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HOW TO
READ FA
Yazan Zahran, M.D., C.V.

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ANATOMY OF THE EYE

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 Retina
The retina composed of two parts :
1.neurosensory retina which composed of 9 layers
The internal limiting membrane
The nerve fiber layer
The ganglion cell layer
The inner plexiform layer
The inner nuclear layer
The outer plexiform layer
The outer nuclear layer
The rod and cone inner and outer segments
The external limiting membrane
2.Retinal pigment epithelium(RPE):which composed from
monolayer of cells & its functions are :
• Absorption of
scattered light. • Control of
fluid and nutrients in the subretinal space (blood-retinal
barrier function). •
Visual pigment regeneration and synthesis.
• Synthesis of growth factors to modulate adjacent
structures.
• Maintenance of retinal adhesion.
• Phagocytosis and digestion of photoreceptor
wastes. • Electrical homeostasis.
• Regeneration and repair after injury
or surgery.
Blood supply:The retina receives its nutrition from two
discrete circulatory systems—the retinal blood vessels
and the uveal or choroidal blood vessels. Both are
derived from the ophthalmic artery, which is the first
branch of the internal carotid artery
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POSTERIOR FUNDUS

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 Choroid
■ The uveal tract is a thin, brown, continuous layer
composed primarily of blood vessels,
melanocytes, and connective tissue. From
anterior to posterior, the uveal tract has three
distinct subdivisions: the iris, the ciliary body,
and the choroid .The iris and ciliary body are
referred to as the anterior uvea. The posterior
uvea is synonymous with the choroid .
■ The choroid can be subdivided into three distinct
parts from internal to external: (1) Bruch's
membrane; (2) choriocapillaris; and (3) the
vessel layer .
■ The choroid, located between the retina and the
sclera .
■ Function :The choroid nourishes the outer retina
and a portion of the optic nerve .
■ Blood supply:mainly from posterior ciliary
arteries
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Ocular Circulation
 The ocular fundus has two separate
vascular systems—retinal and choroidal—
separated by a specialized pigmented monolayer
the retinal pigment epithelium (RPE).
 The choroid and its vasculature lie posterior to
the RPE. The fluorescein angiographic patterns
of the posterior uvea are, therefore, always
partially obscured by the RPE .The degree of
pigmentation and the pathologic changes in this
pigmented layer markedly influence the choroidal
angiographic appearance.

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 ANATOMICAL
BARRIERS
There is two barrier in the retina:
1.Outer retinal barrier .
2.Inner retinal barrier.

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•OUTER RETINAL
BARRIER

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 INNER RETINAL
BARRIER

CHOROIDAL RETINAL
CAPILLARY CAPILLARY
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•NORMAL
ANGIOGRAPHIC
PATTERN
CHOROIDAL PHASE
ARETERIAL PHASE
EARLY ARTERIOVENOUS
PHASE
ARTERIOVENOUS PHASE
RECIRCULATION PHASE
LATE PHASE

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 CHOROIDAL
PHASE
Begins 10 to 12 seconds after dye
injection in young and 12 to 15
seconds after injection in older
patients
Early choroidal fluorescence is
faint patchy and irregular called the
choroidal flush.
Areas of choroidal filling and non-
filling becomes more distinct called
patchy choroidal filling.

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 ARTERIAL
PHASE
Starts 1 to 3 seconds after
choroidal fluorescence with filling
of the central retinal artery.
After the central retinal artery
begins to fill,the dye flows into the
retinal arterioles,precapillary
arterioles,the capillaries ,the
postcapillary venules,and finally
the retinal veins.

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 EARLY
ARTERIOVENOUS
PHASE
The fluorescein dye from the smaller
venules enters the vein along their walls
resulting in a laminar flow of the dye in
the vein.
As the vascular flow is faster in the
center of the vessel than on its side ,the
fluorescein dye sticks to the walls of the
vein :another contributing factor for
laminar flow .
With time the laminae along the walls of
the veins become thicker .

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 ARTERIOVENO
US PHASE
The dye completely fills the lumen of the
vein.
Perifoveal capillary network is best
visualized at 20 to 25 seconds after the
injection of the dye when the
concentration of the dye is maximum.
The fovea appears hypofluorescent
because of the absence of the blood
vessels in the foveal avascular zone
(FAZ) and due to the blockage of the
background choroidal fluorescence by
the increased pigment in the tall RPE
cells at the fovea.

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 Recirculation
PHASE & LATE
PHASE
Recirculation phase: begins about
30 seconds after the dye injection
,fluorescence within the vessels
reduces as lower concentration of
fluorescein recirculates.
Late phase :retinal vessels are
empty of the fluorescein dye by 10
minutes after injection,disc
remains hyperfluorescent in late
films due to staining .

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 New
ophthalmic
residents

RAWAN DUDU

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 ABNORMAL
ANGIOGRAPHIC
PATTERN
ABNORMAL ANGIOGRAPHIC PATTERN

HYPOFLUORESCENCE HYPERFLUORESCENCE

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 HYPOFLUORESCEN
CE

HYPOFLUORESCENCE

BLOCKED VASCULAR FILLING DEFECT

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 Blocked
fluorescence
Blocked fluorescence when
stimulation or visualization
fluorescein blocked by :
Blood.
Pigment.
Fibrosis.

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 Vascular filling
defect
Vascular filling defect: occurs when
the retinal or choroidal vessels do
not fill properly as in non-perfusion
of
Artery.
Vein .
Capillary.

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■ A and B. Acute nonischemic central retinal vein occlusion in a 36-year-old
hypertensive man. His visual acuity was 20/200. C and D. Six weeks later, he
presented with eye pain, decreased vision, and neovascular glaucoma. The type
of occlusion now is ischemic Jump to first page
 Fluorescein angiogram of acute ischemic retinal vein
occlusion. Capillary nonperfusion is essentially 100%.
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 HYPERFLUORESCENC
E

HYPERFLUORESCENCE

PREINJECTION TRANSMITTED
FLUORESCENCE FLUORESCENCE pooling leaking staining

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 Autofluorescen
ce

Autofluorescence of optic nerve head drusen. A.

Preinjection photograph of the optic nerve in a patient
with optic nerve head drusen. Both barrier and exciter
filters are in place. B. Same patient after filling of retinal
vessels. Jump to first page
 Transmission
defect )window
defect)
A window defect refers to the
choroidal fluorescence produced
by a relative decrease or absence
of pigment in the RPE or an
absence of RPE .
The hyperfluorescence occurs
early and reaches its greatest
intensity with the peak of choroidal
filling.

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 Transmission
defect

Fenestrated sheen macular dystrophy. Fluorescein angiography reveals a

large, confluent, annular RPE transmission window defect.

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 A. Color photograph of geographic atrophy and drusen. B.
Angiogram shows window defect type of hyperfluorescence
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 Leaking
Leakage of fluorescein dye is defined as
hyperfluorescence of fluorescein in the
extravascular space .
Typically the area of fluorescence
increases in both size and intensity as
the study progresses .
The borders of hyperfluorescence
become increasingly blurred,& the
greatest intensity of the
hyperfluorescence is appreciated in the
late phases of the study .

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diffuse leakage of dye clouds the retina and underlying
choroid. Jump to first page
 Pooling
Pooling refers to the accumulation
of fluorescein dye into an
anatomical space .
Pooling is seen in both neural
retina and RPE detachments.
The margins of the space trapping
the fluorescein are usually distinct .

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 Staining
Staining results from fluorescein
entry into a solid tissue such as a
scar ,optic nerve tissue,or sclera.
The pattern of hyperfluorescence
with gradually increasing intensity
of fluorescence ,but the borders of
the hyperfluorescence remain fixed
throughout the angiogram process.

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 Color (A) and red-free (B) photgraphs of a fundus with soft drusen and
hyperpigmentation. Soft drusen hyperfluoresce during the early phase of
angiography (C) and stain in the late phase (D) Jump to first page
 How to read FA

Comment on the red-free photograph.

Indicate the phase of the angiogram.
Indicate any hyper- or hypofluorescence
and any delay in filling.
Indicate any characteristic features such
as a smoke-stack .
Indicate any change in the area or
intensity of fluorescence.

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 CYRUS THE VIRUS
C.V.

THANK YOU
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