FFA

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

4. FFA reveals: Cont
 Subretinal fluid status
 Cystoid macular edema
 Intraretinal/ preretinal haemorrhages
 Optic nerve disorders
 RPE integrity and disorders
 Choroidal neovessels and chorioretinal atrophy

5. BASIC PRINCIPLES:

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

9. FILTERS
1.Blue excitation filter
2.Yellow-green filter

10. Blood supply to retina

11. Layers & blood supply

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.

14. ANGIOGRAPHIC PHASES
 Five angiographic phases:
• Pre arterial (Choroidal 9-15 seconds)
• Arterial
• Arteriovenous(capillary)
• Venous
• Recirculation

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.

16. BASIC ANATOMY

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.

18. ARTERIAL PHASE

19. ARTERIAL PHASE Cont…

20. ARTERIOVENOUS PHASE

21. VENOUS PHASE

22. Recirculation phase

23. ABNORMAL ANGIOGRAPHIC FINDINGS
 Hypofluorescence:
Filling defect
Blocking defect
 Hyperfluorescence :
Window defect
Leakage
Pooling
Staining

24. Hypofluorescence
 Blocked fluorescence (Transmission defects- blood, pigment,
hard exudates etc)
 Vascular filling defects (Circulation abnormality)
 Blocked Retinal fluorescence
1. Arterial segment material
2. Vitreous material
3. Inner retinal material
 Blocked choroidal fluorescence
1. Deep retinal material
2. Subretinal material
3. Sub RPE material
4. Choroidal material

25. Hypofluorescence.Cont

26. Hyperfluorescence
Anomalous vessels
Choroid
Retina
Optic nerve
head
Subretinal neovasculari-
zation
Tumor vessels
Chorioretinal anastomosis
Vascular tortuosities
Dilation and shunts
Anastomosis
Neovascularization
Aneurysms
Teleangiectasia
Tumor vessels
Hamatoma
Neovascularization
Tortuosity
Dilation
Hamatoma
Tumor vessels

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

28. Leakage

29. Fluorescence
without the
administration
of fluorescein
Autofluorescence
Pseudofluorescence
Drusen of the optic
nerve head
Hamatoma
Scleral exudate
Myelinate nerve
Fibers, optic nerve drusen
Scar tissue
Foreign body

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

33. Vascular occlusion
Capillary non-perfusion
(venous occlusion)
Loss of vascular tissue
Choroideremia or high myopia
Causes of Hypofluorescence

34. BRVO- HYPO F- BLOCKED F

35. BRVO

36. SUB HYLOID. Hge/ PRERETINAL Hge HYPO
F- BLOCKED

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.

38. AION – HYPO F OF DISC

39. Red-free Fundus photos
Normal appearance Autofluorescence

40. Macular Hole

41. ARMD - HYPER- STAINING

42. CHOROIDAL NAEVUS

43. DIABETIC RETINOPATHY
Diabetic retinopathy gives a combination of both
hyper/ hypofluorescence. Several pathologies are seen
in this frame:

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)

45. DIABETIC MACULOPATHY TREATED WITH
LASER

46. PDR- HYPER F

47. BACKGROUND DIABETIC RETINOPATHY

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

50. HYPERTENSIVE RETINOPATHY

51. Limitations of FFA

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.

53. Thank you