1. Fundus Fluorescein
Angiography
Dr Md Afzal Mahfuzullah
MCPS,FCPS,Felow Vitreo-Retina
Retina Specialist & Surgeon
Bangabandhu Sheikh Mujib Medical University
2. WHY FFA
To confirms the elements already revealed by clinical
examination.
Flow characteristics in the blood vessels as the dye
reaches and circulates through the retina and choroid.
Gives a clear picture of the retinal vessels and assessment
of their functional integrity.
To monitor the disease intensity and impact of therapy.
Provides guidance for application of focal laser in
photocoagulation therapy.
To detect the leakages without clinical manifestation of
edema
3. What are the informations we get from FFA
FFA reveals:
Inflammatory status of retinal and choroidal blood
vessels.
Localization of intra retinal lesions e.g. depth of
pathological involvement in DR.
CNV
Neovascularisation in disc or retina
6. BASIC PRINCIPLES:
Based on luminescence and fluorescence.
Luminescence – is the emission of light from any source
other than high temperature.
Fluorescence is luminescence that is maintained only by
continuous excitation. Excitation occurs at one wave length
and immediate emission occurs through a longer wave
length.
7. FLUORESCENCE
Refers to fluorescein sodium (C20H10Na2O5)
A brown or orange red crystalline substance, alkaline in
nature.
MW- 376 dalton
Readily diffuses through body fluids and choriocapillaries
but does not diffuse through vascular endothelial cells
and RPE (Blood retina barriers)
8. OPTICAL PRINCIPLE
Absorbs blue light (465-
490nm ) and Emits
yellow-green light (520-
530nm)
Metabolized by liver and
exerted by kidney
12. GENERAL PRINICIPLES OF FFA
Fluorescein
• 85% bound to serum proteins
• 15% unbound ‘free’ fluorescein
• Impermeable to fluorescein
Outer blood-retinal
barrier (zonula occludens)
• Impermeable to fluorescein
Choriocapillaris
Permeable only to ‘free’ fluoresce
Inner blood-retinal barrier
(retinal capillaries)
13. Circulation of NaF
Dye injected from peripheral vein
Venous circulation
Heart
Arterial system
INTERNAL CAROTID ARTERY
Ophthalmic artery
Short posterior ciliary artery) Central retinal artery
(choroidal circulation.) ( retinal circulation)
N.B. The choroidal filling is 1 second prior to the retinal filling.
15. Basic anatomy :
The inner retina contains the retinal blood vessels.
The larger vessels in the Nerve fiber layer.
The retinal capillaries in the Inner nuclear layer.
Both are impermeable to dye.
The outer retina is primarily interstitial space of the retina, where
hemorrhages, edematous fluid and hard exudates accumulate.
In normal conditions this layer does contain NaF as because of RPE
tight junctions(Outer BRB)
Large choroidal vessels do not leake NaF but choriocapillaris does
leak.
17. PRE-ARTERIAL/ CHOROIDAL PHASE
Choroidal flush
Patchy Choroidal filling because of
lobular arrangements of
choriocapillaris
10-12 sec in young
12-15 sec in old
Cilioretinal artery fills at the same
time with choroid circulation
Macula remains dark due to tall
RPE and more pigments.
27. Hyper-
fluorescence
In a preformed
space (pooling)
Into tissue
(staining)
Retinal
Subretinal
Retina
Subretinal
Cystoid edema
Detachment of
the pigment
epithelium
Detachment of
the sensory
retina
noncystoid
edema
e.g.dursen
30. Causes of dark appearance of fovea
-Avascularity
• Increased density of
xanthophyll
• Large RPE cells with more
melanin
-Blockage of background
choroidal fluorescence
by:
31. Causes of Hyperfluorescence
RPE ‘ window’ defect
RPE atrophy
(bull’s eye maculopathy
Pooling of dye
Under RPE
(pigment epithelial detachment)
Under sensory retina
(central serous retinopathy)
32. Causes of Hyperfluorescence
Leakage of dye Prolonged dye retention
( staining )
Into sensory retina
(cystoid macular oedema)
From new vessels
(choroidal neovascularization
Associated with drusen
37. STARGARDT'S DISEASE
Fundusflavimaculatus: (Stargardt disease (STGD) is the most
common childhood recessively inherited macular dystrophy.
Blocked the choroidal fluorescence, so fundus background looks
black.
44. DIABETIC RETINOPATHY
Hypofluorescence:
Retinal haemorrhage (1)
Ischaemia (2).
Hyperfluorescence:
microaneurysms (3) and
neovascularization (4)
In addition, there are IRMA
(5) between the retinal
artery and vein and venous
beading (6)
48. CENTRAL SEROUS RETINOPATHY
POOLING/ HYPER F
Late phase of FFA shows a spot of pigment
epithelium leakage has enlarged & fuzzy,in this
case there is pooling of fluorescein under the
detched retina
49. HYPER F- WINDOW/ POOLING EFFECT
Fundus photography shows PED & late phase of
angiogram showing the corresponding well defined
hyperfluorescent lesion
52. 1) Does not permit study of choroidal circulation details due to
a) melanin in RPE
b) low mol wt of fluorescein
2) More adverse reaction
3) Inability to obtain angiogram in patient with excess
hemoglobin or serum protein.
