RETINAL IMAGING AND FLUORESCEIN ANGIOGRAPHY - PowerPoint Presentation

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RETINAL IMAGING AND FLUORESCEIN ANGIOGRAPHYSlide3

RETINAL ANATOMY

*Choroid

*Retina

*Optic nerveSlide4
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Retinal Vasculature

Central retinal artery

Branch retinal arteries

Arterioles

Capillaries

Venules

Branch retinal veins

Central retinal veinSlide6

Reasons for physician wanting FA

Macular degeneration

To determine if exudative and what is the best treatment protocol

Histoplasmosis

To assess choroidal neovascularization

CME

To assess leakage, typical flower petal pattern

White Dot Syndromes

APMPPE

(Acute posterior multifocal placoid pigment epitheliopathy

MEWDS

multiple evanescent white dot syndrome

PIC

punctate inner choroidopathy

Panuveitis

Diffuse subretinal fibrosisSlide7

Reason for physician ordering FA

Vascular

CRAO

BRAO

CRVO

BRVO

HTN

Diabetes

Nonproliferative diabetic retinopathy

Diabetic macular edema

Ischemia

Proliferative diabetic retinopathySlide8

Setting up FA

*Schedule if possible

*Eat prior to procedure (reduces chance of nausea and vomiting)

*Should be well hydrated (optimizes vein access)

*Optimal dilation with 1% Tropicamide and 2.5% phenylephrine (x 2 sometimes)

*Informed consentSlide9
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Color Photos F1 and F2Slide11

MosaicSlide12

Seven Standard FieldsSlide13

Red Free Photos

Green filterSlide14

Set up

5cc Fluorescein Sodium 10% or 2cc Fluorescein Sodium 25% use filter needle if in glass ampule

IV kit

Tourniquet

Alcohol wipes

Gauze

Tape

Bandage

23 or 25 G butterfly needle

GlovesSlide15

Starting Angiogram

Filter in place (exciter only on our Topcon 50DX)Slide16

Position patientSlide17

Start timer and injection

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Start photographing

One photo taken as soon as dye is completely injected to let physician know injection time.

Take one photo every second for approx 40-45 seconds.

Photograph fellow eye.

Photograph both eyes at around one minute. (End of early phase).Slide19

Angiogram continued

After one minute pictures, patient gets break

Sit back

Remove needle

Many times this is about when adverse effects occur

Mid-phase pictures at 3 minutes

Late phase pictures at 5-15 minutes, depends on pathology, will need to adjust flash.Slide20

Early phase: Choroidal/Arterial

Choroidal Flush ~10 seconds Slide21

Early phase: arterial

Artery fills 1-2 seconds after

Average arm to eye 12 seconds

Delayed arm to eye can mean:

-carotid disease

-heart disease

-PVD(peripheral vascular dx)Slide22

Early phase: arteriovenous phase

Complete filling of retinal capillary bed

Veins begin to fill

First fill along vein wall (laminar flow)Slide23

Laminar flowSlide24

Early Phase: venous phase

Complete filling of veins

Best time to view perifoveal capillariesSlide25

Mid phase

2-4 minutes after injection

Veins and arteries equal

Diminished brightness

Dye removed from bloodstreamSlide26

Late phase: Five to fifteen minutes post injection

Elimination of dye from retina

And choroidal vasculature

Disc staining

Other areas of hyperfluorescenceSlide27

Risks of Fluorescein injection

Extravasation of dye into tissues

Small butterfly needles helpful due to blood being injected first.

If dyes gets into tissues stop ASAP

If happens, use ice and beware of necrosis and phlebitis.

Educate patientSlide28
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Flushing

NauseaVomiting

Usually occurs at one minute mark

Dependent on amount of dye, speed of injection and possibly concentration 25%

Advise patient to eat and be hydrated prior to procedure

If happens, advise deep breaths and reassure that it will pass quickly

Have basket available “just in case”

Phenergan can be used if they have had in past and physician determines FA essential to diagnosis and treatmentSlide30

Vasovagal response

Happens usually due to anxiety

Be ready for them to pass out

Frequently happens in younger patientsSlide31

Hives

Liquid Benadryl

Make sure patient knows that they need to let you know of this or any other reaction so it can be documented in medical record and taken into account if they need another FA in future

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Bronchospasm

Laryngeal edema

L

iquid Benadryl

Epipen

Document in medical recordSlide33

Anaphylaxis

Epipen

Crash cart

Physician in area whenever FA is doneSlide34

Hypotension

SyncopeSeizures

MI/cardiac arrest

CVA

Need for physician and emergency medical equipment/crash cart available

Call for code

Call 911

Epinephrine

CorticosteroidsSlide35

Abnormalities of Angiogram

Hypofluorescence

*Reduction or absence of normal fluorescence due to blockage such as blood or abnormalities in choroidal or retinal perfusion. (occlusion or ischemia)Slide36

Abnormalities of Angiogram

Hyperfluorescence

Increased transmission or abnormal presence of dye.

Autofluorescence

hyperfluorescence in absence of dye (optic nerve head drusen)

Pseudofluorescence

usually found in old filters that need replacement

Transmission defect

absence of pigment allowing choroidal fluorescence to be seen (window defect)Slide37

Transmission defectSlide38

Hyperfluorescence

Leakage

due to extravasation of dye due to DME, CME, CSR.

Occurs with neovascularization from PDR and AMDSlide39

Staining

Late hyperfluorescence from dye accumulation. Occurs with drusen, chorioretinal scar, optic nerve.

Visible where there is reduction/absence of RPE.Slide40

Pooling

Accumulation within distinct space such as CSR or serous detachmentSlide41

Improving Images

Focus ocular eyepiece.

Place white paper in front of lens to focus reticle.

Turn eyepiece to high plus power.

Relax eyes by focusing on distance for few seconds to decrease accommodation.

Focus with both eyes open to prevent accommodation.

Turn toward plano and stop when reticle is just in focus.

Repeat several times.

Check it every time you use camera, especially if sharing camera with other staff members

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Position patient properly with chin and forehead placed correctly

P

u

ll focusing knob toward you, slowly turn away until image just in focus.Slide42

ArtifactsSlide43

IrisSlide44

BlinkSlide45

DustSlide46

PathologySlide47

Cotton wool spotsSlide48

Exudate

Blot hemesSlide49

MicroaneurysmsSlide50

Intraretinal microvascular abnormalities (IRMA)Slide51

IRMASlide52

IRMASlide53

Retinal neovascularizationSlide54

NeovascularizationSlide55

NeovascularizationSlide56

Rubeosis/neovascularization of iris (NVI)Slide57

Preretinal hemorrhage from PDRSlide58

IschemiaSlide59

Crossing changes/AV nickingSlide60

Crossing changesSlide61

Venous Beading in diabetic retinopathy

Also enlarged foveal avascular zone Slide62

Venous beadingSlide63

Cystoid Macular EdemaSlide64

Retinitis pigmentosaSlide65

White dot syndrome: Acute posterior multifocal placoid pigment epitheliopathy

(APMPPE)Slide66

APMPPE Red FreeSlide67

??????Slide68

CRAO with Cilioretinal arterySlide69

CRAO with Cilioretinal arterySlide70

CRAO with PDR (1 minute post injection)Slide71

Choroidal foldsSlide72

Choroidal folds red freeSlide73

Choroidal folds FA lateSlide74

Kissing choroidals (Choroidal hemorrhage)Slide75

Kissing ChoroidalsSlide76

Kissing choroidalsSlide77

Diabetic papillopathySlide78

Diabetic papillopathy red freeSlide79

Central Serous RetinopathySlide80

CNVM with histoplasmosisSlide81

CNVM Histo FASlide82