retinal circulation
 Fluorescein can’t leak out from these vessels normally
Principle
3. Capillaries in the ciliary processes
 permeable to fluorescein
 Rapidly appears in the aqueous following the injection
 Diffuse to vitreous as well
 Emit the yellow light which reflects off white structure
below → falsely to appear fluorescein (reflected
flourescence)
 Optic disc, myelinated RNFL, & exudates (hard
exudates)
Principle
Digital Imaging
FPRC (Fundus Photo Reading Center) Protocol
 Colour
 3M-D (Modified 3 Standard Field Digital)
 4W-D (4-Wide Field Digital)
 7M-D (Modified 7 Standard Field Digital)
 7Std-D (7 Standard Field Digital)
 9Std-D (9 Standard Field Digital)
 FFA
Digital Imaging
Commonly used
 3M-D : Macular Degeneration, Diabetic Retinopathy
and Odema
 7M-D: PDR
 9Std-D: CMV retinitis, AIDS retinopathy, peripheral
retinitis, and uveitis diseases.
Digital Imaging
3M-D
 30̊ – 35̊ magnification setting
 3 Fields: F 1M, F2, F3M
 Sequence: F 1M → F2 → F3M
 F1M: Optic Disc
 Center the temporal edge of optic disc at the cross hair
intersection
 Partial view of macula
 Stereo pair
Digital Imaging
 F2: Macula
 Center the macula near the cross hair intersection
 Stereo pair
 F3: temporal to Macula
 Position the cross hair intersection in the ocular 1-1.5 DD
to the center of macula
 Stereo pair
Digital Imaging
7M-D
 30̊ – 35̊ magnification setting
 7 Fields: F 1M, F2, F3M, F4, F5, F6, F7
 Sequence: F 1M → F2 → F3M → F4 → F6 → F5 → F7
 F1M, F2, & F3M ~ 3M-D
 F4: superior temporal
 Lower edge ~ tangential to horizontal line passing through
the upper edge of optic disc
 Nasal edge ~ tangent to vertical line passing through the
center of the disc
 Stereo pair
Digital Imaging
 F6: superior nasal
 Lower edge ~ tangential to horizontal line passing through
the upper edge of optic disc
 Temporal edge ~ tangent to vertical line passing through the
center of the disc
 Stereo pair
 F5: inferior temporal
 Upper edge ~ tangential to horizontal line passing through
the lower edge of optic disc
 Nasal edge ~ tangent to vertical line passing through the
center of the disc
 Stereo pair
Digital Imaging
 F7: inferior nasal
 Upper edge ~ tangential to horizontal line passing
through the lower edge of optic disc
 Temporal edge ~ tangent to vertical line passing through
the center of the disc
 Stereo pair
Digital Imaging
 F4, F5, F6, F7
Digital Imaging
9Std-D
 50̊-60̊ magnification setting
 9 Fields: F 1-2, F3, F4, F5, F6, F7, F8, F9, F10
 Sequence: F 1-2 → F3 → F8 → F9 → F4 → F6 → F10 →
F5 → F7
 F1-2: Optic disc / Macula
 Center the camera midway between temporal margin of
the optic disc and the center of macula
 Stereo pair
 Should include: optic disc & macula
Digital Imaging
 F3: temporal to Macula
 The same horizontal meredian with F1-2
 Nasal edge: 1 DD temporal to the center of macula
 Overlap ± 3DD with F1-2
 F8: nasal to optic disc
 The same horizontal meredian with F1-2
 Temporal edge: adjacent to nasal margin of the disc
 Overlap ± 3DD with F1-2
Digital Imaging
 F9: Superior
 Superior to F1-2
 Inferior edge: overlap the superior edge of F1-2 by 1-1.5 DD
 Try to choose the landmark
 F4: Superior temporal
 The same horizontal meredian with F9
 Nasal edge: at the center of F9
 Overlap ± 5DD with F9
 F6: Superior nasal
 The same horizontal meredian with F9
 Temporal edge: at the center of F9
 Overlap ± 5DD with F9
Digital Imaging
 F10: Inferior
 Inferior to F1-2
 Superior edge: overlap the superior edge of F1-2 by 1-1.5 DD
 Try to choose the landmark
 F5: Inferior temporal
 The same horizontal meredian with F10
 Nasal edge: at the center of F10
 Overlap ± 5DD with F10
 F7: Inferior nasal
 The same horizontal meredian with F9
 Temporal edge: at the center of F10
 Overlap ± 5DD with F10
Standard FA (FA-D)
 30̊-35̊ magnification setting
 2 Fields: F 1M, F2
 F1M: Optic disc
 Center the temporal edge of the optic disc at the cross hair
 Optic disc off center, partial view of macula
 F2: Macula
 Center the macula at the cross hair
 F2 and Stereoscopic Red Free pre-injection taken at F2
 1st Fellow eye, then study eye
 Stereo pair: 1st left then right
 To ensure the focus throughout the FA
Standard FA (FA-D)
 Pre – injection sequence:
 FE: F2 → Red Free
 SE: F2 → Red Free
 All in stereo pair
F2 F1M F1M F2
Standard FA (FA-D)
Injection:
 Do not delete any images taken during fill phase (0-5 sec)
 Early phase
 Pair: Time ‘0’: start of injection; second frame: end of
injection
 “Control” pair: the integrity of exciter and barrier fillters
 Time shown: duration of injection
 Control photograph
 10-16 exposures at 1-2 sec intervals, begin at 15 sec after the time ’0’
 Capture the earliest appearance of dye
 Sooner (<15 sec) or delaying (>15 sec)
 Culminating about : 40-45 sec
 NOT to delete any images captured
Standard FA (FA-D)
 Mid phase
 60-90 sec:
 Stereo pairs of F2 then F1M of SE
 2 minutes
 Stereo pair of F2 of FE

 2-3 minutes
 Stereo pair of F2 of SE

 Late phase
 5 minutes:
 Stereo pair of F2 of SE
 10 minutes:
 Stereo pairs of F2 of SE and FE
Standard FA (FA-D)
Timing SE / FE Field
Time ‘0’ start injection SE F2 Not stereo
Stop injection ~ 5 sec Not stereo
Stereo
Transit 15-45 sec (5-8 pairs)
60-90 sec SE F2 Stereo
F1M Stereo
2 min FE F2 Stereo
2-3 min SE F2 Stereo
5 min SE F2 Stereo
10 min SE F2 Stereo
10 min FE F2 Stereo
Preparation
 Explain
 Informed consent
 Premed:
 Benadryl 25mg for pre- & post- allergy medication
 Compazine 5 mg for pre- medication
 Resuscitation facilities
 ‘Code Blue’ team
FFA – Phases and Normal Timing

Phase Timing
Choroidal filling 8-15 sec after injection
Retinal arterial filling 1-2 sec after choroidal filling
Venous lamellar filling 2-3 sec after arterial filling
Full venous circulation < 11 sec after arterial filling
Recirculation 30 – 150 sec after injection
Late 10-30 min after injection
FFA - Normal
1. Normal timing
2. Normal phases
FFA – Phases and Normal Timing
 Early: AV ~ V
 Mid: ~ recirculation
 Late
Pathologic pattern
 Hyperfluorescence
1. Window defect
2. Pooling
3. Stanining
4. Leakage
 Hypofluorescence
1. Blockage
2. Non-perfusion/filling defect
Pathologic pattern
Window defect
 Transmission of dye from choroid
 Occurs: early in FFA
 Atrophy / destruction of RPE, RPE tear, drusen
Pooling
 Increase in intensity but not size
 Occurs: early in FFA
 Dye in sub-RPE space: PED
 Dye in sub-retinal space: SRF, exudative RD
Pathologic pattern
Leakage
 Increase in size and intensity
 Occurs:
 Early: CNV (choroidal vessels)
 Late:
 NVD, NVE (retinal vessels)
 Optice nerve head: papilloedema

Staining
 Retinal scars, sclera, abN vessels
 Occurs: late
Pathologic pattern
Blockage
 Masking effect
 Retinal haemorrhage
 Oedema & exudates (hard exudates)
 Pigments (melanin & xanthophyll)
 Lipofuscin (Best’s desease)
Filling defect
 Retinal ischaemia: RVO, RAO, DR
 Choroidal ischaemia: HR
 Retinal atrophy: myopia
Window defect
Chorio-retinal scar
Window defect
 Dry AMD - Drusen
 CSCR

Pooling

PED

CMO
Leakage
Wet AMD – classic CNV
Staining
GA
Staining
Blockage & non perfusion
DR
Filling defect & CNP
Fluorescence lesions unrelated to
vascular permeability
1. “Pseudofluorescent” lesions
 Missmatched/poorly matched exciting & barrier filters
 Blue light reflected from the surface of any white / light
coloured non-fluoresecent lession
 Bypass the barrier filter → appear to be fluorescent
2. Reflected fluorescence
 Exciting & barrier filters are carefully matched
 Light coloured, non fluorescein lesions may exhibit
flourescence during late stages
 Because of reflection from their surface of yellow green light
 Dye normally escapes into ocular media
Fluorescence lesions unrelated to
vascular permeability
3. Autofluoresecence lesions
 Some fundus lession before administration of
fluorescein are capable of emiting yellow green light
when irradiated with blue light
 Example:
 Calcified drusen of optic nerve head
 Large deposit of lipofuscin
Autofluorescence
FAF (Fundus Auto Fluoresecein)
 Lipofuscin
 Pigment
 Autofluoresces when excited with blue light or UV light
 RPE accumulate lipofuscin over time
 Background autofluoresecence
 Increase /decrease in certain diseases
 A2E and others (iso A2E, A2-PE-H2, A2PE, and A2-
rhodopsin) can also contribute
 Formed at outer segment prior to phagocytosis
FAF (Fundus Auto Fluoresecein)
 Heidelberg machine
 Exciting: 488 nm
 Barrier: 488 nm
 Topcon machine
 Exciting: 512 nm
 Barrier: 488 nm