Anatomy, Physiology, Pathology
16%of exam
Patient Management and Safety
6%of exam
General Photography
10%of exam
Data and Image Management
4%of exam
Fundus Photography and SLO
23%of exam
Monochromatic and Autofluorescence
5%of exam
Fluorescein Angiography
25%of exam
ICG Angiography
3%of exam
Pharmacology
5%of exam
Other Imaging Technology
3%of exam
Quick Facts
- Exam
- OPS CRA
- Items
- 175 four-option questions
- Time
- 2 hours
- Format
- Closed book, computer-based
- Guessing
- No penalty; blanks incorrect
- Pass
- Angoff cut, scaled score
- Vendor
- Prometric test centers
- Fee
- $465 member, $590 non-member
- Retake
- $285; four per 12 months
- Eligibility
- Portfolio, 2 years, CPR
- Renew
- 3 years, 15 CECs
- Blueprint
- Guide v15.1, June 2026
Blueprint Weight Order
FA 25, fundus 23, anatomy 16, photography 10
FA: 43 itemsFundus: 40 itemsAnatomy: 28 itemsPhotography: 18 items
Ocular Anatomy Essentials
- Inner retina supply
- Central retinal artery
- Choroid supply
- Short posterior ciliary arteries
- Outer retina supply
- Choriocapillaris by diffusion
- Choriocapillaris
- Fenestrated; leaks dye freely
- Large choroidal vessels
- Impermeable to fluorescein
- Inner barrier
- Tight endothelial junctions
- Outer barrier
- RPE tight junctions
- RPE role
- Filters choroidal fluorescence
- Xanthophyll
- Absorbs blue exciting light
- Foveal avascular zone
- Capillary-free, appears dark
- Late staining sites
- Disc, Bruch membrane, sclera
Disease FA Signatures
- Stargardt disease
- Silent choroid, bull's-eye macula
- APMPPE
- Blocks early, stains late
- Central serous
- Smokestack or inkblot leak
- Cystoid macular edema
- Late petaloid leakage
- Classic CNV
- Early lacy net, late leak
- Occult CNV
- Late, ill-defined leakage
- Microaneurysms
- Pinpoint dots that leak
- RPE window
- Bright early, no growth
- Preretinal hemorrhage
- Dense early blockage
- Vein occlusion
- Delayed filling, late leakage
- Artery occlusion
- Delayed arterial filling
- Normal disc
- Late staining is expected
Adverse Reaction Response
- Transient nausea→Reassure, keep shooting(Clears 1-2 min)
- Vomiting→Basin, pause imaging(Protect airway)
- Itching or hives→Antihistamine, observe(Watch for escalation)
- Wheeze or stridor→Epinephrine, oxygen, physician(Airway emergency)
- Pale, sweating, faint→Lay flat, elevate legs(Vasovagal)
- Dye infiltrates arm→Stop, cold compress(Reassess until resolved)
- Seizure or arrest→Activate emergency response(Begin CPR)
Adverse Reactions
- Nausea
- Most common reaction
- Onset
- 30-60 s after injection
- Duration
- One to two minutes
- Moderate reactions
- Under 2 percent
- Recent overall rate
- Just over 1 percent
- Historic rate
- 5-10 percent reported
- Death risk
- 1 in 222,000
- Extravasation
- Painful; dye pH 8-9.8
- Extravasation care
- Cold compress 5-10 min
- Vasovagal
- Anxiety drops pulse, pressure
- Crash cart
- Epinephrine, oxygen, airway
Patient Prep and Consent
- Flashlight exam
- Screen before dilating
- Dilation contraindication
- Narrow angles
- Written consent
- Required for angiography
- History review
- Allergies, pregnancy, ocular history
- Prior reaction
- Sensitivity can increase
- Universal precautions
- CDC standard practice
- CPR
- Current certificate required
- HIPAA
- Images are protected information
- Fourth retest failed
- Six-month wait follows
Digital Imaging Terms
- Resolution
- Detail the sensor records
- Bit depth
- Tonal steps per channel
- Dynamic range
- Darkest to brightest recorded
- Gain
- Amplifies signal and noise
- ISO
- Sensor sensitivity setting
- Gamma
- Shape of tone curve
- Color balance
- Neutralizes illumination color
- Monitor calibration
- Matches display to standard
- Lossless
- No data discarded
- Resampling
- Changes total pixel count
- Montage
- Composite of several fields
Digital Artifacts
- Blooming
- Charge spills into neighbors
- Noise
- Random speckle from gain
- Over-sharpening
- Bright halos along edges
- Interpolation
- Software-invented pixel data
- Sensor dust
- Fixed dark specks
- Pixel dropout
- Dead sensor elements
- Oversaturation
- Color clipped, detail lost
- Underexposure
- Dark, noisy shadow detail
Data and Archiving
- DICOM
- Medical imaging file standard
- PACS
- Image archive and retrieval
- EMR
- Electronic medical record
- HIPAA
- Privacy and security rules
- Firewall
- Blocks unauthorized network access
- Wireless risk
- Transmissions need protection
- Backup
- Second copy, separate media
- Retention
- State and federal rules
Portfolio Numbers
Thirty colors, four angiograms, sixteen proofs
30 color images4 different patients3 must show pathology16 images per proof
Fundus Camera vs SLO
Fundus camera
- Flash floods whole field
- White light illumination
- Manual stereo shift
SLO
- Laser scans point by point
- Confocal rejects scatter
- High frame rates
Flash vs scanning laser
Fundus Camera Basics
- Standard field
- 30 degrees for macula
- Wide field
- 50-60 degree cameras
- Ultra-wide field
- 100 degrees or greater
- Reticule
- Set to photographer's eye
- Focus order
- Reticule first, then fundus
- Stereo technique
- Lateral camera shift
- Diopter compensation
- High myopia, aphakia
- Astigmatic device
- Corrects corneal astigmatism
- Routine maintenance
- Bulbs, flash tubes, fuses
- SLO advantage
- Confocal; rejects scattered light
Mydriatic vs Non-mydriatic
Mydriatic
- Dilating drops first
- Best image quality
- Angle screening needed
Non-mydriatic
- Infrared alignment view
- Works on small pupils
- Screening workflows
Quality vs convenience
Image Quality Faults
- Crescent
- Lateral misalignment at pupil
- Eyelash shadow
- Dark arc from lid
- Dust artifact
- Same spot every frame
- Small pupil
- Peripheral haze, vignetting
- Media opacity
- Cataract scatters light
- Focus error
- Reticule not set
- Motion blur
- Patient or operator movement
- Lost fixation
- Eye drifts off target
Portfolio Requirements
- Color section
- Thirty required images
- Portfolio A
- 90 degrees or less
- Portfolio B
- 100 degrees or greater
- Angiogram section
- Four different patients
- Pathology rule
- Three of four
- Proof sheet
- 16 images, timer visible
- FA frames
- Early, mid, late
- Monochromatic pair
- Disc field, fovea field
- Rating standards
- Intent, field, focus
- More standards
- Exposure, contrast, artifacts
- Extra images
- Cause an unsatisfactory rating
- Lead time
- Submit eight weeks ahead
Monochromatic Wavelengths
Blue 480, green 540, red 640, infrared 800
Blue: nerve fiber layerGreen: vessels and bloodRed: RPE and choroidInfrared: deepest layers
Filter Picker
- Nerve fiber layer→Blue ~480 nm(Also epiretinal membranes)
- Vessels and hemorrhage→Green ~540 nm(Red-free baseline)
- Choroidal nevus→Red ~640 nm(Pigment turns transparent)
- Deep choroidal detail→Infrared ~800 nm(Best penetration)
- Map lipofuscin→Blue autofluorescence(488 nm excitation)
- Map melanin→Infrared autofluorescence(No dye needed)
Monochromatic and Autofluorescence
- Blue ~480 nm
- Nerve fiber layer, membranes
- Green ~540 nm
- Vessels, hemorrhage, drusen, exudate
- Red ~640 nm
- RPE and choroidal lesions
- Infrared ~800 nm
- Deepest choroidal penetration
- Red-free origin
- Vogt named it, 1925
- Scatter rule
- Shorter wavelength scatters more
- Blue AF excitation
- 488 nm laser
- Blue AF fluorophore
- Lipofuscin in RPE
- Infrared AF fluorophore
- Melanin
- Normal vessels
- Dark; blood absorbs light
- Normal fovea
- Dark from xanthophyll
- Averaging
- Raises signal, cuts noise
- Bleaching artifact
- Repeated exposure dims signal
FA Phase Order
Choroid, artery, AV, vein, mid, late
Choroid: 10-12 sArtery: 1-2 s laterAV: laminar veinsPeak: 30-35 sMid: 2-4 minLate: 5+ min
Leakage vs Staining
Leakage
- Area grows larger
- Margins blur out
- Brightens through study
Staining
- Area stays same size
- Margins stay defined
- Appears only late
Spreads vs holds shape
Hyperfluorescence Picker
- Bright early, unchanged late→Transmission defect(RPE atrophy)
- Bright early, grows late→Leakage(New or leaky vessels)
- Bright late, borders fixed→Staining(Dye held in tissue)
- Bright late, fills space→Pooling(Serous detachment)
- Bright before injection→Autofluorescence(Disc drusen)
- Bright on control frame→Pseudofluorescence(Replace worn filters)
FA Phase Timing
- Arm-to-retina
- 10-15 s typical
- Choroidal flush
- Dye in choroid, 10-12 s
- Flush look
- Patchy, mottled, lobular
- Arterial phase
- 1-2 s after choroid
- Arteriovenous phase
- Laminar flow in veins
- Venous phase
- Veins fill over 10 s
- Peak fluorescence
- 30-35 s post-injection
- Mid phase
- 2-4 min, recirculation
- Late phase
- 5+ min, elimination
- Cilioretinal artery
- Fills with choroidal flush
Four Hyperfluorescence Mechanisms
Transmission, leakage, staining, pooling
Transmission: RPE windowLeakage: dye escapesStaining: tissue holds dyePooling: fills a space
Pooling vs Leakage
Pooling
- Fills an anatomic space
- Sharp-edged reservoir
- Serous detachment
Leakage
- No confining space
- Diffuses into tissue
- Neovascular membrane
Contained vs diffusing
Hypofluorescence Picker
- Vessels fill, area dark→Blockage(Something covers it)
- Retinal vessels hidden→Superficial blocker(Preretinal blood)
- Retinal vessels still seen→Deep blocker(Sub-RPE or choroidal)
- Vessels never fill→Filling defect(Ischemia)
- Patchy capillary dropout→Nonperfusion(Diabetic or occlusive)
- Whole study delayed→Poor ocular perfusion(Check carotid)
Hyperfluorescence Causes
- Transmission defect
- RPE atrophy unmasks choroid
- Leakage
- Dye escapes abnormal vessels
- Staining
- Late dye held in tissue
- Pooling
- Dye fills anatomic space
- Autofluorescence
- Real fluorescence, no dye
- Pseudofluorescence
- Filter crossover artifact
- Neovascularization
- New vessels leak profusely
Two Hypofluorescence Mechanisms
Either blocked or never filled
Blocked: covered fluorescenceFilling defect: no perfusion
Blockage vs Filling Defect
Blockage
- Vessels fill normally
- Something covers the glow
- Blood, pigment, exudate
Filling defect
- Vessels do not fill
- No dye arrives
- Ischemia or occlusion
Covered vs unperfused
Hypofluorescence Causes
- Blockage
- Material covers fluorescence
- Preretinal blood
- Hides retinal vessels too
- Deep blood
- Retinal vessels still visible
- Pigment
- Melanin blocks choroidal glow
- Hard exudate
- Lipid blocks fluorescence
- Filling defect
- Dye never arrives
- Capillary nonperfusion
- Ischemic dark patches
- Vascular occlusion
- Delayed or absent filling
Filter Wavelengths
Excite 465-490, barrier 520-530
Exciter: blue goes inBarrier: yellow-green comes outICG: 805 in, 830 out
Autofluorescence vs Pseudofluorescence
Autofluorescence
- Genuine tissue fluorescence
- Disc drusen, lipofuscin
- Present before injection
Pseudofluorescence
- Filter transmission overlap
- Reflected, not emitted, light
- Fix by replacing filters
Tissue vs filters
FA Filters and Optics
- Exciter filter
- Blue, 465-490 nm
- Barrier filter
- Yellow-green, 520-530 nm
- Fluorescence
- Absorb blue, emit green
- Matched pair
- Exciter and barrier together
- Filter overlap
- Causes pseudofluorescence
- Control photo
- Angiographic settings, before injection
- Red-free baseline
- Green filter, 540-570 nm
- Stereo pair
- Shift camera few millimeters
- Capture rate
- About 1 frame per second
FA vs ICG
Fluorescein
- Exciter 465-490 nm
- Emits 520-530 nm
- About 80% protein bound
- Shows retinal circulation
ICG
- Absorbs about 805 nm
- Emits about 830 nm
- Nearly 98% protein bound
- Shows choroidal circulation
Retina vs choroid
ICG Dye Facts
- Peak absorption
- 805 nm, near infrared
- Peak emission
- 830 nm
- Working band
- 800-850 nm
- Why infrared
- RPE transmits it efficiently
- Protein bound
- Nearly 98 percent
- Main carrier
- Albumin, about 95 percent
- Vial
- 25 mg lyophilized powder
- Contains
- Up to 5% sodium iodide
- Diluent
- Sterile water for injection
- Clearance
- Liver into bile
- Best target
- Choroidal circulation
Sodium Fluorescein Facts
- Adult dose
- 500 mg intravenous bolus
- Packaging
- 5 mL 10%, 2 mL 25%
- Pediatric dose
- 35 mg per 10 lb
- Protein bound
- About 80 percent
- Free fraction
- Only unbound dye fluoresces
- Molecular weight
- 376
- Peak fluorescence pH
- 7.4
- Solution pH
- 8 to 9.8
- Clearance
- Kidneys, urine 24-36 h
- Skin color
- Yellow, fades in hours
- Lab tests
- Fluorescein skews assays
Topical Agents
- Mydriatic
- Dilates the pupil
- Tropicamide
- Short-acting mydriatic
- Phenylephrine
- Dilates without cycloplegia
- Cycloplegic
- Also blocks accommodation
- Miotic
- Constricts the pupil
- Pilocarpine
- Classic miotic agent
- Topical anesthetic
- Numbs corneal surface
- Punctal occlusion
- Limits systemic absorption
- Expiry check
- Verify dates, contamination
Imaging Modality Picker
- Retinal leakage question→Fluorescein angiography(Gold standard)
- Choroidal circulation question→ICG angiography(Sees through blood)
- Measure retinal thickness→OCT(Cross-section)
- Flow map without dye→OCT angiography(No injection)
- Documented dye allergy→OCT or OCT-A(Avoids injection)
- Screening without drops→Non-mydriatic camera(Infrared alignment)
- Far peripheral lesion→Ultra-wide field(One capture)
Other Imaging Modalities
- OCT
- Cross-sectional retinal scan
- OCT angiography
- Flow contrast, no dye
- Anterior segment OCT
- Cornea and angle
- Slit lamp imaging
- Anterior segment photography
- Non-mydriatic camera
- Infrared view, no drops
- Ultra-wide field
- Periphery in one capture
Common Traps
Window defect vs transmission defect
Same mechanism, two names ≠ RPE atrophy unmasks choroid
Portfolio is not an exam
Portfolio gates eligibility ≠ One written exam only
Web page conflicts with guide
Requirements page says 2.5 hours ≠ Program guide says 2 hours
Staining is not leakage
Staining keeps its borders ≠ Leakage expands over time
Autofluorescence is not pseudofluorescence
Autofluorescence comes from tissue ≠ Pseudofluorescence comes from filters
Iodide belongs to ICG
ICG vial contains sodium iodide ≠ Fluorescein carries no iodide
Dye clearance routes differ
Fluorescein leaves by kidneys ≠ ICG leaves by liver
Green filter is not barrier
Red-free is baseline illumination ≠ Barrier filter sits after fluorescence
Blanks are not neutral
Unanswered scored as incorrect ≠ No penalty for guessing
Passing gives no score
Pass reported without number ≠ Failures get scaled score
Retest limit is per year
Four retests within 12 months ≠ Six-month wait after the fourth
Last Minute
- 1.175 items, 2 hours, four options
- 2.FA 25%, fundus 23%, anatomy 16%
- 3.Photography 10%, patient care 6%
- 4.ICG 3%, other imaging 3%
- 5.Choroidal flush 10-12 seconds
- 6.Peak fluorescence 30-35 seconds
- 7.Mid phase 2-4 minutes
- 8.Late frames 5+ minutes post-injection
- 9.Exciter 465-490; barrier 520-530
- 10.ICG 805 in, 830 out
- 11.Fluorescein 80% bound; ICG 98%
- 12.Fluorescein renal; ICG hepatic
- 13.Hyper: transmission, leakage, staining, pooling
- 14.Hypo: blockage or filling defect
- 15.Pooling fills a space
- 16.Blockage spares vessel filling
- 17.Portfolio: 30 colors, 4 angiograms
- 18.Extravasation: cold compress, reassess
- 19.Recert: 15 CECs, 3 years
- 20.Prometric centers; guessing not penalized
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