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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 11  |  Issue : 3  |  Page : 243-247

The role of fundus fluorescein angiography in classification and diagnosis of macular diseases: A hospital-based study


Department of Ophthalmology, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India

Date of Web Publication25-Sep-2018

Correspondence Address:
Dr. Sangameshwarayya Salimath
Department of Ophthalmology, Jawaharlal N Medical College, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_188_17

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  Abstract 


AIMS AND OBJECTIVES: The aims and objectives of this study is to assess the role of fundus fluorescein angiography (FFA) in classification and diagnosis of macular diseases.
SETTING AND DESIGN: This was an 1-year hospital-based study conducted at KLES, Dr. Prabhakar Kore Hospital, Belagavi, Karnataka.
METHODOLOGY: The present study was conducted in the Department of Ophthalmology, KLES, Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, on 66 participants from January 1st, 2016 to December 31st, 2016.
METHODS: An 1-year hospital-based study was conducted on 66 patients who attended the outpatient department. A detailed history was obtained from all the patients and a thorough ocular and systemic examination were done. All the patients were examined by conventional methods of ophthalmoscopy (direct, indirect, and slit lamp examination with +90 D lens) followed by FFA. The clinical ophthalmoscopy and fluorescein angiography findings were analyzed and categorized.
RESULTS: Sixty-six participants were analyzed and sub-divided into categories of age-related macular degeneration (ARMD), diabetic maculopathy, vascular occlusive disorders, Central Serous Chorioretinopathy (CSCR), inflammatory causes, macular dystrophy, and macular hole. FFA confirmed the diagnosis in 62% of the cases and altered the diagnosis in 38% of cases. It also classified the lesions in 64% of cases.
CONCLUSION: FFA has played a major role in diagnosing wet ARMD. It was of immense value in diagnosis and classification of diabetic maculopathy cases. It is a superior diagnostic modality in differentiating macular edema from macular ischemia in vascular disorders. It provides definitive diagnosis in CSCR by detecting the exact site of leakage. It is of immense value in the diagnosis of macular edema in inflammatory diseases. FFA played an important role in the diagnosis of macular dystrophy and macular hole cases.

Keywords: Age-related macular degeneration, central serous chorioretinopathy, fundus fluorescein angiography, macular diseases, macular dystrophy and macular hole


How to cite this article:
Salimath S, Patil SB, Tenagi AL, Harakuni U, Bubanale S C, Rekha B K. The role of fundus fluorescein angiography in classification and diagnosis of macular diseases: A hospital-based study. Indian J Health Sci Biomed Res 2018;11:243-7

How to cite this URL:
Salimath S, Patil SB, Tenagi AL, Harakuni U, Bubanale S C, Rekha B K. The role of fundus fluorescein angiography in classification and diagnosis of macular diseases: A hospital-based study. Indian J Health Sci Biomed Res [serial online] 2018 [cited 2018 Dec 15];11:243-7. Available from: http://www.ijournalhs.org/text.asp?2018/11/3/243/242040




  Introduction Top


The pattern of retinal blindness has changed over the years in developing countries. The important causes of retinal blindness are diabetic retinopathy, age-related macular degeneration (ARMD) and retinopathy of prematurity. It is expected that there would be 57 million diabetics in India by 2025 and 137 million people older than 65 years of age by 2021. In developing countries, the prevalence of ARMD ranges from 0.6% to 1.1%.[1]

Diabetic macular edema (DME) is one of the leading causes of loss of visual acuity and blindness worldwide. The prevalence of DME found to be 3% in mild nonproliferative diabetic retinopathy (NPDR), 38% in moderate-to-severe NPDR and 71% with PDR.[2]

ARMD is the leading cause of vision loss in people over the age of 50 years in the developed world. ARMD leads to blindness in 18% of the population in the age group of 65–75 years and almost in 30% of persons aged above 75 years.[3]

Macula lutea also known as a clinical posterior pole which contains central 1.5 mm depression the fovea centralis, where only cones are present in the neuroepithelial layers. The macula is concerned with the precise visual function of acuity, form sense, color differentiation, and stereopsis.

Macular diseases such as ARMD, central serous chorioretinopathy (CSCR), DME, vascular occlusive diseases can cause irreversible blindness and thus require detailed evaluation and management.[4]

Fundus fluorescein angiography (FFA) was introduced in clinical use in 1961 by Novotny and Alvis. It helps us to examine structures in the macular region which are beyond the reach of direct ophthalmoscopy and fundus photography. It is relatively a safe procedure with no life-threatening complications.[5]


  Methodology Top


Sample size

The sample size for the study is calculated by following formula: Cross-sectional study.



P = true positivity rate of fundus fluorescein angiography in detection of macular diseases = 80%, so P = 80.

q = 100-p = 20

Taking 10% as an error.

d = 10

If the values are normally distributed, then 95% of the values will fall within 2 standard errors of the mean. The value of z corresponding to this is 1.96 (from the standard normal variate tables).





N = 64

Sampling method

Purposive sampling

The present study was conducted on 66 participants at the Department of Ophthalmology, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, from January 1st, 2016 to December 31st, 2016. The ethical clearance was obtained from the Ethical Committee of the Institution. Informed consent was obtained from all the participants. Patients with suspected macular diseases such as ARMD, diabetic maculopathy, vascular occlusive disorders, macular dystrophy, CSCR, inflammatory diseases, and macular hole were included in the study. Pregnant women, very old aged, immunocompromised patients, patients with hypersensitivity to fluorescein dye, renal insufficiency, and cardiovascular diseases were excluded from the study.

The detailed history was obtained from each patient followed by thorough clinical examination that included unaided visual acuity and best-corrected visual acuity with Snellens chart and near vision, pupil size and reactions, anterior segment examination and slit lamp biomicroscopy, measurement of intraocular pressure was done using Goldmann applanation tonometer. Patient's pupils were dilated with a combination of 5% phenylephrine and 1% tropicamide. A thorough, careful, and detailed examination of the fundus was done initially by a direct ophthalmoscope and subsequently with an indirect ophthalmoscope and slit lamp examination with +90 D lens giving special attention to macula.

An intradermal test dose of the dye was given 10 min before the procedure. A 21 gauge scalp vein set was put in the antecubital vein. Patient was seated comfortably in front of the fundus camera and the fluorescein dye was injected. Procedure was conducted under supervision of standby anesthetist. Using a Zeiss fundus camera color fundus photographs, monochromatic fundus (red-free) photographs were taken before performing fluorescein angiography. A volume of 3 ml of 25% fluorescein dye was injected in the anticubital vein. Pictures were taken after 10 s at an interval of 1.5–2 s approximately. The serial photographs were taken. Patient was monitored for 1 h after procedure. The clinical ophthalmoscopy and fluorescein angiography findings were analyzed and categorized.


  Results Top


A total of 66 participants were included in the study. These participants with suspected macular diseases were evaluated in detail using clinical ophthalmoscopy and FFA. In the present study, majority of the participants were male (63.6%). The mean age of the study population was 58.95 ± 19.70 years.

Majority of the participants had ARMD (30.30%) and diabetic maculopathy (31.81%), whereas 15.15% of participants had CSCR and 12.12% had vascular occlusions. The least participants had inflammatory causes followed by macular dystrophy and macular hole [Graph 1].



Out of 20 patients of ARMD, 50% were of dry ARMD and 50% were of wet ARMD. Majority (80%) of wet ARMD cases were altered in diagnosis by FFA. On analysis of 20 cases of ARMD, FFA confirmed the diagnosis in 60% of cases and altered the diagnosis in 40% of cases. FFA classified the lesions in 50% of cases of ARMD.

Out of 21 cases of diabetic maculopathy, majority of participants had clinically significant macular edema (CSME) (33.33%) and focal diabetic maculopathy (28.57%) followed by diffuse maculopathy (23.80%). The least participants (14.28%) had ischemic maculopathy. Among 21 diabetic maculopathy cases, FFA confirmed the diagnosis only in 33.33% of cases and altered the diagnosis in 66.66% cases. In our study, ischemic maculopathy cases were confirmed only by FFA. FFA classified the diabetic maculopathy in 66.66% of cases.

Among vascular occlusions, majority (75%) of the cases had branch retinal vein occlusion followed by central retinal vein occlusion and cilioretinal artery occlusion. Majority (62.50%) of the cases had macular edema followed by macular ischemia (37.50%). Out of 8 cases, FFA as confirmed the diagnosis in 62.50% of cases and altered the diagnosis in 37.50% of cases. Macular ischemia due to vascular occlusion was confirmed only by FFA.

Out of 3.03% of macular dystrophy cases, 50% had Stargadt's disease and 50% had adult vitelliform dystrophy. In the present study, all the cases of macular dystrophy were confirmed by FFA.

In the present study, 15.15% of participants were diagnosed with CSCR. Out of which 60% had inkblot pattern of leakage and 40% had smoke stack pattern of leakage on fluorescein angiography.

Out of two cases of full-thickness macular hole, FFA has confirmed diagnosis in all the cases.

Out of three cases of inflammatory causes, majority (66.66%) of the cases had choroiditis followed by cytomegalovirus (CMV) retinitis. FFA confirmed the diagnosis in 66.66% of cases and altered the diagnosis in 33.33% of cases. Macular edema due to vascular occlusions was confirmed only by FFA.

In the present study, out of 66 participants who underwent FFA, Nausea was the most common side effect seen only in 4.68% of cases. No other cases experienced any anaphylactic reactions.

In our study, out of 66 cases of macular diseases, FFA confirmed the diagnosis in 62% of the cases and altered the diagnosis in 38% of cases [Graph 2]. There was 90.91% agreement between clinical ophthalmoscopy and FFA which is found to be statistically significant (P < 0.001). FFA also classified the lesions in 64% of cases.



Limitations of the study

The nonavailability of optical coherence tomography which provides quantitative analysis of the retinal vasculature and three-dimensional imaging of the macula.


  Discussion Top


In our study, a total of 66 participants with macular pathologies were evaluated in detail both by clinical ophthalmoscopy and FFA. Among 66 cases, 30.30% of cases of ARMD, 31.81% of cases of diabetic maculopathy, 12.12% of cases of vascular occlusions, 15.15% of cases of CSCR, 3.03% of cases of macular dystrophies, 4.54% of cases of inflammatory causes and 3.03% of cases of macular hole were included in the study.

In the present study, majority of the participants were male (63.60%). The mean age of the study population was 58.95 ± 19.70 years.

FFA played a major role in the diagnosis of wet ARMD. It confirmed the diagnosis in 20% of cases and altered the diagnosis in 80% of cases of wet ARMD. The retrospective study conducted by Talks et al. showed that 81% of Wet ARMD cases could be diagnosed only by fluorescein angiography.[6]

On overall analysis of 20 cases of ARMD, FFA confirmed the diagnosis in 60% of cases and altered the diagnosis in 40% of cases. The results of this study are correlating with study conducted by Nainiwal and Dandaliya who concluded that FFA confirmed the diagnosis in 68.42% of ARMD cases, altered the diagnosis in 31.57% of cases.[7]

In our study, FFA classified the Wet ARMD into occult choroidal neo vascular membrane (CNVM) and classic CNVM in 50% of cases. Arvind et al. in their study on fluorescein angiography in posterior segment diseases concluded that FFA classified the lesion in 47% of cases of ARMD.[8]

In our study, among 21 cases of diabetic maculopathy, majority (33.33%) of the cases had CSME followed by of focal maculopathy and diffuse maculopathy. The least patients had ischemic maculopathy. The prevalence is correlating to the study done by Syed et al. on incidence of angiographic patterns of diabetic maculopathy who found that diffuse maculopathy and focal diabetic maculopathy was seen predominantly followed by ischemic type.[9]

Among 21 diabetic maculopathy cases in our study, FFA confirmed the diagnosis only in 33.33% of cases and altered the diagnosis in 66.66% of cases. The results are in agreement with the research done by Rajappa et al. who concluded that FFA has confirmed type of diabetic maculopathy only in 24% of cases and has altered diagnosis in 76% of cases.[10]

Out of 21 cases of diabetic maculopathy FFA classified the lesions into diffuse maculopathy, focal maculopathy, ischemic maculopathy, and CSME in 66.66% of cases. Arvind et al. in their study showed that FFA is instrumental in categorizing the lesion of diabetic retinopathy and also helpful in identification of clinically significant macular edema and foveal avascular zone.[8]

Among 10 cases CSCR, majority (60%) were of inkblot pattern followed by smokestack pattern of leakage seen in 40% of cases. How and Koh in their study on angiographic characteristics of acute CSCR in an Asian population confirmed that the inkblot pattern of leakage was the most common pattern seen.[11]

In this study, out of 8 cases of vascular occlusions, FFA has confirmed the diagnosis in 62.50% of cases and altered the diagnosis in 37.50% of cases. Macular ischemia due to vascular occlusions was confirmed only by FFA. The study results are in agreement with Rajappa et al. who concluded that FFA has confirmed diagnosis in 57.14% of cases and altered its diagnosis in 42.85% of cases.[10]

Out of three inflammatory causes, two cases of choroiditis and one case of CMV retinitis were included. In this study, FFA has confirmed the diagnosis in 66.66% of cases and altered the diagnosis in 33.33% of cases. Nainiwal and Dandaliya in their study who concluded that FFA has confirmed diagnosis in 73.33% of cases and has altered its diagnosis in 26.67% cases of inflammatory lesions.[7]

In this study, among 2 cases of macular dystrophy, one case of Stargadt's disease and one case of adult onset vitelliform dystrophy was included in the study. FFA has confirmed the diagnosis in all the cases. Wykes and Livesey in their study concluded that fluorescein angiography confirmed 100% of cases of hereditary macular degeneration which was diagnosed by clinical examination.[12]

Among two cases of full thickness macular hole in our study, FFA has confirmed the diagnosis in all the cases. Thompson et al. in their study found that FFA is most useful tool when the diagnosis of a full-thickness macular hole is in question.[13]

In our study, among 66 fluorescein angiography performed, 4.68% of cases experienced nausea as the most common side effect. No other cases experienced any anaphylactic reactions. Xu et al. in their study on adverse reactions during FFA concluded that only 3.3% cases experienced adverse reactions with nausea and vomiting as the most common adverse effect.[14] A prospective study by Beleña et al. on adverse reactions of FFA showed that major adverse reaction was nausea which occurred in least participants.[15]

In our study, out of 66 cases of macular diseases, FFA confirmed the diagnosis in 62% of the cases and altered the diagnosis in 38% of cases. There was 90.91% agreement between clinical ophthalmoscopy and FFA which is found to be statistically significant (P < 0.001).


  Conclusion Top


The present study conducted on 66 participants with suspected macular pathologies at KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi during the study period of 1 year from January 1st, 2016 to December 31st, 2016.

In this study, we examined all the participants by conventional methods of ophthalmoscopy followed by FFA. The findings were analyzed and categorized.

The following conclusions were drawn from the study.

  • FFA confirmed the diagnosis in all the dry ARMD cases. FFA played a definitive role in diagnosing wet ARMD by early detection and localization of the site of CNVM in relation to the foveal avascular zone
  • FFA confirmed and classified the diabetic maculopathy into focal maculopathy, diffuse maculopathy, ischemic maculopathy and CSME. FFA is gold standard in the diagnosis of ischemic diabetic maculopathy
  • Among vascular occlusions FFA played a major role in differentiating macular edema from macular ischemia which helped in the prognosis of these conditions
  • In the study of macular dystrophy fluorescein angiography confirmed the diagnosis in all the cases
  • FFA gave a definitive diagnosis in CSCR cases by detecting the number of leakage points and the exact site of leakage. It classified the leakage pattern into inkblot and smokestack pattern and played an immense role in laser photocoagulation by detecting exact site of leakage points in CSCR
  • Fluorescein angiography confirmed the diagnosis in full-thickness macular hole by detecting the pattern of leakage
  • In our study, nausea was the most common adverse effect seen only in 3 cases with no anaphylactic reactions seen.


In conclusion, FFA can be used as a safe and superior diagnostic modality in classification and diagnosis of macular diseases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Nazimul H, Rohit K, Anjli H. Trend of retinal diseases in developing countries. Expert Rev Ophthalmol 2008;3:43-50.  Back to cited text no. 1
    
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Kański J, Bowling B, Nischal K, Pearson A. Clinical Ophthalmology. Edinburgh: Elsevier/Saunders; 2012.  Back to cited text no. 2
    
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Fine SL, Berger JW, Maguire MG, Ho AC. Age-related macular degeneration. N Engl J Med 2000;342:483-92.  Back to cited text no. 3
    
4.
Sachdeva RP. Functional anatomy of macula and diagnostic procedures for macular function in clear media. Indian J Ophthalmol 1983;31:105-7.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Saine PJ. Landmarks in the historical development of fluorescein angiography. J Ophthalmic Photogr 1993;15:17-23.  Back to cited text no. 5
    
6.
Talks J, Koshy Z, Chatzinikolas K. Use of optical coherence tomography, fluorescein angiography and indocyanine green angiography in a screening clinic for wet age-related macular degeneration. Br J Ophthalmol 2007;91:600-1.  Back to cited text no. 6
    
7.
Nainiwal SK, Dandaliya I. Study by fundus fluorescein angiography as a diagnostic tool in various retinal and choroidal disorders. IOSR J Dent Med Sci 2016;15:05-12.  Back to cited text no. 7
    
8.
Arvind R, Surendar S, Rao JM. Role of fluorescein angiography in evaluation of posterior segment disorders. Perspect Med Res 2017;5:8-12.  Back to cited text no. 8
    
9.
Syed SH, Arif M, Saleem F. Incidence of angiographic patterns of diabetic maculopathy. Agric Produced Mark Comm 2009;3:148-51.  Back to cited text no. 9
    
10.
Rajappa SA, Molleti D, Nandini C. The role of fluorescein angiography as an important tool in diagnosis of macular disorders. Int J Biomed Res 2014;5:636-639.  Back to cited text no. 10
    
11.
How AC, Koh AH. Angiographic characteristics of acute central serous chorioretinopathy in an Asian population. Ann Acad Med Singapore 2006;35:77-9.  Back to cited text no. 11
    
12.
Wykes WN, Livesey SJ. Review of fluorescein angiograms performed in one year. Br J Ophthalmol 1991;75:398-400.  Back to cited text no. 12
    
13.
Thompson JT, Hiner CJ, Glaser BM, Gordon AJ, Murphy RP, Sjaarda RN, et al. Fluorescein angiographic characteristics of macular holes before and after vitrectomy with transforming growth factor beta-2. Am J Ophthalmol 1994;117:291-301.  Back to cited text no. 13
    
14.
Xu K, Tzankova V, Li C, Sharma S. Intravenous fluorescein angiography-associated adverse reactions. Can J Ophthalmol 2016;51:321-5.  Back to cited text no. 14
    
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Beleña JM, Núñez M, Rodríguez M. Adverse reactions due to fluorescein during retinal angiography. JSM Ophthalmol 2013;1:1004.  Back to cited text no. 15
    




 

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