The Sankara Nethralaya Atlas of Fundus Fluorescein Angiography Parveen Sen, Tarun Sharma, Muna Bhende, Pukhraj Rishi, Ekta Rishi
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The Sankara Nethralaya: Atlas of Fundus Fluorescein Angiography2
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The Sankara Nethralaya: Atlas of Fundus Fluorescein Angiography
Second Edition
Pukhraj Rishi MS DO Ekta Rishi MS Tarun Sharma MD FRCSEd MBA Muna Bhende MS Parveen Sen MS Dhanashree Ratra MS DNB FRCSEd Pradeep Susvar DO DNB MBA FRCS (Glas) Suchitra Pradeep DO Chetan Rao MS Vikas Khetan DO DNB Vinata Rajendran MS Rajesh P DNBSuganeswari G MSRupak Ray MS Rajeev Raman MS DNB Kasinathan N DO DNB FRCS (Glas) Lingam Gopal MS DNB FRCSEd All Authors are Consultants of Sri Bhagwan Mahavir Vitreoretinal Service, Sankara Nethralaya, Chennai, Tamil Nadu, India or have served as faculty in the past Foreword Lawrence A Yannuzzi
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This book has been published in good faith that the contents provided by the authors contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the authors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the authors. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device.
The Sankara Nethralaya Atlas of Fundus Fluorescein Angiography
First Edition: 2004
Reprint: 2006
Second Edition: 2013
9789350255773
Printed at
5Dedicated to
Our dear patients who indeed are the source for our knowledge and experience.
The Sankara Nethralaya Philosophy
“Let the word Sankara of Sankara Nethralaya ever remind me and my associates His Holiness' command that there be missionary spirit in the project.
Let the word Nethralaya constantly remind me and my colleagues that the place of our work is an alaya (temple).
Work will be our worship which we shall do with sincerity, dedication and utmost love.”
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7Foreword
For more than three decades, retinal specialists and ophthalmologists have enhanced their diagnostic and therapeutic skills through the diagnostic adjunct, fluorescein angiography. Numerous texts and atlases have been written on the interpretation of this procedure in English, French, Italian, German, and Japanese. The authors of this text have taken full advantage of their regional experience and encyclopedic knowledge of chorioretinal diseases by focusing on seven distinct divisions of retinal and macular disease in categorizing a myriad of abnormalities.
Thanks to them, there is for the first time an atlas on the subject of fluorescein angiography with a preferential emphasis on disorders prevalent in India. Arrays of excellent photographs have been used to fulfill this purpose, preceded by a section on technique and methodology to provide physicians-in-training and ophthalmic technicians, with the fundamentals needed to incorporate this discipline in their overall ophthalmic evaluations. The text is not meant for to describe new disease or new clinical manifestations and pathogenetic mechanisms in old disease. Nor does it provide an extensive bibliography to expand the potential for research of a given subject. The principal purposes are to introduce images for pattern recognition by clinicians to use in their practice, to enable a more accurate diagnosis, and in turn, to offer patients a more appropriate and effective treatment. Yet, the authors have in their preparation introduced new insight into pathophysiological mechanism of disease in the ocular fundus and offered unusual and challenging images which enhances our appreciation of these peculiar diseases.
In short, this volume represents a high level of industry, initiative, intuition, and intelligence by a group of skilled ophthalmologists and clinical scientists. Their efforts will be reciprocally rewarded by the gratitude of the ophthalmologists and retinal specialists who read this text and by the incalculable pleasure their photographs will bring, even to the casual and discerning reader.
Lawrence A Yannuzzi md
Vice-Chairman
Department of Ophthalmology and Director of Retinal Services
Manhattan Eye, Ear and Throat Hospital
Professor of Clinical Ophthalmology College of Physicians and Surgeons Columbia University, USA
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9Preface to the Second Edition
A lot has changed in the field of vitreous-retina since the first edition of The Sankara Nethralaya Atlas of Fundus Fluorescein Angiography came out in 2004. Not only has our ability to investigate and diagnose clinical conditions improved but also the rapidly evolving treatment options have had a major impact on disease modulation. This has been possible due to the significant advances in multimodal retinal imaging, the advent of anti-VEGF era and path-breaking changes in drug delivery systems. A good knowledge of the changes occurring in the fluorescein angiogram is not only important for correct diagnosis and management of eye disorders, but also in determining treatment end-points. Even though OCT is fast emerging as a non-invasive retinal imaging tool, the role of FFA in diagnosis and treatment follow-up remains integral to the management of retinal conditions.
The aim of bringing out this Atlas is to have a comprehensive reference guide on the fluorescein angiographic findings in different disorders, so as to help the reader in understanding and managing these types of cases. The book is not intended to be a textbook on fluorescein angiography; the script has been kept to the minimum. This book intends to be a ready-reckoner for the practicing vitreoretinal surgeon/medical retina specialist as much as a reference guide for the vitreoretinal fellow. The same holds true for the Uvea specialists and fellows, respectively. Comprehensive ophthalmologists will find this atlas extremely useful in arriving at the correct diagnosis and appropriate management of their patients.
In this edition, we have added twenty-one new chapters and revised most of the previous ones. In doing so, we have preserved the original format of the chapters and the layout of the sections. A ‘Self-test’ chapter has been included in the end. Each section has been color coded which improves its user-friendliness while adding to the esthetic appeal of the book. Approximately, 400 new images have been added. References have been revised and updated. Also, in this edition we have included a Photo CD-ROM so that the tech-savvy user can browse the book ‘on the go’.
Authors
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11Preface to the First Edition
Fundus fluorescein angiography has played a crucial role in our understanding of different disease processes affecting the eye. A good knowledge of the changes occurring in the fluorescein angiogram is important for correct diagnosis and management of eye disorders. With this in mind, we decided to compile the cases seen at Sankara Nethralaya and publish it in the form of an Atlas. The aim of bringing out this Atlas is to have a comprehensive book on the fluorescein angiographic findings in different disorders, so as to help the reader in understanding the disorder and in managing these types of cases.
The vitreoretinal service at Sankara Nethralaya examines about 300 patients and undertakes 25 to 30 fluorescein angiography procedures everyday. These images are stored in the digital archival system, an excellent source for selecting cases for this Atlas. The meticulous manner in which records are maintained has greatly helped in making of this Atlas. All the cases, without exception, have been seen at Sankara Nethralaya, Chennai.
The book is not intended to be a textbook on fluorescein angiography; the script has been kept to the minimum. On the other hand, a color fundus photograph, a red free photograph and pictures of different phases of the angiogram are included for almost all cases. A detailed legend is given for all photographs.
The book has been divided into seven major sections with separate color coding for each. This was done to make the book as user-friendly as possible. Every attempt has been made to include as many representative cases as possible in each section.
Authors
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13Acknowledgments
As in the first edition of this Atlas, Dr SS Badrinath has been the driving force in bringing out the second edition of this Atlas, too. His constant emphasis on maintaining good clinical records in the electronic medical record (EMR) era proved extremely useful in bringing out this edition. This Atlas is a testimony of the excellent teamwork involving all the Consultants and the Vitreoretinal fellows at Sankara Nethralaya. Cases published in this Atlas were contributed by the Consultants. Special thanks to Dr Jyotirmay Biswas and Dr Suchitra Pradeep from the Uvea department for their contributions. The vitreoretinal fellows helped in collecting and compiling the cases. Our sincere thanks and gratitude to all the following:
Consultants
Vitreoretinal Fellows
Dr Jyotirmay Biswas
Dr Sabyasachi Sen Gupta
Dr Pramod Bhende
Dr Harshali Kamat
Dr Pratik Ranjan Sen
Dr Sukant Pandey
Dr Rajeev Raman
Dr Bindu Appukuttan
Dr Kasinathan N
Dr V Jaya Prakash
Dr Pradeep S
Dr Aditi Gupta
Dr Suchitra Pradeep
Dr Sayalee Lahane
Dr Chetan Rao
Dr Sandhya Hegde
Dr Vikas Khetan
Dr J Sumanth Reddy
Dr Vinata R
Dr Yogesh Patil
Dr Rajesh P
Dr Suganeswari
Dr Rupak Ray
Dr Kumar Saurabh
Dr Sudipta Das
Special thanks go to our photography department headed by chief photographer, Mr MS Krishna and ably supported by Mr K Chidambaram, Mr CS Hariharan, Mr T Ravishankar, Mr M Thilak, Mr Shankar K (photographers), and Mrs Vanitha S and Shanthi P (Nursing staff). The entire credit for the quality of photographs goes to the photography team.
Mr Sampath Kumar, Mr Manavalan and their team from the IT department facilitated retrieval of images and provided easy solutions for data management.
Our sincere thanks to the publishers M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi for their technical assis­tance and for printing and publishing the Atlas on time.
Last but by no means the least, we offer our humble gratitude to all our patients for trusting us and letting us participate in the management of their eye problems.
We thank Dr Nitin Shetty, Dr Mahesh Shanmugam, Dr Lekha Gopal, and Dr Preetam Samant for their efforts in bringing out the first edition to this Atlas.