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Fluorescein Angiography – FFA Test

More about Retina

What is the FFA eye test, and what is FFA full form?

The full form of the FFA eye test is Fundus Fluorescein angiography. It is one of the fundamental imaging techniques of the eye, mainly the retina, and helps diagnose and differentiate retinal diseases. The FFA eye test determines the need for laser treatment of the retina. Angiography of the heart looks in detail at the heart's blood vessels. Similarly, an FFA eye test is an angiography for the retinal blood vessels using the Fluorescein dye. It gives us minute details about the blood supply of the retina.

How is this angiography for the eyes performed?

This angiogram for the eyes takes about 20 to 30 minutes. 

  1. The pupils are dilated.
  2. An anaesthetist makes sure the patient is comfortable.
  3. An anaesthetist inserts a vein flow (IV Line)in one vein of the patient's forearm and secures it.
  4. Your ophthalmologist prepares the fundus camera and enters all patient details into the system.
  5. A black and white fundus photograph or photo of the retina and optic nerve is taken. 
  6. A colour photograph of the retina and optic nerve is also taken
  7. The anaesthetist then gives a 6-second bolus injection of 2-5 cc of sodium fluorescein into a vein in the arm through the vein flow. We gave the dye orally in the earlier days, known as oral fluorescein angiography. These days only use the intravenous injection route.
  8. We take a series of black-and-white or digital photographs of the retina before and after the fluorescein reaches the retinal circulation (approximately 10 seconds after injection).
  9. These early images are important because they allow for recognising autofluorescence of the retinal tissues. Photos are taken approximately once every second for about 20 seconds, then less often.
  10. A delayed image is obtained at 5 and 10 minutes. Some doctors like to see a 15-minute image as well.

How does the FFA camera work

The FFA equipment is a camera that can take pictures of the retina.

A filter is placed in the camera, so only the fluorescent, yellow-green light (530 nm) is recorded.

The camera may, however, pick up signals from pseudofluorescence or autofluorescence. In pseudofluorescence, non-fluorescent light is imaged. This occurs when blue light reflected from the retina passes through the filter. This is generally a problem with older filters, and annual replacement of these filters is thus done. In autofluorescence, fluorescence from the eye occurs without the injection of the dye. This may be seen with optic nerve head drusen, astrocytic hamartoma, or calcific scarring.

Black-and-white photos give better contrast than colour photos, which aren't necessary because the filter transmits only one colour of light.

The dye flows through the retinal vessels, and this is what the fundus photographs pick up if there is any fluorescein leakage from these blood vessels that will be seen in the pictures.

What are the phases of an FFA test for an eye?

These timings are approximate

  1. 0 seconds – injection of fluorescein
  2. 9.5 sec – posterior ciliary arteries
  3. 10 sec – choroidal flush or choroidal fluorescence (or "pre-arterial phase") - this is when the dye is entering the choroidal circulation. The choroid is a highly vascular tissue, and as the choroidal vessels fill up with the dye, there is generalised fluorescence seen in the fundus photograph. The entire picture appears to light up. This, however, is not a detailed view of the choroid, and this lack of detail is because of a layer in front of the choroid called the retinal pigment epithelium.  
  4. 10–12 sec – retinal arterial stage
  5. 13 sec – capillary transition stage or arteriovenous phase
  6. 14–15 sec – early venous stage (or "laminar stage", "arterial-venous stage")
  7. 16–17 sec – venous phase
  8. 18–20 sec – late venous stage
  9. After 4-5 minutes after injection begins the recirculation phase and the late phase
  10. Five minutes – late staining or late phase. 

The retinal vessels empty the fluorescein by 10 minutes after the injection. The optic nerve head appears fluorescent in the late phases due to staining.

Which parts of the eye do the FFA eye test check?

The FFA is an angiography and can take pictures of all areas of the eye, which can be photographed and have blood vessels.

  1. Retina
  2. Optic Nerve
  3. Choroid
  4. Iris

The choroid and Iris are supplied by ciliary arteries, which are branches of the ophthalmic artery.

Apart from these parts of the eye, what else does an FFA test for the eye tell us?

We mentioned earlier that the dye takes approximately 10-12 seconds to reach the eye. However, if the time is increased, that indicates impaired blood flow to the eye. In other words, even though the patient has vision problems, the primary problem may be something else. A Doppler sonography is advised to rule out the common carotid and internal carotid artery blockage.

In which conditions is this angiography for eyes / FFA test done?

Here is a list of a few conditions where this angiography for eyes is advised.  

  1. Diabetic Retinopathy - Diabetic macular oedema will show pooling of the dye
  2. Choroidal neovascular membrane ( CNVM)
  3. Central retinal vein occlusion
  4. Central retinal artery occlusion -  This can occur because of a vascular event or also a
  5. Neuroophthalmic conditions like Giant cell arteritis
  6. Polypoidal choroidal vasculopathy
     

Following are some eye conditions where FFA is not done these days routinely.

  1. ARMD - Age-related macular degeneration - OCT or Optical Coherence Tomography has become the primary investigation for this condition
  2. Retinal detachment 

Terms used to describe the behaviour of dye in the photographs

  1. Blocked fluorescence
    This is when the fluorescence is blocked. Depending on which circulation is not visible, one can ascertain which part of the eye is affected.
    • If the problem is preretinal or in front of the retina, then the retinal and choroidal vasculature will be blocked like in vitreous haemorrhage, cataract, preretinal haemorrhage.
    • If the problem is in the retina, then the capillary circulation in the retina is not seen. Still, the larger vessels in the retina are seen like in dot and blot haemorrhages of the retina or intraretinal lipid that occurs in diabetic retinopathy.
    • If the problem is prechoroidal or in front of the choroid, then the choroidal circulation is not seen while retinal circulation is seen. Like in retinal pigment epithelium hypertrophy, subretinal haemorrhage 
  2. Hypo - fluorescence - This means that the blood flow to the retina is compromised and happens in diabetic retinopathy, retinal vein occlusions, inflammation of the retinal blood vessels ( Vasculitis).
  3. Hyper - Fluorescence - Capillary hyper fluorescence is mainly divided into
    1. Autofluorescence
    2. Transmission defect (window defect)
    3. Leaking
    4. Pooling
    5. Staining
  4. Filling defect
  5. Pooling of dye - by looking at the retinal vessels, one may even say Sub-retinal pooling. The dye gets collected in the potential spaces of the retina, viz. subretinal space ( like in CSR) or sub RPE space ( Like in PED). This dye collection may also happen in specific malformations of the retina or choroid blood vessels, like capillary hemangiomas.
  6. Transmission defect (window defect): A window defect refers to the choroidal fluorescence produced by a relative decrease or absence of pigment in the RPE or Retinal pigment epithelium.
  7. Laminar flow occurs in the early venous phase, followed by more homogenous vein filling in the later venous stage. Laminar means initially, the dye only flows along the vessel walls, and the vessel's centre does not contain dye. 
  8. Optic disc leakage is also described as excess fluorescence and seen in conditions like Anterior Ischaemic Optic Neuropathy or AION and Leber's hereditary neuropathy. Giant cell arteritis usually causes arteritic AION and should be treated urgently and seen in Leber's hereditary.

What are the possible adverse effects of the FFA eye test?

  1. A person may feel a wave of nausea (feel sick) for 30 to 60 seconds after the injection, especially if you have had a heavy meal before the test. For this reason, it is a good idea not to have a heavy meal before your appointment.
  2. Sneezing
  3. A strange taste at the back of your mouth after the injection
  4. The injection site can be painful if the dye leaks from the vein into the surrounding tissue.
  5. A mild headache.
  6. An allergic reaction. Please let the doctor know if you have allergies or have had a severe allergic reaction before performing the FFA eye test.
  7. Your urine would be yellow as the body throws out the dye for that day.

When can fundus fluorescein angiography not be done

Usually, we cannot perform the FFA test for an eye because of dye related issues

  1. If the patient has chronic kidney disease, then the dye can cause renal toxicity
  2. If the patient is allergic to the dye.
  3. We avoid angiography during pregnancy.

Frequently Asked Questions ?

What precautions are taken before injecting the dye ?
For all fundus angiographies done we have an anesthetist who is standing by to take care of any untoward incident. Most of the times nothing really happens but we still do have an anesthetist as a standby.

You don't have to do anything in particular apart from coming on an empty stomach.
What is the cost FFA eye test in Mumbai ?
An FFA test costs you Rs 4500 and for pictures of both eyes. Anesthetist charges are extra and are usually Rs 2000. Even though some eye hospitals may choose not to have an anesthetist for this FFA test, we always choose to have one as a rule.
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