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Table 11.1. Synopsis of typical fluorescein angiography findings in most commonly examined entities
Disease Localization Clinical picture Early arteriovenous Arteriovenous phase Late phase Essentials
phase
AMD
Classic CNV Central macula Grayish protrusion in central Early, well demarcated Increasing hyperfluo- Persisting hyper- Early, well demarcated hyper-
Retina/RPE/ macula hyperfluorescence rescence leaking from fluorescence fluorescence with increasing
choriocapillaris intraretinal blood the edges of the CNV and persisting leakage
exudates Vessel structure of CNV some-
RPE changes times visible
surrounded by pigmented ring

Occult CNV Central macula Grayish tumor in central macula Hypofluorescence from Pinpoint or larger Increasing leakage No bright and early hyperfluo-
Retina/RPE/cho- intraretinal blood retinal edema hyperfluorescences of unknown or rescence
riocapillaris exudates starting in the middle fibrovascular origin Increasing leakage of unknown
RPE changes to late AV phase origin
Stereo viewing essential

Pigment epithelial Macula Orange/yellowish dome-shaped Hypofluorescence from Increasing, smooth Increasing and per- Notching of RPE detachment
detachment Retina/RPE elevation with smooth borders retinal edema hyperfluorescence sistent leakage with points at possible occult CNV
smooth borders Consider ICG angiography

RAP (Retinal angio- Central macula More exudates, localized intrare- Filling of the CNV from Like classic or pre- Like classic or pre- Consider high speed ICG
matous proliferation) Retina/RPE/cho- tinal hemorrhages, retinal anas- communicating retinal dominantly classic dominantly classic Clinical picture points at
riocapillaris tomosis can sometimes be seen vessel CNV CNV diagnosis
clinically as retinal vessel of con- Early bright hyperfluores-
stant caliber „dipping” into the cence
CNV

Pigment epithelial tear Central macula Well demarcated, often L-
RPE shaped area brighter than sur-
rounding macular tissue bor-
dered by hyperpigmented patch
to one side
Early, well demarcated Increasing hyperfluo- Persistent hyper- Clinical picture points at diag-
hyperfluorescence in the rescence in the area fluorescence in the nosis
area of missing RPE of the tear area of the tear Tear often follows treatment of
(window defect), bor- occult CNV (or spontaneously)
dered by hypofluorescent
patch (retracted RPE)
Drusen Macula, mostly Yellowish round protusions Mostly slightly hypofluo- Increasing hyperfluo- Persisting or diminish- No leakage from edges of dru-
around the rescent but some can rescence ing hyperfluorescence sen
fovea have early, well demar- No leakage No leakage
Retina/RPE cated hyperfluorescence

Geographic atrophy Central macula Well demarcated area void of Early, sharply demarcat- Hyperfluorescence par- Decreasing hyperfluo- No leakage
Initially slightly RPE ed hyperfluorescence allels choroidal filling rescence parallels No thickness on stereo
eccentric (window defect) No leakage from the regression of choroidal Consider autofluorescence for
RPE edges filling follow-up

Diabetic retinopathy
Focal edema Slightly eccen- Clustered groups of micro- Hypofluorescence from Filling of microaneu- Increasing and persist- Consider focal laser for areas
tric aneurysm associated with retinal thickening rysm parallels filling of ing leakage around of leakage
Retina retinal thickening and exu- retinal vessels aneurysm
dates Slow, increasing leak-
age around aneurysm

Diffuse edema Central macula Diffuse thickening Hypofluorescence from Diffuse leakage over Increasing and persist- Consider grid treatment
Retina exudates retinal thickening parafoveal vessels ing leakage Consider OCT for follow-up
microaneurysm cystoid configura-
tion

11 A Practical Guide to Fluorescein Angiography

Ischemic retinopathy Central macula Diffuse thickening
Retina visible ghost vessels
IRMA or neovasculariza-
tions bordering ischemic
areas
Hypofluorescence over Persisting hypofluores- Persisting hypofluores- No benefit from focal laser
affected areas cence due to absent cence or leakage from
retinal vessels bordering neos or
IRMA

Proliferative reti- On the optic Visible epiretinal neovascu- Early filling of neovascu- Leakage over neovas- Persisting diffuse epi- Clinical picture
nopathy nerve head or larizations larizations parallel filling cularizations retinal leakage over Minute neovascularizations
along the major sheets of fibrous tissue of retinal vasculature neovascularizations can sometimes be document-
vessel arcades traction on retina ed by FA only
Epiretinal

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Table 11.1. (Cont.)
Disease Localization Clinical picture Early arteriovenous Arteriovenous phase Late phase Essentials
phase

Tumors
Choroidal melanoma Anywhere on Pigmented or non pigmented
the fundus choroidal tumor
Choroid Occasionally breakthrough
through Bruchs membrane or
retinal infiltration
subretinal hemorrhages
drusen on surface
Hypofluorescence Increasing hyperfluo- Persisting hyperfluo- „Second circulation” within
though pigment and rescence within tumor rescence within tumor tumor supports diagnosis but
tumor volume pinpoint leakages is not always present
Early filling of tumor increasing leakage
vessels characteristic from tumor vessels
but not always present

Choroidal Posterior pole Reddish or grayish tumor with Very early filling of Increasing hyperfluo- Persisting leakage Very early frames (before
hemangioma Choroid surrounding fluid tumor vessels parallel rescence within tumor within tumor and retinal filling) essential
to choroidal filling surrounding tissues
before retinal vessels

Miscellaneous
Central serous Posterior pole Yellowish lesion in the macula Hypofluorescence Pinpoint leakage, slow- Persisting leakage In questionable cases look for
retinopathy RPE caused by subretinal ly expanding to more within the space of possible sources of leakage
fluid widespread leakage detached retina outside the major vessel
arcades

Chronic central Posterior pole Pigmentary changes in the Early window defects Either window defects Persisting window Important differential diagno-
serous retinopathy RPE macula in areas of depigmenta- or leakages in cases of defects or leakage in sis to occult CNV, appears less
tion of RPE active lesions active lesions prominent than CNV
Clinical course and stereos
important for diagnosis
Retinal Posterior pole Red dot-like lesions around Early filling of telean- Increasing moderate Persisting leakage Stereos and clinical pictures
teleangiectasis Retina fovea giectasis parallel to leakage from telean- essential for identifying lesion
pigmentary changes retinal vessels giectasis within the retina
exudates OCT offen shows thinning or
outer retinal layers

Cystoid macular Fovea and Cystoid spaces or bleb- or Hypofluorescence due to Slowly accumulating Increasing leakage fill- Clinical picture important
edema central macula hole like lesions in the fovea fluid within cystoid hyperfluorescence ing the cystoid spaces Consider OCT as initial exam-
Retina spaces within cystoid spaces ination technique or in ques-
tionable cases

Macular hole Central macula Yellowish lesion or round
retinal defect around the
fovea with raised edges
Hypofluorescence in the Occasionally some Occasionally persisting Clinical picture and OCT
area of the hole hyperfluorescence hyperfluorescence more important for diagnosis
within yellowish within or around the
deposits in the area of hole or cystoid edema
the hole or in cystoid at the edges
spaces around the hole

Macular pucker Macula Distortion of macular Distortion of retinal ves- Mild hyperfluorescence Increasing hyperfluo- Diagnosis can usually be made

11 A Practical Guide to Fluorescein Angiography

Retina vessels sels is better visualized secondary to leakage rescence from leaking without angiography
Epiretinal membrane from retinal vessels vessels OCT more important

Retinal vasculitis Segmental or all Vascular sheathing, hemor- Attenuated filling of Increasing hyperfluo- Increasing hyperfluo- Extensive differential diagno-
quadrants rhages, vitritis affected arteries/veins rescence over affected rescence through sis
Retina and Weak early hyperfluores- vessels leakage Angiography sometimes aug-
choroid cence through leakage filling defects ments identification of affect-
from affected vessels ed vessels

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Table 11.1. (Cont.)
Disease Localization Clinical picture Early arteriovenous Arteriovenous phase Late phase Essentials
phase

Choroidal vasculitis Segmental or all Pigmentary changes or „white Hypofluorescent spots Transition from hypo- Hyperfluorescence in Extensive differential diagnosis
quadrants dots” in affected choroidal fluorescence to hyper- affected areas ICG angiography usually more
Choroid and vitritis areas fluorescence in affected helpful in identifying affected
retina areas areas

Retinal vascular occlusions

Central retinal vein All retinal Dot and flame-shaped intra- Hypofluorescence Delayed filling of reti- Diffuse increased Classification of ischemic ver-
occlusion (CRVO) quadrants and preretinal hemorrhages, through edematous nal veins, leakage over hyperfluorescence sus non-ischemic central reti-
macular ede- dilated veins, (cystoid) macu- retina and hemor- veins, hypofluores- through leakage from nal vein occlusion according
ma lar edema, cotton wool spots rhages cence in areas of capil- dysfunctioning veins to fluorescein angiography is
lary dropout cystoid or diffuse controversial
leakage in the macula

Branch vein One/two retinal Dot and flame-shaped intra- Hypofluorescence Delayed filling of reti- Diffuse increased Indication for laser coagula-
occlusion quadrants and preretinal hemorrhages, through edematous nal veins, leakage over hyperfluorescence tion based on fluorescein
macular ede- dilated veins, (cystoid) macu- retina and hemor- veins, hypofluores- through leakage from angiography according to
ma lar edema, cotton wool spots rhages in the affected cence in areas of capil- dysfunctioning veins Branch Vein Occlusion Study
quadrant(s) lary dropout in the cystoid or diffuse
affected quadrant(s) leakage in the macula

Central retinal Retina Retinal edema Delayed and segment- Delayed and segment- Diffuse leakage Fluorescein angiography usu-
artery/arterial All quadrants or Cherry red spot in the macula ed or no filling of ed filling of arteries through dysfunctio- ally unnecessary for diagnosis
branch occlusion one to two visible plaques in the arteri- affected retinal arteries and veins in the affect- ning retinal vessels in
quadrants al stem and/or branches Choroidal filling visible ed quadrants the affected quadrants
unless occlusion of
ophthalmic artery is
present