DR.SHAH-NOOR HASSAN FCPS,FRCS Consultant, Vitreo-Retina Bangladesh Eye Hospital & Institute

1. FUNDUS
AUTOFLUORESCENCE
DR.SHAH-NOOR HASSAN FCPS,FRCS
Consultant, Vitreo-Retina
Bangladesh Eye Hospital & Institute

2. Fluorophore

3. Autofluorescence
 Some materials contain a naturally
autofluorescent component that can be
visualised when excited with a light of
particular wavelength

4. Retinoid Fluorophores

5. RPE and lipofuscin
 RPE constitutes a monolayer of
polygonal cells between the
choroid and neuro-sensory
retina
 Multiple functions
 RPE dysfunction implicated in
variety of retinal diseases
 LF is a byproduct of
accumulation of sheded outer
segments of the photoreceptors

6.  Lipofuscin accumulates as a byproduct
of phagocytosis of photoreceptors’ outer
segment
 In advanced age: It may occupy 20% of
free cytoplasmic space of RPE cells
The older we grow the more we glow

7. lipofuscin
 WHY IS IT DANGEROUS ?
 A2-E (N-retinylidene-N-retinylethanol-
amine) the dominant fluorophore possess
toxic properties
 Interferes with the normal cell function
 Precursors of A2-E are also toxic
 Products of photo-oxidation of RPE
lipofuscin serves as trigger for
complement activation inflammation

8. Fundus Autofluorescence
 Major source of fundus
autofluorescence is the lipofuscin of the
RPE

9. Fundus autofluorescence
 Metabolically mapping the RPE
 Developed as a tool to evaluate the RPE
during aging and ocular disease
Andrea von Ruckmann, Fredrick W. Fitzke and Alan C. Bird- Moorfield’s
eye hospital

10. Scanning Laser
Ophthalmoscope
 Webb and co-workers
 55° of field in one frame
 Low power laser source
 Scan in x and y axis
 Confocality ensures that light fluorescence
and reflectance is derived from same ocular
plane
 HRA2: Excitation 488nm
Emitted light above 500nm

11. FAF image acquisition
ART Mean image
Live image
FAF image
OCT image

12. FAF image acquisition
 Align the camera using the IR
illumination.
 Spectralis HRA+OCT only: Once you
see a sharp well-focused image,
change to Redfree illumination to fine-
tune focus.
 Change to the FA illumination. The
image will now be considerably darker.
 Automatic (recommended!) or
manual (Spectralis HRA+OCT only)
sensitivity control will outline the
retinal blood vessels.
Turn
or
automatic

13. FAF image acquisition – Mean
function
 Activate the ART (Automatic Real
Time) Mean function to generate a ‘live
Mean’ Autofluorescence image online
and view it as it is created.
 Note: Following the injection of
fluorescein dye, it will be impossible to
perform FAF imaging.
Press

14. Normal Autofluorescence
distribution
 Optic nerve head
 Absence of
autofluorescent pigment
 Retinal blood vessels
 Absorption by blood
vessels
 Foveal area
 Absorption by luteal
pigment
 Parafoveal area
 Mildly decreased
intensity due to high
melanin content and
lower density of
lipofuscin granules in
central RPE

15. In disease state
 Excessive accumulation of lipofuscin in
the lysosomal compartment of the RPE
is the downstream process in many
hereditary and age related diseases

17. AF and ARMD- Basic
Considerations
 RPE is thought to play a key role in the
early and late phases of the disease
 Hallmark of aging is the accumulation of
lipofuscin granules in the cytoplasm of
the RPE cells
 Lipofuscin accumulation is the common
downstream process

18.  Ability to document spatial distribution of
lipofuscin and its changes over time.
 The amount of autofluorescence is signature for
previous or possible future oxidative injury
Hyperfluorescence in FAF FA 36 sec FA 69 sec

19. Geographic Atrophy
 Seen as hypo-
autofluorescent areas
 No RPE, NO
LIPOFUSCIN  NO
AUTOFLUORESCENCE
 Measure the atrophic
area to see for the
progression

20. Geographic atrophy
 Identification of peri-lesional abnormalities
 Hyperautofl signals bordering  denote sick
RPE
 The damage marches in areas of high signals
 Predictor of future trouble

21. Pigment Epithelial Detachment
 Serous PED:
 Increased FAF signal
corresponding to area of
detachmet
 Underlying CNVM: No
specific findings
 Surrounding area: Hypo AF
signal

22. Choroidal
neovascularization
 Irregular FAF in areas of CNV
 High FAF outside the edge of the
lesion
 FAF intensity decreased over the
disciform scars
 In early stages, preservation of
FAF
 Extent of abnormal areas on FAF
is more than that on FA

23. CNVM
CLASSIC FA

24. CSR
 Leaks at the level of RPE
leading to central serous
detachment
 Chronic disease associated
with atrophic changes at the
level of RPE and retina
 FA and ICG – hemodynamics
and fluid dynamics
 OCT- clues to size and
elevation of detachment
 Autofluorescence- functional
status

25. CSR

26. Bull’s eye maculopathy

27. Macular dystrophies-
Stargradt’s disease
 Areas of atrophy on fundus
corresponded to hypo-
autofluorescence
 Flecks seen as
depigmented lesion
appeared as areas of hypo-
autofl
 Predictive value is yet to be
determined

28. Macular dystrophies: Best’s
disease
 Autofl characters: central round
area of increased FAF
 Pseudohypopyon stage:
increased FAF in the lower part
 Late stages: irregular FAF
within the lesion with
disseminated spots of
increased FAF

29. Macular dystrophies: Best’s
disease
 Pattern of spread on FAF: centrifugal
 Atrophic regions are associated with low
levels of background FAF, lower visual
acuity, abnormal colour vision, central
scotomas and poorer
electrophysiological results
 FAF appears more striking and
widespread
 Spoke like, diffuse or combination

30. X-linked retinoschisis
 FAF finding reflect typical radiating
cystic changes
 The changes on FAF are most likely due
to altered passage of exciting and
emitted light from the retinal folds

31. Retinitis Pigmentosa
 In dominant and recessive
and rod-cone dystrophies
 Absent FAF in areas of outer
retinal atrophy
 Normal FAF in adjacent
regions of surviving retina
 High FAF in surviving areas in
some cases
 Macular oedema of more than
4 months  high FAF

32. Retinitis Pigmentosa
 Parafoveal ring of increased FAF
 Correlation exists between these areas
of high FAF and photopic and scotopic
sensitivity

33. Serpigenous Choroiditis
 In SC: Autofluorescence is
detected within 2-5 days
after the appearance of
lesion
 Provides a clear
delineation of the area of
RPE damage
 Progressive decrease in
autofluorescence was seen
during the scarring phase

34. APMPPE
 Affected RPE
demonstrate
increase AF in
early phase of the
disease
 More pronounced
after 3 wks
 Fade away after 1
yr.

35. Macular Hole
 Bright fluorescence of macular holes
similar to images on FA
 Pseudoholes: no such high
autofluorescence
 Attached operculum shows focal
decreased autofluorescence

36. Macular hole surgery

37. VKH
 Hypo AF in the areas of serous
detachments
 NIR AF: hyper AF at the macula and
hypo AF in the areas of serous
detachment
 With treatment: BL-FAF: subtle FAF
 NIR FAF: more wide spread FAF

38. LASER & AF
1 hour 3 hour 3 month

39. Applications for therapeutic
interventions
 In advanced atrophic AMD: useful to
develop and assess the therapeutic
interventions
 Fenritidine, an oral medicine shown to
reduce the production of toxic fluophores
 In retinal dystrophies: useful to assess
the functional preservation of the outer
retina
 In Leber’s: normal or slightly reduced FAF

40. RPE FAF & therapeutic
outcome
 The RPE-FAF of exudative AMD lesions varies
greatly.
 FAF differences have a great influence on the
chances of antivascular endothelial growth factor
(VEGF) therapy success.
 Development of visual acuity is less favorable in
eyes with initially increased central FAF.
Heimes et al. - Foveal RPE FAF as a prognostic factor for anti-VEGF therapy in exudative AMD - GraefesArch 2008

41. CONCLUSION
 Non invasive ,Easy to perform
 Provides a novel prognostic marker for
disease progression
 Metabolic changes and loss of RPE
integrity corresponds to visual function
 In combination with SD OCT it adds to
our understanding of retinal diseases
from a broad point of view.

42. THANK YOU