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Fluorescein Angiography and Optical Coherence Tomography Correlation

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Fluorescein Angiography and Optical Coherence Tomography Correlation FEATURE STORY IMAGING Fluorescein Angiography and Optical Coherence Tomography Correlation in Various Retinal Diseases It is important to know the strengths and weaknesses of imaging modalities and their unique uses for diagnosing different retinal diseases. BY JAY CHHABLANI, MD; AND ADITYA SUDHALKAR, MD luorescein angiography (FA) and optical coherence (CME), diabetic macular edema (DME), central serous cho- tomography (OCT) scans are important tools used in rioretinopathy (CSC), and vitreomacular interface disorder. the examination and management of retinal diseases. Each modality has unique strengths and weaknesses. These investigative modalities complement each Kozak et al,1 in analyzing discrepancy rates between intrave- Fother, and many situations require both imaging methods nous FA and time-domain OCT (TD-OCT) for diagnosing to make the correct diagnosis and treatment plan. This arti- macular edema, found that the sensitivity of FA and OCT cle compares the 2 technologies in various clinical situations. was 98.7% and 96.1%, respectively. In 3.86% of eyes, they Fluorescein angiography provides retinal circulation found that FA showed dye leakage in the macular area, but details, and OCT offers high-quality anatomic images. TD-OCT showed normal foveal contour. Similarly, TD-OCT Fluorescein angiography is invasive, nonquantitative, and detected both intraretinal and subretinal fluid in 1.17% eyes, subjective, with limited use for patients with small pupils or while FA failed to detect any fluid. The largest number of insufficient media clarity. Optical coherence tomography discrepancies was found while scanning for DME, and FA is objective and is not so much affected by pupil size or was more sensitive than TD-OCT for this condition: 42.2% media clarity. Registration of OCT scans helps clinicians of eyes showed discrepancy. Fluorescein angiography and properly assess patients during follow-up visits. Both diag- TD-OCT were equivalent when testing for AMD. nostic tools depend heavily upon patient cooperation. Barteselli et al2 compared oral FA with spectral- Both are useful, and often complimentary, in the diagnosis domain OCT (SD-OCT) in diagnosing macular edema. and management of a variety of retinal disorders, such Fluorescein angiography was as sensitive as SD-OCT for as age-related macular degeneration (AMD), idiopathic management of AMD; however, FA provided better juxtafoveolar retinal telangiectasis (IJRT), myopic choroidal details in cases of DME and macular edema associated neovascularization (CNV), uveitic cystoid macular edema with retinal vein occlusions. Spectral-domain OCT was JANUARY/FEBRUARY 2014 RETINA TODAY 77 FEATURE STORY IMAGING more sensitive in the diagnosis and manage- A B C ment of purely anatomic disorders such as macular holes. The overall discrepancy between FA and SD-OCT was 4.56%. This discrepancy was greater in cases of diabetic retinopathy and uveitis. The highest agree- ment rate (0.95) and lowest rate of disagree- ment (0.83) was noted in AMD, particularly D in wet AMD. WET AGE-RELATED MACULAR DEGENERATION Neovascular AMD is diagnosed based on leakage patterns found on FA. Optical coher- ence tomography, however, is more useful for following up with patients after they have Figure 1. Type 2A idiopathic juxtafoveolar retinal telangiectasis. Color been diagnosed. Fluorescein angiography is fundus photograph (A) shows graying of the parafoveal retina (arrow) required to reassess the diagnosis in patients with pigments (arrow) and telangiectatic vessels. Fluorescein angiography who do not respond to a given treatment. shows early hyperfluorescence from the telangiectatic vessels along with Optical coherence tomography provides blocked fluorescence due to pigments (arrow; B) leading to diffuse hyper- quantitative evaluation of the disease and fluorescence in the late phase (arrow; C). Spectral-domain optical coherence provides information about structural chang- tomography shows thinning of fovea with back-shadowing due to pigments es, particularly for outer retinal structures. (arrow; D) with no intraretinal or subretinal fluid. Barteselli et al2 reported the highest agree- ment rate (0.95) and the highest sensitivity neovascularization secondary to IJRT for FA was 52.3%; (0.99) for both techniques in eyes with AMD. They also the specificity for diagnosing the same disease for FA was reported the lowest discrepancy rate (0.83) in patients 70.0%. Regarding SD-OCT, the sensitivity and specificity with AMD compared with those with other retinal was 72.7% and 64.1%, respectively, in reference to color pathologies. Physicians should consider simultaneous fundus photography. The negative predictive value of evaluation using FA and SD-OCT to detect all cases of SD-OCT (80.6%) was higher than that of FA (73.7%). new, persistent, or recurring macular edema in cases of Interobserver agreement was better for SD-OCT com- wet AMD. pared with FA in making the diagnosis of subretinal neo- Giani et al3 evaluated SD-OCT findings that predict vascularization. SD-OCT is better than FA for ruling out angiographic leakage in CNV. They reported a statistically the presence of subretinal neovascularization. As with significant association between SD-OCT and FA findings AMD patients, serial monitoring of response to treat- for eyes that displayed fluid and neurosensory detachment, ment is best done with noninvasive imaging modalities intraretinal flecks, and low reflectivity or undefined bound- such as OCT. aries from subretinal material, but not for intraretinal cystic spaces or retinal pigment epithelium (RPE) detachment. MYOPIC CHOROIDAL NEOVASCULARIZATION SUBRETINAL NEOVASCULARIZATION IN Myopic CNV is difficult to diagnose clinically because IDIOPATHIC JUXTAFOVEOLAR RETINAL of concomitant posterior pole chorioretinal atrophic TELANGIECTASIS changes, prominent choroidal vessels, subretinal hemor- Diagnosis of subretinal neovascularization associated rhage associated with lacquer cracks, pigments, and scar- with IJRT is challenging due to presence of associated ring (Figure 2).5,6 leakage from telangiectatic vessels on FA and presence Occasionally, FA and OCT both fail to make a diagnosis of cystic changes on OCT (Figure 1). We reported an of myopic CNV. This can be for any number of reasons, interobserver agreement (measured in kappa, k) for diag- including smaller areas of neovascularization, less exuda- nosis of subretinal neovascularization on FA and SD-OCT. tion, eccentric fixation and poor focusing during testing, The k value for subretinal neovascularization on FA was or the inability to obtain images due to long axial length. 0.373; for subretinal neovascularization on SD-OCT, it was Fluorescein angiography and OCT frequently display 0.775.4 The sensitivity to make a diagnosis of subretinal substantial disagreement regarding the activity in eyes with 78 RETINA TODAY JANUARY/FEBRUARY 2014 FEATURE STORY IMAGING A B C free of macular thickening, whereas macular thickening was present in 34% of cases with- out macular leakage. Biomicroscopic evalu- ation for macular edema failed to detect 40% of cases of macular thickening and 45% of cases of macular leakage. Biomicroscopic evaluation diagnosed 17% of cases with mac- D ular edema that did not have macular thick- ening and diagnosed 17% of cases of macular edema that did not have macular leakage. Overall, OCT is the best initial test for evaluation of suspected uveitic CME and is the best method to evaluate the response Figure 2. Myopic choroidal neovascular membrane. Color fundus photogra- to treatment in cases of uveitis. phy (A) shows gray membrane (arrow) with high myopic fundus. Fluorescein angiography shows early hyperfluorescence with noticeable membrane DIABETIC MACULAR EDEMA (arrow; B) leading to hyperfluorescence in the late phase (arrow; C), In DME, FA is not required to make the suggestive of staining. Spectral-domain optical coherence tomogra- diagnosis but is required to plan laser pho- phy shows hyperreflective lesion above the retinal pigment epithelium tocoagulation. Additionally, FA is required (arrow; D) with no intraretinal or subretinal fluid suggestive of scarred to diagnose clinically concealed neovas- choroidal neovascular membrane. cularization, particularly before cataract surgery. Fluorescein angiography also helps myopic CNV. Leveziel et al5 reported that, although diagnose macular ischemia in eyes with more than 80% of eyes with exudative myopic CNV unexplained vision loss. Optical coherence tomography displayed leakage on FA, less than half had corrobora- helps quantify and classify macular edema, evaluate tive evidence of exudation on OCT. When recently outer retinal structure damage, and perform adequate diagnosed cases of myopic CNV were included, they follow-up. found that reliable and interpretable diagnosis of CNV Discrepancy between FA and OCT is not uncommon in was made by FA alone in 61.3% of cases (38 of 62), by eyes of patients with diabetes. Barteselli et al2 reported a SD-OCT alone in 22.6% of cases (14 of 62), and by both high discrepancy rate (18.12%) and a low kappa agreement SD-OCT and FA in 16.1% of cases (10 of 62). There was (0.52) between the 2 imaging modalities in eyes with DME. no agreement about signs of active CNV between these Fluorescein angiography appeared to be more sensitive 2 imaging methods (k 25.7 ±10%; P = .0044). than SD-OCT in detecting macular edema (1.00 vs 0.79). Spectral-domain OCT has a lower sensitivity in cases of UVEITIC CYSTOID MACULAR EDEMA low-grade leakage from vessels or microaneurysms.
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