Retinal oxygen consumption during hyperglycemia in patients with diabetes without retinopathy

Comparison of the optical coherence tomography-angiography (OCT-A) vascular measurements between molecularly confirmed MODY and age-matched healthy controls

AIMS

Previous structural, vascular density, and perfusion studies have mostly comprised type 1 and type 2 diabetes, even in the absence of retinopathy. The current study aimed to compare macular vessel density (VD) measurements between maturity-onset diabetes of the young (MODY) patients and controls.

METHODS

The macular VD of superficial, deep retina, and choriocapillaris (CC), and central macular thickness (CMT), foveal avascular zone (FAZ), FAZ perimetry, VD of the total retina at 300 µm around the FAZ (FD), and acirculatory index (AI) measurements were taken and analyzed via OCT-A (RTVue XR 100-2 Avanti, AngioVue) and were compared between molecularly confirmed MODY (glucokinase (GCK) variants) patients and healthy controls.

RESULTS

Twenty-five MODY patients and 30 healthy controls were included in the study. The mean plasma hemoglobin A1c level in the MODY group was 6.39 ± 0.38. The mean age was 13.8 ± 2.1 in the MODY group and was 12.6 ± 2.5 years among controls. There was no significant difference in terms of the age, superficial and deep retinal VD, FAZ, FAZ perimetry, CMT, FD, or AI between the groups. Compared to the healthy controls, a slight but significant increase in the CC-VD was detected in the MODY group, but only in the parafoveal and perifoveal regions (p = 0.034, p = 0.009).

CONCLUSION

The significant CC-VD increase in the MODY group might be associated with hyperglycemia and/or relatively poor and vulnerable peripheral vascular CC perfusion compared to the central. Previous thickness and VD results of childhood or adolescent diabetes were distributed in a wider range, suggesting that various factors, including some not yet clearly defined, may affect the choroidal vasculature independently of glycemia or as a contributing factor.

Potential measurement error from vessel reflex and multiple light paths in dual-wavelength retinal oximetry

PURPOSE

This study aims to characterize the dependence of measured retinal arterial and venous saturation on vessel diameter and central reflex in retinal oximetry, with an ultimate goal of identifying potential causes and suggesting approaches to improve measurement accuracy.

METHODS

In 10 subjects, oxygen saturation, vessel diameter and optical density are obtained using Oxymap Analyzer software without diameter correction. Diameter dependence of saturation is characterized using linear regression between measured values of saturation and diameter. Occurrences of negative values of vessel optical densities (ODs) associated with central vessel reflex are acquired from Oxymap Analyzer. A conceptual model is used to calculate the ratio of optical densities (ODRs) according to retinal reflectance properties and single and double-pass light transmission across fixed path lengths. Model-predicted values are compared with measured oximetry values at different vessel diameters.

RESULTS

Venous saturation shows an inverse relationship with vessel diameter (D) across subjects, with a mean slope of -0.180 (SE = 0.022) %/μm (20 < D < 180 μm) and a more rapid saturation increase at small vessel diameters reaching to over 80%. Arterial saturation yields smaller positive and negative slopes in individual subjects, with an average of -0.007 (SE = 0.021) %/μm (20 < D < 200 μm) across all subjects. Measurements where vessel brightness exceeds that of the retinal background result in negative values of optical density, causing an artifactual increase in saturation. Optimization of model reflectance values produces a good fit of the conceptual model to measured ODRs.

CONCLUSION

Measurement artefacts in retinal oximetry are caused by strong central vessel reflections, and apparent diameter sensitivity may result from single and double-pass transmission in vessels. Improvement in correction for vessel diameter is indicated for arteries however further study is necessary for venous corrections.

Sensitivity and specificity of optical coherence tomography angiography for diagnosis and classification of diabetic retinopathy; a systematic review and meta-analysis

BACKGROUND

Optical coherence tomography angiography (OCTA) is a noninvasive imaging method that can be used for the staging of diabetic retinopathy. In addition, alterations in OCTA parameters can precede the clinical fundus changes. In this review, we aimed to assess the accuracy of OCTA in diagnosis and staging of diabetic retinopathy.

METHODS

Two independent reviewers participated in the literature search using electronic databases (PubMed, Embase, Cochrane Library Central Register of Controlled Trials, ISI, and Scopus) from inception till December 2020. The heterogeneity of data was assessed by Q statistics, Chi-square test and I2 index.

RESULTS

Forty-four articles published from 2015 to the end of 2020 were included in this meta-analysis. Of these, 27 were case-control studies, 9 were case series, and 8 were cohort studies. In total, 4284 eyes of 3553 patients were assessed in this study. OCTA could differentiate diabetic retinopathy from diabetes without diabetic retinopathy with a sensitivity of 88% (95% CI: 85% to 92%) and specificity of 88% (95% CI: 85% to 91%). In addition, it could differentiate proliferative diabetic retinopathy from non-proliferative diabetic retinopathy with a sensitivity of 91% (95% CI: 86% to 95%) and specificity of 91% (95% CI:86% to 96%). The sensitivity of OCTA for diagnosing diabetic retinopathy was increased by the size of scan (3 × 3 mm: 85%; 6 × 6 mm: 91%, 12 × 12 mm: 96%).

CONCLUSION

OCTA, as a non-invasive method, has acceptable sensitivity and specificity for diagnosis and classification of diabetic retinopathy. A larger scan size is associated with more sensitivity for discriminating diabetic retinopathy.

Dual wavelength retinal vessel oximetry - influence of fundus pigmentation

BACKGROUND

Clinical methods examining oxygenation parameters in humans have been used in many different care settings, but concerns have been raised regarding their clinical utility when assessing people with darker skin pigmentation. While saturation values can be crucial in emergency medicine, they are equally valuable in assessing disease mechanisms and monitoring change in disease progression. Retinal pigmentation varies across individuals and hence, can impact on retinal oxygen parameters. The objective of this study was to quantify and eliminate the impact of retinal pigmentation on retinal vessel oxygen saturation parameters measured in the superficial retinal arterioles and venules.

METHODS

105 healthy individuals of varying skin colour, iris colour and heritage were included. Following a full eye exam to exclude any ocular abnormality, all participants underwent intraocular pressure, systemic blood pressure measurements and dilated dual wavelength retinal photography. Rotation matrices were employed to minimise the dependency of retinal pigmentation on arterial and venous oxygen saturation measurements determined in a concentric measurement annulus.

RESULTS

Retinal oxygen saturation in venules showed a linear correlation with retinal pigmentation (y = 0.34 × x + 38.598), whereas arterial saturation followed a polynomial pattern (y = 0.0089 × x2 + 0.7499 × x + 85.073). Both arterial and venous saturation values were corrected using local fundus pigmentation. Pre-correction retinal arterial and venous oxygen saturation were 89.0% (±13.1) and 43.7% (±11.5), respectively, and post- correction values were 94.8% (±8.7) for arteries and 56.3% (±7.0) veins.

CONCLUSIONS

When assessing multi-ethnic cohorts, it is important to consider the impact of pigmentation on imaging parameters and to account for it prior to clinical interpretation.

Oxygen-saturation-related functional parameter as a biomarker for diabetes mellitus-extraction method and clinical validation

Purpose: To develop a computational method for oxygen-saturation-related functional parameter analysis of retinal vessels based on traditional color fundus photography, and to explore their characteristic alterations in type 2 diabetes mellitus (DM). Methods: 50 type 2 DM patients with no-clinically detectable retinopathy (NDR) and 50 healthy subjects were enrolled in the study. An optical density ratio (ODR) extraction algorithm based on the separation of oxygen-sensitive and oxygen-insensitive channels in color fundus photography was proposed. With precise vascular network segmentation and arteriovenous labeling, ODRs were acquired from different vascular subgroups, and the global ODR variability (ODR_v) was calculated. Student's t-test was used to analyze the differences of the functional parameters between groups, and regression analysis and receiver operating characteristic (ROC) curves were used to explore the discrimination efficiency of DM patients from healthy subjects based on these functional parameters. Results: There was no significant difference in the baseline characteristics between the NDR and healthy normal groups. The ODRs of all vascular subgroups except the micro venule were significantly higher (p<0.05, respectively) while ODR_v was significantly lower (p<0.001) in NDR group than that in healthy normal group. In the regression analysis, the increased ODRs except micro venule and decreased ODR_v were significantly correlated with the incidence of DM, and the C-statistic for discrimination DM with all ODR is 0.777 (95% CI 0.687-0.867, p<0.001). Conclusion: A computational method to extract the retinal vascular oxygen-saturation-related optical density ratios (ODRs) with single color fundus photography was developed, and increased ODRs and decreased ODR_v of retinal vessels could be new potential image biomarkers of DM.

Topical Review: Studies of Ocular Function and Disease Using Hyperspectral Imaging

SIGNIFICANCE

Advances in imaging technology over the last two decades have produced significant innovations in medical imaging. Hyperspectral imaging (HSI) is one of these innovations, enabling powerful new imaging tools for clinical use and greater understanding of tissue optical properties and mechanisms underlying eye disease.Hyperspectral imaging is an important and rapidly growing area in medical imaging, making possible the concurrent collection of spectroscopic and spatial information that is usually obtained from separate optical recordings. In this review, we describe several mainstream techniques used in HSI, along with noteworthy advances in optical technology that enabled modern HSI techniques. Presented also are recent applications of HSI for basic and applied eye research, which include a novel method for assessing dry eye syndrome, clinical slit-lamp examination of corneal injury, measurement of blood oxygen saturation in retinal disease, molecular changes in macular degeneration, and detection of early stages of Alzheimer disease. The review also highlights work resulting from integration of HSI with other imaging tools such as optical coherence tomography and autofluorescence microscopy and discusses the adaptation of HSI for clinical work where eye motion is present. Here, we present the background and main findings from each of these reports along with specific references for additional details.

Photoacoustic Spectroscopy and Hyperglycemia in Experimental Type 1 Diabetes

According to the World Health Organization, diabetes was the seventh leading cause of death in 2016. Long-term diabetes complications are associated with hyperglycemia. It is difficult to predict the beginning and evolution of those complications. The goal of the study was to evaluate the relationship between glycemia and blood spectroscopic variables in an experimental model of type 1 diabetes (streptozotocin model). Blood samples were taken weekly (10 weeks) from the tail of male Wistar rats with or without diabetes. Blood optical absorption spectra were obtained by means of photoacoustic spectroscopy. It was possible to estimate the time-course of blood characteristic peak ratios. The area under the curve of those peaks correlated with hyperglycemia. The evolution of the optical absorption at 450 nm, related to cytochrome p450, was obtained by using the phase-resolved method. The area under the curve of p450 correlated also with hyperglycemia. It is concluded that photoacoustic spectroscopy is a reliable technology to detect the effects of hyperglycemia on blood with possible applications in the study of long-term diabetes complications.

Imaging Modalities Employed in Diabetic Retinopathy Screening: A Review and Meta-Analysis

INTRODUCTION

Urbanization has caused dramatic changes in lifestyle, and these rapid transitions have led to an increased risk of noncommunicable diseases, such as type 2 diabetes. In terms of cost-effectiveness, screening for diabetic retinopathy is a critical aspect in diabetes management. The aim of this study was to review the imaging modalities employed for retinal examination in diabetic retinopathy screening.

METHODS

The PubMed and Web of Science databases were the main sources used to investigate the medical literature. An extensive search was performed to identify relevant articles concerning "imaging", "diabetic retinopathy" and "screening" up to 1 June 2021. Imaging techniques were divided into the following: (i) mydriatic fundus photography, (ii) non-mydriatic fundus photography, (iii) smartphone-based imaging, and (iv) ultrawide-field imaging. A meta-analysis was performed to analyze the performance and technical failure rate of each method.

RESULTS

The technical failure rates for mydriatic and non-mydriatic digital fundus photography, smartphone-based and ultrawide-field imaging were 3.4% (95% CI: 2.3-4.6%), 12.1% (95% CI: 5.4-18.7%), 5.3% (95% CI: 1.5-9.0%) and 2.2% (95% CI: 0.3-4.0%), respectively. The rate was significantly different between all analyzed techniques (p < 0.001), and the overall failure rate was 6.6% (4.9-8.3%; I2 = 97.2%). The publication bias factor for smartphone-based imaging was significantly higher than for mydriatic digital fundus photography and non-mydriatic digital fundus photography (b = -8.61, b = -2.59 and b = -7.03, respectively; p < 0.001). Ultrawide-field imaging studies were excluded from the final sensitivity/specificity analysis, as the total number of patients included was too small.

CONCLUSIONS

Regardless of the type of the device used, retinal photographs should be taken on eyes with dilated pupils, unless contraindicated, as this setting decreases the rate of ungradable images. Smartphone-based and ultrawide-field imaging may become potential alternative methods for optimized DR screening; however, there is not yet enough evidence for these techniques to displace mydriatic fundus photography.

Photoreceptor cells and RPE contribute to the development of diabetic retinopathy

Diabetic retinopathy (DR) is a leading cause of blindness. It has long been regarded as vascular disease, but work in the past years has shown abnormalities also in the neural retina. Unfortunately, research on the vascular and neural abnormalities have remained largely separate, instead of being integrated into a comprehensive view of DR that includes both the neural and vascular components. Recent evidence suggests that the most predominant neural cell in the retina (photoreceptors) and the adjacent retinal pigment epithelium (RPE) play an important role in the development of vascular lesions characteristic of DR. This review summarizes evidence that the outer retina is altered in diabetes, and that photoreceptors and RPE contribute to retinal vascular alterations in the early stages of the retinopathy. The possible molecular mechanisms by which cells of the outer retina might contribute to retinal vascular damage in diabetes also are discussed. Diabetes-induced alterations in the outer retina represent a novel therapeutic target to inhibit DR.

Early Detection of Microvascular Impairments With Optical Coherence Tomography Angiography in Diabetic Patients Without Clinical Retinopathy: A Meta-analysis

PURPOSE

To evaluate microvascular impairments with optical coherence tomography angiography (OCTA) in the eyes of diabetic patients with no diabetic retinopathy (NDR).

DESIGN

Systematic review and meta-analysis.

METHODS

The PubMed and Embase databases were comprehensively searched to identify studies comparing the microvascular changes between diabetic eyes without clinical retinopathy and healthy controls using OCTA. Data of interest were extracted and analyzed by Review Manager V.5.3 and Stata V.14.0. The weighted mean differences and their 95% confidence intervals were used to assess the strength of the association.

RESULTS

Forty-five cross-sectional studies involving 2241 diabetic and 1861 healthy eyes were ultimately included. OCTA unambiguously revealed that compared with the healthy control group, the NDR group manifested enlarged areas and increased perimeters of the foveal avascular zone, with decreased perfusion density (PD) in both superficial and deep capillary plexus of the macula (except parafoveal PD of the inner retina and foveal PD) and reduced radial peripapillary capillary PD. In addition, subgroup analyses according to the type of diabetes mellitus indicated that most of those differences became nonsignificant (except parafoveal PD in the deep capillary plexus) in type 1 diabetes mellitus, while in type 2 diabetes mellitus they remained statistically significant.

CONCLUSION

Our results suggested that retinal microvascular impairments might have occurred antecedent to clinically visible diabetic retinopathy and could be detected early by OCTA. However, those manifestations could be inconsistent according to the types of diabetes mellitus.

Current use of the automatic retinal oximetry. Review

PURPOSE

To inform about possible use of the automatic retinal oximetry for the retinal oxygen saturation measurement in the eye and systemic diseases.

METHODS

We performed a literature review dealing with issues of retinal oxygen saturation monitoring by dual non-invasive retinal oximetry Oxymap T1 (Oxymap ehf. Reykjavík, Iceland).

RESULTS

We have found two main strains writing our paper on retinal oxygen saturation eye diseases. The first section concerns diseases created by having hypoxia as its main pathological factor  - for example diabetes mellitus and retinal vein occlusion. The second group deals with atrophy as the main pathological mechanism which is typical for decreasing retinal oxygen consumption - for example glaucoma or retinitis pigmentosa (the second one named is not included in our work). Oximetry in systemic diseases creates a relatively new chapter of this branch with a very big potential of interdisciplinary cooperation for the future. It is possible the cooperation will not only include diabetologists but also neurologists (for example, in diseases like sclerosis multiplex or Devics, Alzheimers and Parkinsons disease) and haematologists (retinal oxygen saturation changes in patients with different rheological attributes of blood).

CONCLUSION

Retinal oxygen saturation measuring by automatic retinal oximetry is a relatively new method with scientifically confirmed high reproducibility of results. Currently it is the only experimental method with vast potentials not only in the realm of the possibility of observing eye diseases (diabetic retinopathy, retinal vein occlusion or glaucoma) but also in developing interdisciplinary cooperation with diabetologists, neurologists and haematologists.

Automatic analysis of normative retinal oximetry images

Retinal oximetry is an important screening tool for early detection of retinal pathologies due to changes in the vasculature and also serves as a useful indicator of human-body-wide vascular abnormalities. We present an automatic technique for the measurement of oxygen saturation in retinal arterioles and venules using dual-wavelength retinal oximetry images. The technique is based on segmenting an optic-disc-centered ring-shaped region of interest and subsequent analysis of the oxygen saturation levels. We show that the two dominant peaks in the histogram of the oxygen saturation levels correspond to arteriolar and venular oxygen saturations from which the arterio-venous saturation difference (AVSD) can be calculated. For evaluation, we use a normative database of Asian Indian eyes containing 44 dual-wavelength retinal oximetry images. Validations against expert manual annotations of arterioles and venules show that the proposed technique results in an average arteriolar oxygen saturation (SatO₂) of 87.48%, venular SatO₂ of 57.41%, and AVSD of 30.07% in comparison with the expert ground-truth average arteriolar SatO₂ of 89.41%, venular SatO₂ of 56.32%, and AVSD of 33.09%, respectively. The results exhibit high consistency across the dataset indicating that the automated technique is an accurate alternative to the manual procedure.

Outer Retinal Dysfunction on Multifocal Electroretinography May Help Differentiating Multiple Sclerosis From Neuromyelitis Optica Spectrum Disorder

Purpose: To evaluate the intermediate and outer retina of patients with multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD) using OCT and multifocal electroretinography (mf-ERG). Methods: Patients with MS (n = 30), NMOSD (n = 30), and healthy controls (n = 29) underwent visual field (VF), OCT, and mf-ERG testing. The eyes were distributed into 5 groups: MS with or without history of ON (MS+ON, MS-ON), NMOSD with or without ON (NMOSD+ON, NMOSD-ON), and controls. The thickness of the macular retinal nerve fiber layer (mRNFL), ganglion cell layer (GCL), inner plexiform layer (IPL), inner nuclear layer, outer plexiform layer, outer nuclear layer, and photoreceptor layer was measured. mf-ERG P1 and N1 responses were registered and grouped in 3 sets of rings. The groups were compared using GEE models, and effect size (ES) calculated. Results: Compared to controls, GCL and IPL thickness was significantly smaller in MS+ON (both p < 0.01), MS-ON (p < 0.01 and p = 0.015, respectively), NMOSD+ON (both p < 0.01) and NMOSD-ON (p = 0.03 and p = 0.018, respectively). ES was >0.80. mRNFL was smaller in three of the above groups (p < 0.01, p < 0.001, and p = 0.028; ES > 0.80) but not in MS-ON eyes (p = 0.18). No significant difference was observed for the remaining layers. Compared to controls, P1 and N1 peak times were shorter in MS (p-values in the range 0.049-0.002, ES < 0.50; and 0.049-0.010; ES < 0.50, respectively) but not in NMOSD. These abnormalities were strongly correlated with intermediate and outer retinal layer thickness. Conclusions: mf-ERG data suggest outer retinal abnormalities in MS, but not in NMOSD. Our results may help understand how the two conditions differ regarding retinal damage.

Convolutional Neural Networks for Spectroscopic Analysis in Retinal Oximetry

Retinal oximetry is a non-invasive technique to investigate the hemodynamics, vasculature and health of the eye. Current techniques for retinal oximetry have been plagued by quantitatively inconsistent measurements and this has greatly limited their adoption in clinical environments. To become clinically relevant oximetry measurements must become reliable and reproducible across studies and locations. To this end, we have developed a convolutional neural network algorithm for multi-wavelength oximetry, showing a greatly improved calculation performance in comparison to previously reported techniques. The algorithm is calibration free, performs sensing of the four main hemoglobin conformations with no prior knowledge of their characteristic absorption spectra and, due to the convolution-based calculation, is invariable to spectral shifting. We show, herein, the dramatic performance improvements in using this algorithm to deduce effective oxygenation (SO₂), as well as the added functionality to accurately measure fractional oxygenation (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${{\bf{SO}}}_{{\bf{2}}}^{{\boldsymbol{f}}{\boldsymbol{r}}}$$\end{document}SO2fr). Furthermore, this report compares, for the first time, the relative performance of several previously reported multi-wavelength oximetry algorithms in the face of controlled spectral variations. The improved ability of the algorithm to accurately and independently measure hemoglobin concentrations offers a high potential tool for disease diagnosis and monitoring when applied to retinal spectroscopy.

Associated risk factors in the early stage of diabetic retinopathy

Background

To investigate the retinal capillary density (RCD) of the macula using optical coherence tomography angiography (OCT-A) in type 2 diabetic patients and to further determine the association with risk factors.

Methods

A total of 212 eyes from 212 subjects were recruited; subjects included diabetics with no retinopathy (NDR, n = 90 eyes), diabetics with mild retinopathy DR (MDR, n = 36 eyes), and healthy participants (Control, n = 86 eyes). All participants underwent OCT-A scanning. RCD was quantified by superficial and deep retinal capillary layers (SRCL and DRCL) from OCT-A images.

Results

RCD in SRCL and DRCL was lower in NDR (P < 0.001) as well as in MDR (P < 0.001) when compared with control eyes. Diabetic patients were subdivided according to individual risk factors, complications related to diabetes, and hyperglycemia. Diabetic patients showed lower RCD in both the SRCL and DRCL when compared with healthy controls. Diabetics with age > 55y, HbA1c > 7% had significantly reduced DRCL (P < 0.05) when compared with the other group of diabetics (age < 55y, HbA1c < 7%). Diabetics with a blood urea nitrogen (BUN) > 8.2 mmol/L had significantly reduced SRCL and DRCL when compared to the other group of diabetics.

Conclusions

Risk factors including older age, higher level of HbA1c, LDL-C and BUN, were associated with lower RCDs found in type 2 diabetic patients with and without mild DR by OCT-A. The impairment of retinal capillary by OCT-A may play a key role in the early monitoring of management in diabetes.

Clinical applications of the retinal functional imager: A brief review

The advances in treating blinding conditions often depends on the development of new techniques that allows early detection, treatment, and follow-up of the disease. Functional changes often precede structural changes in many retinal disorders. Therefore, detecting these changes helps in early diagnosis and management, with the intention of preventing permanent morbidity. The Retinal Functional Imager (RFI) is a non-invasive imaging system that allows us to assess the various functional parameters of the retina. The RFI quantitatively measures the retinal blood-flow velocity, oxygen saturation, metabolic demand and generates a non-invasive capillary perfusion map that provides details similar to a fluorescein angiography. All of these parameters correlate with the health of the retina, and are known to get deranged in retinal disease. This article is a brief review of published literature on the clinical utility of the RFI.

Optimal wavelengths for subdiffuse scanning laser oximetry of the human retina

Retinal blood vessel oxygenation is considered to be an important marker for numerous eye diseases. Oxygenation is typically assessed by imaging the retinal vessels at different wavelengths using multispectral imaging techniques, where the choice of wavelengths will affect the achievable measurement accuracy. Here, we present a detailed analysis of the error propagation of measurement noise in retinal oximetry, to identify optimal wavelengths that will yield the lowest uncertainty in saturation estimation for a given measurement noise level. In our analysis, we also investigate the effect of hemoglobin packing in discrete blood vessels (pigment packaging), which may result in a nonnegligible bias in saturation estimation if unaccounted for under specific geometrical conditions, such as subdiffuse sampling of smaller blood vessels located deeper within the retina. Our analyses show that using 470, 506, and 592 nm, a fairly accurate estimation of the whole oxygen saturation regime [0 1] can be realized, even in the presence of the pigment packing effect. To validate the analysis, we developed a scanning laser ophthalmoscope to produce high contrast images with a maximum pixel rate of 60 kHz and a maximum 30-deg imaging field of view. Confocal reflectance measurements were then conducted on a tissue-mimicking scattering phantom with optical properties similar to retinal tissue including narrow channels filled with absorbing dyes to mimic blood vessels. By imaging at three optimal wavelengths, the saturation of the dye combination was calculated. The experimental values show good agreement with our theoretical derivations.

Myogenic Response Reduction by High Blood Glucose Levels in Human Retinal Arterioles

PURPOSE

The effect of elevated blood glucose level on the myogenic response of human retinal arterioles to acute increases in blood pressure is investigated.

METHODS

The vascular response to raised blood pressure (Bayliss effect) was measured in 12 healthy volunteers by use of the retinal vessel analyzer (RVA). For a 9-minute period an on-line measurement of the diameter of a retinal branch arteriole was performed. After the first 3 minutes (baseline measurement) a second phase with 3 minutes of isometric exercise caused an acute rise in blood pressure, followed by 3 minutes of recovery (phase III). After the first session 100 g glucose were administered per os. After 30 minutes blood glucose was measured again and an identical second session was performed with higher blood glucose levels. The Wilcoxon test was used for statistical analysis.

RESULTS

During the first session a rise in mean arterial pressure of 22.8 (+/-8.4) mmHg was followed by an arterial vasoconstriction of -6.6 (+/-1.7) %. The administration of 100 g glucose resulted in a significant rise in blood glucose levels within 30 minutes between the two sessions (4.35 mmol/L vs 7.46 mmol/L) (p=0.002). The blood pressure rise of 25.7 (+/-7.3) mm Hg in the second session was associated with a significant loss in arterial vasoconstriction of -2.3 (+/-1.4) % (session I vs session II p=0.002).

CONCLUSIONS

The myogenic response of the arterial wall in human retinal arterioles was significantly reduced during acute rise of blood glucose levels.

Assessing oxygen saturation in retinal vessels in high myopia patients pre- and post-implantable collamer lens implantation surgery

PURPOSE

To determine whether posterior chamber phakic implantable collamer lens (ICL) surgery in high myopia patients impedes oxygen saturation of retinal vessels.

METHODS

Mean oxygen saturation and diameter in retinal blood vessels were measured before and after ICL implantation surgery to correct high myopia refractive errors (i.e. -6.00 to -20.25 dioptres [D]), using an Oxymap T1 retinal oximeter.

RESULTS

In 17 eyes of 17 patients, the Oxymap T1 retinal oximeter detected a small but significant decrease in oxygen saturation of retinal venules, 1-week postoperatively (compared to preoperative measurements). Moreover, at 1 week after ICL implantation, the diameter of patient retinal vessels had consistently contracted, compared to preoperative measurements. By 1 month after ICL surgery, however, both the oxygen saturation and retinal vessel diameter had returned to preoperative levels. Otherwise, no statistically significant difference in oxygen saturation and diameter of retinal arterioles was found when comparing their measurements before and 1 week after implantation.

CONCLUSION

Stable levels of oxygen saturation in retinal vessels, as detected by the Oxymap T1 oximeter, show ICL implantation would not leave lasting impact or adverse effects to retina oxygen saturation in high myopia patients.

Retinal oximetry in patients with ischaemic retinal diseases

The retinal oximeter is a new tool for non-invasive measurement of retinal oxygen saturation in humans. Several studies have investigated the associations between retinal oxygen saturation and retinal diseases. In the present systematic review, we examine whether there are associations between retinal oxygen saturation and retinal ischaemic diseases. We used PubMed and Embase to search for retinal oxygen saturation and retinal ischaemic diseases. Three separate searches identified a total of 79 publications. After two levels of manual screening, 10 studies were included: six about diabetic retinopathy (DR) and four about retinal vein occlusion. No studies about retinal artery occlusion were included. In diabetes, all studies found that increases in retinal venous oxygen saturation (rvSatO₂ ) were associated with present as well as increasing levels of DR. Four of six studies also found increased retinal arterial oxygen saturation (raSatO₂ ) in patients with DR. In patients with central retinal vein occlusion (CRVO), all studies found that rvSatO₂ was reduced, but raSatO₂ remained unchanged. Branch retinal vein occlusion was not associated with changes in retinal oxygen saturation, but this was based on a single study. In conclusion, DR is associated with increased rvSatO₂ and might also be related to increased raSatO₂ . Central retinal vein occlusion (CRVO) is correlated with increased rvSatO₂ but unrelated to raSatO₂ . Prospective studies are needed to expand these findings. These would tell whether retinal oximetry could be a potential tool for screening or a biomarker of treatment outcome in patients with ischaemic retinal diseases.

Retinal oxygen: from animals to humans

This article discusses retinal oxygenation and retinal metabolism by focusing on measurements made with two of the principal methods used to study O₂ in the retina: measurements of PO₂ with oxygen-sensitive microelectrodes in vivo in animals with a retinal circulation similar to that of humans, and oximetry, which can be used non-invasively in both animals and humans to measure O₂ concentration in retinal vessels. Microelectrodes uniquely have high spatial resolution, allowing the mapping of PO₂ in detail, and when combined with mathematical models of diffusion and consumption, they provide information about retinal metabolism. Mathematical models, grounded in experiments, can also be used to simulate situations that are not amenable to experimental study. New methods of oximetry, particularly photoacoustic ophthalmoscopy and visible light optical coherence tomography, provide depth-resolved methods that can separate signals from blood vessels and surrounding tissues, and can be combined with blood flow measures to determine metabolic rate. We discuss the effects on retinal oxygenation of illumination, hypoxia and hyperoxia, and describe retinal oxygenation in diabetes, retinal detachment, arterial occlusion, and macular degeneration. We explain how the metabolic measurements obtained from microelectrodes and imaging are different, and how they need to be brought together in the future. Finally, we argue for revisiting the clinical use of hyperoxia in ophthalmology, particularly in retinal arterial occlusions and retinal detachment, based on animal research and diffusion theory.

Contemporary retinal imaging techniques in diabetic retinopathy: a review

Over the last decade, there has been an expansion of imaging modalities available to clinicians to diagnose and monitor the treatment and progression of diabetic retinopathy. Recently, advances in image technologies related to OCT and OCT angiography have enabled improved visualization and understanding of this disease. In this review, we will describe the use of imaging techniques such as colour fundus photography, fundus autofluorescence, fluorescein angiography, infrared reflectance imaging, OCT, OCT-Angiography and techniques in adaptive optics and hyperspectral imaging in the diagnosis and management of diabetic retinopathy.

Retinal vascular and structural dynamics during acute hyperglycaemia

PURPOSE

To compare retinal vascular dynamics during acute hyperglycaemia in patients with type 2 diabetes and healthy volunteers.

METHODS

Twenty-one patients with type 2 diabetes and 27 healthy controls were examined with fundus photographic measurement of retinal vessel diameters, retinal oximetry, macular perfusion velocities and optical coherence tomographic measurement of subfoveal choroidal thickness every 30 min during a 3-hr 75 g oral glucose tolerance test (OGTT). Patients paused antidiabetic therapy for 1 week prior to the OGTT.

RESULTS

Plasma glucose (PG) and fluctuations in PG were larger in patients with diabetes (p < 0.0001). PG increased significantly 30 min after ingestion of glucose (p < 0.0001 in both groups). With a delay of 0-120 min, the PG increase was followed by increased retinal arterial oxygen saturations and arteriovenous oxygen saturation differences, narrowed retinal veins and increased arteriovenous diameter ratios. No effect of age, gender or diabetes status was observed. Choroidal thickness was transiently reduced in controls and unchanged in patients with diabetes (p = 0.021). Macular perfusion velocities increased after 150 min in patients with diabetes but not in controls (arterial p = 0.059; venous p = 0.16). Higher age and diabetes tended to be associated with higher retinal arterial oxygen saturation.

CONCLUSION

The transition from fasting to acute hyperglycaemia is followed, with a delay of up to 2 hr, by retinal vascular changes, notably increased oxygen extraction, suggesting an effect of secondary metabolic changes. Retinal responses were similar in patients with type 2 diabetes and controls despite differences in glucose levels. It is necessary to standardize measurement conditions in studies of retinal physiology.

Monte Carlo Investigation of Optical Coherence Tomography Retinal Oximetry

Optical coherence tomography (OCT) oximetry explores the possibility to measure retinal hemoglobin oxygen saturation level (sO2). We investigated the accuracy of OCT retinal oximetry using Monte Carlo simulation in a commonly used four-layer retinal model. After we determined the appropriate number of simulated photon packets, we studied the effects of blood vessel diameter, signal sampling position, physiological sO2 level, and the blood packing factor on the accuracy of sO2 estimation in OCT retinal oximetry. The simulation results showed that a packing factor between 0.2 and 0.4 yields a reasonably accurate estimation of sO2 within a 5% error tolerance, which is independent of vessel diameter and sampling position, when visible-light illumination is used in OCT. We further explored the optimal optical spectral range for OCT retinal oximetry. The simulation results suggest that visible spectral range around 560 nm is better suited than near-infrared spectral range around 800 nm for OCT oximetry to warrant accurate measurements.

Retinal hemodynamic oxygen reactivity assessed by perfusion velocity, blood oximetry and vessel diameter measurements

PURPOSE

To test the oxygen reactivity of a fundus photographic method of measuring macular perfusion velocity and to integrate macular perfusion velocities with measurements of retinal vessel diameters and blood oxygen saturation.

METHODS

Sixteen eyes in 16 healthy volunteers were studied at two examination sessions using motion-contrast velocimetry and retinal oximetry with vessel diameter corrections. To test oxygen reactivity, participants were examined during normoxia, after 15 min of hyperoxia and finally after 45 min of normoxia. Repeatability was assessed by intraclass correlation coefficients (ICC) and limits of agreement.

RESULTS

Fifteen minutes of hyperoxia was accompanied by mean reductions in arterial and venous perfusion velocities of 14% and 16%, respectively (p = 0.0080; p = 0.0019), constriction of major arteries and veins by 5.5% and 8.2%, respectively (p < 0.0001), increased retinal arterial oxygen saturation from 95.1 ± 5.0% to 96.6 ± 6.4% (p = 0.038) and increased retinal venous oxygen saturation from 62.9 ± 6.7% to 70.3 ± 7.8% (p = 0.0010). Parameters returned to baseline levels after subsequent normoxia. Saturation and vessel diameter ICCs were 0.88-0.98 (range). For perfusion velocities, short-term ICCs were 0.79-0.82 and long-term ICCs were 0.06-0.11. Intersession increases in blood glucose were associated with reductions in perfusion velocities (arterial p = 0.0067; venous p = 0.018).

CONCLUSION

Oxygen reactivity testing supported that motion-contrast velocimetry is a valid method for assessing macular perfusion. Results were consistent with previous observations of hyperoxic blood flow reduction using blue field entoptic and laser Doppler velocimetry. Retinal perfusion seemed to be regulated around individual set points according to blood glucose levels. Multimodal measurements may provide comprehensive information about retinal metabolism.

Assessment of oxygen saturation in retinal vessels of normal subjects and diabetic patients with and without retinopathy using Flow Oximetry System

PURPOSE

To assess oxygen saturation (StO2) in retinal vessels of normal subjects and diabetic patients with and without retinopathy using the modified version of the Flow Oximetry System (FOS) and a novel assessment software.

METHODS

The FOS and novel assessment software were used to determine StO2 levels in arteries and veins located between 1 and 2 mm from the margin of the optic disc and in the macular area.

RESULTS

Eighteen normal subjects, 15 diabetics without diabetic retinopathy (DM no DR), and 11 with non-proliferative diabetic retinopathy (NPDR) were included in final analysis. The mean [± standard deviation (SD)] StO2 in retinal arteries was 96.9%±3.8% in normal subjects; 97.4%±3.7% in DM no DR; and 98.4%±2.0% in NPDR. The mean venous StO2 was 57.5%±6.8% in normal subjects; 57.4%±7.5% in DM no DR; and 51.8%±6.8% in NPDR. The mean arterial and venous StO2 across the three groups were not statistically different (P=0.498 and P=0.071, respectively). The arterio-venous differences between the three study groups, however, were found to be statistically significant (P=0.015). Pairwise comparisons have demonstrated significant differences when comparing the A-V difference in the NPDR group to either normal subjects (P=0.02) or diabetic patients without DR (P=0.04).

CONCLUSIONS

The arterio-venous difference was greater, and statistically significant, in patients with NPDR when compared to normal subjects and to patients with diabetes and no retinopathy. The mean venous StO2 was lower, but not statistically significant, in NPDR compared with diabetics without retinopathy and with normal subjects.

Pathway to Retinal Oximetry

Events and discoveries in oxygen monitoring over the past two centuries are presented as the background from which oximetry of the human retina evolved. Achievements and the people behind them are discussed, showing parallels between the work in tissue measurements and later in the eye. Developments in the two-wavelength technique for oxygen saturation measurements in retinal vessels are shown to exploit the forms of imaging technology available over time. The last section provides a short summary of the recent research in retinal diseases using vessel oximetry.

Recent advances in ophthalmic molecular imaging

The aim of molecular imaging techniques is the visualization of molecular processes and functional changes in living animals and human patients before morphological changes occur at the cellular and tissue level. Ophthalmic molecular imaging is still in its infancy and has mainly been used in small animals for pre-clinical research. The goal of most of these pre-clinical studies is their translation into ophthalmic molecular imaging techniques in clinical care. We discuss various molecular imaging techniques and their applications in ophthalmology.

Retinal Oxygen Saturation and Metabolism: How does it Pertain to Glaucoma? An Update on the Application of Retinal Oximetry in Glaucoma

Purpose

To discuss the techniques and mechanisms of retinal oximetry with a focus on utilization of retinal oximetry in the assessment of retinal oxygen saturation in glaucoma.

Methods

We reviewed recent literature found by searching combinations of the following search terms: glaucoma, retinal oximetry, ocular blood flow, retinal blood flow, oxygen saturation. We also reviewed pertinent references from articles found in this search.

Results

Retinal oximetry offers the potential for directly assessing oxygen saturation in retinal tissue. This capability can contribute to the knowledge of ocular blood flow and its role in the pathogenesis of glaucoma.

Conclusions

Recent research has shown that retinal oximetry could become an important clinical tool in glaucoma. However, more research is needed to validate the reliability and reproducibility of retinal oximetry, and to fully deduce its clinical role in ocular diseases.

Retinal oximetry

ABSTRACT.:

PURPOSE

Malfunction of retinal blood flow or oxygenation is believed to be involved in various diseases. Among them are retinal vessel occlusions, diabetic retinopathy and glaucoma. Reliable, non-invasive technology for retinal oxygen measurements has been scarce and most of the knowledge on retinal oxygenation comes from animal studies. This thesis describes human retinal oximetry, performed with novel retinal oximetry technology. The thesis describes studies on retinal vessel oxygen saturation in (1) light and dark in healthy volunteers, (2) central retinal vein occlusion, (3) branch retinal vein occlusion, (4) central retinal artery occlusion, (5) diabetic retinopathy, (6) patients undergoing glaucoma surgery and (7) patients taking glaucoma medication.

METHODS

The retinal oximeter (Oxymap ehf., Reykjavik, Iceland) is based on a fundus camera. An attached image splitter allows the simultaneous capture of four images of the same area of the fundus. Two images are used for further analysis, one acquired with 586 nm light and one with 605 nm light. Light absorbance of retinal vessels is sensitive to oxygen saturation at 605 nm but not at 586 nm. Measurement of reflected light at these wavelengths allows estimation of oxygen saturation in the main retinal vessels. This is performed with custom-made analysis software.

RESULTS

LIGHT AND DARK: After 30 min in the dark, oxygen saturation in retinal arterioles of healthy volunteers was 92 ± 4% (mean ± SD, n = 15). After 5 min in 80 cd/m(2) light, the arteriolar saturation was 89 ± 5%. The decrease was statistically significant (p = 0.008). The corresponding values for retinal venules were 60 ± 5% in the dark and 55 ± 10% in the light (p = 0.020). Similar results were found after alternating 5 min periods of darkness and light. In a second experiment (n = 19), a significant decrease in retinal vessel oxygen saturation was found in 100 cd/m(2) light compared with darkness but 1 and 10 cd/m(2) light had no significant effect. CENTRAL RETINAL VEIN OCCLUSION: In patients with central retinal vein occlusion, the mean saturation in affected retinal venules was 49 ± 12%, while the mean value for venules in the fellow eye was 65 ± 6% (mean ± SD, p = 0.003, n = 8). The retinal arteriolar saturation was the same in affected (99 ± 3%) and the unaffected (99 ± 6%) eyes. The venous oxygen saturation showed much variation between affected eyes. BRANCH RETINAL VEIN OCCLUSION: Median oxygen saturation in venules affected by branch retinal vein occlusion was 59% (range, 12-93%, n = 22), while it was 63% (23-80%) in unaffected venules in the affected eye and 55% (39-80%) in venules in the fellow eye. The difference was not statistically significant (p > 0.05). There was a significant difference between affected arterioles (median 101%; range, 89-115%) and unaffected arterioles (95%, 85-104%) in the affected eye (p < 0.05, n = 18). CENTRAL RETINAL ARTERY OCCLUSION: In a patient with a day's history of central retinal artery occlusion due to temporal arteritis, the mean arteriolar saturation was 71 ± 9% and 63 ± 9% in the venules. One month later, after treatment with prednisolone, the mean arteriolar saturation was 100 ± 4% and the venous saturation 54 ± 5%. DIABETIC RETINOPATHY: When compared with healthy volunteers (n = 31), patients with all categories of diabetic retinopathy had on average 7-10 percentage points higher saturation in retinal arterioles (p < 0.05 for all categories, n = 6-8 in each category). In venules, the saturation was 8-12 percentage points higher (p < 0.05 for all categories). GLAUCOMA SURGERY: Oxygen saturation in retinal arterioles increased by 2 percentage points on average (p = 0.046, n = 19) with surgery, which lowered intraocular pressure from 23 ± 7 mmHg (mean ± SD) to 10 ± 4 mmHg (p < 0.0001). No other significant changes were found (p ≥ 0.35). DORZOLAMIDE: A significant reduction of 3 percentage points was found in arterioles (p < 0.01) and venules (p < 0.05) when patients with glaucoma or ocular hypertension changed from dorzolamide-timolol combination eye drops to timolol alone (n = 6). No change was found in patients, who started on timolol and switched to the combination therapy (p > 0.05, n = 7).

CONCLUSIONS

Dual wavelength oximetry can be used to non-invasively measure retinal vessel oxygen saturation in health and disease. The results indicate that retinal vessel oxygen saturation is (1) increased in the dark, (2) lower in venules affected by central retinal vein occlusions, (3) variable in branch retinal vein occlusion, (4) lower in retinal arterioles in central retinal artery occlusion, (5) increased in diabetic retinopathy, (6-7) mildly affected by glaucoma surgery or dorzolamide.

Retinal oximetry using ultrahigh-resolution optical coherence tomography

BACKGROUND

The purpose of this study was to investigate the repeatability of retinal oximetry using slit-lamp adapted ultrahigh-resolution optical coherence tomography (SL-UHR-OCT).

METHODS

SL-UHR-OCT was developed and fringe patterns were obtained for a major retinal artery and a major retinal vein. A-scans at the central wavelengths of 805 nm and 855 nm were analyzed for calculating optical density ratios (ODRs), from which the percentage oxygen saturation was calculated. Measurements were made on two occasions for each person. Repeatability and coefficients of repeatability were calculated.

RESULTS

The mean ODRs of the artery were 0.79 ± 0.86 and 0.88 ± 0.97 in sessions 1 and 2, respectively. The mean ODRs of the vein were -0.08 ± 0.69 and 0.14 ± 0.77 between the two sessions, and were significantly lower than that of the artery (P < 0.05). The coefficients of repeatability were 1.44 and 1.81 for the artery and vein, respectively. The mean oxygen saturation of the major retinal artery was 94% ± 45% and 98% ± 51% in sessions 1 and 2, respectively, and the mean oxygen saturation of the major retinal vein was 48% ± 36% and 60% ± 40% between sessions.

CONCLUSION

Optical coherence tomographic oximetry for evaluating retinal oxygen saturation was subject to variation, although the averaged measurements in repeated sessions were matched. Further work on reducing variation will be needed.

Spectral imaging of the retina

INTRODUCTION

The work described here involved the use of a modified fundus camera to obtain sequential hyperspectral images of the retina in 14 normal volunteers and in 1 illustrative patient with a retinal vascular occlusion.

METHODS

The paper describes analysis techniques, which allow oximetry within retinal vessels; these results are presented as retinal oximetry maps.

RESULTS

Using spectral images, with wavelengths between 556 and 650 nm, the mean oxygen saturation (OS) value in temporal retinal arterioles in normal volunteers was 104.3 (± 16.7), and in normal temporal retinal venules was 34.8 (± 17.8). These values are comparable to those quoted in the literature, although, the venular saturations are slightly lower than those values found by other authors; explanations are offered for these differences.

DISCUSSION

The described imaging and analysis techniques produce a clinically useful map of retinal oximetric values. The results from normal volunteers and from one illustrative patient are presented. Further developments, including the recent development of a 'snapshot' spectral camera, promises enhanced non-invasive retinal vessel oximetry mapping.

Abnormal retinal vascular oxygen tension response to light flicker in diabetic rats

PURPOSE

To test the hypothesis that the intravascular oxygen response to light flicker is abnormal in diabetes.

METHODS

Ten eyes of normal rats and 10 eyes of rats made diabetic with streptozotocin were examined. Oxygen tension (PO(2)) was measured noninvasively in the retinal arteries and veins on optical section retinal images. PO(2) was estimated based on the quenching by oxygen of the phosphorescence of an intravenously injected palladium porphyrin molecular probe. Measurements were conducted with and without light flicker at 10 Hz. Oxygen saturation (SO(2)) was calculated with adjustment for the arterial pH.

RESULTS

In the normal rats flicker induced an increase in arterial PO(2) and in the difference in arterial and venous (A-V difference) PO(2) from 51 +/- 5 (mean and SD) to 55 +/- 7 mm Hg and from 22 +/- 3 to 26 +/- 5 mm Hg, respectively (P < 0.002 and 0.015, respectively). Flicker induced an increase of arterial SO(2) and A-V SO(2) difference from 64% +/- 8% to 68% +/- 7% and from 34% +/- 4% to 38% +/- 6%, respectively (P < 0.002 and 0.035, respectively). No changes in PO(2) or SO(2) were observed with flicker in the veins. In the diabetic rats, no significant flicker-induced changes were seen in PO(2) or SO(2) in the retinal arteries, veins, or A-V differences.

CONCLUSIONS

The diabetic rats lacked the flicker induced increase in arterial PO(2) and SO(2) and also the A-V difference in PO(2) and SO(2) observed in the normal rats. The best explanation appeared to be that diabetes impairs the increase in oxygen consumption normally provoked by light flicker.

Functional imaging using the retinal function imager: direct imaging of blood velocity, achieving fluorescein angiography-like images without any contrast agent, qualitative oximetry, and functional metabolic signals

The Retinal Function Imager (RFI; Optical Imaging, Rehovot, Israel) is a unique, noninvasive multiparameter functional imaging instrument that directly measures hemodynamic parameters such as retinal blood-flow velocity, oximetric state, and metabolic responses to photic activation. In addition, it allows capillary perfusion mapping without any contrast agent. These parameters of retinal function are degraded by retinal abnormalities. This review delineates the development of these parameters and demonstrates their clinical applicability for noninvasive detection of retinal function in several modalities. The results suggest multiple clinical applications for early diagnosis of retinal diseases and possible critical guidance of their treatment.

Oxygen Saturation in Optic Nerve Head Structures by Hyperspectral Image Analysis

PURPOSE

A method is presented for the calculation and visualization of percent blood oxygen saturation from specific tissue structures in hyperspectral images of the optic nerve head (ONH).

METHODS

Trans-pupillary images of the primate optic nerve head and overlying retinal blood vessels were obtained with a hyperspectral imaging (HSI) system attached to a fundus camera. Images were recorded during normal blood flow and after partially interrupting flow to the ONH and retinal circulation by elevation of the intraocular pressure (IOP) from 10 mmHg to 55 mmHg in steps. Percent oxygen saturation was calculated from groups of pixels associated with separate tissue structures, using a linear least-squares curve fit of the recorded hemoglobin spectrum to reference spectra obtained from fully oxygenated and deoxygenated red cell suspensions. Color maps of saturation were obtained from a new algorithm that enables comparison of oxygen saturation from large vessels and tissue areas in hyperspectral images.

RESULTS

Percent saturation in retinal vessels and from the average over ONH structures (IOP = 10 mmHg) was (mean +/- SE): artery 81.8 +/- 0.4%, vein 42.6 +/- 0.9%, average ONH 68.3 +/- 0.4%. Raising IOP from 10 mmHg to 55 mmHg for 5 min caused blood oxygen saturation to decrease (mean +/- SE): artery 46.1 +/- 6.2%, vein 36.1 +/- 1.6%, average ONH 41.9 +/- 1.6%. The temporal cup showed the highest saturation at low and high IOP (77.3 +/- 1.0% and 60.1 +/- 4.0%) and the least reduction in saturation at high IOP (22.3%) compared with that of the average ONH (38.6%). A linear relationship was found between saturation indices obtained from the algorithm and percent saturation values obtained by spectral curve fits to calibrated red cell samples.

CONCLUSIONS

Percent oxygen saturation was determined from hyperspectral images of the ONH tissue and retinal vessels overlying the ONH at normal and elevated IOP. Pressure elevation was shown to reduce blood oxygen saturation in vessels and ONH structures, with the smallest reduction in the ONH observed in the temporal cup. IOP-induced saturation changes were visualized in color maps using an algorithm that follows saturation-dependent changes in the blood spectrum and blood volume differences across tissue. Reduced arterial saturation at high IOP may have resulted from a flow-dependent mechanism.

Blue-green spectral minimum correlates with oxyhemoglobin saturation in vivo

An imaging multi-spectral retinal oximeter with intravitrial illumination is used to perform the first in vivo test of the blue-green minima shift oximetry method (BGO) in swine eyes [K. R. Dennighoff, R. A. Chipman, and L. W. Hillman, Opt. Lett. 31, 924-926 (2006); J. Biomed. Opt. 12, 034020 (2007).] A fiber optic intravitreal illuminator inserted through the pars plana was coupled to a monochromator and used to illuminate the retina from an angle. A camera viewing through the cornea recorded a series of images at each wavelength. This intravitreal light source moves the specular vessel glint away from the center of the vessel and directly illuminates the fundus behind most blood vessels. These two conditions combine to provide accurate measurements of vessel and perivascular reflectance. Equations describing these different light paths are solved, and BGO is used to evaluate large retinal vessels. In order to test BGO calibration in vivo, data were acquired from swine with varied retinal arterial oxyhemoglobin saturations (60-100% saturation.). The arterial saturations determined using BGO to analyze the multispectral image sets showed excellent correlation with co-oximeter data (r2=0.98, and residual error +/-3.4% saturation) and are similar to results when hemoglobin and blood were analyzed using this technique.

Regulation of retinal blood flow in health and disease

Optimal retinal neuronal cell function requires an appropriate, tightly regulated environment, provided by cellular barriers, which separate functional compartments, maintain their homeostasis, and control metabolic substrate transport. Correctly regulated hemodynamics and delivery of oxygen and metabolic substrates, as well as intact blood-retinal barriers are necessary requirements for the maintenance of retinal structure and function. Retinal blood flow is autoregulated by the interaction of myogenic and metabolic mechanisms through the release of vasoactive substances by the vascular endothelium and retinal tissue surrounding the arteriolar wall. Autoregulation is achieved by adaptation of the vascular tone of the resistance vessels (arterioles, capillaries) to changes in the perfusion pressure or metabolic needs of the tissue. This adaptation occurs through the interaction of multiple mechanisms affecting the arteriolar smooth muscle cells and capillary pericytes. Mechanical stretch and increases in arteriolar transmural pressure induce the endothelial cells to release contracting factors affecting the tone of arteriolar smooth muscle cells and pericytes. Close interaction between nitric oxide (NO), lactate, arachidonic acid metabolites, released by the neuronal and glial cells during neural activity and energy-generating reactions of the retina strive to optimize blood flow according to the metabolic needs of the tissue. NO, which plays a central role in neurovascular coupling, may exert its effect, by modulating glial cell function involved in such vasomotor responses. During the evolution of ischemic microangiopathies, impairment of structure and function of the retinal neural tissue and endothelium affect the interaction of these metabolic pathways, leading to a disturbed blood flow regulation. The resulting ischemia, tissue hypoxia and alterations in the blood barrier trigger the formation of macular edema and neovascularization. Hypoxia-related VEGF expression correlates with the formation of neovessels. The relief from hypoxia results in arteriolar constriction, decreases the hydrostatic pressure in the capillaries and venules, and relieves endothelial stretching. The reestablished oxygenation of the inner retina downregulates VEGF expression and thus inhibits neovascularization and macular edema. Correct control of the multiple pathways, such as retinal blood flow, tissue oxygenation and metabolic substrate support, aiming at restoring retinal cell metabolic interactions, may be effective in preventing damage occurring during the evolution of ischemic microangiopathies.

Automatic Identification of Retinal Arteries and Veins From Dual-Wavelength Images Using Structural and Functional Features

This paper presents an automated method to identify arteries and veins in dual-wavelength retinal fundus images recorded at 570 and 600 nm. Dual-wavelength imaging provides both structural and functional features that can be exploited for identification. The processing begins with automated tracing of the vessels from the 570-nm image. The 600-nm image is registered to this image, and structural and functional features are computed for each vessel segment. We use the relative strength of the vessel central reflex as the structural feature. The central reflex phenomenon, caused by light reflection from vessel surfaces that are parallel to the incident light, is especially pronounced at longer wavelengths for arteries compared to veins. We use a dual-Gaussian to model the cross-sectional intensity profile of vessels. The model parameters are estimated using a robust M-estimator, and the relative strength of the central reflex is computed from these parameters. The functional feature exploits the fact that arterial blood is more oxygenated relative to that in veins. This motivates use of the ratio of the vessel optical densities (ODs) from images at oxygen-sensitive and oxygen-insensitive wavelengths (ODR = OD600/OD570) as a functional indicator. Finally, the structural and functional features are combined in a classifier to identify the type of the vessel. We experimented with four different classifiers and the best result was given by a support vector machine (SVM) classifier. With the SVM classifier, the proposed algorithm achieved true positive rates of 97% for the arteries and 90% for the veins, when applied to a set of 251 vessel segments obtained from 25 dual wavelength images. The ability to identify the vessel type is useful in applications such as automated retinal vessel oximetry and automated analysis of vascular changes without manual intervention.

Spectral oximetry assessed with high-speed ultra-high-resolution optical coherence tomography

We use Fourier domain optical coherence tomography (OCT) data to assess retinal blood oxygen saturation. Three-dimensional disk-centered retinal tissue volumes were assessed in 17 normal healthy subjects. After removing DC and low-frequency a-scan components, an OCT fundus image was created by integrating total reflectance into a single reflectance value. Thirty fringe patterns were sampled; 10 each from the edge of an artery, adjacent tissue, and the edge of a vein, respectively. A-scans were recalculated, zeroing the DC term in the power spectrum, and used for analysis. Optical density ratios (ODRs) were calculated as ODR(Art)=ln(Tissue(855)Art(855))ln(Tissue(805)Art(805)) and ODR(Vein)=ln(Tissue(855)Vein(855))ln(Tissue(805)Vein(805)) with Tissue, Art, and Vein representing total a-scan reflectance at the 805- or 855-nm centered bandwidth. Arterial and venous ODRs were compared by the Wilcoxon signed rank test. Arterial ODRs were significantly greater than venous ODRs (1.007+/-2.611 and -1.434+/-4.310, respectively; p=0.0217) (mean+/-standard deviation). A difference between arterial and venous blood saturation was detected. This suggests that retinal oximetry may possibly be added as a metabolic measurement in structural imaging devices.

Blood oxyhemoglobin saturation measurements by blue-green spectral shift

Previous work describing a resilient method for measuring oxyhemoglobin saturation using the blue-green spectral shift was performed using cell free hemoglobin solutions. Hemoglobin solution and whole blood sample spectra measured under similar conditions in a spectrophotometer are used here to begin evaluating the impact of cellular scattering on this method. The blue-green spectral shift with changing oxyhemoglobin saturation was preserved in these blood samples and the blue-green spectral shift was relatively unaffected by physiological changes in blood pH (6.6, 7.1, and 7.4), path length through blood (100 and 200 microm), and blood hematocrit (19 to 48%). The packaging of hemoglobin in red blood cells leads to a decreased apparent path length through hemoglobin, and an overall decrease in scattering loss with increasing wavelength from 450 to 850 nm. The negative slope of the scattering loss in the 476 to 516-nm range leads to a +3.0 nm shift in the oxyhemoglobin saturation calibration line when the blue-green spectral minimum in these blood samples was compared to cell free hemoglobin. Further research is needed to fully evaluate the blue green spectral shift method in cellular systems including in vivo testing.

Snapshot hyperspectral imaging in ophthalmology

Retinal imaging spectroscopy can provide functional maps using chromophore spectra. For example, oxygen saturation maps show ischemic areas from diabetes and venous occlusions. Obtaining retinal spatial-spectral data has been difficult due to saccades and long data acquisition times (>5 s). We present a snapshot imaging spectrometer with far-reaching applicability that acquires a complete spatial-spectral image cube in approximately 3 ms from 450 to 700 nm with 50 bands, eliminating motion artifacts and pixel misregistration. Current retinal spectral imaging approaches are incapable of true snapshot operation over a wide spectral range with a large number of spectral bands. Coupled to a fundus camera, the instrument returns true color retinal images for comparison to standard fundus images and for image validation while the patient is still dilated. Oxygen saturation maps were obtained with a three-wavelength algorithm: for healthy subjects arteries were approximately 95% and veins 30 to 35% less. The instrument is now undergoing clinical trials.