Retinal imaging

Demeke Tsegaye

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 Outline
• OCT
• Fundus Flurescien Angiography (FFA)
• ICG angiography

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 OCT

• a noninvasive, noncontact
• micrometer-resolution images of
tissue
• Low-coherence light is directed
into tissue and
in to a reference arm.
• An interferometer

interferogram

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 Cont’d…
• Based on the principle of low-coherence interferometry
– A low-coherence (high-bandwidth) light beam is directed on to
the target tissue
– The scattered back-reflected light is combined with a second
beam (reference beam).
– an axial A-scan, which represents the scattering properties of the
tissue along the beam path.
• Moving the beam of light along the tissue in a line results in a
compilation of A-scans with each A-scan having a different incidence
point.
– B scans
• If these B-scans are repeated at multiple adjacent positions using a
raster scan pattern, then a 3D volume of structural and flow
information can be compiled.
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 Cont’d…

 TD OCT  SD OCT
• A single detector • Array of detectors instead of
• Changes the mirror position to multiple beams from a
change the path of the reference mirror
reference beam. • Scanning speed is 200 x
• Limited scanning speed faster
• Lower image quality • Broad and superluminescent
• Lower axial resolution diode light
• Higher image quality
• Higher axial resolution

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 Cont’d…
SS OCT
• Tunable laser light with a center wavelength of
1050 nanometers.
• Single detector
• Faster scanning speed
• Enhanced depth

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 Cont’d…
Quantitative analysis
• Retinal thickness
• Measurement of specific retinal layer thickness
– Ganglion cell layer
– Photoreceptor outer segments
– Area of geographic atrophy
– Deformations caused by drusen

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 Normal macular anatomy
• The OCT image closely approximates the histologic appearance
of the macula.
– In vivo optical biopsy
• OCT relies on intrinsic differences in tissue optical properties to
produce image contrast.
• When light travels through the retinal tissue it can be reflected,
scattered, or absorbed, and this creates the multilayered pattern
of the retina.
• The angle of incidence of the light, motion artifacts, speckled
noise, and image contrast can affect the axial resolution of the
retinal imaging.
• The OCT features of the outer retina are less well understood

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Commonly Encountered Pathologies

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 Fundus Fluorescein Angiography
 Luminescence
• The emission of light from any source other than high
temperature.
• Occurs when energy in the form of electromagnetic radiation is
absorbed and then re-emitted at another frequency.
– free electrons are elevated into higher energy states.
– reemission by spontaneous decay of the electrons into their
lower energy states.
• When this decay occurs in the visible spectrum, it is called
luminescence.
• A shift from a shorter wavelength to a longer wavelength.

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 Cont’d…
 Fluorescence
• Luminescence that is maintained only by continuous excitation.
• Excitation at one wavelength occurs and is emitted immediately
through a longer wavelength.
• Sodium fluorescein is a hydrocarbon that responds to light energy
between 465 and 490 nm and fluoresces at a wavelength of 520–
530 nm.
• If blue light between 465 and 490 nm is directed to unbound
sodium fluorescein, it emits a light that appears green–yellow
(520–530 nm).

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 Cont’d…
• Blue flash
– excites unbound fluorescein
• Blue filter
– Filters all other wave lengths
• The blue reflected light and the green–yellow fluorescent light
are directed back to the fundus camera.
• A filter is placed that allows the green–yellow fluorescent light
through but keeps out the blue reflected light.

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 Cont’d…
 Pseudofluorescence
• Occurs when nonfluorescent light passes through the entire
filter system.
• If green–yellow light penetrates the original blue filter, it will
pass through the entire system.
• If blue light reflected from nonfluorescent fundus structures
penetrates the green–yellow filter, pseudofluorescence occurs.

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 Cont’d…
 Fluorescein
• An orange-red crystalline hydrocarbon (C20H12O5Na)
• Has a low molecular weight (376.27 Da).
• 80% protein-bound in circulation.
• Leakage can show in areas:
 with new vessel growth
 which lack a blood–ocular barrier, or
 with blood–ocular barrier defects induced by inflammation or
ischemia.
• Readily leaks from the choriocapillaris.

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 Cont’d…
 Fluorescein…
• Typically, 2–3 mL of a 25% sterile solution or 5 mL of a 10%
sterile solution is injected in the antecubital vein.
• Can also be administered PO.
• Eliminated by the liver and kidneys within 24 hours
– traces may be found in the body for up to a week after
injection.
• The skin has a yellowish tinge for a few hours after injection,
and the urine has a characteristic yellow–orange color for most
of the first day after injection.

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 Adverse effects….
• Extravasation
 Sloughing of the skin
 Superficial phlebitis
 Subcutaneous granuloma
 Toxic neuritis
• Nausea
• Vomiting
• Vasovagal attacks
• Hives and itching
• Bronchospasm and anaphylaxis
• Death

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 Normal FFA
• The first true fluorescence
begins to show in the choroid:
– ̴ 10–12 seconds after
injection in young patients
– 12–15 seconds after injection
in older patients.
• The choroid occasionally begins
to fluoresce 1 or 2 seconds
before the initial filling of the
CRA.
– faint, patchy, and irregularly
scattered.

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 Cont’d…
• ̴ 20–25 seconds after injection, the
angiogram becomes very bright for
about 5 seconds because of the
extreme choroidal fluorescence.
• A cilioretinal artery usually begins
to fluoresce as the choroid
fluoresces.

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 Cont’d…

• The perifoveal capillary net can

be seen about 20–25 seconds after
a rapid fluorescein injection.
– the “peak” phase of the FA.
• Generally, 3–5 minutes after
injection
– the choroidal and retinal
vasculatures slowly begin to
empty of fluorescein and
become gray.

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Cont’d…
• Choroidal phase
• Arterial phase
• Arteriovenous phase
• Venous phase
• Late recirculation phase

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 Abnormal FFA
1. Autofluorescence
2. Hypofluorescence
– optical obstruction (masking or blockage) of normal
fluorescein density or
– inadequate perfusion of tissue (filling defect).
3. Hyperfluorescence
– Increased visualization or
– Increased fluorescein content

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 Hypofluorescence
 Vascular filling defects
• Retinal or choroidal vessels fail to
fill
• Nonperfusion of an artery, vein,
or capillary.
• Either a delay in or complete
absence of filling of the involved
vessels.
• Loss of the vascular bed as in
myopic degeneration and
choroideremia

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 Cont’d…
 Blocked fluorescence
• Fluorescein is present but cannot
be seen in blocked fluorescence.
• Ophthalmoscopically visible
material that corresponds in size,
shape, and location to the
hypofluorescence on the
angiogram.

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 Hyperfluorescemce
• Occurs when the fluorescence is abnormally excessive,
typically extending beyond the borders of recognized
structures
• Manifests in a few major patterns:
 leakage
 staining
 pooling
 transmission, or window, defect
 autofluorescence

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 Cont’d…
 Leakage
• Hyperfluorescence increases in
area and intensity.
• Seepage across the blood–retina
barrier.
 NPDR
 Papilledema
 RVO
 CME
 PDR
 CNV
 Tumors
• Later phase
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 Cont’d…
 Staining
• Hyperfluorescence in increases in
intensity through transit views, and
persists in late views.
• The borders remain intact throughout
the study.
• Fluorescein entry into a solid tissue or
material that retains the fluorescein,
such as
 a scar or fibrous tissue
 drusen
 optic nerve tissue, or
 sclera.
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 Cont’d…
 Pooling
• The accumulation of
fluorescein in a fluid-filled
space in the retina or choroid.
• The margins of the space trap
the fluorescein and appear
distinct.
 CSR
 PED

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 Cont’d…
 Window defect
• A view of the normal choroidal
fluorescence through a defect in the
pigment of the RPE.
• Hyperfluorescence occurs early, and
reaches its greatest intensity with the
peak of choroidal filling.
 atrophic age-related macular
degeneration
 full-thickness macular hole
 RPE tears and
 some drusen.
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 Fundus autofluorescence
• A rapid, noncontact, noninvasive way to visualize fluorophores
in the fundus.
• Excitation light is introduced to the eye; fluorescence from
intrinsic fluorophores is detected by using a barrier filter to
exclude that excitation light from the image.
• Focuses on the fluorescent properties of pigments in the retina to
generate images that help us view various disease processes from
a different perspective.
• It generates an image based on the distribution pattern of a
fluorescent pigment called lipofuscin.

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 Principles…Cont’d
• RPE is responsible for phagocytosis and lysosomal degradation
of photoreceptor outer segments.
• Over the course of a lifetime, each RPE cell will phagocytose 3
billion outer segments.
• With aging, incomplete or partial breakdown of these segments
in the post-mitotic RPE cells causes the accumulation of
lipofuscin (LP).
• Lipofuscin is composed of several different molecules, most
important of which is A2E (N-retinyl-N-retinylidene
ethanolamine)

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 Cont’d…
• A quarter of the RPE cytoplasm is composed of lipofuscin and
melano-lipofuscin in persons over the age of seventy.
• Another component of lipofuscin, a toxic aldehyde known as all-
trans retinal, is produced in the outer segments of the
photoreceptor when exposed to light.
• Photoreceptors lack cis–trans isomerase function for retinal and
are unable to regenerate all-trans-retinal into 11-cis-retinal after
transduction of light energy into electrical impulses.
• The excess all-trans-retinal accumulates within the
photoreceptor, forming bisretinoids which upon oxidation
contribute to lipofuscin production.

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 Findings…Cont’d
• The optic nerve head typically appears
dark due to the absence of lipofuscin
in this area.
• Retinal vessels are characterized by a
reduced FAF signal due to the
absorption by blood.
• FAF signal is also reduced in the
macular area, particularly around the
fovea due to the absorption of the
luteal pigment.

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 Interpretations… Cont’d
• The topographic mapping of lipofuscin distribution in the
RPE.
• The intensity portrayed by FAF corresponds to the
accumulation of lipofuscin, which increases with:
– Aging
– RPE cell dysfunction or
– An abnormal metabolic load on the RPE.

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 Cont’d…
 Reasons for a reduced FAF
signal may include but are
not limited to:
 RPE loss or atrophy
 Intraretinal fluid
 Reduction in RPE lipofuscin
density
 Fibrosis or presence of luteal
pigment.

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 Cont’d…
 Causes for increased FAF
signal may include but are
also not limited to:
 drusen in the sub-pigmented
epithelial space
 excessive RPE lipofuscin
accumulation
 AMD or
 the occurrence of
fluorophores anterior or
posterior to the RPE cell
monolayer.

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 Clinical applications
 AMD
• Increased FAF is seen due to
excessive accumulation of
lipofuscin within the
lysosomal compartment of
RPE
• Decreased FAF is
characteristic in patients
with geographic atrophy
(GA) due to absence of
lipofuscin granules in the
RPE.

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 Cont’d…

 Retinal artery occlusion

• FAF has proven to be a useful tool in pointing out areas of
retinal artery occlusion.
• Occlusions inhibit proper autofluorescence of the retinal
pigment epithelium due to increased thickness resulting in a
decrease in FAF.
• Such property allows the identification of areas of the retina
that are ischemic and of lower AF intensity.

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 Indocyanine Green Angiography
• ICG is a water-soluble, tricarbocyanine dye that is almost
completely protein-bound (98%) after intravenous injection.
• Diffusion through the small fenestrations of the choriocapillaris is
limited.
• Ideal for imaging choroidal vessels.
• ICG is metabolized in the liver and excreted into the bile.
• Both the excitation (790–805 nm) and emission peak (825–835
nm) are in the near-infrared range.
• Low fluorescence efficacy.

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 Cont’d…
Advantages over FA
• The near-infrared light utilized in indocyanine green
angiography (ICGA) penetrates ocular pigments such as melanin
and xanthophyll, as well as exudate and thin layers of subretinal
blood.
• About 98% of ICG molecules bind to serum protein (mainly
albumin); considerably higher than the binding of fluorescein.
• Infrared light is also scattered less than visible light, making
ICGA superior to FA in eyes with media opacity.

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 Cont’d…
 Technique
• Similar to that of FA, but with an increased emphasis on the
acquisition of later images (up to about 45 minutes) than with FA.
• A dose of 25–50 mg in 1–2 ml water for injection is used.
 Phases of ICGA
 early phase
– when the retinal artery is not yet filled
– Up to 1 min.
 a mid phase
– where both arteries and veins are filled, and
– Early or late
 a late or recirculation phase
– after more than 15 minutes after injection .
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 Cont’d…
• The first choroidal vessels to be
filled are the ones of the deeper
Haller’s layer, followed by
Sattler’s layer.
• The choriocapillaris is the last
layer to be filled.
• Choroidal vortex veins are visible
in the late phase of ICGA.

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 ICGA interpretation
 Hyperfluorescence
• A window defect similar to those
seen with FA.
• Leakage from retinal or choroidal
vessels, the optic nerve head or the
RPE
• Abnormal retinal or choroidal
vessels with an anomalous
morphology and/or exhibiting
greater fluorescence than normal.

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 Cont’d…
 Hypofluorescence
 Blockage (masking) of fluorescence.
• Pigment and blood
• Fibrosis
• Infiltrate
• exudate and
• serous fluid
 Pigment epithelial detachment appears hypofluorescent.
 Filling defects
• Choriocapillaris non-perfusion manifests as dark geographic
areas of hypofluorescence
• Choroidal stromal foci manifest as regular round evenly
distributed dark dots in the early phase . 61
 Cont’d…
 PCV
• A common form of CNV.
• Posterior uveal bleeding syndrome
• Multiple, recurrent serosanguineous
RPE detachments.
• A network of polyps is associated
with feeder vessels that adhere to the
RPE monolayer of the fibrovascular
ped in a “string-of-pearls”
configuration.

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 Cont’d…
 RAP
• a variant of neo-vascular
AMD (Type 3)
• ICGA is diagnostic in most
cases, showing
 a hot spot in mid and/or
late frames
 a perfusing retinal
arteriole and draining
venule (‘hairpin loop’
when linked).

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 Cont’d…
 Central serous chorioretinopathy (CSC)
• an idiopathic serous detachment of the
retina
• related to leakage at the level of the retinal
pigment epithelium (RPE), secondary to
hyperpermeability of the choriocapillaris
• OCT
– Pachychoroid
• ICGA
– Midphase…multiple hyperfluorescent
clouds
– Late…leakage in the stroma

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Cont’d…

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 References
• BCSC 2019/20: retina and vitreous
• Ryan’s retina; 6th edition
• Kanski’s clinical ophthalmology; 9th edition
• Online sources

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 NK
H A
T U !
YO

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