21.imaging in Ophthalmology

Imaging In Ophthalmology
Fluorescein Angiography
• FA used to study of circulation of retina and choroid in normal and diseased states
• Black & white photographs are taken IV injection of 10% sodium fluorescein
• 80% fluorescein is albumin bound, 20% is unbound
• Circulates in vasculature of retina and choroid can be visualised
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FA / FFA
• 10% Na Fluorescein dye injected through Antecubital vein-ophthalmic artery to short posterior
ciliary arteries in 8-10 seconds
• 5 phases are pre retinal, retinal, arteriovenous, venous and late recirculation
• First choroidal vessels fill, then retinal vessels
• Dye leaks out of capillaries into retina when endothelium is damaged
• Dye leaks from choriocapillaries into interstitium
• When RPE is damaged

Blood Retina Barrier
Blood Retina Barrier
Outer Barrier Inner Barrier
Endothelium Retinal Pigment Epithelium

Fluorescein Angiography

Dark Choroid – STARGARDT’S DISEASE

Smoke Stack CSR / Ink Blot

Indocyanine Green Angiography
• ICG is 90% protein bound diffusion through fenestrations of choriocapillaries limited
• Retention of ICG makes it ideal for imaging choroidal circulation
• Longer wavelength, fluoresces better through pigment fluid, lipid & hemorrhage, detects
abnormalities such as CNVMs obscured by overlying hemorrhage, melanin, xanthophyll
• Occult CNVMs

Indocyanine Green Angiography
Indications
• Occult CNVMs
• Polypoidal choroidal vasculopathy → Most Important
• Pigment Epithelial Detachments
• Serpiginous Choroidopathy
• Birdshot Retinochoroidopathy
• Multiple evanescent white dot Syndromes [MEWDS]

Polypoidal Choroidal Vasculopathy

Optical Cohorence Tomography

• A non invasive technique reveals cross sectional area
• Interferometry to create a cross sectional map of Retina
• Each layer of Retina can be seen and their thickness measured
• Accurate 10-15 microns
• Two significant advantages :

 Cross –sectional imaging
 Quantification in the form of thickness map


Indications
• Macular Edema
• Macular Pucker
• Central Serous Retinopathy → Most Important
• Vitreo Macular Traction
• Macular Holes
• Glaucoma

Central Serous Retinopathy

Cystoid Macular Edema

OCT Angiography
• A non invasive technique imaging microvasculature of retina and choroid
• Laser light reflectance from surface of moving RBCs to accurately depict vessels,
eliminating intravascular dyes
• Each layer of Retina can be seen and their thickness measured
• Advantages of OCTA :
 Non invasive
 Image acquisition speed faster
 Image detail and resolution much better

OCT Angiography

OCT Angiography
Indications
• Diabetic Retinopathy
• Dry ARMD
• Wet ARMD
• CSR
• Vascular occlusions

OCTA In CRVO

Anterior Segment OCT

Anterior Segment OCT
• As OCT uses higher wavelength of light than posterior segment OCT
• Greater absorption & lesser penetration so anterior segment structures (cornea, AC, iris, angle,
lens) can be seen

ASOCT –Applications
• Angle anatomy, particularly angle occludability and closure
• Plateau iris
• Ciliary body tumors and cysts
• Corneal thickness measurement
• Keratoconus

AS OCT

Ultrasound Biomicroscopy (UBM)
• Non invasive technique for imaging anterior segment using high frequency, 50 MHZ
• Depth of tissue structure determined by measuring time delay of returning ultrasound signal
• Requires contact with eye and a coupling media necessary
• Scanning performed through immersion bath
• Tissue depth penetration, approx 5mm, can view through opaque media, unlike OCT




UBM –Clinical Applications
• All structures upto lens
• AC anatomy and pathology
• Angle closure glaucoma
• Corneal pathology, Keratoconus, dystrophies, scars

AS-OCT vs UBM
AS OCT UBM
• Non contact • Requires contact & a liquid coupling media
• Does not require skilled operator • Requires skilled operator
• Higher axial solution • Lower axial solution
• Limited ability to visualize structures posterior • Can visualize structures posterior to the iris
to the iris pigment epithelium pigment epithelium
• Faster acquisition time • Slower acquisition time

• Wider field of view • Smaller field of view
• Seated upright position • Seated upright / supine position
• Use for clear corneas • Can image through opaque corneas

Confocal Microscopy
• Non invasive technique allowing in vivo visualization of entire corneal thickness
• Microbial keratitis diagnosis and treatment
 Hyphae in Fungal keratitis
 Cysts / Trophozites in Acanthamoeba
 Langerhans cells activation in viral

Confocal Microscopy
• Endothelial disorders
 Fuchs’ Endothelial Dystrophy
 Neurotrophic Keratopathy

Confocal Microscopy


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Imaging In Ophthalmology

• 80% fluorescein is albumin bound, 20% is unbound

• Circulates in vasculature of retina and choroid can be visualised

With From www.medicoapps.org

• First choroidal vessels fill, then retinal vessels

• Dye leaks out of capillaries into retina when endothelium is damaged

• Dye leaks from choriocapillaries into interstitium

• When RPE is damaged

With From www.medicoapps.org

Blood Retina Barrier

Outer Barrier Inner Barrier

Endothelium Retinal Pigment Epithelium

With From www.medicoapps.org

With From www.medicoapps.org

With From www.medicoapps.org

With From www.medicoapps.org

• Retention of ICG makes it ideal for imaging choroidal circulation

With From www.medicoapps.org

• Polypoidal choroidal vasculopathy → Most Important

• Pigment Epithelial Detachments

• Multiple evanescent white dot Syndromes [MEWDS]

With From www.medicoapps.org

With From www.medicoapps.org

With From www.medicoapps.org

• Interferometry to create a cross sectional map of Retina

• Each layer of Retina can be seen and their thickness measured

• Accurate 10-15 microns

• Two significant advantages :

 Quantification in the form of thickness map

With From www.medicoapps.org

With From www.medicoapps.org

• Central Serous Retinopathy → Most Important

• Vitreo Macular Traction

With From www.medicoapps.org

With From www.medicoapps.org

With From www.medicoapps.org

• Each layer of Retina can be seen and their thickness measured

 Image acquisition speed faster

 Image detail and resolution much better

With From www.medicoapps.org

With From www.medicoapps.org

With From www.medicoapps.org

With From www.medicoapps.org

With From www.medicoapps.org

With From www.medicoapps.org

• Ciliary body tumors and cysts

• Corneal thickness measurement

With From www.medicoapps.org

With From www.medicoapps.org

• Requires contact with eye and a coupling media necessary

• Scanning performed through immersion bath

With From www.medicoapps.org

With From www.medicoapps.org

With From www.medicoapps.org

With From www.medicoapps.org

• AC anatomy and pathology

• Angle closure glaucoma

• Corneal pathology, Keratoconus, dystrophies, scars

With From www.medicoapps.org