Reporting FFA for Choroidal Neovascular Membrane (CNVM) and Polypoidal Choroidal Vasculopathy (PCV)

Part 1: FFA Reporting for CNVM (Macular Neovascularization / MNV)

A. Preparation & Technical Adequacy

• Field of view: typically 30-40 degree stereoscopic images
• Phases captured: choroidal/pre-arterial, arterial, arteriovenous, venous, and late (recirculation) phase up to 10 minutes
• Image quality: adequacy of dye transit, media clarity, patient fixation
• Laterality: right eye / left eye, both eyes if bilateral

B. Classify the CNVM Type (MPS-Based Classification, still clinically used)

1. Classic CNVM (= Type 2 MNV)

• Early phase: well-defined, bright "lacy" or "wheel-within-a-wheel" pattern of hyperfluorescence appearing in the arterial or early arteriovenous phase (within first 30-60 seconds)
• Mid phase: progressive, intense hyperfluorescence with leakage expanding beyond the original borders over 1-2 minutes
• Late phase: persistent staining of fibrous tissue; boundaries become indistinct due to leakage into subretinal space
• Key report phrase: "Well-defined area of early hyperfluorescence with progressive leakage consistent with classic (Type 2) MNV"

2. Occult CNVM (= Type 1 MNV)

• Early-mid phase (1-2 min): irregular, stippled or mottled hyperfluorescence with ill-defined borders at the level of the RPE
• Fluorescence persists or increases in intensity into the late phase without pooling
• Key report phrase: "Irregular stippled hyperfluorescence of undetermined extent appearing in the early-mid phase, consistent with fibrovascular PED (occult/Type 1 MNV)"

• Early and mid phases: no discernible abnormality
• Late phase only (>2 min): poorly demarcated leakage at the level of RPE, appearing without any corresponding early-phase source
• Key report phrase: "Late-phase poorly demarcated leakage at the RPE level with no early-phase correlate, consistent with LLUS (occult MNV)"

3. Mixed CNVM (Predominantly Classic / Minimally Classic)

C. Lesion Characteristics to Report

Location Relative to Fovea

• Subfoveal: center of lesion involves the geometric center of the foveal avascular zone (FAZ)
• Juxtafoveal: lesion within 1-199 µm from the FAZ center (or within 200 µm of FAZ)
• Extrafoveal: lesion margin is ≥200 µm from the FAZ center

Lesion Size

• Greatest Linear Dimension (GLD): measured in disc areas (DA) or disc diameters (DD), or in microns on calibrated digital systems
• Measure from the frame where the CNV first becomes visible:
  • Classic: earliest arterial frame where the lacy network appears
  • Occult FV-PED: early-mid phase (1-2 min frame)
  • LLUS: late-phase frame
• Report: "GLD approximately ___µm / ___DA"

Associated Non-CNV Lesion Components

• Elevated blocked fluorescence (hypofluorescent): due to blood, pigment, or fibrous tissue overlying or adjacent to CNV
• Thick blood: uniform blocked fluorescence without internal detail
• Serous PED: smooth dome-shaped hyperfluorescence with uniform pooling, well-demarcated borders, no leakage beyond the PED margins
• RPE atrophy / window defect: early hyperfluorescence persisting without change in intensity or size throughout the study (transmission defect)
• Fibrous scar/disciform: late staining without early leakage in an evolved lesion

Total Lesion Area

D. Lesion Activity

• Active: progressive leakage increasing in intensity and area across phases
• Inactive / Fibrotic: staining without leakage; no progression across phases
• Hemorrhage: blocked fluorescence; note extent relative to lesion

E. Additional Features

• Feeder vessel (if visible): location and course
• Retinal angiomatous proliferation (Type 3 MNV): focal intraretinal hot spot, hairpin loop vessel on ICGA; FA resembles occult MNV
• Associated RPE tear: relative hypofluorescence over the folded flap + adjacent hyperfluorescence where RPE is absent

Part 2: FFA Reporting for Polypoidal Choroidal Vasculopathy (PCV)

Important Caveat on FFA vs. ICGA in PCV

A. FFA Findings in PCV (What to Report)

B. ICGA Findings in PCV (Essential for Complete Reporting)

C. PCV Classification Based on FFA + ICGA (Tan et al.)

D. Lesion Characterization in PCV (Report These Elements)

1. Location: peripapillary (most common), macular, peripheral
2. Number of polyps: single vs. multiple
3. Cluster pattern: grape-like cluster carries higher risk of severe visual loss
4. PED characteristics: number, size, type (serous, hemorrhagic), "double-hump" or "inverted V" sign
5. Subretinal/sub-RPE hemorrhage: extent, proximity to fovea
6. Greatest linear dimension (GLD): measured from combined FFA + ICGA (FFA alone may underestimate due to poor BVN visualization)
7. Neurosensory detachment: presence and extent
8. Activity: active leakage vs. quiescent

Part 3: Structured Reporting Template

For CNVM:

FFA Report - CNVM / MNV

Eye: R / L / Bilateral
Indication: Suspected MNV / follow-up post anti-VEGF

Technical adequacy: Adequate / Suboptimal (reason)
Phases captured: Choroidal / Arterial / Arteriovenous / Venous / Late (10 min)

FINDINGS:

1. CNV Type:
   [ ] Classic (Type 2 MNV) — early lacy hyperfluorescence with progressive leakage
   [ ] Occult - FV-PED (Type 1 MNV) — stippled early-mid phase hyperfluorescence
   [ ] Occult - LLUS — late-phase leakage only
   [ ] Mixed: predominantly classic / minimally classic

2. Lesion Location (relative to FAZ center):
   [ ] Subfoveal  [ ] Juxtafoveal (<200 µm)  [ ] Extrafoveal (≥200 µm)
   Distance from FAZ center: ___µm

3. Lesion Size:
   GLD: ___µm / ___DA   Total lesion area: ___DA

4. Non-CNV Lesion Components:
   [ ] Elevated blocked fluorescence  [ ] Thick blood  
   [ ] Serous PED  [ ] RPE atrophy/window defect
   [ ] Fibrous scar

5. Activity:
   [ ] Active (progressive leakage)  [ ] Inactive (staining only)

6. Hemorrhage: [ ] Present — extent ___  [ ] Absent

IMPRESSION:
[Type] MNV, [location] location, [size] GLD, [active/inactive].
Suggest ICGA if Type 1/PCV suspected.

For PCV:

FFA + ICGA Report - PCV

Eye: R / L / Bilateral
Indication: Suspected PCV / follow-up

FFA FINDINGS:
- PED: number ___, type (serous/hemorrhagic), size ___
- Polypoidal hyperfluorescence: present / absent
- Blocked fluorescence (hemorrhage): extent ___
- Window defects (RPE atrophy): present / absent
- Leakage pattern: occult-type / late leakage

ICGA FINDINGS:
- Branching vascular network (BVN): present / absent; location ___
- Polypoidal lesions: number ___, location (peripapillary / macular / peripheral)
- Hypofluorescent halo: present / absent (pathognomonic)
- Late geographic hyperfluorescence: present / absent
- Choroidal hyperpermeability: present / absent
- Cluster of polyps: present / absent

LESION CHARACTERIZATION:
- GLD (FFA + ICGA combined): ___µm / ___DA
- Neurosensory detachment: present / absent
- Sub-RPE hemorrhage: present / absent; extent ___

PCV CLASSIFICATION (Tan et al.):
[ ] PCV with leaky BVN
[ ] PCV with interconnecting channels
[ ] PCV with non-leaking BVN

ACTIVITY: Active / Quiescent

IMPRESSION:
Polypoidal choroidal vasculopathy with [number] polyp(s) at [location], 
[with/without] leaky BVN, GLD ___, [active/quiescent].
[Recommend PDT +/- anti-VEGF based on EVEREST-II protocol]

Key Distinguishing Points: CNVM vs. PCV on FFA