Despite being an older procedure, fluorescein angiography (FA) is proving to an effective tool for ophthalmologists.
This article was reviewed by Steven Yeh, MD
Imaging modalities have been continuously evolving over the years and becoming more powerful. Fluorescein angiography (FA) is one of the oldest procedures used by ophthalmologists, but its age does not decrease its value.
Steven Yeh, MD, described the patterns of various diseases and how FA adds to the clinical evaluations of these patients. Dr. Yeh is the M. Louise Simpson Associate Professor of Ophthalmology, Emory Eye Center, Emory University School of Medicine, Atlanta.
Birdshot Retinochoroidopathy (BRC)
Dr. Yeh described a 40-year-old man who complained of floaters and debris in the visual field for two years. He underwent laser retinoplexy for suspicious lesions. An examination showed 1+ anterior vitreous cells bilaterally, trace vitreous haze, and mild disc edema. The optic disc had some hyperfluorescence with leakage and the vessels had characteristic segmental periphlebitis.
No lesions characteristic of birdshot retinochoroidopathy (BRC) were apparent in the left eye, and the segmental periphlebitis was even more prominent with leakage from the optic disc in the late frames and a retinal pigment epithelial (RPE) blush.
Indocyanine green angiography (ICGA) images showed multiple hyposinus lesions that define the BRC phenotype but no cystoid macular edema (CME).
“There was a paucity of lesions on FA images, but ICGA showed more lesions,” Dr. Yeh said. “It is important to pair the two technologies when this disease is suspected.”
BRC can lead to severe CME and resultant changes in visual acuity. In another patient in whom BRC developed, optical coherence tomography (OCT) showed the diffuse RPE blush bilaterally that developed because of the chronic nature of the disease. OCT also showed intraretinal and subretinal fluid and an epiretinal membrane. Local and systemic treatments resulted in improved vision.
BRC can also result in choroidal neovascularization (CNV). A 53-year-old woman with HLA-A29+ BRC had accompanying bilateral distorted vision of 20/40 in the right eye. OCT showed the presence of subretinal hyperreflective material over a pigment epithelial detachment (PED).
Dr. Yeh explained that fluorescein still has a role in patients such as this.
“It showed hyperfluorescence in an early angiogram with leakage within the choroidal neovascular membrane and the optic disc,” he said. “This suggests that the disease has both inflammatory and neovascular components. The patient was treated with adalimumab (Humira, AbbVie) and serial anti-vascular endothelial growth factor (VEGF) injections and had a good outcome as seen on FA and OCT.
According to Dr. Yeh, CNV can occur in about 5% to 10% of BRC cases.
“The risk of CNV in these cases is not surprising because the macula is involved,” he said. “In this context, combination therapy is important.”