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QUESTION

WHAT ADDITIONAL INFORMATION CAN I GET FROM ULTRA-WIDEFIELD FLUORESCEIN ANGIOGRAPHY THAT I CAN’T GET FROM A 30-DEGREE ANGIOGRAM?

Jeremy A. Lavine, MD, PhD
Justis P. Ehlers, MD

Standard 7-field 30° fluorescein angiography (FA) is the historical gold standard for the diagnosis and monitoring of many retinal diseases. In focal macular diseases, such as pseudophakic cystoid macular edema, age-related macular degeneration, myopic degeneration, and other causes of posterior pole choroidal neovascularization, 30° angiography with or without sweeps will often determine the diagnosis. However, there are several retinal diseases, including inflammatory eye disease, retinal vascular disease, and peripheral retinal lesions, that may be more optimally assessed with ultra-widefield fluorescein angiography (UWFFA), which images 200° of retina.

Retinal Vascular Diseases

Diabetic retinopathy and retinal venous occlusive disease are the 2 most common retinal vascular disorders. UWFFA may facilitate diagnosis, disease burden assessment, and help guide management. In diabetic retinopathy, macular leakage, macular ischemia, and posterior neovascularization may be detected on standard 7-field 30° FA with sweeps. In Figure 24-1A, neovascularization of the disc is evident, the superior nasal sweep identifies retinal neovascularization elsewhere, and the inferior sweeps show blockage from vitreous hemorrhage (blue asterisk). However, a single focal area of ischemia is only visualized on the nasal sweep (red asterisk). Instead, with UWFFA, the massive ischemic burden in the temporal periphery is identified (green asterisk). Equipped with this information, panretinal laser photocoagulation can be performed with a priority to the areas of peripheral nonperfusion. In Figure 24-1B, the standard 7-field 30° FA demonstrates no significant ischemia or neovascularization; however, the UWFFA displays nasal neovascularization (magenta asterisk) and ischemia (green asterisk). Overall, UWFFA in diabetic retinopathy is particularly useful for localizing ischemia, determining extent of ischemia, identifying peripheral neovascularization, and assessing overall disease burden.

Retinal vein occlusions may be diagnosed with standard 30° angiography, but the evaluation of disease burden is significantly limited compared to UWFFA. In Figure 24-2A, a branch retinal vein occlusion (BRVO) is shown with blockage from hemorrhage (blue asterisk) in the macula and superior temporal periphery. In the standard 7-field 30° FA, no ischemia is detectable, and this BRVO would be classified as non-ischemic according to the Branch Vein Occlusion Study.¹ However, with UWFFA, the superotemporal periphery demonstrates extensive nonperfusion (green asterisk) and vascular remodeling (magenta asterisk), consistent with significant ischemia. Figure 24-2B demonstrates a central retinal vein occlusion with blockage from hemorrhage in all standard 7-field 30° sweeps and only focal ischemia in the temporal sweep (red asterisk) and thus, might be considered non-ischemic.² Conversely, the UWFFA illustrates massive ischemia (green asterisk) and nonperfusion in all of 4 quadrants of the periphery. In this case example, enhanced surveillance and close follow-up will be encouraged to evaluate for neovascularization given the extensive ischemia identified on UWFFA.

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