Michael F. Marmor, MD

Fluorescein dye entered ophthalmology in 1882 when Paul Ehrlich, MD, used it to study aqueous humor dynamics in rabbits. It was used in the ensuing decades for many applications in the eye, but not for following retinal circulation. Around 1959, Edward Maumenee, MD—then at the Stanford University Hospital in San Francisco, and later to become chair at Johns Hopkins—used fluorescein injections to distinguish retinal hemangiomas (leakage) from melanomas (no leakage) by looking at them through a cobalt blue filter at the slit lamp.[1] But he never photographed the retinal circulation.

Maumenee’s student, Milton Flocks, MD, and a fellow, Peter Chao, MD, had injected trypan blue into cats in 1958 to study circulation time, but when they tried to photograph human circulation using fluorescein and the blue filter on a Zeiss fundus camera,[2] they failed because of “insufficient light”. Meanwhile, at the University of Oregon, Drs. Kenneth Swan and Paul Bailey Jr., developed a system for fundus cinematography without using dyes.[3]

The concept of angiography might have languished at this point, but serendipity, open minds, and a bit of luck converged in 1959 outside the field of ophthalmology. At Indiana University. Pulmonologist John Hickam, MD, chair of medicine, acquired a Zeiss fundus camera, hoping that visualizing retina circulation would help him to study oxygenation. Hickam hired a medical student, Harold Novotny, to work in the lab, followed later by another medical student, David Alvis. While looking through the camera one day, Novotny commented that the lens appeared to be emitting light—and Alvis answered reflexively that it might be fluorescence. That casual remark led them to consider whether fluorescence from the fluorescein dye might be used to follow the circulation. They studied fluorescein’s spectral properties and found that fluorescein absorbed light best at 490 nm, while emitting light with a peak at 520 nm; fortuitously, these wavelengths were separable with Kodak Wratten 47 and 48 filters.  

Alvis and Novotny proposed a trial to Ophthalmology Chair Fred Wilson, MD, but he was doubtful the idea would work because of lens fluorescence. However, Hickham was still interested in oxygenation, so Alvis and Novotny persisted. They opened the Zeiss camera to insert filters in the flash and image, sought the fastest available film (2400 ASA), and took some pictures of their own eyes (long before any institutional reviews were needed). They recorded Alvis’ eye first (Figure 1), then Novotny’s, and then imaged girlfriends and others. When Hickam encouraged them to look at diseases, they walked up to the wards and asked patients if they would like their eyes tested.

Alvis and Novotny promptly wrote a paper about use of this new technique of fluorescein angiography, realizing that to be successful in science, you not only have to make a discovery but sell the product. Remember that Jan Purkinje developed an ophthalmoscope almost 30 years before Hermann von Helmholtz, but he published in Latin in Breslau (now Wroclaw). When Helmholtz rediscovered the technique, he disseminated the news rapidly in German media and became known as the father of ophthalmoscopy. But Alvis and Novotny’s paper was rejected by Derrick Vail, MD, editor of the American Journal of Ophthalmology (AJO). The reviewers said that Chao had previously imaged circulation in the cat and that Swan and Bailey had already developed fundus cinematography. The material might have died there—but the students presented their findings at the Association for Research in Vision and Ophthalmology (ARVO) meeting in 1960 and the abstract appeared in AJO. Hickam also had connections to get the paper published in Circulation in 1961,[4] although that was not read by most ophthalmologists. Meanwhile, Novotny left Indiana to study psychiatry, and Alvis started an ophthalmology residency at Wayne State University, where the chair, A.D. Ruedemann Sr, MD, had little interest in the project.

Fortunately, the word did trickle out. Noble David, MD, at Duke University saw the ARVO abstract and imaged the circulation,[5] and Sir Colin Dollery, MB, Ch, MD (Hon) in London saw the Circulation article and published a clinical paper in 1962.[6] Hickam remained interested in retinal oxygenation and didn’t use fluorescein until years later,[7] but Noble David was recruited by J. Lawton Smith, MD, to the Bascom Palmer Eye Institute, and photographer Johnny Justice soon came to produce high-quality clinical images there. Bascom Palmer Chair Edward Norton, MD, and a young retina specialist, J. Donald M. Gass, MD (Figure 2), embarked on a series of seminal reports in the mid-1960s that showed the world the power of fluorescein angiography for a wide variety of retinal diseases.[8] Eight years later, Derrick Vail apologized for missing one of the great advances in ophthalmology.  

Alvis practiced psychiatry in Palo Alto, California without regrets about leaving angiography behind, and Novotny practiced general ophthalmology and never did an angiogram again (although he kept a picture of the first one on his wall to occasionally tell the story.[9] As newer imaging techniques and dyes enter ophthalmology practice, the future of classical fluorescein angiography is uncertain. However, an understanding of retinal vasculature—its flow, its leakage, and its interaction with retinal health—remains central to the pathophysiology of retinovascular disease.

References:

1. MacLean AL, Maumenee AE. Hemangioma of the choroid. Trans Am Ophthalmol Soc. 1959;57:171-194.

2. Flocks M, Miller J, Chao P. Retinal circulation time with the aid of fundus cinephotography. Am J Ophthalmol. 1959;48:3-6. doi:10.1016/0002-9394(59)90234-x

3. Swan KC, Bailey Jr P. Cinematography of the retinal vessels. Trans Am Ophthalmol Soc. 1959;57:210-220.

4. Novotny HR, Alvis DL. A method of photographing fluorescence in circulating blood in the human retina. Circulation. 1961;24:82-86. doi:10.1161/01.cir.24.1.82

5. David NJ, Saito Y, Heyman A. Arm to retina fluorescein appearance time. A new method of diagnosis of carotid artery occlusion. Arch Neurol. 1961;5:165-170. doi:10.1001/archneur.1961.00450140047004

6. Dollery CT, Hodge JV, Engel M. Studies of the retinal circulation with fluorescein. Br Med J. 1962;2(5314):1210-1215. doi:10.1136/bmj.2.5314.1210

7. Hickam JB, Frayser R. A photographic method for measuring the mean retinal circulation time using fluorescein. Invest Ophthalmol. 1965;4(5):876-884.

8. Norton EW, Gass JD, Smith JL, Curtin VT, David NJ, Justice Jr J. Macular Diseases: Diagnosis. Fluorescein in the study of macular disease. Trans Am Acad Ophthalmol Otolaryngol. 1965;69:631-642.

9. Alvis DL. Twenty-fifth anniversary of fluorescein angiography. Arch Ophthalmol. 1985;103(9):1269. doi:10.1001/archopht.1985.01050090019002

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(Milestone essay published 2025)