FLUORESCEIN ANGIOGRAPHY

Properties of Sodium Fluorescein

 hydrocarbon salt of sodium with molecular

formula C20H10O5Na2  MW 376.67 d  highly water soluble  orange/red/brown crystalline powder

Properties of Sodium Fluorescein

 Like all luminescent chemicals, fluorescein

has the ability to give off light after exposure to a specific wavelength (excitation wavelength).  The dye is able to absorb the energy of the excitation wavelength and subsequently emit the absorbed energy as light of a lower frequency.

Properties of Sodium Fluorescein

 Excitation wavelength: 465 to 490 nm  Fluorescence wavelength: 520 to 530 nm  In the human bloodstream at a pH of 7.4:
absorption wavelength is refined to blue light of 465 nm emission wavelength to yellow-green light of 525 nm

Properties of Sodium Fluorescein

 MW 376.27 d:
sufficiently large to prevent its escape from capillaries of the central nervous system, including the retina, which have tight junctions between endothelial cells (physiologic inner blood retinal barrier)

Properties of Sodium Fluorescein

 MW 376.27 d:
too large to diffuse through the RPE (outer blood retinal barrier) and the larger choroidal vessels

Six Phases of Fluorescein Angiography

1. Choroidal (C) 2. Arterial (A) 3. Arteriovenous (AV) 4. Venous (V) 5. Recirculation (R) 6. Late (L)

Choroidal
 appears 8 to 20 seconds after start of the dye

injection  earliest indication of dye entering the eye  marked by a patchy blush of hyperfluorescence in the background of the retina and the cilioretinal artery present in about 15% of the population begins to fill

Choroidal

Arterial
 follows the choroidal phase by 1 to 2

seconds  dye begins to fill arterioles

Arterial

Arteriovenous
 occurs about 12 to 15 seconds after the dye first

appears in the eye  A characteristic laminar flow is seen in the veins as dye passes from the arteries through the capillary interface and slowly begins to fill the veins while background fluorescence continues to increase.

Arteriovenous

Venous
 occurs around 25 seconds after the dye first shows up in the eye  lasts for several minutes  veins fully perfused with the concentration of dye being greater in the veins than in the arteries  middle to later part: veins appear slightly more hyperfluorescence than the arteries

Venous

Recirculation
 sometimes called the midphase  begins about 2.5 minutes after the end of    

injection usually documented at the 3- to 5-minute postinjection mark arteries and veins are of equal brightness marked decrease of overall fluorescence dye leakage and pooling starts to be evident

Recirculation

Late
 Photographs are typically taken from 7 to 10

minutes after injection  Concentration of background dye is low and appears somewhat flat in contrast  Remaining hyperfluorescence is from staining, leakage, and pooling

The Six Phases of Fluorescein Angiogram with Normal Transit Times

Autofluoresence
 Appearance of fluorescence from the fundus

captured prior to intravenous fluorescein injection

vitamin A calcium salts lipofuscin pigment

Autofluorescence

Optic nerve head drusen

Hypofluorescence
 Vascular filling defects  Blocked fluorescence

Vascular filling defects

 Retinal or choroidal vessels do not fill

properly  Delay or a complete absence in filling of the involved vessels

Vascular filling defects

Retinal arterial occlusion

Blocked fluorescence
 Stimulation or visualization of the fluorescein

is blocked by fibrous tissue or another barrier (pigment or blood), producing an absence of normal retinal or choroidal fluorescence in the area

Blocked fluoresence

Preretinal hemorrhage

Hyperfluorescence
 Leakage  Staining  Pooling  Window defect

Leakage
 Hyperfluorescence that is seen expands in the

late phase of the angiogram with respect to both the intensity and the size of the lesion

Leakage
 Inflammation
increased vascular permeability normal vessels become incompetent

 Neovascularization
new abnormal vascular tissue that is inherently leaky

Leakage

CSME from leakage from microaneurysms

Leakage

CNV from myopia

Leakage

CNV from ARMD

Staining
 Increased intensity of hyperfluorescence

within a given lesion, but the size of the hyperfluorescent area remains constant (no or minimal leakage of dye)

Staining
 Disciform and other scars  Regressed neovascular tissue  Visible areas of sclera as seen in peripapillary

atrophy  Myopic degeneration  Gyrate atrophy

Staining

Disciform scar

Pooling
 accumulation of dye within a fluid-filled

space  increase in intensity throughout the angiogram  border of the lesions stay well defined and elevation is seen on the clinical exam

Pooling
 Pigment epithelial detachments seen in AMD  Pooling within an intraocular tumor  Subretinal pooling in central serous

chorioretinopathy

Pooling

Smokestack appearance from CSR

Pooling

Pigment epithelial defect

Window defect
 implies an area of reduced density or total

absence of RPE localized and well-defined area of hyperfluorescence  Increased visibility of the choroidal fluorescence, it is most noted early in the angiogram and gradually fades in the later frames of the angiogram as dye exits the choroid

Window defect
 Drusen  Rip or tear of the RPE  Geographic atrophy of macular degeneration  Chorioretinal scars  Macular holes

Window defect

Drusen in ARMD

Pathologic Patterns of Fluorescence

Side effects
 Yellowing of the skin and conjunctiva lasting

from 6-12 hours after injection  Orange-yellow discoloration of the urine, lasts from 24-36 hours

Side effects
 Nausea, vomiting, or vasovagal reactinos  Extravasation with subcutaneous granuloma,

toxic neuritis, or local tissue necrosis  Urticaria  Cardiovascular shock

THANK YOU.

Window defect

Chorioretinal scar