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

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 Blood Retina Barrier

Blood Retina Barrier

Outer Barrier Inner Barrier

Endothelium Retinal Pigment Epithelium

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Fluorescein Angiography

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Dark Choroid – STARGARDT’S DISEASE

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Smoke Stack CSR / Ink Blot

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 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

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 Indocyanine Green Angiography
Indications

• Occult CNVMs

• Polypoidal choroidal vasculopathy → Most Important

• Pigment Epithelial Detachments

• Serpiginous Choroidopathy

• Birdshot Retinochoroidopathy

• Multiple evanescent white dot Syndromes [MEWDS]

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Polypoidal Choroidal Vasculopathy

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Optical Cohorence Tomography

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 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

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Optical Cohorence Tomography

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 Optical Cohorence Tomography
Indications

• Macular Edema

• Macular Pucker

• Central Serous Retinopathy → Most Important

• Vitreo Macular Traction

• Macular Holes

• Glaucoma

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Central Serous Retinopathy

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Cystoid Macular Edema

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 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

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OCT Angiography

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 OCT Angiography
Indications

• Diabetic Retinopathy

• Dry ARMD

• Wet ARMD

• CSR

• Vascular occlusions

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 OCTA In CRVO

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Anterior Segment OCT

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 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

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 ASOCT –Applications
• Angle anatomy, particularly angle occludability and closure

• Plateau iris

• Ciliary body tumors and cysts

• Corneal thickness measurement

• Keratoconus

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 AS OCT

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 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

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Ultrasound Biomicroscopy (UBM)

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Ultrasound Biomicroscopy (UBM)

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Ultrasound Biomicroscopy (UBM)

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 UBM –Clinical Applications
• All structures upto lens

• AC anatomy and pathology

• Angle closure glaucoma

• Corneal pathology, Keratoconus, dystrophies, scars

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 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

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 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

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 Confocal Microscopy
• Endothelial disorders

 Fuchs’ Endothelial Dystrophy

 Neurotrophic Keratopathy

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Confocal Microscopy

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