Fluorescein Angiography

[DrZeke]

Hey there,

My program is one that doesn't provide us with any lectures for FA. Does anyone have any recommendations of a good online resource for learning FA patterns and reading FAs?

Thanks

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[Slide]

Send me a PM I have a great powerpoint from AAO last year.

 

[Visionary]

Soap box commentary here. I'm amazed at how many retina docs have abandoned FA as a diagnostic tool. Yes, we have quick, easy OCTs, but they don't tell you about the physiology. They only show you the anatomy.

 

[Dusn]

That's really sad that a residency program does not think it's important to provide lectures on FA. I don't know of an online source either unfortunately. The occult vs classic stuff that I remember in the BSCS is not nearly as important anymore. Getting good at identifying staining vs leakage vs pooling vs window defect and whether its choroidal vs retinal circulation is extremely important. Also each imaging modality should not be looked at in isolation. You should be comparing the corresponding anatomy on whatever imaging you have: FA, ICG, autofluorescence and OCT images to each other to get a complete picture and to understand why that lesion is causing that particular pattern.

 

[Dusn]

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[ophthope]

Soap box commentary here. I'm amazed at how many retina docs have abandoned FA as a diagnostic tool. Yes, we have quick, easy OCTs, but they don't tell you about the physiology. They only show you the anatomy.

In their defense nobody ever died of anaphylactic shock from an OCT. But FA.... 😱

In my very limited experience so far in residency, we mostly get FAs because we think we have a grand rounds case or because someone sent the patient as a consult for possible FA. I haven't seen a lot of dilemmas solved by FA.

I'm curious to hear from you Visionary as an expert on the topic - are there any specific clinical situations where you feel like an FA result makes a difference in how a patient needs to be treated?

 

[dantt]

In their defense nobody ever died of anaphylactic shock from an OCT. But FA.... 😱

In my very limited experience so far in residency, we mostly get FAs because we think we have a grand rounds case or because someone sent the patient as a consult for possible FA. I haven't seen a lot of dilemmas solved by FA.

I'm curious to hear from you Visionary as an expert on the topic - are there any specific clinical situations where you feel like an FA result makes a difference in how a patient needs to be treated?

I find FA valuable for doing a good focal laser.

 

[DrZeke]

That's really sad that a residency program does not think it's important to provide lectures on FA. I don't know of an online source either unfortunately. The occult vs classic stuff that I remember in the BSCS is not nearly as important anymore. Getting good at identifying staining vs leakage vs pooling vs window defect and whether its choroidal vs retinal circulation is extremely important. Also each imaging modality should not be looked at in isolation. You should be comparing the corresponding anatomy on whatever imaging you have: FA, ICG, autofluorescence and OCT images to each other to get a complete picture and to understand why that lesion is causing that particular pattern.

Hmmm... Well I think my residency thinks it's important to learn these things. They just aren't really into didactic. In general we average 2.5 hours per week of lecture. Not as many didactics as some places. Due to exposure to tons of pathology and patients we end up learning it on the go.

 

[Visionary]

In their defense nobody ever died of anaphylactic shock from an OCT. But FA.... 😱

In my very limited experience so far in residency, we mostly get FAs because we think we have a grand rounds case or because someone sent the patient as a consult for possible FA. I haven't seen a lot of dilemmas solved by FA.

I'm curious to hear from you Visionary as an expert on the topic - are there any specific clinical situations where you feel like an FA result makes a difference in how a patient needs to be treated?

That is so exceedingly rare. You have a better chance of being struck by lightning. I only know of one death associated with an FA from all the retina docs I know, and it was most likely coincidental, rather than anaphylactic.

Regardless, FA (and ICGA) demonstrate physiology. OCT just shows anatomy. IMO, angiography is important for numerous things: assessing perfusion status in vascular disorders (RVO, RAO, DR), discriminating types of AMD and AMD from CSR, and identifying targets for focal laser or PDT (yes, both are still viable and useful treatments in the right circumstances), to name a few. These findings guide disease management decisions. They're important. I've seen docs doing focal laser based on OCT. OCT! Are you kidding me?! Same thing with PDT. Unbelievable.

Soon, we'll have noninvasive angiography using phase variance OCT, so the dye issue will be out the window, anyway.

 

[RestoreSight]

Agree with above. You can't guide treatment without knowing the pathophys of the condition. You can get spectacular images with combo ICG/FA. Is it AMD or polypoidal? Is the CSCR chronic or acute with multiple areas of pooling or just one central lesion? Ischemic vs nonischemic RVO? OCT won't tell you. The patient wants to know his risk of developing NVI after a BRVO or CRVO? Only FA can predict this. Is it MEWDS, MCP, AZOOR or APMPEE? The DME patient is resistant to anti-VEGF agents, phakic, and needs focal. OCT is no help here. Its hard to see FA/ICG disappearing forever and the risk of death or serious anaphylaxis from injection is case-reportable.

 

[ophthope]

Thanks for all these great comments! Any focal laser is scary to me, but without an FA is even more so. At my program we have Fluorescein lectures and in my limited experience so far I've seen a lot of cases where the FA/ICG looks a lot different than you might predict it would based on fundus photos and OCT. Would make me nervous not to see an FA before I planned where to shoot laser.

 

[MstaKing10]

FA is a great tools in the above circumstances. I get it on the first visit for all my wet AMD and diabetic retinopathy patients with disease. It is also great to help distinguish between CSR, polypoidal and AMD and very useful in uveitic patients. Wide field is fantastic for vascular occlusion patients. ICG and FA are very useful to guide PDT and other laser procedures.

On the other hand, I do not believe patients need these done frequently. In fact, I rarely repeat it unless there is a change in the exam/vision or perhaps the patient is not responding as expected or if I am anticipating doing laser. I will perform OCT and autofluorescence much more often than repeat angiograms/ICG.

I think the move towards using OCT more often (or as replacement for) FA is based on a few things: cost, time and resources to perform photography vs OCT, ease of interpretation, invasiveness of the test etc. Many years ago FA was the "gold standard" for diagnosis and management of retinal disease, but now with OCT this is less clear. Most recent pivotal trails (ie. CATT etc) use vision and macular thickness (as measured on OCT) as endpoints, making FA seem less important, though most require FA at baseline.
Interesting discussion.

 

[MstaKing10]

Visionary: how does one perform PDT based on OCT???? That is way outside the standard of care. Shocked!

 

[Visionary]

The same way that they perform focal: poorly. I'm with you on angiogram frequency. There are some docs on the other extreme who get angiograms on nearly every visit. That's as ridiculous as never getting them. They are very helpful, when used properly.

 

[pianist]

Difficult to find and out of print, but if you're serious about learning FA/ICG, the book by Gisele Soubrane is excellent.