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Martin E, Cook AG, Frost SM, Turner AW, Chen FK, McAllister IL, Nolde JM, Schlaich MP. Ocular biomarkers: useful incidental findings by deep learning algorithms in fundus photographs. Eye (Lond) 2024:10.1038/s41433-024-03085-2. [PMID: 38734746 DOI: 10.1038/s41433-024-03085-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 04/03/2024] [Accepted: 04/11/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND/OBJECTIVES Artificial intelligence can assist with ocular image analysis for screening and diagnosis, but it is not yet capable of autonomous full-spectrum screening. Hypothetically, false-positive results may have unrealized screening potential arising from signals persisting despite training and/or ambiguous signals such as from biomarker overlap or high comorbidity. The study aimed to explore the potential to detect clinically useful incidental ocular biomarkers by screening fundus photographs of hypertensive adults using diabetic deep learning algorithms. SUBJECTS/METHODS Patients referred for treatment-resistant hypertension were imaged at a hospital unit in Perth, Australia, between 2016 and 2022. The same 45° colour fundus photograph selected for each of the 433 participants imaged was processed by three deep learning algorithms. Two expert retinal specialists graded all false-positive results for diabetic retinopathy in non-diabetic participants. RESULTS Of the 29 non-diabetic participants misclassified as positive for diabetic retinopathy, 28 (97%) had clinically useful retinal biomarkers. The models designed to screen for fewer diseases captured more incidental disease. All three algorithms showed a positive correlation between severity of hypertensive retinopathy and misclassified diabetic retinopathy. CONCLUSIONS The results suggest that diabetic deep learning models may be responsive to hypertensive and other clinically useful retinal biomarkers within an at-risk, hypertensive cohort. Observing that models trained for fewer diseases captured more incidental pathology increases confidence in signalling hypotheses aligned with using self-supervised learning to develop autonomous comprehensive screening. Meanwhile, non-referable and false-positive outputs of other deep learning screening models could be explored for immediate clinical use in other populations.
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Affiliation(s)
- Eve Martin
- Commonwealth Scientific and Industrial Research Organisation (CSIRO), Kensington, WA, Australia.
- School of Population and Global Health, The University of Western Australia, Crawley, Australia.
- Dobney Hypertension Centre - Royal Perth Hospital Unit, Medical School, The University of Western Australia, Perth, Australia.
- Australian e-Health Research Centre, Floreat, WA, Australia.
| | - Angus G Cook
- School of Population and Global Health, The University of Western Australia, Crawley, Australia
| | - Shaun M Frost
- Commonwealth Scientific and Industrial Research Organisation (CSIRO), Kensington, WA, Australia
- Australian e-Health Research Centre, Floreat, WA, Australia
| | - Angus W Turner
- Lions Eye Institute, Nedlands, WA, Australia
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Perth, Australia
| | - Fred K Chen
- Lions Eye Institute, Nedlands, WA, Australia
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Perth, Australia
- Centre for Eye Research Australia, The Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia
- Ophthalmology, Department of Surgery, The University of Melbourne, East Melbourne, VIC, Australia
- Ophthalmology Department, Royal Perth Hospital, Perth, Australia
| | - Ian L McAllister
- Lions Eye Institute, Nedlands, WA, Australia
- Centre for Ophthalmology and Visual Science, The University of Western Australia, Perth, Australia
| | - Janis M Nolde
- Dobney Hypertension Centre - Royal Perth Hospital Unit, Medical School, The University of Western Australia, Perth, Australia
- Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre - Royal Perth Hospital Unit, Medical School, The University of Western Australia, Perth, Australia
- Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth, Australia
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Zhao Y, Dong D, Yan D, Yang B, Gui W, Ke M, Xu A, Tan Z. Increased retinal venule diameter as a prognostic indicator for recurrent cerebrovascular events: a prospective observational study. Neural Regen Res 2024; 19:1156-1160. [PMID: 37862222 PMCID: PMC10749590 DOI: 10.4103/1673-5374.382863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/27/2023] [Accepted: 06/28/2023] [Indexed: 10/22/2023] Open
Abstract
Microvasculature of the retina is considered an alternative marker of cerebral vascular risk in healthy populations. However, the ability of retinal vasculature changes, specifically focusing on retinal vessel diameter, to predict the recurrence of cerebrovascular events in patients with ischemic stroke has not been determined comprehensively. While previous studies have shown a link between retinal vessel diameter and recurrent cerebrovascular events, they have not incorporated this information into a predictive model. Therefore, this study aimed to investigate the relationship between retinal vessel diameter and subsequent cerebrovascular events in patients with acute ischemic stroke. Additionally, we sought to establish a predictive model by combining retinal veessel diameter with traditional risk factors. We performed a prospective observational study of 141 patients with acute ischemic stroke who were admitted to the First Affiliated Hospital of Jinan University. All of these patients underwent digital retinal imaging within 72 hours of admission and were followed up for 3 years. We found that, after adjusting for related risk factors, patients with acute ischemic stroke with mean arteriolar diameter within 0.5-1.0 disc diameters of the disc margin (MAD0.5-1.0DD) of ≥ 74.14 μm and mean venular diameter within 0.5-1.0 disc diameters of the disc margin (MVD0.5-1.0DD) of ≥ 83.91 μm tended to experience recurrent cerebrovascular events. We established three multivariate Cox proportional hazard regression models: model 1 included traditional risk factors, model 2 added MAD0.5-1.0DD to model 1, and model 3 added MVD0.5-1.0DD to model 1. Model 3 had the greatest potential to predict subsequent cerebrovascular events, followed by model 2, and finally model 1. These findings indicate that combining retinal venular or arteriolar diameter with traditional risk factors could improve the prediction of recurrent cerebrovascular events in patients with acute ischemic stroke, and that retinal imaging could be a useful and non-invasive method for identifying high-risk patients who require closer monitoring and more aggressive management.
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Affiliation(s)
- Ying Zhao
- Department of Neurology and Stroke Center, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
- Clinical Neuroscience Institute, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Dawei Dong
- Department of Neurology and Stroke Center, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
- Clinical Neuroscience Institute, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Ding Yan
- Department of Neurology and Stroke Center, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
- Clinical Neuroscience Institute, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Bing Yang
- Department of Neurology and Stroke Center, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
- Clinical Neuroscience Institute, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Weirong Gui
- Department of Neurology and Stroke Center, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
- Clinical Neuroscience Institute, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Man Ke
- Department of Neurology and Stroke Center, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
- Clinical Neuroscience Institute, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Anding Xu
- Department of Neurology and Stroke Center, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
- Clinical Neuroscience Institute, the First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Zefeng Tan
- Department of Neurology, the First People’s Hospital of Foshan, Foshan, Guangdong Province, China
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Dai G, Yu S, Hu S, Luan X, Yan H, Wang X, Song P, Liu X, He X. A Novel Method for the Measurement of Retinal Arteriolar Bifurcation. Ophthalmol Ther 2024; 13:917-933. [PMID: 38294630 PMCID: PMC10912395 DOI: 10.1007/s40123-023-00881-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 12/21/2023] [Indexed: 02/01/2024] Open
Abstract
INTRODUCTION The purpose of this research was to develop protocols for evaluating the bifurcation parameters of retinal arteriole and establish a reference range of normal values. METHODS In this retrospective study, we measured a total of 1314 retinal arteriolar bifurcations from 100 fundus photographs. We selected 200 from these bifurcations for testing inter-measurer and inter-method agreement. Additionally, we calculated the normal reference range for retinal arteriolar bifurcation parameters and analyzed the effects of gender, age, and anatomical features on retinal arteriolar bifurcation. RESULTS The measurement method proposed in this study has demonstrated nearly perfect consistency among different measurers, with interclass correlation coefficient (ICC) for all bifurcation parameters of retinal arteriole exceeding 0.95. Among healthy individuals, the retinal arteriolar caliber was narrowest in young adults and increased in children, teenagers, and the elderly; retinal arteriolar caliber was greater in females than in males; and the diameter of the inferior temporal branch exceeded that of the superior temporal branch. The angle between the two branches of retinal arteriolar bifurcation was also greater in females than in males. When using the center of the optic disc as a reference point, the angle between the two branches of the retinal arteriole at the proximal or distal ends increased. In contrast, the estimated optimum theoretical values of retinal arteriolar bifurcation were not affected by these factors. CONCLUSIONS The method for the measurement of retinal arteriolar bifurcation in this study was highly accurate and reproducible. The diameter and branching angle of the retinal arteriolar bifurcation were more susceptible to the influence of gender, age, and anatomical features. In comparison, the estimated optimum theoretical values of retinal arteriolar bifurcation were relatively stable. Video available for this article.
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Affiliation(s)
- Guangzheng Dai
- Dragonfleye Healthcare Technology LLC, Shenyang, China
- He Eye Specialist Hospital, Shenyang, China
| | - Sile Yu
- Department of Public Health, He University, Shenyang, 110034, China
| | - Shenming Hu
- Department of Public Health, He University, Shenyang, 110034, China
| | - Xinze Luan
- Department of Public Health, He University, Shenyang, 110034, China
| | - Hairu Yan
- Dragonfleye Healthcare Technology LLC, Shenyang, China
| | - Xiaoting Wang
- Department of Public Health, He University, Shenyang, 110034, China
| | | | - Xinying Liu
- Dragonfleye Healthcare Technology LLC, Shenyang, China
| | - Xingru He
- Department of Public Health, He University, Shenyang, 110034, China.
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Soecknick F, Breher K, Nafar Z, Kubach S, Straub J, Wahl S, Ziemssen F. The clinical evaluation of a widefield lens to expand the field of view in optical coherence tomography (OCT-A). Sci Rep 2024; 14:6936. [PMID: 38521801 PMCID: PMC10960788 DOI: 10.1038/s41598-024-57405-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/18/2024] [Indexed: 03/25/2024] Open
Abstract
This study aimed to evaluate the clinical benefits of incorporating a widefield lens (WFL) in optical coherence tomography angiography (OCT-A) in patients with retinal vascular diseases in comparison to standard single-shot OCT-A scans. Sixty patients with retinal vascular diseases including diabetic retinopathy (DR) and retinal vein occlusion (RVO) were recruited. OCT-A imaging (PlexElite 9000) with and without WFL was performed in randomized order. The assessment included patient comfort, time, field of view (FoV), image quality and pathology detection. Statistical analysis included paired t-tests, Mann-Whitney U-tests and Bonferroni correction for multiple tests, with inter-grader agreement using the kappa coefficient. Using a WFL did not lead to statistically significant differences in DR and RVO group test times. Patient comfort remained high, with similar responses for WFL and non-WFL measurements. The WFL notably expanded the scan field (1.6× FoV increase), enhancing peripheral retinal visibility. However, image quality varied due to pathology and eye dominance, affecting the detection of peripheral issues in RVO and DR cases. The use of a WFL widens the scan field, aiding vascular retinal disease imaging with minor effects on comfort, time, and image quality. Further enhancements are needed for broader view angles, enabling improved quantification of non-perfused areas and more reliable peripheral proliferation detection.
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Affiliation(s)
- Fritz Soecknick
- Department of Ophthalmology, University of Tübingen, Tübingen, Germany.
- Institute for Ophthalmic Research, University of Tübingen, Tübingen, Germany.
| | | | | | | | | | - Siegfried Wahl
- Institute for Ophthalmic Research, University of Tübingen, Tübingen, Germany
- Carl Zeiss Vision International GmbH, Aalen, Germany
| | - Focke Ziemssen
- Department of Ophthalmology, University of Tübingen, Tübingen, Germany
- Department of Ophthalmology, University of Leipzig, Leipzig, Germany
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5
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Nivison-Smith L, Faiza A, Roy T, Trinh M. Retinal vessel diameters in intermediate age-related macular degeneration using en face optical coherence tomography. Clin Exp Optom 2024:1-6. [PMID: 38412525 DOI: 10.1080/08164622.2024.2311703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 01/22/2024] [Indexed: 02/29/2024] Open
Abstract
CLINICAL RELEVANCE Clinical assessment of age-related macular degeneration (AMD) relies on biomarkers that do not necessarily reflect the contributions of vascular dysfunction. Validation of clinically accessible methods of measuring retinal vascular integrity could provide a more holistic understanding of AMD-related changes to facilitate appropriate care. BACKGROUND There is conflicting evidence if retinal vessel calibre is significantly altered in the early stages of AMD. This study examined the outer and inner diameters of first order retinal vessels in intermediate AMD eyes using en face optical coherence tomography (OCT). METHODS Retinal en face (6 × 6 mm) OCT images were examined in a single eye of participants with intermediate AMD (n = 46) versus normal macula (n = 43) for arterioles (all identifiable) and venules (40/46 and 39/43 identifiable). All participants were aged ≥50 years without diabetes mellitus, hypertension, or other systemic vascular disease. RESULTS Intra- and inter-grader agreement was good-to-excellent for all en face OCT measurements of arteriole and venule diameters (intraclass correlation coefficient = 0.87 to 0.99). Arteriolar outer diameters (82.3 ± 19.8 µm vs 73.8 ± 16.1 µm; p < 0.05) and inner diameters (35.1 ± 8.4 µm vs 31.5 ± 8.1 µm; p < 0.05) were significantly greater in AMD eyes compared to normal eyes. Venular inner diameter was significantly greater (43.1 ± 9.5 µm vs 39.2 ± 10.1 µm; p < 0.05), but outer diameter remained unchanged (p = 0.17) in AMD eyes compared to normal eyes. CONCLUSION Arteriolar dilation and altered venular inner diameter were observed in intermediate AMD eyes. These results support further investigation of vascular contributions to AMD in the early stages of disease, possibly using the en face OCT imaging modality.
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Affiliation(s)
- Lisa Nivison-Smith
- School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
| | - Alvia Faiza
- School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
| | - Tithi Roy
- School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
| | - Matt Trinh
- School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
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Matulevičiūtė I, Tatarūnas V, Skipskis V, Čiapienė I, Veikutienė A, Lesauskaitė V, Dobilienė O, Žaliūnienė D. Coronary artery disease, its associations with ocular, genetic and blood lipid parameters. Eye (Lond) 2024; 38:372-379. [PMID: 37587376 PMCID: PMC10810895 DOI: 10.1038/s41433-023-02703-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 07/31/2023] [Accepted: 08/07/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND/OBJECTIVES To investigate the associations between ophthalmic parameters, CYP4F2 (rs2108622) and ABCA1 (rs1883025) polymorphisms and coronary artery disease, considering the accessibility, non-invasive origin of retinal examination and its possible resemblance to coronary arteries. SUBJECTS/METHODS Overall 165 participants divided into groups based on the coronary angiography results and clinical status: control group (N = 73), MI group (N = 63), 3VD (three vessel disease) (N = 24). All the participants underwent total ophthalmic examination - optical coherence tomography (OCT) and OCT angiography of the macula region were performed and evaluated. Total cholesterol, high-density lipoprotein, low-density lipoprotein and triglyceride cholesterol (Tg-C) were tested. A standard manufacturer's protocol for CYP4F2 (rs2108622) and ABCA1 (rs1883025) was used for genotyping with TaqMan probes. RESULTS GCL+ layer was thicker in control group vs. 3VD group (74.00; 62.67-94.67 (median; min.-max.) vs. 71.06; 51.33-78.44, p = 0.037). T allele carriers under ABCA1 rs1883025 dominant model were shown to have ticker retina and smaller foveal avascular zone in superficial capillary plexus and smaller Tg-C concentration. ABCA1 rs1883025 was associated with retinal thickness (OR = 0.575, 95% CI 0.348-0.948, p = 0.030). Univariate logistic regression showed that ABCA1 rs1883025 CT genotype is associated with decreased risk for coronary artery disease development under overdominant genetic model (OR = 0.498, 95% CI 0.254-0.976; p = 0.042) and codominant genetic model (OR = 0.468, 95% CI 0.232-0.945, p = 0.034). CONCLUSIONS Results of this study confirmed that non-invasive methods such as OCT of eye might be used for identification of patients at risk of CAD.
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Affiliation(s)
- Indrė Matulevičiūtė
- Department of Ophthalmology, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - Vacis Tatarūnas
- Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vilius Skipskis
- Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ieva Čiapienė
- Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Audronė Veikutienė
- Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vaiva Lesauskaitė
- Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Olivija Dobilienė
- Department of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Dalia Žaliūnienė
- Department of Ophthalmology, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Zekavat SM, Jorshery SD, Rauscher FG, Horn K, Sekimitsu S, Koyama S, Nguyen TT, Costanzo MC, Jang D, Burtt NP, Kühnapfel A, Shweikh Y, Ye Y, Raghu V, Zhao H, Ghassemi M, Elze T, Segrè AV, Wiggs JL, Del Priore L, Scholz M, Wang JC, Natarajan P, Zebardast N. Phenome- and genome-wide analyses of retinal optical coherence tomography images identify links between ocular and systemic health. Sci Transl Med 2024; 16:eadg4517. [PMID: 38266105 DOI: 10.1126/scitranslmed.adg4517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/03/2024] [Indexed: 01/26/2024]
Abstract
The human retina is a multilayered tissue that offers a unique window into systemic health. Optical coherence tomography (OCT) is widely used in eye care and allows the noninvasive, rapid capture of retinal anatomy in exquisite detail. We conducted genotypic and phenotypic analyses of retinal layer thicknesses using macular OCT images from 44,823 UK Biobank participants. We performed OCT layer cross-phenotype association analyses (OCT-XWAS), associating retinal thicknesses with 1866 incident conditions (median 10-year follow-up) and 88 quantitative traits and blood biomarkers. We performed genome-wide association studies (GWASs), identifying inherited genetic markers that influence retinal layer thicknesses and replicated our associations among the LIFE-Adult Study (N = 6313). Last, we performed a comparative analysis of phenome- and genome-wide associations to identify putative causal links between retinal layer thicknesses and both ocular and systemic conditions. Independent associations with incident mortality were detected for thinner photoreceptor segments (PSs) and, separately, ganglion cell complex layers. Phenotypic associations were detected between thinner retinal layers and ocular, neuropsychiatric, cardiometabolic, and pulmonary conditions. A GWAS of retinal layer thicknesses yielded 259 unique loci. Consistency between epidemiologic and genetic associations suggested links between a thinner retinal nerve fiber layer with glaucoma, thinner PS with age-related macular degeneration, and poor cardiometabolic and pulmonary function with a thinner PS. In conclusion, we identified multiple inherited genetic loci and acquired systemic cardio-metabolic-pulmonary conditions associated with thinner retinal layers and identify retinal layers wherein thinning is predictive of future ocular and systemic conditions.
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Affiliation(s)
- Seyedeh Maryam Zekavat
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA 02114, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Saman Doroodgar Jorshery
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
- Departments of Computer Science/Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
- Vector Institute for Artificial Intelligence, Toronto, ON M5G 1M1, Canada
- Department of Computer Science and Electrical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Franziska G Rauscher
- Institute for Medical Informatics, Statistics, and Epidemiology (IMISE), Leipzig University, Leipzig 04107, Germany
- Leipzig Research Centre for Civilization Diseases (LIFE), Leipzig University, Leipzig 04103, Germany
| | - Katrin Horn
- Institute for Medical Informatics, Statistics, and Epidemiology (IMISE), Leipzig University, Leipzig 04107, Germany
| | | | - Satoshi Koyama
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Trang T Nguyen
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Maria C Costanzo
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Dongkeun Jang
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Noël P Burtt
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Andreas Kühnapfel
- Institute for Medical Informatics, Statistics, and Epidemiology (IMISE), Leipzig University, Leipzig 04107, Germany
| | - Yusrah Shweikh
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA 02114, USA
| | - Yixuan Ye
- Computational Biology and Bioinformatics Program, Yale School of Medicine, New Haven, CT 06511, USA
| | - Vineet Raghu
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Hongyu Zhao
- Computational Biology and Bioinformatics Program, Yale School of Medicine, New Haven, CT 06511, USA
- School of Public Health, Yale University, New Haven, CT 06510, USA
| | - Marzyeh Ghassemi
- Departments of Computer Science/Medicine, University of Toronto, Toronto, ON M5S 1A1, Canada
- Vector Institute for Artificial Intelligence, Toronto, ON M5G 1M1, Canada
- Department of Computer Science and Electrical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Tobias Elze
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA 02114, USA
| | - Ayellet V Segrè
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA 02114, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Janey L Wiggs
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA 02114, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Lucian Del Priore
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, CT 06510, USA
| | - Markus Scholz
- Institute for Medical Informatics, Statistics, and Epidemiology (IMISE), Leipzig University, Leipzig 04107, Germany
- Leipzig Research Centre for Civilization Diseases (LIFE), Leipzig University, Leipzig 04103, Germany
| | - Jay C Wang
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, CT 06510, USA
- Northern California Retina Vitreous Associates, Mountain View, CA 94040, USA
| | - Pradeep Natarajan
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Nazlee Zebardast
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA 02114, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
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8
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Hoeft N, Full KM, Misialek JR, Lakshminarayan K, Shrestha S, Deal JA, Lutsey PL. Obstructive sleep apnea, nocturnal hypoxemia, and retinal microvasculature: The Atherosclerosis Risk in Communities Study. SLEEP ADVANCES : A JOURNAL OF THE SLEEP RESEARCH SOCIETY 2024; 5:zpae004. [PMID: 38370439 PMCID: PMC10874212 DOI: 10.1093/sleepadvances/zpae004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/26/2023] [Indexed: 02/20/2024]
Abstract
Study Objectives Retinal microvascular pathology (RMP) and obstructive sleep apnea (OSA) are both cardiovascular disease risk factors. Limited data exists on their interrelationship. We tested the hypotheses that OSA and nocturnal hypoxemia would be associated with RMP and vessel calibers. Methods We conducted a quasi-cross-sectional analysis of 1625 participants in the Atherosclerosis Risk in Communities Sleep Heart Health Study. Participants completed in-home polysomnography monitoring (1996-1998) and were categorized by OSA severity (apnea-hypopnea index: <5, 5-14.9, and ≥15) and proportion of total sleep time with oxygen saturation < 90% (T90). Retinal photography (1993-1995) was used to assess RMP and measure vascular diameters (central retinal arteriolar equivalent [CRAE] and central retinal venular equivalent [CRVE]). Logistic and linear models were adjusted for demographics, behaviors, and BMI. Results Of the participants, 19% had OSA (AHI > 15) and 4% had RMP. Severe OSA was not associated with RMP [OR (95% CI): 1.08 (0.49 to 2.38)] or CRAE in adjusted models. OSA severity showed a positive linear relationship with CRVE; adjusted mean CRVE for those with OSA was 195.8 μm compared to 193.2 μm for those without OSA (Ptrend = 0.03). T90 was strongly associated with CRVE, but not with RMP or CRAE. Adjusted mean CRVE for T90 ≥ 5% was 199.0 and 192.9 for T90 < 1% (ptrend < 0.0001). Conclusions OSA and T90 were not associated with RMP or CRAE. However, both OSA and T90 ≥ 5% were associated with wider venules, which may be early and indicative changes of increased inflammation and future risk of stroke and CHD.
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Affiliation(s)
- Nathan Hoeft
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Kelsie M Full
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey R Misialek
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Kamakshi Lakshminarayan
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Srishti Shrestha
- The Memory Impairment and Neurodegenerative Dementia (MIND) Center, University of Mississippi, Jackson, MS, USA
| | - Jennifer A Deal
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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Gómez Sánchez A, Colucci P, Moran A, Moya López A, Colligris B, Álvarez Y, Kennedy BN. Systemic treatment with cigarette smoke extract affects zebrafish visual behaviour, intraocular vasculature morphology and outer segment phagocytosis. OPEN RESEARCH EUROPE 2023; 3:48. [PMID: 38283058 PMCID: PMC10822043 DOI: 10.12688/openreseurope.15491.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 01/30/2024]
Abstract
Introduction Cigarette smoking adversely affects multiple aspects of human health including eye disorders such as age-related macular degeneration, cataracts and dry eye disease. However, there remains a knowledge gap in how constituents of cigarette smoke affect vision and retinal biology. We used zebrafish to assess effects of short-term acute exposure to cigarette smoke extract (CSE) on visual behaviour and retinal biology. Methods Zebrafish larvae with a developed visual system at three days post-fertilization (dpf) were exposed to CSE for 4, 24 or 48 hours. Visual behaviour, hyaloid vasculature morphology, retinal histology, oxidative stress gene expression and outer segment phagocytosis were investigated using visual behavioural optokinetic and visual motor response assays (OKR and VMR), microscopy (light, fluorescence and transmission electron microscopy), and real-time PCR. Results In zebrafish larvae, 48 hours of CSE treatment resulted in significantly reduced visual behaviour. Larvae treated with 10, 15 or 20 μg/mL CSE showed an average of 13.7, 10.7 or 9.4 saccades per minute, respectively, significantly lower compared with 0.05% DMSO controls (p=0.0093, p=0.0004 and p<0.0001, respectively) that exhibited 19.7 saccades per minute. The diameter of intraocular vessels increased from 4.833 μm in 0.05% DMSO controls to 5.885 μm in the 20 μg/mL CSE-treated larvae (p=0.0333). Biometry analysis highlighted a significant axial length elongation in 20 μg/mL CSE-treated larvae (216.9 μm, p<0.0001) compared to 0.05% dimethyl sulfoxide (DMSO) controls (205.1 μm). Larvae exposed to 20 μg/mL CSE had significantly (p=0.0002) higher numbers of RPE phagosomes compared to vehicle controls (0.1425 and 0.093 phagosomes/μm RPE, respectively). Conclusions Zebrafish larvae with a developed visual system display apparent defects in visual behaviour and retinal biology after acute exposure to CSE, establishing a valuable in vivo model to investigate ocular disorders related to cigarette smoke.
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Affiliation(s)
- Alicia Gómez Sánchez
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, D04 V1W8, Ireland
- Ocupharm Diagnostic Group Research, Faculty of Optic and Optometry, Complutense University of Madrid, Madrid, Spain
| | - Patrizia Colucci
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, D04 V1W8, Ireland
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, Siena, Italy
| | - Ailis Moran
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Alexandro Moya López
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, D04 V1W8, Ireland
- Ocupharm Diagnostic Group Research, Faculty of Optic and Optometry, Complutense University of Madrid, Madrid, Spain
| | - Basilio Colligris
- Ocupharm Diagnostic Group Research, Faculty of Optic and Optometry, Complutense University of Madrid, Madrid, Spain
| | - Yolanda Álvarez
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, D04 V1W8, Ireland
- UCD School of Biomolecular and Biomedical Science, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Breandán N. Kennedy
- UCD Conway Institute of Biomolecular and Biomedical Research, University College Dublin, Dublin, D04 V1W8, Ireland
- UCD School of Biomolecular and Biomedical Science, University College Dublin, Dublin, D04 V1W8, Ireland
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10
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Pappelis K, Jansonius NM. Retinal Vessel Caliber Measurement Bias in Fundus Images in the Presence of the Central Light Reflex. Transl Vis Sci Technol 2023; 12:16. [PMID: 37450282 PMCID: PMC10353742 DOI: 10.1167/tvst.12.7.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 06/16/2023] [Indexed: 07/18/2023] Open
Abstract
Purpose To investigate the agreement between a fundus camera and a scanning laser ophthalmoscope in retinal vessel caliber measurements and to identify whether the presence of the central light reflex (CLR) explains potential discrepancies. Methods For this cross-sectional study, we obtained fundus camera and scanning laser ophthalmoscope images from 85 eyes of 85 healthy individuals (aged 50-65 years) with different blood pressure status. We measured the central retinal artery equivalent (CRAE) and central retinal artery vein equivalent (CRVE) with the Knudtson-Parr-Hubbard algorithm and assessed the CLR using a semiautomatic grading method. We used Bland-Altman plots, 95% limits of agreement, and the two-way mixed effects intraclass correlation coefficient for consistency [ICC(3,1)] to describe interdevice agreement. We used multivariable regression to identify factors associated with differences in between-device measurements. Results The between-device difference in CRAE (9.5 µm; 95% confidence interval, 8.0-11.1 µm) was larger than the between-device difference in CRVE (2.9 µm; 95% confidence interval, 1.3-4.5 µm), with the fundus camera yielding higher measurements (both P < 0.001). The 95% fundus camera-scanning laser ophthalmoscope limits of agreement were -4.8 to 23.9 µm for CRAE and -12.0 to 17.8 µm for CRVE. The corresponding ICCs(3,1) were 0.89 (95% confidence interval, 0.83-0.92) and 0.91 (95% confidence interval, 0.86-0.94). The between-device CRAE difference was positively associated with the presence of a CLR (P = 0.002). Conclusions Fundus cameras and scanning laser ophthalmoscopes yield correlated but not interchangeable caliber measurements. The CLR induces bias in arteriolar caliber in fundus camera images, compared with scanning laser ophthalmoscope images. Translational Relevance Refined measurements could yield better estimates of the association between retinal vessel caliber and ophthalmic or systemic disease.
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Affiliation(s)
- Konstantinos Pappelis
- Department of Ophthalmology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Graduate School of Medical Sciences, Research School of Behavioural and Cognitive Neurosciences, University of Groningen, Groningen, the Netherlands
| | - Nomdo M Jansonius
- Department of Ophthalmology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Graduate School of Medical Sciences, Research School of Behavioural and Cognitive Neurosciences, University of Groningen, Groningen, the Netherlands
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11
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Zekavat SM, Jorshery SD, Shweikh Y, Horn K, Rauscher FG, Sekimitsu S, Kayoma S, Ye Y, Raghu V, Zhao H, Ghassemi M, Elze T, Segrè AV, Wiggs JL, Scholz M, Priore LD, Wang JC, Natarajan P, Zebardast N. Insights into human health from phenome- and genome-wide analyses of UK Biobank retinal optical coherence tomography phenotypes. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.05.16.23290063. [PMID: 37292770 PMCID: PMC10246137 DOI: 10.1101/2023.05.16.23290063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The human retina is a complex multi-layered tissue which offers a unique window into systemic health and disease. Optical coherence tomography (OCT) is widely used in eye care and allows the non-invasive, rapid capture of retinal measurements in exquisite detail. We conducted genome- and phenome-wide analyses of retinal layer thicknesses using macular OCT images from 44,823 UK Biobank participants. We performed phenome-wide association analyses, associating retinal thicknesses with 1,866 incident ICD-based conditions (median 10-year follow-up) and 88 quantitative traits and blood biomarkers. We performed genome-wide association analyses, identifying inherited genetic markers which influence the retina, and replicated our associations among 6,313 individuals from the LIFE-Adult Study. And lastly, we performed comparative association of phenome- and genome- wide associations to identify putative causal links between systemic conditions, retinal layer thicknesses, and ocular disease. Independent associations with incident mortality were detected for photoreceptor thinning and ganglion cell complex thinning. Significant phenotypic associations were detected between retinal layer thinning and ocular, neuropsychiatric, cardiometabolic and pulmonary conditions. Genome-wide association of retinal layer thicknesses yielded 259 loci. Consistency between epidemiologic and genetic associations suggested putative causal links between thinning of the retinal nerve fiber layer with glaucoma, photoreceptor segment with AMD, as well as poor cardiometabolic and pulmonary function with PS thinning, among other findings. In conclusion, retinal layer thinning predicts risk of future ocular and systemic disease. Furthermore, systemic cardio-metabolic-pulmonary conditions promote retinal thinning. Retinal imaging biomarkers, integrated into electronic health records, may inform risk prediction and potential therapeutic strategies.
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Affiliation(s)
- Seyedeh Maryam Zekavat
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Saman Doroodgar Jorshery
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Departments of Computer Science/Medicine, University of Toronto, Toronto, Canada
- Vector Institute for Artificial Intelligence, Toronto, ON, Canada
- Department of Computer Science and Electrical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yusrah Shweikh
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Katrin Horn
- Institute for Medical Informatics, Statistics and Epidemiology University of Leipzig, Germany and Leipzig Research Centre for Civilization Diseases (LIFE), Leipzig University, Leipzig, Germany
| | - Franziska G. Rauscher
- Institute for Medical Informatics, Statistics and Epidemiology University of Leipzig, Germany and Leipzig Research Centre for Civilization Diseases (LIFE), Leipzig University, Leipzig, Germany
| | | | - Satoshi Kayoma
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Yixuan Ye
- Computational Biology and Bioinformatics Program, Yale University, New Haven, CT, USA
| | - Vineet Raghu
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hongyu Zhao
- Computational Biology and Bioinformatics Program, Yale University, New Haven, CT, USA
- School of Public Health, Yale University, New Haven, CT, USA
| | - Marzyeh Ghassemi
- Departments of Computer Science/Medicine, University of Toronto, Toronto, Canada
- Vector Institute for Artificial Intelligence, Toronto, ON, Canada
- Department of Computer Science and Electrical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Tobias Elze
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Ayellet V. Segrè
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Janey L. Wiggs
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Markus Scholz
- Institute for Medical Informatics, Statistics and Epidemiology University of Leipzig, Germany and Leipzig Research Centre for Civilization Diseases (LIFE), Leipzig University, Leipzig, Germany
| | - Lucian Del Priore
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, CT, USA
| | - Jay C. Wang
- Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, CT, USA
- Northern California Retina Vitreous Associates, Mountain View, CA
| | - Pradeep Natarajan
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Nazlee Zebardast
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
- Program in Medical and Population Genetics and Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
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12
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Chaikijurajai T, Ehlers JP, Tang WHW. Retinal Microvasculature: A Potential Window Into Heart Failure Prevention. JACC. HEART FAILURE 2022; 10:785-791. [PMID: 36328644 DOI: 10.1016/j.jchf.2022.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/06/2022] [Accepted: 07/11/2022] [Indexed: 06/16/2023]
Abstract
Endothelial dysfunction and microvascular disease have been shown to play an important role in the development and progression of heart failure (HF). Retinal imaging provides a unique opportunity to noninvasively assess vascular structure and function, vessel features, and microcirculation within the retina. Accumulating evidence suggests that retinal vessel caliber, microvascular features, and vascular characteristics extracted from various imaging modalities are associated with alterations in left ventricular structure and function in stage B HF, as well as incident development of symptomatic HF in the general population. Moreover, dynamic retinal vessel analysis has been shown to differentiate HF patients based on their phenotypes. Given the increasing availability of rapid image acquisition devices (eg, nonmydriatic widefield systems and smartphone-based retinal cameras) and the integration of artificial intelligence-based interrogation/assessment techniques, retinal imaging is a promising noninvasive tool, in conjunction with cardiac imaging and biomarkers, to prevent HF and risk stratify those at risk of developing HF. This review focuses on the current evidence on retinal microvasculature changes, and potential clinical relevance and promising utility of retinal imaging in HF.
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Affiliation(s)
- Thanat Chaikijurajai
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - W H Wilson Tang
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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13
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Guo S, Yin S, Song W, Tse G, Liu J, Hei K, Chen K, Su L, Liu T. Retinal Microvascular Abnormalities Predict Clinical Outcomes in Patients with Heart Failure. Diagnostics (Basel) 2022; 12:diagnostics12092078. [PMID: 36140480 PMCID: PMC9497585 DOI: 10.3390/diagnostics12092078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/22/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Narrower retinal arterioles and wider retinal venules have been associated with the incidence of heart failure (HF). However, whether they are predictive of the prognosis of heart failure (HF) is unclear. We aimed to explore the role of retinal vessel calibers in predicting long-term clinical outcomes of HF. Methods: This is a prospective, single-center, observational study that surveyed patients in a tertiary referral hospital for the treatment of HF. Retinal vessel caliber was graded using retinal photography. The primary endpoint was the composite endpoint of HF rehospitalization and mortality at 12 months. Results: There were 55 patients with chronic HF included in the final analysis. At 12 months, the cumulative incidence of the primary endpoint, HF rehospitalization, and mortality tended to be higher with the widening of the central retinal venular equivalent (CRVE) (p for non-linearity = 0.059) and was significantly increased when CRVE reached a cut-off value (283 μm) (p = 0.011) following adjustment for age, sex, etiology of HF, and diabetes. No association between the central retinal arteriolar equivalent (CRAE) and arteriolar-to-venular caliber ratio (AVR) was found with the clinical outcome in both univariable and multivariable Cox regression. CRAE, CRVE, and AVR had no relationship with the concentration of the N-terminal pro-B-type natriuretic peptide. In addition, CRVE was not associated with cardiac diastolic and systolic function. Conclusions: When the retinal venular caliber widens to a certain point, the composite incidence of HF rehospitalization and mortality significantly increase, suggesting retinal vessel caliber imaging may provide insight into the development of HF.
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Affiliation(s)
- Shaohua Guo
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Songtao Yin
- Department of Ophthalmology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Wenhua Song
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
- Pears Building, Kent and Medway Medical School, University of Kent, Canterbury CT2 7FS, UK
| | - Juping Liu
- Tianjin Key Laboratory of Retinal Functions and Diseases, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
| | - Kaiwen Hei
- Tianjin Key Laboratory of Retinal Functions and Diseases, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin 300384, China
| | - Kangyin Chen
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
| | - Long Su
- Department of Ophthalmology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
- Correspondence: (L.S.); (T.L.)
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin 300211, China
- Correspondence: (L.S.); (T.L.)
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14
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Hatamizadeh A, Hosseini H, Patel N, Choi J, Pole CC, Hoeferlin CM, Schwartz SD, Terzopoulos D. RAVIR: A Dataset and Methodology for the Semantic Segmentation and Quantitative Analysis of Retinal Arteries and Veins in Infrared Reflectance Imaging. IEEE J Biomed Health Inform 2022; 26:3272-3283. [PMID: 35349464 DOI: 10.1109/jbhi.2022.3163352] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The retinal vasculature provides important clues in the diagnosis and monitoring of systemic diseases including hypertension and diabetes. The microvascular system is of primary involvement in such conditions, and the retina is the only anatomical site where the microvasculature can be directly observed. The objective assessment of retinal vessels has long been considered a surrogate biomarker for systemic vascular diseases, and with recent advancements in retinal imaging and computer vision technologies, this topic has become the subject of renewed attention. In this paper, we present a novel dataset, dubbed RAVIR, for the semantic segmentation of Retinal Arteries and Veins in Infrared Reflectance (IR) imaging. It enables the creation of deep learning-based models that distinguish extracted vessel type without extensive post-processing. We propose a novel deep learning-based methodology, denoted as SegRAVIR, for the semantic segmentation of retinal arteries and veins and the quantitative measurement of the widths of segmented vessels. Our extensive experiments validate the effectiveness of SegRAVIR and demonstrate its superior performance in comparison to state-of-the-art models. Additionally, we propose a knowledge distillation framework for the domain adaptation of RAVIR pretrained networks on color images. We demonstrate that our pretraining procedure yields new state-of-the-art benchmarks on the DRIVE, STARE, and CHASE\_DB1 datasets. Dataset link: https://ravirdataset.github.io/data.
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15
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Peng Q, Tseng RMWW, Tham YC, Cheng CY, Rim TH. Detection of Systemic Diseases From Ocular Images Using Artificial Intelligence: A Systematic Review. Asia Pac J Ophthalmol (Phila) 2022; 11:126-139. [PMID: 35533332 DOI: 10.1097/apo.0000000000000515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Despite the huge investment in health care, there is still a lack of precise and easily accessible screening systems. With proven associations to many systemic diseases, the eye could potentially provide a credible perspective as a novel screening tool. This systematic review aims to summarize the current applications of ocular image-based artificial intelligence on the detection of systemic diseases and suggest future trends for systemic disease screening. METHODS A systematic search was conducted on September 1, 2021, using 3 databases-PubMed, Google Scholar, and Web of Science library. Date restrictions were not imposed and search terms covering ocular images, systemic diseases, and artificial intelligence aspects were used. RESULTS Thirty-three papers were included in this systematic review. A spectrum of target diseases was observed, and this included but was not limited to cardio-cerebrovascular diseases, central nervous system diseases, renal dysfunctions, and hepatological diseases. Additionally, one- third of the papers included risk factor predictions for the respective systemic diseases. CONCLUSIONS Ocular image - based artificial intelligence possesses potential diagnostic power to screen various systemic diseases and has also demonstrated the ability to detect Alzheimer and chronic kidney diseases at early stages. Further research is needed to validate these models for real-world implementation.
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Affiliation(s)
- Qingsheng Peng
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Clinical and Translational Sciences Program, Duke-NUS Medical School, Singapore
| | | | - Yih-Chung Tham
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore
| | - Ching-Yu Cheng
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore
| | - Tyler Hyungtaek Rim
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore
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16
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Malyutina SK, Direev AO, Munz IV, Palekhina YY, Ryabikov AN. [Relationship of retinal vascular caliber with age and cardiometabolic diseases in the population over 50 years of age]. Vestn Oftalmol 2022; 138:14-21. [PMID: 36288413 DOI: 10.17116/oftalma202213805114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
UNLABELLED In an aging society, age-dependent diseases with high mortality, including cardiovascular diseases (CVD) and type 2 diabetes mellitus (DM2), occupy a special place. There is only limited population-based data on the relationship between cardiometabolic diseases and target-organ damage, including ocular microvasculature. PURPOSE To explore the associations between the caliber of retinal vessels and cardiometabolic diseases in a population sample of men and women from middle-aged to elderly (Novosibirsk). MATERIAL AND METHODS The subjects were participants of the Russian cohort - part of the international project HAPIEE, and were initially examined in 2003-2005 (n=9360, aged 45-69 years, Novosibirsk). At the third survey in 2015-2017, a random sub-sample of men and women (n=1011) was formed for an in-depth evaluation. We performed a calibrometric analysis involving measurement of central retinal artery equivalent (CRAE), central retinal vein equivalent (CRVE), and CRAE-to-CRVE ratio (AVR). RESULTS In a population sample of men and women aged 55-84 years, age increment is accompanied by a decrease in the calibers of retinal arterioles and venules (p<0.001). Arterial hypertension (AH) was accompanied by a decrease in CRAE, CRVE (p=0.001) and AVR (p<0.001); the associations between AH, CRAE and AVR were independent from other factors. Multivariate analysis showed that CRAE and CRVE were inversely associated with the presence of DM2 (p=0.026). Carotid atherosclerosis was accompanied by an increase in CRVE (p<0.002); this relationship was mainly attributed to age and metabolic factors. There were no associations between carotid atherosclerosis and either CRAE or AVR. The multivariate analysis identified the weak positive associations of CRAE and AVR with the presence of ischemic heart disease and CVD. CONCLUSION In the examined population sample aged 55-84 years, a number of associations were detected between retinal vascular caliber and cardiometabolic diseases. The observed changes in the microvascular bed of the retina may be important for prognosis of the course of common cardiometabolic diseases.
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Affiliation(s)
- S K Malyutina
- Novosibirsk State Medical University, Novosibirsk, Russia
- Federal Research Center Institute of Cytology and Genetics - Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - A O Direev
- Novosibirsk State Medical University, Novosibirsk, Russia
- Federal Research Center Institute of Cytology and Genetics - Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - I V Munz
- Novosibirsk State Medical University, Novosibirsk, Russia
- Federal Research Center Institute of Cytology and Genetics - Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - Yu Yu Palekhina
- Federal Research Center Institute of Cytology and Genetics - Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
| | - A N Ryabikov
- Novosibirsk State Medical University, Novosibirsk, Russia
- Federal Research Center Institute of Cytology and Genetics - Siberian Branch of the Russian Academy of Sciences, Novosibirsk, Russia
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Arsalan M, Haider A, Choi J, Park KR. Diabetic and Hypertensive Retinopathy Screening in Fundus Images Using Artificially Intelligent Shallow Architectures. J Pers Med 2021; 12:jpm12010007. [PMID: 35055322 PMCID: PMC8777982 DOI: 10.3390/jpm12010007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 12/25/2022] Open
Abstract
Retinal blood vessels are considered valuable biomarkers for the detection of diabetic retinopathy, hypertensive retinopathy, and other retinal disorders. Ophthalmologists analyze retinal vasculature by manual segmentation, which is a tedious task. Numerous studies have focused on automatic retinal vasculature segmentation using different methods for ophthalmic disease analysis. However, most of these methods are computationally expensive and lack robustness. This paper proposes two new shallow deep learning architectures: dual-stream fusion network (DSF-Net) and dual-stream aggregation network (DSA-Net) to accurately detect retinal vasculature. The proposed method uses semantic segmentation in raw color fundus images for the screening of diabetic and hypertensive retinopathies. The proposed method's performance is assessed using three publicly available fundus image datasets: Digital Retinal Images for Vessel Extraction (DRIVE), Structured Analysis of Retina (STARE), and Children Heart Health Study in England Database (CHASE-DB1). The experimental results revealed that the proposed method provided superior segmentation performance with accuracy (Acc), sensitivity (SE), specificity (SP), and area under the curve (AUC) of 96.93%, 82.68%, 98.30%, and 98.42% for DRIVE, 97.25%, 82.22%, 98.38%, and 98.15% for CHASE-DB1, and 97.00%, 86.07%, 98.00%, and 98.65% for STARE datasets, respectively. The experimental results also show that the proposed DSA-Net provides higher SE compared to the existing approaches. It means that the proposed method detected the minor vessels and provided the least false negatives, which is extremely important for diagnosis. The proposed method provides an automatic and accurate segmentation mask that can be used to highlight the vessel pixels. This detected vasculature can be utilized to compute the ratio between the vessel and the non-vessel pixels and distinguish between diabetic and hypertensive retinopathies, and morphology can be analyzed for related retinal disorders.
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18
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Maugana VF, Kruger R, Schutte AE, Smith W. Socioeconomic inequalities, modifiable lifestyle risk factors, and retinal vessel calibers: The African-PREDICT Study. Microcirculation 2021; 28:e12714. [PMID: 34008905 DOI: 10.1111/micc.12714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/01/2021] [Accepted: 05/11/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Lifestyle risk factors vary between socioeconomic status (SES) groups and may influence cardiovascular function differently. The retinal microvasculature allows for monitoring early changes in cardiovascular health, and therefore, we investigated whether retinal vessel calibers associate differently with modifiable risk factors in different SES groups. METHODS We included 1064 young adults (aged 20-30 years) grouped by low and high SES. The central retinal artery and vein equivalents (CRAE, CRVE) were determined from fundus images captured using the Dynamic Retinal Vessel Analyzer (Imedos Systems GmbH, Jena, Germany). We collected anthropometry, self-reported alcohol consumption, and biochemical data. RESULTS Retinal vessel calibers did not differ between SES groups (p ≥ .80) after adjusting for sex and ethnicity. Unique independent associations were observed in the low SES group, where CRAE (β = 0.08, p = .042) and CRVE (β = .14, p = .001) associated positively with cotinine and body mass index, respectively. In the high SES group, CRAE (β = -0.09, p = .027) associated negatively with alcohol consumption. CONCLUSION At young ages, retinal vessel calibers associated differently with modifiable lifestyle risk factors within each SES group. Our data highlight the importance of detecting adverse lifestyle risk factors among young adults from diverse socioeconomic settings to improve prevention of cardiovascular disease.
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Affiliation(s)
| | - Ruan Kruger
- Hypertension in Africa Research Team (HART, North-West University, Potchefstroom, South Africa.,Medical Research Council: Unit for Hypertension and Cardiovascular Disease, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Aletta Elisabeth Schutte
- Hypertension in Africa Research Team (HART, North-West University, Potchefstroom, South Africa.,Medical Research Council: Unit for Hypertension and Cardiovascular Disease, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa.,School of Population Health, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Wayne Smith
- Hypertension in Africa Research Team (HART, North-West University, Potchefstroom, South Africa.,Medical Research Council: Unit for Hypertension and Cardiovascular Disease, Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
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19
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Retinal changes in patients with angina pectoris and anginal equivalents: a study of patients with normal coronary angiography. ACTA ACUST UNITED AC 2021; 59:174-179. [PMID: 33565300 DOI: 10.2478/rjim-2020-0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Indexed: 11/21/2022]
Abstract
Background and aims. Approximately 10-30% of the patients with typical symptoms of angina pectoris have normal angiography showing normal macrovasculature. In these patients, however, the microvascular problems should be monitored. Hence, the main aim of this study is to evaluate retinal changes in normal angiographic patients.Methods. In this descriptive cross-sectional study, 60 normal angiographic patients with typical chest pain or anginal equivalents visiting Modarres Hospital Cardiology Research Center between 2018 and 2019 were enrolled and retinal changes were determined in Labbafinejad Hospital by Optical Coherence Tomography Angiography using Foveal Avascular Zone (FAZ), Superficial Vascular Density (SVD), and Deep Vascular Density (DVD).Results. The results of this study demonstrated that FAZ was normal in all subjects, but SVD and DVD were abnormal in 45% and 8.3%, respectively. Totally, 18.5% and 66.7% showed abnormal SVD among stable angina (SA) and unstable angina (UA) cases, respectively (P < 0.001). There was no statistically significant difference between abnormal DVD in SA and UA cases (P = 0.058). Abnormal SVD was significantly more common among diabetic patients (P < 0.001), while DVD was not related to diabetes presence in the study population (P > 0.05). Moreover, abnormal SVD was more common among patients with chest pain (P = 0.036), while there was no significant difference for DVD (P = 0.371). Interestingly, abnormal ECG was associated with both abnormal DVD and SVD.Conclusions. The results of this study showed that nearly half of the patients with angina pectoris or anginal equivalents who revealed normal angiographic findings may suffer from retinal changes. Thus, retinal assessment is needed in these patients to evaluate microvascular changes.
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Lal A, Dave N, Gibbs OJ, Barry MAT, Sood A, Mitchell P, Thiagalingam A. Effect of ECG-gating Retinal Photographs on Retinal Vessel Caliber Measurements in Subjects with and without Type 2 Diabetes. Curr Eye Res 2021; 46:1742-1750. [PMID: 33960254 DOI: 10.1080/02713683.2021.1927112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose/Aim of this study: Retinal vessel caliber is an independent risk marker of cardiovascular disease risk. However, variable mechanical delays in capturing retinal photographs and cardiac cycle-induced retinal vascular changes have been shown to reduce the accuracy of retinal vessel caliber measurements, but this has only ever been investigated in healthy subjects. This cross-sectional study is the first study to investigate this issue in type 2 diabetes. The aim of this study was to determine whether ECG-gating retinal photographs reduce the variability in retinal arteriolar and venular caliber measurements in controls and type 2 diabetes.Materials and Methods: Fifteen controls and 15 patients with type 2 diabetes were arbitrarily recruited from Westmead Hospital, Sydney, Australia. A mydriatic fundoscope connected to our novel ECG synchronization unit captured 10 ECG-gated (at the QRS) and 10 ungated digital retinal photographs of the left eye in a randomized fashion, blinded to study participants. Two independent reviewers used an in-house semi-automated software to grade single cross-sectional vessel diameters across photographs, between 900 and 1800 microns from the optic disc edge. The coefficient of variation compared caliber variability between retinal arterioles and venules.Results: Our ECG synchronization unit reported the smallest time delay (33.1 ± 48.4 ms) in image capture known in the literature. All 30 participants demonstrated a higher reduction in retinal arteriolar (ungated: 1.02, 95%CI 0.88-1.17% vs ECG-gated: 0.39, 95%CI 0.29-0.49%, p < .0001) than venular (ungated 0.62, 95%CI 0.53-0.73% vs ECG-gated: 0.26, 95%CI 0.19-0.35%, p < .0001) coefficient of variation by ECG-gating photographs. Intra-observer repeatability and inter-observer reproducibility analysis reported high interclass correlation coefficients ranging from 0.80 to 0.86 and 0.80 to 0.93 respectively.Conclusion: ECG-gating photographs at the QRS are recommended for retinal vessel caliber analysis in controls and patients with type 2 diabetes as they refine measurements.
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Affiliation(s)
- Anchal Lal
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia.,Centre for Vision Research, The Westmead Institute for Medical Research Hospital, Sydney, Australia
| | - Neha Dave
- School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
| | - Oliver J Gibbs
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia
| | | | - Annika Sood
- Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Paul Mitchell
- Sydney Medical School, The University of Sydney, Sydney, Australia.,Centre for Vision Research, The Westmead Institute for Medical Research Hospital, Sydney, Australia
| | - Aravinda Thiagalingam
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Sydney Medical School, The University of Sydney, Sydney, Australia
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21
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Marques-Vidal P. I can't see your heart from here. Eur J Prev Cardiol 2021; 29:903. [PMID: 33693640 DOI: 10.1093/eurjpc/zwab039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Pedro Marques-Vidal
- Department of Medicine, Internal Medicine, Lausanne University Hospital (CHUV), University of Lausanne, Rue du Bugnon 46, CH-1011 Lausanne, Switzerland
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22
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Pappelis K, Choritz L, Jansonius NM. Microcirculatory model predicts blood flow and autoregulation range in the human retina: in vivo investigation with laser speckle flowgraphy. Am J Physiol Heart Circ Physiol 2020; 319:H1253-H1273. [PMID: 32986964 DOI: 10.1152/ajpheart.00404.2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In this study, we mathematically predict retinal vascular resistance (RVR) and retinal blood flow (RBF), we test predictions using laser speckle flowgraphy (LSFG), we estimate the range of vascular autoregulation, and we examine the relationship of RBF with the retinal nerve fiber layer (RNFL) and ganglion cell complex (GCC). Fundus, optical coherence tomography (OCT), and OCT-angiography images, systolic/diastolic blood pressure (SBP/DBP), and intraocular pressure (IOP) measurements were obtained from 36 human subjects. We modeled two circulation markers (RVR and RBF) and estimated individualized lower/higher autoregulation limits (LARL/HARL), using retinal vessel calibers, fractal dimension, perfusion pressure, and population-based hematocrit values. Quantitative LSFG waveforms were extracted from vessels of the same eyes, before and during IOP elevation. LSFG metrics explained most variance in RVR (R2 = 0.77/P = 6.9·10-9) and RBF (R2 = 0.65/P = 1.0·10-6), suggesting that the markers strongly reflect blood flow physiology. Higher RBF was associated with thicker RNFL (P = 4.0·10-4) and GCC (P = 0.003), thus also verifying agreement with structural measurements. LARL was at SBP/DBP of 105/65 mmHg for the average subject without arterial hypertension and at 115/75 mmHg for the average hypertensive subject. Moreover, during IOP elevation, changes in RBF were more pronounced than changes in RVR. These observations physiologically imply that healthy subjects are already close to LARL, thus prone to hypoperfusion. In conclusion, we modeled two clinical markers and described a novel method to predict individualized autoregulation limits. These findings could improve understanding of retinal perfusion and pave the way for personalized intervention decisions, when treating patients with coexisting ophthalmic and cardiovascular pathologies.NEW & NOTEWORTHY We describe and test a new approach to quantify retinal blood flow, based on standard clinical examinations and imaging techniques, linked together with a physiological model. We use these findings to generate individualized estimates of the autoregulation range. We provide evidence that healthy subjects are closer to the lower autoregulation limit than thought before. This suggests that some retinas are less prepared to withstand hypoperfusion, even after small intraocular pressure rises or blood pressure drops.
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Affiliation(s)
- Konstantinos Pappelis
- Department of Ophthalmology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Research School of Behavioural and Cognitive Neurosciences, Graduate School of Medical Sciences, University of Groningen, Groningen, The Netherlands
| | - Lars Choritz
- University Eye Clinic, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Nomdo M Jansonius
- Department of Ophthalmology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Research School of Behavioural and Cognitive Neurosciences, Graduate School of Medical Sciences, University of Groningen, Groningen, The Netherlands
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