Retina

The retina composed of two parts :

A. Neurosensory retina which composed of 9 layers
3) The internal limiting membrane
4)   The nerve fiber layer
5)   The ganglion cell layer
6)   The inner plexiform layer
7)   The inner nuclear layer
8)   The outer plexiform layer
9)   The outer nuclear layer
10)  The rod and cone inner and outer segments
11) The external limiting membrane

B. 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
 Basic facts

 Normal central retinal

capillaries

 Normal peripheral retinal

capillaries

 Plugged peripheral retinal

capillaries
 Optical phenomena

Transparency of neurosensory retina

1. Normal
 Transparent structures
2. Decreased
1. Post mortem
2. Blood
3. Melanin
 Optical phenomena

Transparency of retinal pigment

epithelium
1. Normal
1. Melanin granules
2. Decreased
1. Macula
2. Hypertrophy of RPE
3. Choroidal folds
4. Choroidal nevi
3. Increased
1. Drusen
2. Scars, degenerative processes
Optical phenomena

Transparency of Bruch’s
membrane
1. Normal
1. Elastic layer
2. Increased
1. Angioid streaks
 Mechanical phenomena
1. Attachment of retinal pigment
epithelium
2. Normal
 Hemidesmosomes
3. Disturbed
 Pigment epithelial detachment
Fluorescein Angiography
 Fluorescein angiography or fluorescent
angiography, is a technique for examining the
circulation of the retina using the dye tracing method.
Described in 1959 by MacLean and Maumenee
 Fluorescein binding: on entering the circulation,
between 80% of
fluorescein molecules bind to serum proteins (mainly
albumin).
The rest remain unbound and are referred to as free
fluorescein.
 It provides three main information:
 the flow characteristics in the blood vessels as the dye
reaches and
circulates through the retina and choroid.
 it records fine details of the pigment epithelium and retinal
circulation that may not otherwise be visible.
 give a clear picture of the retinal vessels and assessment
of
their functional integrity. 15
Characteristics of fluorescein
Nontoxic , inexpensive
and safe.
Sodium fluorescein
(C20H10O5Na2) is an
organic dye. It is an
alkaline solution and is
highly fluorescent.
Absorbs blue light, with
absorption peaking at
490nm (blue).
It emits yellow green
light at.
Effective at pH 7.37-7.45
 It is metabolized by the
liver and excreted by the
kidneys Most dye is cleared
with 24 hours and kidneys
and patients should be
warned that their urine will
appear orange during this
time.
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During pregnancy and lactation

•Controversial
•Fl. Crosses the placenta
•Has been done in pregnancy with no
adverse effect
•Do it when necessary

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 Hazards

Minimal relatively safe drug

Use of dilating drops
Red after – images from the photoflash
Temporary tan skin color
Fl. Urine discoloration
Interfere with serological tests
2-4% Transient nausea and occ. VOMITING
Hives, asthmatic symptoms
Laryngeal edema
Rarely – Syncope, anaphylactic rxn, MI, resp. or
Cardiac arrest
Rx – oral or I.V. Benadryl or Cortisone
A physician in the 1st few minutes
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Anatomic and Physiologic Considerations

Retinal B.V. , choricapillaris,

large choroidal vessels
Optic disc – normal
fluorescent, no leakage
Ciliary body leaks dye in
A/C and vitreous

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 Equipmen
 t
Exciter filter: Allows only blue light to illuminate the
retina. Depending on the specific filter, the excitation
wavelength hitting the retina will be between 465-490 nm.
Most only allow light through at a wavelength of 490 nm.
 Barrier Filter: Allows only yellow-green light (from the
fluorescence) to reach the camera. Both filters are
interference filters, which means they block out all light
except that at a specific wavelength. The barrier filter only
allows light with a wavelength of 525 nm, but depending on
the filter it can be anywhere from 520-530 nm.
 Fundus Camera with camera body containing black and
white, or slide positive film. Also digital cameras tethered to
computers have come into use since the late 1990s and are
beginning to dominate the market today.

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 How is fluorescein angiography performed?
 5ml of 10% sodium fluorescein dye is injected as a bolus into
the vein (preferably antecubital) of the patient's arm.

 The eye is illuminated using blue light produced by a blue

filter (excitation filter).

 The fundus is viewed through a yellow filter (barrier filter).

 As blue light cannot pass through a yellow filter in normal

circumstances nothing can be seen. However, fluorescein dye
within retinal and choroidal blood vessels absorbs blue light and
emits yellow light, this yellow light passes through the filter and
is photographed. Only tissues that contains fluorescein are
visualized .

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23
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Normal circulatory filling

# 0 seconds — injection of fluorescein

# 9.5 sec — posterior ciliary arteries
# 10 sec — choroidal flush
# 10-12 sec — retinal arterial stage
# 13 sec — capillary transition stage
# 14-15 sec — early venous stage
#16-17 sec — venous stage
# 18-20 sec — late venous stage
# 5 minutes — late staining
Fluorescein enters the ocular circulation from the internal carotid artery
via the ophthalmic artery. The ophthalmic artery supplies the choroid
via the short posterior ciliary arteries and the retina via the central
retinal artery, however, the route to the choroid is typically less
circuitous than the route to the retina. This accounts for the short delay
between the "choroidal flush" and retinal filling. 25
 Normal
angiogram can
be divided
into five
 phases:
Choroidal
phase
 Arterial
phase
 Capillary
phase
 Venous phase
 Late phase
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 33
Arterial phase
 34
Venous phase
 35
Venous phase
• Fluorescein angiography is used mainly for the study of abnormal
ocular vasculature. The following are the main indications for fluorescein
angiography
• Diabetic mellitus:
1. detecting any significant macular oedema which is not clinically
obvious;
2. locating the area of oedema for laser treatment;
3. differentiating ischaemic from exudative diabetic maculoplathy;
4. differentiating between IRMA and new blood vessels if clinical
differentiation is difficult.
• Retinal vein occlusion:
1. determining the integrity of the foveal capillary bed and the extent of
2. macular oedema following branch retinal vein occlusion
3. differentiating collaterals from neovascularization less commonly it is
used purely to determine the extent of retinal
4. ischaemia (as this can be done clinically)

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• Age-related macular degeneration:
1. locate the subretinal neovascularization and determine its
2. suitability of treatment

• Other indications:
1. Locating subretinal neovascular membrane in various
conditions (high myopia, angioid streaks, choroidal rupture and
chorioretinitis)
2. Locating abnormal blood vessels (for example idiopathic retinal
telangietasia, retinal retinopathy etc) .
3. Looking for break down of RPE tight junctions (central serous
retinal retinopathy) or the blood retinal barrier (cystoid macular
oedema)
4. Help with diagnosis of retinal conditions (for example
Stargardt's disease gives a characteristic dark choroid).

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38
Interpretation of pathology of FFA

The following are common abnormalities

seen in fluorescein angiography:
•Timing
•Abnormal dye distribution

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 Pooling (in a space)
Leak

Staining (in a tissue).

Transmission Pigment epithelial

Hyperfluorescence
window defect
increase

Retinal

Abnormal vessels Subretinal

Tumors
 Retinal Cystoid edema
Pooling Sensory retina
(in a space) detachment

Subretinal Retinal pigment

epithelium
Hyperfluorescence Leak
Noncystoid edema
Retinal
Perivascular
Staining staining

(in a tissue). Drusen

Scars
Subretinal
Sclera
Lamina cribrosa
(A) Color and (B) red-free photgraphs of a fundus with soft drusen and hyperpigmentatio
(C) Soft drusen hyperfluoresce during the early phase of angiography
(D) stain in the late phase
cystoid macular oedema with petaloid pattern.
 Pigment
Transmission Epithelial Atrophy
Hyperfluorescence
Increase Window
Drusen
Defect
Left macular hole. There is left foveal
hyperfluorescence due to loss of the
marking effect of RPE cells.
 Tortuosity and Dilation
Neovascularization
Microaneurysms
Retinal Aneurysms
Macroaneurysms
Telangiectasias
Shunts and collaterals
Abnormal
Hyperfluorescence
Vessels
Neovascularization
Subretinal
Vessels in scar
Angioma
Retinal
Retinoblastoma
Tumors
Hemangioma
Subretinal Melanoma
Metastases
 Transmission Decrease
(blocking effect)

Hypofluorescence

Filling defect
(delay and occlusion)
 Melanin
Hemoglobin
Pigment Xanthophyll
Lipofuscin

Exudates Hard
Transmissionc
Hypofluorescence Decrease Soft
(blocked) Edema
and
transudate

Other Best`s disease

abnormal Foreign body
materials Fundus
flavimaculatus
 Artery
H
y Retinal Vein
p Capillary bed
o
f
l
u Filling defect
(delay and Choroideremia
o
occlusion) Dystrophies
r Choroidal
e atrophy etc.
Loss of tissue
s
c Myopia
e Subretinal Degeneration
n Central areolar
c atrophy
e Nonperfusion
 Autofluorescence

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.
What are the side effects of
fluorescein angiography?

The side effects include:

 Temporary tan skin colour form the dye.
 Red after-image from the photoflash.
 Discoloration of the urine.
 Nausea and vomiting (10%).
 Vasovagal synocope (1%)
 Anaphylaxis such as bronchospasm, urticarial skin
rash and hypotension (<1%).
 Cardiac and respiratory arrest (<0.01%).
How do ocular structures determine the
distribution of fluorescein angiography?

 Fluorescein cannot diffuse through tight cellular

junctions. These are present at two sites within the
fundus:
retinal blood vessel endothelium
retinal pigment epithelium.
 There are two circulation within the fundus:
Choroidal circulation –the fluorescein freely leaks
out of the fenestrated choroidal capillaries, and from
there through Bruch's membrane. however,tight
junctions between retinal pigment epithelium (RPE)
cells prevents dye reaching the retina
Retinal circulation - the retinal blood vessel
endothelial cells are joined by tight junctions which
prevent leakage of fluorescein into the retina. This
constitutes the blood retina barrier. Any leakage from
the retinal vessels is abnormal
1. Capillaries in the ciliary process
are permeable to fluorescein, so
dye rapidly appears in the
aqueous following intravenous
injection.
2. Fluorescein in the aqueous and
vitreous emits yellow light which
reflects off white structures
within the eye causing these
structures to falsely appear
fluorescent.
3. The optic disc, myelinated fibres
and hard exudates appear
progressively more
pseudofluorescent through the
course of an angiogram for this
reason.
►Indocyanine Green dye is injected into a vein in the
patient. As the dye circulates, it passes through the
vessels of the retina. Digital fundus photographs are
taken to capture the infrared fluorescence of the dye.
This technique aids in visualizing the vessels of the
Choroid
►Its first application for fundus angiography was by
Kogure and others in 1970 when it was used to visualize
the fundus of the owl monkey.
►Most clinical ophthalmologists consider ICG
angiography to be an adjunctive or secondary test which adds
information to the clinical picture and a fluorescein angiogram.
►The recent interest in this procedure has been the result of
two factors: the development of digital systems which let us
see the choroid, and the interest of ophthalmologists in very
carefully directed laser treatment in order to destroy the
smallest amount of working retina.
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Physical properties of ICG

Indocyanine green absorbs and reflects

in the near infrared portion of the
spectrum (805 nm and 835 nm,
respectively).
It has a peak spectral absorption at
about 800 nm.
ICG has a half-life of 150 to 180 seconds
It is removed from circulation
exclusively by the liver to bile juice 67
 Why is it used ?

§Improved imaging of the choroidal circulation.

§The most practical clinical application of the procedure has

been in those patients with age related macular
degeneration (ARMD).

§In situations where the source of leakage may be obscured

by a hemorrhage of the retina.

§Pinpointing the location of the leakage.

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 Indications

#Age-related macular degeneration

#Choroidal polypoidal vasculopathy

#Choroidal haemangiomas.

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 Side Effects

Side effects are minimal.

Patients allergic to iodine or shellfish, or those w

a
history of liver disease, should advise their
physician.

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Choroidal filling defect in early phase ICGA (arrow)
Irregular filling of the choriocapillaris in early phase ICGA
ICG leakage from choroidal vessels in early phase ICGA
 Comparison between FFA and
ICGA
1. The difference between fluorescein and ICG angiography is primarily in the type of dye that
is used:
a. Fluorescence
• The green ICG dye "fluoresces" and, unlike the dye used in the fluorescein
procedure, allows the camera to see through blood, fluid, and pigments that
obscure certain conditions from view.
• The fluorescing quality of the ICG dye also allows special digital cameras to
capture and view images as the test is being done.
b. Protein affinity
• Fluorescein (molecular weight 376) is 80% protein bound; the unbound
fluorescein readily escapes through the fenestrations of the choriocapillaris and
obscures the details of the underlying choroid.
• ICG is a tricarbocyanine dye (molecular weight 775) which is highly protein
bound and does not readily escape from the choriocapillaris.
2. FFA is the accepted standard for imaging the retinal vascular and choroidal circulations
3. ICGA is especially helpful in situations where the source of leakage may be obscured by a
hemorrhage of the retina
4. High-speed ICGA dynamic imaging can identify feeder vessels and retinal choroidal
anastomoses, ensuring safer treatment of choroidal neovascularization

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(A) Hyperfluorescent spots in the late phase of ICGA.
(B) These spots cannot be seen on FA
(A) Hypofluorescent spots in the late phase of ICGA.
(B) These spots cannot be seen on FA
Early phase
of
indocyanine
green
angiography
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