I T S . T I M E . T O . P L A Y
NAME THAT PATHOLOGY

HOW WOULD YOU CLASSIFY THE FIERY LOOKING REGION
(SUPERIOR TEMPORAL TO THE OPTIC DISC) IN THE RETINA ABOVE?
(a) A NEVUS
(b) A BENIGN NEOPLASM
(c) A MELANOMA
(d) A CARCINOMA

THE ANGIOGRAPHY SHOWS ONLY A TRANSMISSIONAL FLUORESCENCE OF THAT AREA OF
THE RETINA WHICH IS INDICATIVE OF A
(b) BENIGN (CHOROIDAL) NEOPLASM.

OPHTHALMIC BLOOPERS I: THE G. F. A.
HERE IS AN ANGIOGRAM I DID LAST WEEK AT OUR FAYETTEVILLE CLINIC. THE COLOR PHOTO
WENT SMOOTHLY ENOUGH, BUT THE ACTUAL F.A. DIDN'T FAIR SO COOLLY. I CHANGED THE LIGHT
SOURCE TO THE GREEN-BLUE LIGHT (490 NM), BUT DIDN'T CHANGE THE DIGITAL CAPTURE SETTINGS
TO BLACK AND WHITE.THE RESULT IS THE GREEN FLUORESCEIN ANGIOGRAM (G.F.A.)

YOU CAN SEE THAT I REALIZED MY MISTAKE BETWEEN SHOTS 26 AND 27, AND IT ISN'T FOR
3 SECONDS THAT I GET MY FIRST VALID ANGIOGRAM. I DID A CRUDE 'AUTO LEVELS'
ADJUSTMENT IN PHOTOSHOP AND THESE ARE THE WACK'D COLORS I GOT.

THE WEEK IN ROCK
I HAD A PRETTY DECENT WEEK, LAST WEEK, REGARDING THE ANGIOGRAPHY I AM
LEARNING AT CAROLINA EYE. HERE IS A SAMPLING OF THE WORK I DID LAST WEEK.

PIGMENT EPITHELIAL DETACHMENT WITH A PROBABLE OCCULT SUBRETINAL NEOVASCULAR MEMBRANE

PATHOLOGIC MYOPIA WITH PERIPAPILLARY ATROPHYDRY AGE RELATED MACULAR DEGENERATION WITH FINE DRUSENI MUST THANK BILL AND MELANY (THE HEART & SOUL OF CAROLINA EYE'S PHOTOGRAPHY DEPT.)

FOR ALL OF THEIR COACHING, ENCOURAGEMENT, AND PATIENCE UP TO THIS POINT.
THEIR MENTORING HAS BEEN THE KEY TO MY DEVELOPMENT AND SUCCESS.

SLITLAMP PHOTOGRAPHY III: A.C.I.O.L.
HERE IS A SLITLAMP PHOTO OF AN ANTERIOR CHAMBER INTER-OCULAR LENS.

THE AC IOL IS A LENS REPLACEMENT AND RESTS IN THE ANTERIOR CHAMBER OF THE EYE,
IN FRONT OF THE IRIS. AS YOU CAN SEE, THE LENS IS HELD INTO PLACE BY TWO PLASTIC
'BRACKETS' (SHOWN IN THE PHOTO AT THE TOP AND BOTTOM OF THE LENS ITSELF.) THIS
TYPE OF LEN REPLACEMENT IS NO LONGER AS COMMON AS POSTERIOR CHAMBER INTER
OCULAR LENS (PC IOL), BUT IS (OBVIOUSLY) STILL USED IN SOME CASES.

D R U S E N
DRUSEN IS A BUILD-UP OF LIPID AND PROTEIN MATERIAL BETWEEN THE RETINAL
PIGMENT EPITHELIAL (RPE) AND THE CHORIOCAPILLARIS LAYERS OF THE RETINA.
THE PALE YELLOW/WHITE SPOTS IN THE COLOR AND RED-FREE PHOTOS BELOW ARE DRUSEN.

ALTHOUGH DRUSEN IS TYPICALLY ASSOCIATED WITH AGE RELATED MACULAR DEGENERATION, THE EXACT CAUSE
OF DRUSEN AND WHETHER IT IS A SYMPTOM OF OR A PRECURSOR TO ARMD IS NOT COMPLETELY CLEAR.

SLITLAMP PHOTOGRAPHY II
CONJUNCTIVAL PYOGENIC GRANULOMA

Pyogenic granuloma is a rather general term for a relatively common benign vascular lesion
of the skin and mucosa whose exact cause is unknown. However, the term, pyogenic granuloma,

is a bit of a misnomer since the lesion is neither pyogenic (pus-forming) nor a granulomatous

reaction (abnormal behavior related to immune specialized cells known as phagocytes).

THIS IS ACTUALLY A POST-OP PHOTO OF A ONCE, MUCH MORE SEVER CASE. THIS IS WHAT WAS LEFT.

PHOTO MONTAGE II:
S C I E N C E . A S . A R T ?
HERE ARE A COUPLE MORE OPHTHALMIC PHOTO MONTAGES WITH A TWIST;
IN BOTH, MERGED A COLOR, FUNDUS PHOTO WITH A RED-FREE, BLACK AND WHITE PHOTO AND A MID-VENOUS PHASE ANGIOGRAM. ALTHOUGH THERE IS PROBABLY NO CLINICAL APPLICATION FOR THESE HYBRID IMAGES,
IT IS SORT OF COOL LOOKING.
GLAUCOMA

DIABETIC RETINOPATHY

PHOTO MONTAGE I
DIGITAL CAPTURE IN FUNDUS PHOTOGRAPHY AND ANGIOGRAPHY
HAS ALLOWED FOR UNIQUE AND INTERESTING WAYS OF RETINAL
IMAGING. BELOW IS A COLOR PHOTO OF A PATIENT WHO
IS SUFFERING FROM DIABETIC RETINOPATHY AND IS PRESENTING
WITH A 'BOAT-SHAPED' PRE-RETINAL HEMORRHAGE.

HERE ARE SEVERAL DIFFERENT VIEWS OF THE SAME RETINA
TAKEN DURING THE ANGIOGRAM.THE SOFTWARE ASSOCIATED WITH OUR DIGITAL CAPTURE SYSTEM CAN 'STITCH' (OR MONTAGE) THESE IMAGES TOGETHER TO GIVE US A BETTER, OVERALL VIEW OF THE RETINA. NOW WE CAN VIEW THE HEMORRHAGE AS WELL AS THE AREA OF NVE (NEO-VASCULARIZATION ELSEWHERE) IN THE SUPERIOR TEMPORAL REGION OF THE RETINA THAT IS LIKELY RESPONSIBLE FOR THAT HEMORRHAGE. WE CAN ALSO SEE THE EXTENT OF PAN-RETINAL LASER TREATMENT THIS PATIENT HAS HAD IN THE PAST (THE SMALL DARK SPLOTCHY SPOTS).

S C A N S III - M A C U L A R H O L E
BELOW ARE TWO OCT SCANS OF A MACULAR HOLE.
A MACULAR HOLE IS TYPICALLY CAUSED BY A PATHOLOGICAL THINNING OR SHRINKING OF THE VITREOUS WITHIN THE EYE. VITREOUS IS THE JELLY-LIKE SUBSTANCE THAT FILLS THE EYE AND IS ATTACHED TO THE RETINA. AS THE VITREOUS 'SHRINKS' IT PULLS AT THE RETINA AND THE MACULA. THIS TRACTION CAUSES THE MACULAR HOLE AND THE OVERALL RESULT IS DISTORTION IN OR COMPLETE LOSS OF FINE DETAILED VISION.

THE TREATMENT FOR THIS CONDITION IS A SURGICAL PROCEDURE KNOWN AS A VITRECTOMY. BASICALLY, THE VITREOUS IS REMOVED FROM THE EYE AND REPLACED WTIH A SALINE SOLUTION. THEN A TINY BIT OF THE REMAINING MACULAR TISSUE IS 'PEELED' TO PROMPT HEALING IN THAT AREA. FINALLY, THE EYE IS FILLED WITH A GAS BUBBLE THAT HOLDS THE TISSUE IN PLACE UNTIL IT IS COMPLETELY HEALED. THE GAS BUBBLE EVENTUALLY DISSIPATES AND THE EYE REFILLS WITH ITS OWN FLUID ONCE MORE. POST OPERATION RECOVERY CAN BE VERY CHALLENGING, HOWEVER, AS THE PATIENT WILL NEED TO POSITION THEIR HEAD 'FACE-DOWN' CONTINUOUSLY FOR SEVERAL DAYS FOLLOWING THE SURGERY.

MORE ANGIOGRAPHY
HERE'S A BIT MORE ABOUT THE PROCESS OF OBTAINING A GOOD ANGIOGRAM.
WE WOULD START BY GETTING A SHARP, WELL EXPOSED COLOR IMAGE OF THE RETINA. BELOW IS A FUNDUS PHOTOGRAPH OF A DIABETIC PATIENT'S LEFT EYE.

THE FUNDUS PHOTO IS USED AS A 'BASE-LINE' IMAGE. IN SOME CASES , A RED-FREE PHOTOGRAPH
IS ALSO USED AS A 'BASE-LINE'. THE FIRST IMAGE IN THE ANGIOGRAM BELOW (TOP RIGHT NUMBERED '7')
IS A RED-FREE PHOTO. NEXT, APPROXIMATELY 5 CC OF SODIUM FLUORESCEIN ARE INJECTED
INTO THE PATIENT'S BLOODSTREAM. FLUORESCEIN IS A MINERAL DYE THAT FLUORESCES UNDER A BLUE
LIGHT (APPROXIMATELY 490 NM). IT TAKES ABOUT 10-20 SECONDS FOR THE DYE TO REACH THE RETINA.
AT THIS POINT, PHOTOS NEED TO BE TAKEN AT A RATE OF ABOUT 1 PER SECOND TO GIVE AN ACCURATE
ACCOUNT OF THE PATIENT'S RETINAL CIRCULATION. BELOW WE CAN TRACE THE DYE THROUGH
THE RETINAL ARTERIAL STAGE (TOP ROW IMAGES # '9','10', AND '11')
THE EARLY VENOUS STAGE (SECOND ROW IMAGES # '12', '13', '14', AND '15')
VENOUS AND LATE VENOUS STAGES (IMAGES # '17', '19', '22', '25', '27', '30', AND '31')
AND FINALLY
THE LATE STAINING OCCURRING ABOUT 5 MINUTES AFTER THE INJECTION (IMAGE #'39').
THE RETINAL IMAGES IN THE ANGIOGRAM 'READ' FROM RIGHT TO LEFT AND THEIR TIMES ARE DISPLAYED IN THE UPPER LEFT OF EACH IMAGE. THE TIMES REFER TO THE POINT THE IMAGE WAS CAPTURED FOLLOWING THE INJECTION.