F. Kianersi MD1390 / 4 / 2

Sodium fluorescein (C20H10Na2) is a highly water-soluble complex organic molecule with a molecular weight of 376.27.

.

Excitation of fluorescein occurs when it is

exposed to Blue wave-lengths between

465 and 490 nm, resulting in emission of

Yellow-Green frequencies (520 to 530 nm).

The excited Fluorescein within the Vessels and extra-cellular spaces emits Yellow-Green Fluorescent Light, which is recorded on the Photographic film.

5 CC of 10% Sodium Fluorescein solution is routinely given IV at the start of the procedure.

Route & Dose of Administration

The Fluorescein dye is injected rapidly into an Antecubital Vein.

Fluorescein first appears in the eye as faint patchy regions of fluorescence in the Choroid approximately 12 to 15 seconds following IV administration.

Normal Angiogram

Background Choroidal FlushThe flow is directed toward the Choriocapillaris,

the filling of which is called the Background Choroidal Flush.

Arterial Phase

Fluorescein dye is seen within the arterioles 1 second of the Choroidal flash.

Laminar Venous Phase(Early A-V Phase)

As blood-borne dye crosses the capillary network and enters the venous system, a columnar appearance to the veins initially is observed.

Full Venous Phase (Late A-V Phase)

As more fluorescein enters the veins, they fill totally.

Late Phase

This phase shows the eventual fate of the dye.

Evaluation of Fluorescein Angiography

1) Hypo-Fluorescence

2) Hyper-Fluorescence

Hypo-Fluorescence

a. Vascular Filling Defect

b. Blockage

Hypo-Fluorescence 1. Vascular Filling Defect

• Carotid Artery• Ophthamic Artery • Retinal Vessels• Capillary Bed• Vessels of Optic Nerve• Choroid

Occlusion of the Carotid

Vascular Filling Defect

CRAO

Vascular Filling Defect (Retinal Vessels)

BRAO

Vascular Filling Defect (Retinal Vessels)

CRVO

Vascular Filling Defect (Retinal Vessels)

Diabetes

Vascular Filling Defect (Capillary Bed)

Cotton Wool Spot

Vascular Filling Defect(Capillary Bed)

Hypo-Fluorescence 2. Blockage

• Pre-Retinal• Intra-Retinal• Sub-Retinal• Different Deposits

Opacities of the Refractive Media and Vitreous

(Pre-Retinal)

Blockage

Pre-Retinal Hemorrhages

Blockage

(Pre-Retinal)

Melanocytoma

Blockage

(Pre-Retinal)

Hemorrhage,

Blockage

(Intra-Retinal)

RPE Hyperplasia

,

Blockage

(Intra-Retinal Pigment)

Hemorrhage

Blockage

(Sub-Retinal)

(Choroidal Nevus)

Blockage (Sub-Retinal Pigment)

Inflammation (Toxoplasmosis)

Blockage

(Sub-Retinal)

Fluid

(CSR)

Blockage

(Sub-Retinal)

Best Vitelliform Degeneration

Blockage

(Different Deposits)

Hyper-Fluorescence

1) Window Defect of RPE

2) Leakage

3) Anomalous Vessels

1) Window Defect of RPEHyper-Fluorescence

Window Defect of the RPE (Decreased Pigment in the RPE)

Degenerative Myopia

Window Defect of the RPE

(Decreased Pigment in the RPE)

Albinism

Window Defect of the RPE

(Atrophy of the RPE)

Geographic, or Areolar Atrophy

Window Defect of the RPE

Angioid Streaks

Window Defect of the RPE (Toxic Damage)

Bull's Eye Maculopathy

(Chloroquine)

Window Defect of the RPE (Trauma)

Choroidal Ruptures

Hyper-Fluorescence

a. Choroid

b. Retina

c. Optic Nerve Head

2) Anomalous Vessels

Anomalous Vessels

CNV

(Choroid)

Anomalous Vessels

Choroidal Tumor (Melanoma)

(Choroid)

Anomalous Vessels (Retina)

Coats' Disease

Anomalous Vessels

Collateral Vessels

Venous-Venous Anastomotic

(Retina)

Anomalous Vessels

(Parafoveal Telangiectasis)

(Retina)

Anomalous Vessels

(Capillary Hemangiomas) Tumor Vessels

(Retina)

3) Leakage

a. Into Tissue

Staining

b. In a Preformed Space

Pooling

Hyper-Fluorescence

Leakage Into Tissue (Staining)

Leakage Into Tissue (Staining)

Drusen

Optic Disk & Sclera

Leakage Into Tissue (Staining)

Schar Tissue(Serpiginous Choroidopathy)

Leakage Into Tissue (Staining)

Vessel Walls

Leakage Into Tissue (Staining)

Leakage in a Preformed Space(Pooling)

CSR

Leakage in a Preformed Space(Pooling)

RPE Detachment (PED)

Leakage in a Preformed Space(Pooling)

Inflammatory Serous Detachment

(Harada Disease)

Leakage in a Preformed Space(Pooling)

Retinal Leakage

A. Cystoid Edema

B. Non-Cystoid Edema

Cystoid Retinal Leakage

Retinal Teleangiectasia

(Juxta-Foveal Retinal Teleangiectasia)

Cystoid Retinal Leakage

Microaneurysms (Leber's Miliary Aneurysms)

Cystoid Retinal Leakage

Diabetic Retinopathy

Cystoid Retinal Leakage

Venous Occlusion (BRVO)

Cystoid Retinal Leakage

Venous Occlusion(Non-Ischemic CRVO)

Cystoid Retinal Leakage

Non-Cystoid Retinal Leakage

Arterial Hypertension

Non-Cystoid Retinal Leakage

Vasa-Occlusive Retinal disease

(BRVO)

Non-Cystoid Retinal Leakage

Diabetic Retinopathy

Non-Cystoid Retinal Leakage

The light used for F/A is absorbed by the RPE, and thus can not take imaging of the Choroidal circulation.

ICG Angiography

ICG Angiography

• Indocyanine green (ICG) is a tricarbocyanine dye that absorbs Infra-Red (non-visible) light.

• ICG is almost 98% plasma protein bound.

• This high degree of protein binding results in the tendency for ICG to remain intravascular.

ICG Angiography

• The Infra-Red wavelenths have the ability to penetrate the retinal layers, enables imaging of the choroidal circulation below the RPE.

• Thus the image usually take through pigmentation, fluid, or blood in the back of the eye.

ICG enhanced imaging of the choroid for,

Ischemic diseases,Tumors, Idiopathic syndromes, and Inflammatory diseases.

Choroidal Malignant Melanoma

Choroidal Hemangiomas

Birdshot Chorioretinopathy

Harada's disease

The most practical clinical application of the ICG/A has been in those patients with ARMD.

ICG/A unique properties mean that areas of CNV beneath Blood, Exudate, or Pigment Epithelial Detachment (PED) can be imaged more readily.

Sub-Retinal Hemorrhage & CNV

PED & CNV

PED & CNV

Hemorrhagic PED & CNV

• ICG/A complements F/A, which captures blood flow above the RPE.

• Although ICG/A is not a replacement for F/A, it

provides adjunctive information which assists in defining the Choroidal circulatory involvement in Retinal pathology.

F/A & ICG/A are valuable adjunct to diagnosis that supports and enhances, but does Not Replace, standard Clinical Examination.