PHOTO MONTAGE III: NPDR
HERE IS YET ANOTHER PATIENT WITH DIABETIC RETINOPATHY - NON PROLIFERATIVE DIABETIC RETINOPATHY (NPDR) TO BE EXACT. NOTE THE 'DOT AND BLOT' HEMORHAGES IN BOTH EYES AS WELL AS 'GHOST CAPILLARIES' IN BOTH MACULAS. (click to enlarge)BELOW ARE LATE PHASE ANGIOGRAPHIC MONTAGES OF EACH EYE.

RIGHT.......................&.........................LEFT

IT IS TYPICALLY A PRETTY GOOD IDEA TO 'LOOK AROUND' DURING THE ANGIOGRAPHY OF THE DIABETIC PATIENT TO CHECK FOR N.V.E. (NEO-VASCULARIZATION ELSEWHERE). THESE NEW BLOOD VESSELS ARE UNSTABLE AND TEND TO 'LEAK' IN THE EYE. IN SPITE OF THIS PATIENT'S MASSIVE CAPILLARY DROP-OUT (DARK, FLAT-LOOKING AREAS OF THE ANGIOGRAM), THERE DOESN'T SEEM TO BE ANY N.V.E. PRESENT

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.

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).

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.

SRNVM REDUX: RETURN OF THE PANDA
THIS IS A FOLLOW-UP ANGIOGRAM OF ONE OF MY EARLIER PATIENTS. UNFORTUNATELY, WITH A SUBRETINAL NEOVASCULAR MEMBRANE THERE IS LITTLE CHANCE OF IMPROVING THE CONDITION. IN A CASE SUCH AS THIS, A RETINAL MD'S AIM IS TO PREVENT ANY PROGRESSION OF THE DISEASE.

AFTER TAKING THIS PICTURE, I TOLD THIS PATIENT THAT I THOUGHT HER CONDITION RESEMBLED A PANDA BEAR. INITIALLY, SHE SEEMED A BIT "PUT-OFF" BY MY COMMENT; BUT AFTER OUR SESSION, SHE WANTED A COPY OF THE ANGIOGRAM TO SHOW FAMILY AND FRIENDS. SHE IS really WONDERFUL TO WORK WITH.

A. I. O. N.
ANTERIOR ISCHEMIC OPTIC NEUROPATHY
IS A CONDITION CAUSED BY THE INFARCTION OF BLOOD VESSELS THAT WOULD OTHERWISE SUPPLY THE ANTERIOR (OR FRONT) OF THE OPTIC NERVE. PATIENTS WITH AION WILL (INEVITABLY) PRESENT WITH A PALE, SWOLLEN OPTIC DISC AS WELL AS ASSOCIATED HEMORRAGING WHICH CAN BE NOTED IN THE COLOR FUNDUS PHOTO BELOW.

THE ANGIOGRAPHY ABOVE SHOWS THE VENOUS STAGE OCCURRING QUITE LATE IN THE ANGIOGRAM (ALMOST A MINUTE), WHICH IS TYPICAL IN AION PATIENTS AS THEIR CIRCULATION IS SUB-STANDARD.

C Y S T O I D . M A C U L A R . E D E M A
OR CME IS A PAINLESS DISORDER CHARACTERIZED BY CYST-LIKE SWELLING WITHIN
THE MACULAR REGION OF THE RETINA. SINCE THE MACULA IS COMPROMISED BY THE
SWELLING, CENTRAL VISION IS COMPROMISED & SYMPTOMS ARE TYPICALLY BLURRED AND
DECREASED CENTRAL VISION.

THIS IS A FUNDUS PHOTO AND A LATE PHASE ANGIOGRAM (6 MINUTES 31 SECONDS) OF A RETINA
EXHIBITING CME. THERE APPEARS TO BE EVIDENCE OF AN OLD OCCLUSION AND THE CME
MAY BE SECONDARY TO THAT. ENJOY THIS HAIKU REGARDING THE ANGIOGRAM.

NOTE PETAL PATTERNS
IN THE MACULA DUE TO
HYPER FLUORESCENCE
06/01/07
TODAY, IT WAS BROUGHT TO MY ATTENTION THAT THE HYPER-FLUORESCENT PETAL PATTERN IN MY ANGIOGRAM (TYPICAL IN CME PATIENTS) IS, IN FACT, SECONDARY TO THE MACULAR SWELLING AND THAT MY HAIKU IS NOT TECHNICALLY ACURATE. ALLOW ME TO REPHRASE:
HYPER FLUORESCENCE
IN THE MACULA IS DUE
TO THE EDEMA

RIGHT EYE__________________________________________________ LEFT EYE

FUNDUS PHOTO

THIS IS A DIABETIC PATIENT WHO IS SUFFERING A NON-ISCHEMIC CENTRAL RETINAL VIEN OCCLUSION WITH MODERATE RETINAL EDEMA IN THE RIGHT EYE AND SHOWING EARLY BACK GROUND DIABETIC CHANGES IN THE LEFT.

RIGHT EYE__________________________________________________ LEFT EYE

RED FREE
A RED FREE PHOTOGRAPH IS A BLACK AND WHITE IMAGE TAKEN WITHOUT DYE USING A GREEN FILTER. THIS HELPS TO DISTINGUISH BLOOD VESSELS FROM THE RETINA. NOTE THE FLAME SHAPED RETINAL HEMORRAGING IN THE RIGHT EYE.

RIGHT EYE__________________________________________________ LEFT EYE

FLUORESCEIN ANGIOGRAM
HERE IS A 'LATE PHASE' ANGIOGRAM OF THE SAME PAIR OF EYES.

I don't know if anyone is actually monitoring my progress here, but I TOOK THESE PICTURES!!!

M O R E F L U O R E S C E I N HERE IS A BIT OF
A N G I O G R A P H Y
I WAS ABLE TO DO
WITH A FAIRLY
"EASY" PATIENT.
THESE SHOTS
WERE TAKEN
20 SECONDS,
23 SECONDS,
1 MINUTE
7 SECONDS,
AND
6 MINUTES
10 SECONDS
AFTER NaFl INJECTION.
THIS PATIENT HAS
IDIOPATHIC SUB RETINAL
NEOVASCULARIZATION,
AND IS A COOL GUY.

MORE ON FLUORESCEIN ANGIOGRAPHY

FLUORESCEIN ANGIOGRAPHY
IS A TECHNIQUE FOR EXAMINING THE CIRCULATION OF
THE RETINA USING A DYE TRACING METHOD. AFTER AN
INJECTION OF SODIUM FLUORESCEIN INTO CIRCULATORY
SYSTEM, AN ANGIOGRAM IS OBTAINED BY PHOTOGRAPHING
THE FLUORESCENCE EMITTED BY THE RETINA WHILE
EXPOSING WITH A BLUE LIGHT (490 NANOMETERS)
Click to Enlarge

SOME MIGHT SAY THIS ANGIOGRAM INDICATES THE PATIENT HAS A SUB RETINAL NEOVASCULAR MEMBRANE WITH A DISCIFORM SCAR AND A SMALL SUB MACULAR HEMORRHAGE.....
BUT PERSONALLY, I THINK IT LOOKS LIKE A PANDA BEAR IN A COAT WALKING TOWARD A TESLA COIL.