1
|
Manafi N, Oncel D, Verma A, Corradetti G, Kadomoto S, Mahmoudi A, Alagorie AR, Yadav NK, Pappuru RR, Tufail A, Esmaeilkhanian H, Nittala MG, Raman R, Sadda S. Relationship between macular perfusion and lesion distribution in diabetic retinopathy. Eye (Lond) 2024; 38:2724-2730. [PMID: 38724702 PMCID: PMC11427675 DOI: 10.1038/s41433-024-03105-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/17/2024] [Accepted: 04/19/2024] [Indexed: 09/28/2024] Open
Abstract
BACKGROUND/OBJECTIVES To assess the relationship between macular vessel density metrics and foveal avascular zone (FAZ) characteristics on optical coherence tomography angiography (OCTA) and lesion distribution in eyes with diabetic retinopathy (DR). SUBJECTS/METHODS Patients with DR who underwent both Optos ultrawidefield (UWF) pseudocolor imaging and macular OCTA (Cirrus Angioplex, 6 × 6 mm) were included in this cross-sectional observational study. The distribution of DR lesions was assessed by comparing each of the peripheral ETDRS extended fields (3-7) against their corresponding ETDRS field, hence eyes were defined as either having predominantly peripheral lesions (PPL) or predominantly central lesions (PCL). En face OCTA images from the superficial and deep capillary plexuses (SCP and DCP) were then analysed using Image J software. Perfusion density (PD), vessel length density (VLD), and fractal dimensions (FD) were calculated following binarization and skeletonization of the images. RESULTS Out of 344 eyes, 116 (33.72%) eyes had PPL and 228 (66.28%) eyes had PCL. For all DRSS levels, VLD, PD, and FD were not significantly different between eyes with PPL and PCL. The FAZ in eyes with PPL, however, was found to be more circular in shape compared to eyes with PCL (p = 0.037). CONCLUSION Although the presence of PPL has been associated with a higher risk for diabetic retinopathy progression, the macular perfusion is similar in eyes with PPL and PCL. The FAZ is more circular in eyes with PPL, but the clinical relevance of this difference remains to be defined.
Collapse
Affiliation(s)
- Navid Manafi
- Doheny Eye Institute, Pasadena, CA, USA
- Department of Ophthalmology, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | - Deniz Oncel
- Loyola University, Chicago, Stritch School of Medicine, Chicago, IL, 60153, USA
| | - Aditya Verma
- Doheny Eye Institute, Pasadena, CA, USA
- Department of Ophthalmology and Visual Sciences, University of Louisville, Louisville, KY, USA
| | - Giulia Corradetti
- Doheny Eye Institute, Pasadena, CA, USA
- Department of Ophthalmology, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | - Shin Kadomoto
- Doheny Eye Institute, Pasadena, CA, USA
- Department of Ophthalmology, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | - Alireza Mahmoudi
- Doheny Eye Institute, Pasadena, CA, USA
- Department of Ophthalmology, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | - Ahmed Roshdy Alagorie
- Doheny Eye Institute, Pasadena, CA, USA
- Department of Ophthalmology, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
- Department of Ophthalmology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Naresh Kumar Yadav
- Smt. Kanuri Santhamma Centre for Vitreo-Retinal Diseases, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, 500034, India
| | - Rajeev R Pappuru
- Smt. Kanuri Santhamma Centre for Vitreo-Retinal Diseases, L. V. Prasad Eye Institute, Kallam Anji Reddy Campus, Hyderabad, 500034, India
| | - Adnan Tufail
- Moorfields Eye Hospital NHS Foundation Trust, London, London, UK
| | - Houri Esmaeilkhanian
- Doheny Eye Institute, Pasadena, CA, USA
- Department of Ophthalmology, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | - Muneeswar G Nittala
- Doheny Eye Institute, Pasadena, CA, USA
- Department of Ophthalmology, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA
| | - Rajiv Raman
- Shri Bhagwan Mahavir Vitreoretinal Services, Medical Research Foundation, Sankara Nethralaya, Chennai, India
| | - Srinivas Sadda
- Doheny Eye Institute, Pasadena, CA, USA.
- Department of Ophthalmology, David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA, USA.
| |
Collapse
|
2
|
Kimyon S, Mete A, Seyyar SA. Retinopathy of prematurity screening: can the examination time be reduced? Clin Exp Optom 2024:1-4. [PMID: 39348796 DOI: 10.1080/08164622.2024.2410025] [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: 01/23/2024] [Revised: 08/09/2024] [Accepted: 08/15/2024] [Indexed: 10/02/2024] Open
Abstract
CLINICAL RELEVANCE Retinopathy of prematurity (ROP) is a significant cause of childhood blindness. Screening examinations that maintain accuracy, while improving the experience for families, could increase adherence to follow-up and decrease workload. BACKGROUND Traditional ROP screening examinations are known to be uncomfortable for babies and stressful for parents. A new strategy is proposed and tested for the accuracy of the outcome and the time taken. METHODS In this new screening strategy, the examiner performs a complete retinal examination on the first visit. If the area and stage of the nasal and temporal retinal regions are similar or the stage of the temporal half is worse, only the posterior pole and temporal half of the retina are evaluated at subsequent visits. A retrospective patient file review was conducted to compare the new proposal with accepted methods. ROP examination time was compared prospectively. RESULTS The data of 57 consecutive patients treated for ROP were evaluated. The ROP zone was the same in the nasal and temporal retina in all eyes at the first and last visit before treatment. Only two eyes had worse ROP stage in the nasal half at presentation but both halves developed the same degree of stage during follow-up. None of the treatment decisions were based only on the nasal region of the retina. Examination time was evaluated in 40 eyes of 20 infants. The average total time required for an examination with the accepted method was 241.3 ± 112.5 seconds. However, with the proposed strategy, the examination time was significantly reduced to 172.3 ± 69.2 seconds (p < 0.001). CONCLUSIONS This screening strategy shortens examination time, which may help reduce pain and related adverse events.
Collapse
Affiliation(s)
- Sabit Kimyon
- Gaziantep University Hospital Ophthalmology Department, Gaziantep, Turkey
| | - Alper Mete
- Gaziantep University Hospital Ophthalmology Department, Gaziantep, Turkey
| | - Sevim Ayça Seyyar
- Gaziantep University Hospital Ophthalmology Department, Gaziantep, Turkey
| |
Collapse
|
3
|
Ehlers JP, Josic K, Yordi S, Martin A, Srivastava SK, Sun JK. Assessment of Baseline Ultra-Widefield Fluorescein Angiographic Quantitative Leakage Parameters with Ultra-widefield Fundus Features and Clinical Parameters in Diabetic Retinopathy in Protocol AA. Ophthalmol Retina 2024:S2468-6530(24)00402-0. [PMID: 39216727 DOI: 10.1016/j.oret.2024.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 08/17/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE Evaluate quantitative leakage parameters on ultra-widefield fluorescein angiography (UWF-FA) images and explore their association with Diabetic Retinopathy Severity Scale (DRSS), predominantly peripheral lesions (PPLs), visual acuity, and clinical characteristics. DESIGN A post-hoc analysis of baseline UWF-FA images in the DRCR Retina Network observational study Protocol AA. PARTICIPANTS N = 575 eyes from 384 adults across 38 sites in the US and Canada with gradable UWF-FA. METHODS A machine learning-enhanced feature extraction platform provided initial leakage segmentation of UWF-FA images sequentially reviewed and corrected by two certified readers for segmentation accuracy. UWF-FA leakage was measured in five retinal zones: panretinal (whole retina), central macular (3-disc diameter fovea-centered circle), posterior pole (6-disc diameter fovea-centered circle), peripheral (outside 6-disc diameter circle) and widefield far peripheral (outside 9-disc diameter circle); associations with clinical factors were evaluated with marginal beta regression models. MAIN OUTCOME MEASURES UWF-FA leakage index, calculated as the area with leakage divided by the analyzable retinal area. RESULTS The mean quantitative leakage index was 3.5% for panretinal, 6.6% for macular, 4.8% for posterior pole, 3.3% for peripheral and 2.8% for wide-field far peripheral retinal zones. Panretinal leakage was associated with DRSS (mean 2.2% for no to mild NPDR, 3.4% for moderate NPDR, 4.2% for moderately severe NPDR, 4.8% for severe NPDR and 5.1% for PDR; P<.001), HbA1c (3.2% for HbA1c <8% vs. 3.8% for HbA1c ≥8%; P=.01 for continuous HbA1c), visual acuity (3.3% for 20/25 or better vs. 4.7% for 20/32 or worse; continuous P<.001), and UWF-FA-PPL types of IRMA (4.3% vs. 3.3%; P=.005) or NVE (5.7% vs. 3.4%; P=.003). DRSS was also statistically significant for leakage within all retinal zones (P<.001); eyes with non-central DME versus no DME had higher mean leakage in the central macular (11.2% vs. 5.9%; P=0.005) and posterior pole regions (9.2% vs. 4.2%; P=.002). CONCLUSION Quantitative UWF-FA leakage analysis identified associations between leakage and DRSS, visual acuity, and presence of DME. In the future, quantitative UWF-FA leakage parameters may be explored as potential biomarkers for disease progression risk.
Collapse
Affiliation(s)
| | | | - Sari Yordi
- Cole Eye Institute, Cleveland Clinic, Ohio
| | | | | | - Jenifer K Sun
- Joslin Diabetes Center, Beetham Eye Institute, Harvard Department of Ophthalmology, Boston, Massachusetts
| |
Collapse
|
4
|
Fleifil S, Azzouz L, Yu G, Powell C, Bommakanti N, Paulus YM. Quantitative Biomarkers of Diabetic Retinopathy Using Ultra-Widefield Fluorescein Angiography. Clin Ophthalmol 2024; 18:1961-1970. [PMID: 39005586 PMCID: PMC11244066 DOI: 10.2147/opth.s462223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 06/05/2024] [Indexed: 07/16/2024] Open
Abstract
Introduction Diabetic retinopathy (DR) is a leading cause of blindness. Retinal imaging is an important tool to monitor the progression of DR. While seven-standard retinal fields are the traditional method for evaluating DR, ultra-widefield (UWF) imaging allows for improved visualization of peripheral areas of nonperfusion (NP) and neovascularization (NV), which could be used as biomarkers to monitor and predict progression of DR. Methods A retrospective, cross-sectional study was conducted on 651 eyes from 363 patients diagnosed with type 1 or type 2 diabetes who received UWF-FA over 10 years. Fluorescein Angiography (FA) images were segmented, and surface areas of NP and NV were analyzed using multivariate regression to determine if biomarkers of DR and DR severity are associated with increasing areas of NP and NV. Results Each additional year with a diagnosis of DR was associated with a 10.75 mm2 increase in the total NP (95% CI, 1.94-19.56; P = 0.02) and 7.87 mm2 increase in NP far-periphery (95% CI, 1.62-14.13; P = 0.01). A one-unit change in severity as defined by the Early Treatment of Diabetic Retinopathy Study (ETDRS) classification was associated with a 25.75 mm2 increase in total NP (95% CI, 11.16-40.33; P = 0.001), a 13.15 mm2 increase in mid-periphery NP (95% CI, 6.93-19.38; P < 0.0001), and a 12.29 mm2 increase in far-periphery NP (95% CI, 3.62-20.97; P = 0.01). Discussion Biomarkers identified through UWF imaging such as total and regional areas of NP can be used to monitor and predict the progression of DR. This may provide a quantitative method for prognostication in patients with DR.
Collapse
Affiliation(s)
- Salma Fleifil
- Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lyna Azzouz
- Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center University of Michigan Medical School, Ann Arbor, MI, USA
| | - Gina Yu
- Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center University of Michigan Medical School, Ann Arbor, MI, USA
| | - Corey Powell
- Department of Statistics, University of Michigan, Ann Arbor, MI, USA
| | - Nikhil Bommakanti
- Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center University of Michigan Medical School, Ann Arbor, MI, USA
| | - Yannis M Paulus
- Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
5
|
Nouri H, Abtahi SH, Mazloumi M, Samadikhadem S, Arevalo JF, Ahmadieh H. Optical coherence tomography angiography in diabetic retinopathy: A major review. Surv Ophthalmol 2024; 69:558-574. [PMID: 38521424 DOI: 10.1016/j.survophthal.2024.03.004] [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: 09/23/2023] [Revised: 02/29/2024] [Accepted: 03/11/2024] [Indexed: 03/25/2024]
Abstract
Diabetic retinopathy (DR) is characterized by retinal vasculopathy and is a leading cause of visual impairment. Optical coherence tomography angiography (OCTA) is an innovative imaging technology that can detect various pathologies and quantifiable changes in retinal microvasculature. We briefly describe its functional principles and advantages over fluorescein angiography and perform a comprehensive review on its clinical applications in the screening or management of people with prediabetes, diabetes without clinical retinopathy (NDR), nonproliferative DR (NPDR), proliferative DR (PDR), and diabetic macular edema (DME). OCTA reveals early microvascular alterations in prediabetic and NDR eyes, which may coexist with sub-clinical neuroretinal dysfunction. Its applications in NPDR include measuring ischemia, detecting retinal neovascularization, and timing of early treatment through predicting the risk of retinopathy worsening or development of DME. In PDR, OCTA helps characterize the flow within neovascular complexes and evaluate their progression or regression in response to treatment. In eyes with DME, OCTA perfusion parameters may be of predictive value regarding the visual and anatomical gains associated with treatment. We further discussed the limitations of OCTA and the benefits of its incorporation into an updated DR severity scale.
Collapse
Affiliation(s)
- Hosein Nouri
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran; School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Seyed-Hossein Abtahi
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Ophthalmology, Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mehdi Mazloumi
- Eye Research Center, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Sanam Samadikhadem
- Department of Ophthalmology, Imam Hossein Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - J Fernando Arevalo
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Hamid Ahmadieh
- Ophthalmic Research Center, Research Institute for Ophthalmology and Vision Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| |
Collapse
|
6
|
Guo Y, Hormel TT, Gao M, You Q, Wang J, Flaxel CJ, Bailey ST, Hwang TS, Jia Y. Multi-Plexus Nonperfusion Area Segmentation in Widefield OCT Angiography Using a Deep Convolutional Neural Network. Transl Vis Sci Technol 2024; 13:15. [PMID: 39023443 PMCID: PMC11262538 DOI: 10.1167/tvst.13.7.15] [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: 01/16/2024] [Accepted: 06/05/2024] [Indexed: 07/20/2024] Open
Abstract
Purpose To train and validate a convolutional neural network to segment nonperfusion areas (NPAs) in multiple retinal vascular plexuses on widefield optical coherence tomography angiography (OCTA). Methods This cross-sectional study included 202 participants with a full range of diabetic retinopathy (DR) severities (diabetes mellitus without retinopathy, mild to moderate non-proliferative DR, severe non-proliferative DR, and proliferative DR) and 39 healthy participants. Consecutive 6 × 6-mm OCTA scans at the central macula, optic disc, and temporal region in one eye from 202 participants in a clinical DR study were acquired with a 70-kHz OCT commercial system (RTVue-XR). Widefield OCTA en face images were generated by montaging the scans from these three regions. A projection-resolved OCTA algorithm was applied to remove projection artifacts at the voxel scale. A deep convolutional neural network with a parallel U-Net module was designed to detect NPAs and distinguish signal reduction artifacts from flow deficits in the superficial vascular complex (SVC), intermediate capillary plexus (ICP), and deep capillary plexus (DCP). Expert graders manually labeled NPAs and signal reduction artifacts for the ground truth. Sixfold cross-validation was used to evaluate the proposed algorithm on the entire dataset. Results The proposed algorithm showed high agreement with the manually delineated ground truth for NPA detection in three retinal vascular plexuses on widefield OCTA (mean ± SD F-score: SVC, 0.84 ± 0.05; ICP, 0.87 ± 0.04; DCP, 0.83 ± 0.07). The extrafoveal avascular area in the DCP showed the best sensitivity for differentiating eyes with diabetes but no retinopathy (77%) from healthy controls and for differentiating DR by severity: DR versus no DR, 77%; referable DR (rDR) versus non-referable DR (nrDR), 79%; vision-threatening DR (vtDR) versus non-vision-threatening DR (nvtDR), 60%. The DCP also showed the best area under the receiver operating characteristic curve for distinguishing diabetes from healthy controls (96%), DR versus no DR (95%), and rDR versus nrDR (96%). The three-plexus-combined OCTA achieved the best result in differentiating vtDR and nvtDR (81.0%). Conclusions A deep learning network can accurately segment NPAs in individual retinal vascular plexuses and improve DR diagnostic accuracy. Translational Relevance Using a deep learning method to segment nonperfusion areas in widefield OCTA can potentially improve the diagnostic accuracy of diabetic retinopathy by OCT/OCTA systems.
Collapse
Affiliation(s)
- Yukun Guo
- Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Tristan T. Hormel
- Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
| | - Min Gao
- Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Qisheng You
- Kresge Eye Institute, Wayne State University, Detroit, MI, USA
| | - Jie Wang
- Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
| | | | - Steven T. Bailey
- Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
| | - Thomas S. Hwang
- Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
| | - Yali Jia
- Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| |
Collapse
|
7
|
Vujosevic S, Fantaguzzi F, Silva PS, Salongcay R, Brambilla M, Torti E, Nucci P, Peto T. Macula vs periphery in diabetic retinopathy: OCT-angiography and ultrawide field fluorescein angiography imaging of retinal non perfusion. Eye (Lond) 2024; 38:1668-1673. [PMID: 38402286 PMCID: PMC11156842 DOI: 10.1038/s41433-024-02989-3] [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: 06/23/2023] [Revised: 01/28/2024] [Accepted: 02/08/2024] [Indexed: 02/26/2024] Open
Abstract
OBJECTIVES To investigate the association between peripheral non-perfusion index (NPI) on ultrawide-field fluorescein angiography (UWF-FA) and quantitative OCT-Angiography (OCT-A) metrics in the macula. METHODS In total, 48 eyes with UWF-colour fundus photos (CFP), UWF-FA (California, Optos) and OCT-A (Spectralis, Heidelberg) were included. OCT-A (3 × 3 mm) was used to determine foveal avascular zone (FAZ) parameters and vessel density (VD), perfusion density (PD), fractal dimension (FD) on superficial capillary plexus (SCP). NPI's extent and distribution was determined on UWF-FA within fovea centred concentric rings corresponding to posterior pole (<10 mm), mid-periphery (10-15 mm), and far-periphery (>15 mm) and within the total retinal area, the central macular field (6×6 mm), ETDRS fields and within each extended ETDRS field (P3-P7). RESULTS Macular PD was correlated to NPI in total area of retina (Spearman ρ = 0.69, p < 0.05), posterior pole (ρ = 0.48, p < 0.05), mid-periphery (ρ = 0.65, p < 0.05), far-periphery (ρ = 0.59, p < 0.05), P3-P7 (ρ = 0,55 at least, p < 0.05 for each), central macula (ρ = 0.47, p < 0.05), total area in ETDRS (ρ = 0.55, p < 0.05). Macular VD and FD were correlated to NPI of total area of the retina (ρ = 0.60 and 0.61, p < 0.05), the mid-periphery (ρ = 0.56, p < 0.05) and far-periphery (ρ = 0.60 and ρ = 0.61, p < 0.05), and in P3-P7 (p < 0.05). FAZ perimeter was significantly corelated to NPI at posterior pole and central macular area (ρ = 0.37 and 0.36, p < 0.05), and FAZ area to NPI in central macular area (ρ = 0.36, p < 0.05). CONCLUSIONS Perfusion macular metrics on OCT-A correlated with UWF-FA's non-perfusion (NP), particularly in the retina's mid and far periphery, suggesting that OCT-A might be a useful non-invasive method to estimate peripheral retinal NP.
Collapse
Affiliation(s)
- Stela Vujosevic
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
- Eye Clinic, IRCCS MultiMedica, Milan, Italy.
| | | | - Paolo S Silva
- Harvard Department of Ophthalmology, Joslin Diabetes Center, Beetham Eye Institute, Boston, MA, USA
| | | | - Marco Brambilla
- Department of Medical Physics, University Hospital Maggiore della Carità, Novara, Italy
| | - Emanuele Torti
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Paolo Nucci
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| |
Collapse
|
8
|
Sun G, Wang X, Yi Z, Su Y, He L, Zheng H, Chen C. RELATIONSHIP BETWEEN RETINAL HEMORRHAGE ON GREEN AND RED CHANNELS OF ULTRA-WIDEFIELD FUNDUS IMAGES AND RETINAL PERFUSION IN ACUTE BRANCH RETINAL VEIN OCCLUSION. Retina 2024; 44:887-894. [PMID: 38165995 DOI: 10.1097/iae.0000000000004030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
PURPOSE To explore the relationship between retinal hemorrhage in the green and red channels on ultra-widefield fundus images and the nonperfusion area (NPA) on ultra-widefield fundus fluorescein angiography in patients with acute branch retinal vein occlusion (BRVO). METHODS This was a retrospective cross-sectional study with 96 patients, including 46 with ischemic BRVO and 50 with nonischemic BRVO. Correlation analysis between green channel hemorrhage (GCH), red channel hemorrhage (RCH), and NPA was performed. Panretina was divided into posterior and peripheral areas. RESULTS Ischemic BRVO showed significantly higher GCH% and RCH% than nonischemic BRVO in the peripheral regions (both P < 0.001), whereas no significant differences were observed in the panretinal and posterior areas (all P > 0.05). Significant correlations were found between NPA% in the panretinal and peripheral areas and the corresponding GCH% and RCH% (all P < 0.01). However, no significant correlation was observed between posterior NPA% and posterior GCH% or RCH% (both P > 0.05). In addition, peripheral GCH% and RCH% were related to panretinal NPA% (r = 0.506, P < 0.001; r = 0.558, P < 0.001). CONCLUSION Retinal hemorrhage on ultra-widefield fundus image was significantly associated with NPA, providing insights for assessing retinal perfusion status in acute BRVO patients.
Collapse
Affiliation(s)
- Gongpeng Sun
- Eye Center, Renmin Hospital of Wuhan University, Wuhan, China ; and
| | - Xiaoling Wang
- Eye Center, Renmin Hospital of Wuhan University, Wuhan, China ; and
| | - Zuohuizi Yi
- Eye Center, Renmin Hospital of Wuhan University, Wuhan, China ; and
| | - Yu Su
- Eye Center, Renmin Hospital of Wuhan University, Wuhan, China ; and
| | - Lu He
- Physical Examination Center, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hongmei Zheng
- Eye Center, Renmin Hospital of Wuhan University, Wuhan, China ; and
| | - Changzheng Chen
- Eye Center, Renmin Hospital of Wuhan University, Wuhan, China ; and
| |
Collapse
|
9
|
Tan TE, Jampol LM, Ferris FL, Tadayoni R, Sadda SR, Chong V, Domalpally A, Blodi BL, Duh EJ, Curcio CA, Antonetti DA, Dutta S, Levine SR, Sun JK, Gardner TW, Wong TY. Imaging Modalities for Assessing the Vascular Component of Diabetic Retinal Disease: Review and Consensus for an Updated Staging System. OPHTHALMOLOGY SCIENCE 2024; 4:100449. [PMID: 38313399 PMCID: PMC10837643 DOI: 10.1016/j.xops.2023.100449] [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: 08/11/2023] [Revised: 12/05/2023] [Accepted: 12/05/2023] [Indexed: 02/06/2024]
Abstract
Purpose To review the evidence for imaging modalities in assessing the vascular component of diabetic retinal disease (DRD), to inform updates to the DRD staging system. Design Standardized narrative review of the literature by an international expert workgroup, as part of the DRD Staging System Update Effort, a project of the Mary Tyler Moore Vision Initiative. Overall, there were 6 workgroups: Vascular Retina, Neural Retina, Systemic Health, Basic and Cellular Mechanisms, Visual Function, and Quality of Life. Participants The Vascular Retina workgroup, including 16 participants from 4 countries. Methods Literature review was conducted using standardized evidence grids for 5 modalities: standard color fundus photography (CFP), widefield color photography (WFCP), standard fluorescein angiography (FA), widefield FA (WFFA), and OCT angiography (OCTA). Summary levels of evidence were determined on a validated scale from I (highest) to V (lowest). Five virtual workshops were held for discussion and consensus. Main Outcome Measures Level of evidence for each modality. Results Levels of evidence for standard CFP, WFCP, standard FA, WFFA, and OCTA were I, II, I, I, and II respectively. Traditional vascular lesions on standard CFP should continue to be included in an updated staging system, but more studies are required before they can be used in posttreatment eyes. Widefield color photographs can be used for severity grading within the area covered by standard CFPs, although these gradings may not be directly interchangeable with each other. Evaluation of the peripheral retina on WFCP can be considered, but the method of grading needs to be clarified and validated. Standard FA and WFFA provide independent prognostic value, but the need for dye administration should be considered. OCT angiography has significant potential for inclusion in the DRD staging system, but various barriers need to be addressed first. Conclusions This study provides evidence-based recommendations on the utility of various imaging modalities for assessment of the vascular component of DRD, which can inform future updates to the DRD staging system. Although new imaging modalities offer a wealth of information, there are still major gaps and unmet research needs that need to be addressed before this potential can be realized. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Collapse
Affiliation(s)
- Tien-En Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Ophthalmology & Visual Sciences Academic Clinical Programme (EYE ACP), Duke-National University of Singapore Medical School, Singapore
| | - Lee M. Jampol
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Ramin Tadayoni
- Ophthalmology Department, Lariboisière, AP-HP, Saint Louis and Fondation Adolphe de Rothschild Hospitals, Université Paris Cité, Paris, France
| | - Srinivas R. Sadda
- Doheny Eye Institute, Pasadena, California
- Department of Ophthalmology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Victor Chong
- UCL Institute of Ophthalmology, University College London, London, UK
| | - Amitha Domalpally
- Department of Ophthalmology and Visual Sciences, Wisconsin Reading Center, University of Wisconsin-Madison, Madison, Wisconsin
| | - Barbara L. Blodi
- Department of Ophthalmology and Visual Sciences, Wisconsin Reading Center, University of Wisconsin-Madison, Madison, Wisconsin
| | - Elia J. Duh
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christine A. Curcio
- Department of Ophthalmology and Visual Sciences, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | - David A. Antonetti
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - S. Robert Levine
- The Mary Tyler Moore & S. Robert Levine, MD Charitable Foundation, Greenwich, Connecticut
| | - Jennifer K. Sun
- Joslin Diabetes Center, Beetham Eye Institute, Harvard Medical School, Boston, Massachusetts
| | - Thomas W. Gardner
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, Michigan
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Ophthalmology & Visual Sciences Academic Clinical Programme (EYE ACP), Duke-National University of Singapore Medical School, Singapore
- Tsinghua Medicine, Tsinghua University, Beijing, China
| |
Collapse
|
10
|
Duncan N, Barrett N, Schildroth K, Chang JS, Channa R, Rickels K, Domalpally A, Blodi B. Comparison of Standard 7-Field, Clarus, and Optos Ultrawidefield Imaging Systems for Diabetic Retinopathy (COCO Study). OPHTHALMOLOGY SCIENCE 2024; 4:100427. [PMID: 38284100 PMCID: PMC10818251 DOI: 10.1016/j.xops.2023.100427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/12/2023] [Accepted: 11/06/2023] [Indexed: 01/30/2024]
Abstract
Purpose The purpose of this study was to compare diabetic retinopathy (DR) severity levels assessed from 7 standard-field stereoscopic color photographs on a 35° fundus camera to both Clarus and Optos ultrawidefield color images. Design Cross-sectional, comparative imaging study. Participants Participants with DR imaged at a single-center retina practice. Methods Participants were imaged on 3 cameras at a single visit with the Topcon 35° fundus camera, Clarus, and Optos. The DR Severity Scale (DRSS) level was determined within the 7-field (7F) area of each image set using the ETDRS scale. An additional global DRSS was assigned for both Clarus and Optos images using the entire visible retina. Weighted kappa (wκ) measured the agreement between cameras. Main Outcome Measures The primary outcome was a 3-way comparison of DRSS level within the 7F area imaged on the 3 cameras. Secondary outcomes included a comparison of the DRSS obtained with standard 7F imaging to the global DRSS of Clarus and Optos and a comparison of the global DRSS between Clarus and Optos only. Results Ninety-seven eyes (50 participants) were evaluated. Agreement within 1-step of ETDRS levels between standard 7F imaging and Clarus 7F was 90.1% (wκ = 0.65), and with Optos 7F in 85.9%, (wκ = 0.58). Agreement within 1-step between standard 7F imaging and Clarus global was 88.9% of eyes (wκ = 0.63), and Optos global was 85.7%, (wκ = 0.54). Agreement between Clarus and Optos global DR level within 1-step was 89.1% (wκ = 0.68). Intergrader agreement for the 7F ETDRS level was 96% for standard 7F imaging, 98% for Clarus, and 95.5% for Optos. Conclusions These findings suggest that when evaluating the 7F area on Clarus and Optos, DR severity grades are comparable to standard 7F imaging. However, it is important to understand the unique attributes and differences of each fundus camera when changing the type of system used in a clinical setting due to upgrading equipment. Additionally, if the facility has access to > 1 device, there should not be an exchange between cameras for the same patient. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Collapse
Affiliation(s)
- Nicole Duncan
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Nancy Barrett
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kathleen Schildroth
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jonathan S. Chang
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Roomasa Channa
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kelsey Rickels
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Amitha Domalpally
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- McPherson Eye Research Institute, University of Wisconsin-Madison, Madison, Wisconsin
| | - Barbara Blodi
- Department of Ophthalmology and Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
- McPherson Eye Research Institute, University of Wisconsin-Madison, Madison, Wisconsin
| |
Collapse
|
11
|
Lu ES, Cui Y, Le R, Zhu Y, Wang JC, Laíns I, Katz R, Lu Y, Zeng R, Garg I, Wu DM, Husain D, Kim LA, Miller JB. Widefield swept-source optical coherence tomography angiography metrics associated with neovascular glaucoma in patients with proliferative diabetic retinopathy. Graefes Arch Clin Exp Ophthalmol 2024; 262:1111-1120. [PMID: 37962666 DOI: 10.1007/s00417-023-06290-z] [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: 04/21/2023] [Revised: 10/12/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
PURPOSE To explore the association between widefield swept-source optical coherence tomography angiography (WF SS-OCTA) metrics, including nonperfusion area (NPA) and neovascularization (NV), and presence of neovascular glaucoma (NVG) in patients with proliferative diabetic retinopathy (PDR). METHODS A prospective, cross-sectional study was conducted from November 2018 to February 2020. A total of 85 eyes of 60 PDR patients without NVG and 9 eyes of 8 PDR patients with NVG were included. Retinal ischemic parameters (NPA; ischemia index [NPA/total retinal area]) and NV features (NV number; NV area; NV vessel density) were evaluated. Foveal avascular zone (FAZ), macular thickness/volume, and choroidal thickness/volume were obtained using the Zeiss ARI Network. WF SS-OCTA retinal and choroidal metrics, systemic, and ocular parameters were screened using Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression for variable selection. Firth's bias-reduced logistic regression (outcome: presence of NVG) was subsequently used to identify parameters associated with NVG. RESULTS After LASSO variable selection, 8 variables were significantly associated with the presence of NVG: DM duration (years), insulin (yes/no), best-corrected visual acuity (BCVA) (logMAR), IOP, ischemia index, skeletonized vessel density, macular thickness (inner inferior, outer temporal regions). Firth's bias-reduced logistic regression showed ischemia index (odds ratio [OR]=13.2, 95% confidence interval [CI]:5.3-30.7, P<0.001) and BCVA (OR=5.8, 95%CI:1.2-28.8, P<0.05) were associated with the presence of NVG. NV metrics, FAZ, and choroidal parameters were not related to NVG. CONCLUSIONS Retinal ischemia but not NV was associated with the presence of NVG in patients with PDR using WF SS-OCTA. Larger, longitudinal studies are needed to validate imaging biomarkers associated with diabetic NVG.
Collapse
Affiliation(s)
- Edward S Lu
- Harvard Retinal Imaging Lab, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Ying Cui
- Harvard Retinal Imaging Lab, Boston, MA, USA
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, 243 Charles St, Boston, MA, 02114, USA
- Department of Ophthalmology, Guangdong Eye Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Rongrong Le
- Harvard Retinal Imaging Lab, Boston, MA, USA
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, 243 Charles St, Boston, MA, 02114, USA
- Wenzhou Medical University Affiliated Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ying Zhu
- Harvard Retinal Imaging Lab, Boston, MA, USA
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, 243 Charles St, Boston, MA, 02114, USA
- Eye Center of Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jay C Wang
- Harvard Retinal Imaging Lab, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, 243 Charles St, Boston, MA, 02114, USA
| | - Inês Laíns
- Harvard Retinal Imaging Lab, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, 243 Charles St, Boston, MA, 02114, USA
| | - Raviv Katz
- Harvard Retinal Imaging Lab, Boston, MA, USA
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, 243 Charles St, Boston, MA, 02114, USA
| | - Yifan Lu
- Harvard Retinal Imaging Lab, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | | | - Itika Garg
- Harvard Retinal Imaging Lab, Boston, MA, USA
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, 243 Charles St, Boston, MA, 02114, USA
| | - David M Wu
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, 243 Charles St, Boston, MA, 02114, USA
| | - Deeba Husain
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, 243 Charles St, Boston, MA, 02114, USA
| | - Leo A Kim
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, 243 Charles St, Boston, MA, 02114, USA
| | - John B Miller
- Harvard Retinal Imaging Lab, Boston, MA, USA.
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA.
- Retina Service, Massachusetts Eye and Ear, Department of Ophthalmology, Harvard Medical School, 243 Charles St, Boston, MA, 02114, USA.
| |
Collapse
|
12
|
Santos AR, Almeida AC, Rocha AC, Reste-Ferreira D, Marques IP, Cunha-Vaz Martinho A, Mendes L, Santos T, Lewis W, Cunha-Vaz J. CENTRAL AND PERIPHERAL INVOLVEMENT OF THE RETINA IN THE INITIAL STAGES OF DIABETIC RETINOPATHY. Retina 2024; 44:700-706. [PMID: 38109709 DOI: 10.1097/iae.0000000000004021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
PURPOSE To determine the degree of central microvascular closure using optical coherence tomography angiography in eyes of patients with type 2 diabetes with visible lesions only in the central retina or only in the periphery. METHODS Cross-sectional study. All 127 eyes underwent ultra-widefield fundus photography 200° examinations with OPTOS California (Optos, Dunfermline, United Kingdom) and Cirrus Angioplex optical coherence tomography angiography 3 × 3 mm acquisitions (ZEISS, Dublin, CA). RESULTS Twenty-five eyes showed visible lesions only in the central retina, 57 only in the peripheral retina, and 45 presented visible lesions in entire retina. The group with visible lesions only in the periphery showed definite closure in the superficial capillary plexus in 49% of the eyes, whereas the group with visible lesions only in the central seven-early treatment diabetic retinopathy study fields area showed a definite closure in 64%. CONCLUSION Central capillary closure is already present in the initial stages of diabetic retinopathy even when lesions are only visible in the peripheral retina. Capillary closure in the superficial capillary plexus is three times more frequent than in the deep capillary plexus, demonstrating earlier closure of the superficial capillary plexus. Eyes with visible lesions only in the periphery show a milder form of retinopathy.
Collapse
Affiliation(s)
- Ana Rita Santos
- AIBILI-Association for Innovation and Biomedical Research on Light and Image, Coimbra, Portugal
- CORC-Coimbra Ophthalmology Reading Center, Coimbra, Portugal
- Department of Orthoptics, School of Health, Polytechnic of Porto, Porto, Portugal
| | - Ana Catarina Almeida
- AIBILI-Association for Innovation and Biomedical Research on Light and Image, Coimbra, Portugal
| | - Ana Cláudia Rocha
- AIBILI-Association for Innovation and Biomedical Research on Light and Image, Coimbra, Portugal
| | - Débora Reste-Ferreira
- AIBILI-Association for Innovation and Biomedical Research on Light and Image, Coimbra, Portugal
| | - Inês Pereira Marques
- AIBILI-Association for Innovation and Biomedical Research on Light and Image, Coimbra, Portugal
- CORC-Coimbra Ophthalmology Reading Center, Coimbra, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | | | - Luís Mendes
- AIBILI-Association for Innovation and Biomedical Research on Light and Image, Coimbra, Portugal
| | - Torcato Santos
- AIBILI-Association for Innovation and Biomedical Research on Light and Image, Coimbra, Portugal
| | - Warren Lewis
- Bayside Photonics, Inc, Yellow Springs, Ohio; and
| | - José Cunha-Vaz
- AIBILI-Association for Innovation and Biomedical Research on Light and Image, Coimbra, Portugal
- University of Coimbra, Faculty of Medicine, Coimbra, Portugal
| |
Collapse
|
13
|
Ashrafkhorasani M, Habibi A, Nittala MG, Corradetti G, Emamverdi M, Sadda SR. Peripheral retinal lesions in diabetic retinopathy on ultra-widefield imaging. Saudi J Ophthalmol 2024; 38:123-131. [PMID: 38988777 PMCID: PMC11232752 DOI: 10.4103/sjopt.sjopt_151_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/03/2023] [Indexed: 07/12/2024] Open
Abstract
Peripheral retinal imaging plays a crucial role in the diagnosis, management, and prognosis of diabetic retinopathy (DR). Traditional fundus imaging techniques have limited coverage of the retina, resulting in missed peripheral lesions. The advent of ultra-widefield (UWF) imaging has revolutionized the assessment of the peripheral retina. UWF imaging modalities provide comprehensive visualization of the retina, enabling the detection of peripheral lesions without the need for mydriasis. Integration of UWF imaging with other modalities, including fluorescein angiography (FA), indocyanine green angiography, pseudocolor imaging, and fundus autofluorescence, further enhances our understanding of peripheral retinal lesions. UWF imaging has demonstrated improved detection of DR lesions and presumably more accurate management of DR compared to traditional fundus photography and dilated fundus examination. UWF-FA and UWF-optical coherence tomography angiography have emerged as valuable tools for assessing retinal and choroidal vascular abnormalities, nonperfusion areas, neovascularization, and microvascular abnormalities. The presence and increasing extent of predominantly peripheral lesions detected using UWF FA are associated with a higher risk of DR progression and proliferative DR. UWF imaging provides a comprehensive evaluation of DR severity, aiding in more accurate risk stratification and treatment decision-making. Overall, UWF imaging modalities have significantly advanced our understanding of peripheral retinal lesions in DR, facilitating early detection and targeted management for better visual outcomes.
Collapse
Affiliation(s)
- Maryam Ashrafkhorasani
- Doheny Image Reading and Research Lab, Doheny Eye Institute, Los Angeles, California, USA
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Abbas Habibi
- Doheny Image Reading and Research Lab, Doheny Eye Institute, Los Angeles, California, USA
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Muneeswar G. Nittala
- Doheny Image Reading and Research Lab, Doheny Eye Institute, Los Angeles, California, USA
| | - Giulia Corradetti
- Doheny Image Reading and Research Lab, Doheny Eye Institute, Los Angeles, California, USA
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Mehdi Emamverdi
- Doheny Image Reading and Research Lab, Doheny Eye Institute, Los Angeles, California, USA
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Srinivas R. Sadda
- Doheny Image Reading and Research Lab, Doheny Eye Institute, Los Angeles, California, USA
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| |
Collapse
|
14
|
Hormel TT, Liang GB, Wei X, Guo Y, Gao M, Wang J, Huang D, Bailey ST, Hwang TS, Jia Y. Visualizing features with wide-field volumetric OCT angiography. OPTICS EXPRESS 2024; 32:10329-10347. [PMID: 38571248 PMCID: PMC11018334 DOI: 10.1364/oe.510640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 01/16/2024] [Accepted: 02/14/2024] [Indexed: 04/05/2024]
Abstract
Optical coherence tomography (OCT) and its extension OCT angiography (OCTA) have become essential clinical imaging modalities due to their ability to provide depth-resolved angiographic and tissue structural information non-invasively and at high resolution. Within a field of view, the anatomic detail available is sufficient to identify several structural and vascular pathologies that are clinically relevant for multiple prevalent blinding diseases, including age-related macular degeneration (AMD), diabetic retinopathy (DR), and vein occlusions. The main limitation in contemporary OCT devices is that this field of view is limited due to a fundamental trade-off between system resolution/sensitivity, sampling density, and imaging window dimensions. Here, we describe a swept-source OCT device that can capture up to a 12 × 23-mm field of view in a single shot and show that it can identify conventional pathologic features such as non-perfusion areas outside of conventional fields of view. We also show that our approach maintains sensitivity sufficient to visualize novel features, including choriocapillaris morphology beneath the macula and macrophage-like cells at the inner limiting membrane, both of which may have implications for disease.
Collapse
Affiliation(s)
- Tristan T. Hormel
- Casey Eye Institutue, Oregon Health and Science University, Portland, OR 97239, USA
| | - Guangru B. Liang
- Casey Eye Institutue, Oregon Health and Science University, Portland, OR 97239, USA
| | - Xiang Wei
- Casey Eye Institutue, Oregon Health and Science University, Portland, OR 97239, USA
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, OR 97239, USA
| | - Yukun Guo
- Casey Eye Institutue, Oregon Health and Science University, Portland, OR 97239, USA
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, OR 97239, USA
| | - Min Gao
- Casey Eye Institutue, Oregon Health and Science University, Portland, OR 97239, USA
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, OR 97239, USA
| | - Jie Wang
- Casey Eye Institutue, Oregon Health and Science University, Portland, OR 97239, USA
| | - David Huang
- Casey Eye Institutue, Oregon Health and Science University, Portland, OR 97239, USA
| | - Steven T. Bailey
- Casey Eye Institutue, Oregon Health and Science University, Portland, OR 97239, USA
| | - Thomas S. Hwang
- Casey Eye Institutue, Oregon Health and Science University, Portland, OR 97239, USA
| | - Yali Jia
- Casey Eye Institutue, Oregon Health and Science University, Portland, OR 97239, USA
- Department of Biomedical Engineering, Oregon Health and Science University, Portland, OR 97239, USA
| |
Collapse
|
15
|
Ma X, Ji Z, Chen Q, Ge L, Wang X, Chen C, Fan W. Controllable editing via diffusion inversion on ultra-widefield fluorescein angiography for the comprehensive analysis of diabetic retinopathy. BIOMEDICAL OPTICS EXPRESS 2024; 15:1831-1846. [PMID: 38495723 PMCID: PMC10942674 DOI: 10.1364/boe.517819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 03/19/2024]
Abstract
By incorporating multiple indicators that facilitate clinical decision making and effective management of diabetic retinopathy (DR), a comprehensive understanding of the progression of the disease can be achieved. However, the diversity of DR complications poses challenges to the automatic analysis of various information within images. This study aims to establish a deep learning system designed to examine various metrics linked to DR in ultra-widefield fluorescein angiography (UWFA) images. We have developed a unified model based on image generation that transforms input images into corresponding disease-free versions. By incorporating an image-level supervised training process, the model significantly reduces the need for extensive manual involvement in clinical applications. Furthermore, compared to other comparative methods, the quality of our generated images is significantly superior.
Collapse
Affiliation(s)
- Xiao Ma
- School of Computer Science and Engineering, Nanjing University of Science and Technology, 200 XiaoLinwei, Nanjing, Jiangsu 210094, China
| | - Zexuan Ji
- School of Computer Science and Engineering, Nanjing University of Science and Technology, 200 XiaoLinwei, Nanjing, Jiangsu 210094, China
| | - Qiang Chen
- School of Computer Science and Engineering, Nanjing University of Science and Technology, 200 XiaoLinwei, Nanjing, Jiangsu 210094, China
| | - Lexin Ge
- Department of Ophthalmology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu 210029, China
| | - Xiaoling Wang
- Eye Center, Renmin Hospital of Wuhan University, No. 9 ZhangZhiDong Street, Wuchang District, Wuhan, Hubei 430060, China
| | - Changzheng Chen
- Eye Center, Renmin Hospital of Wuhan University, No. 9 ZhangZhiDong Street, Wuchang District, Wuhan, Hubei 430060, China
| | - Wen Fan
- Department of Ophthalmology, The First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, Jiangsu 210029, China
| |
Collapse
|
16
|
Cicinelli MV, Gravina S, Rutigliani C, Checchin L, La Franca L, Lattanzio R, Bandello F. Assessing Diabetic Retinopathy Staging With AI: A Comparative Analysis Between Pseudocolor and LED Imaging. Transl Vis Sci Technol 2024; 13:11. [PMID: 38488432 PMCID: PMC10946690 DOI: 10.1167/tvst.13.3.11] [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: 12/02/2023] [Accepted: 02/04/2024] [Indexed: 03/19/2024] Open
Abstract
Purpose To compare the diagnostic performance of artificial intelligence (AI)-based diabetic retinopathy (DR) staging system across pseudocolor, simulated white light (SWL), and light-emitting diode (LED) camera imaging modalities. Methods A cross-sectional investigation involved patients with diabetes undergoing imaging with an iCare DRSplus confocal LED camera and an Optos confocal, ultra-widefield pseudocolor camera, with and without SWL. Macula-centered and optic nerve-centered 45 × 45-degree photographs were processed using EyeArt v2.1. Human graders established the ground truth (GT) for DR severity on dilated fundus exams. Sensitivity and weighted Cohen's weighted kappa (wκ) were calculated. An ordinal generalized linear mixed model identified factors influencing accurate DR staging. Results The study included 362 eyes from 189 patients. The LED camera excelled in identifying sight-threatening DR stages (sensitivity = 0.83, specificity = 0.95 for proliferative DR) and had the highest agreement with the GT (wκ = 0.71). The addition of SWL to pseudocolor imaging resulted in decreased performance (sensitivity = 0.33, specificity = 0.98 for proliferative DR; wκ = 0.55). Peripheral lesions reduced the likelihood of being staged in the same or higher DR category by 80% (P < 0.001). Conclusions Pseudocolor and LED cameras, although proficient, demonstrated non-interchangeable performance, with the LED camera exhibiting superior accuracy in identifying advanced DR stages. These findings underscore the importance of implementing AI systems trained for ultra-widefield imaging, considering the impact of peripheral lesions on correct DR staging. Translational Relevance This study underscores the need for artificial intelligence-based systems specifically trained for ultra-widefield imaging in diabetic retinopathy assessment.
Collapse
Affiliation(s)
- Maria Vittoria Cicinelli
- Department of Ophthalmology, IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Salvatore Gravina
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Carola Rutigliani
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Lisa Checchin
- Department of Ophthalmology, IRCCS San Raffaele Hospital, Milan, Italy
| | | | | | - Francesco Bandello
- Department of Ophthalmology, IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| |
Collapse
|
17
|
Wijesingha N, Tsai WS, Keskin AM, Holmes C, Kazantzis D, Chandak S, Kubravi H, Sivaprasad S. Optical Coherence Tomography Angiography as a Diagnostic Tool for Diabetic Retinopathy. Diagnostics (Basel) 2024; 14:326. [PMID: 38337841 PMCID: PMC10855126 DOI: 10.3390/diagnostics14030326] [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: 01/05/2024] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/12/2024] Open
Abstract
Diabetic retinopathy (DR) is the most common microvascular complication of diabetes mellitus, leading to visual impairment if left untreated. This review discusses the use of optical coherence tomography angiography (OCTA) as a diagnostic tool for the early detection and management of DR. OCTA is a fast, non-invasive, non-contact test that enables the detailed visualisation of the macular microvasculature in different plexuses. OCTA offers several advantages over fundus fluorescein angiography (FFA), notably offering quantitative data. OCTA is not without limitations, including the requirement for careful interpretation of artefacts and the limited region of interest that can be captured currently. We explore how OCTA has been instrumental in detecting early microvascular changes that precede clinical signs of DR. We also discuss the application of OCTA in the diagnosis and management of various stages of DR, including non-proliferative diabetic retinopathy (NPDR), proliferative diabetic retinopathy (PDR), diabetic macular oedema (DMO), diabetic macular ischaemia (DMI), and pre-diabetes. Finally, we discuss the future role of OCTA and how it may be used to enhance the clinical outcomes of DR.
Collapse
Affiliation(s)
- Naomi Wijesingha
- UCL Institute of Ophthalmology, London EC1V 9EL, UK;
- Moorfields Eye Hospital, London EC1V 2PD, UK; (W.-S.T.); (A.M.K.); (C.H.); (D.K.); (S.C.); (H.K.)
| | - Wei-Shan Tsai
- Moorfields Eye Hospital, London EC1V 2PD, UK; (W.-S.T.); (A.M.K.); (C.H.); (D.K.); (S.C.); (H.K.)
| | - Ayse Merve Keskin
- Moorfields Eye Hospital, London EC1V 2PD, UK; (W.-S.T.); (A.M.K.); (C.H.); (D.K.); (S.C.); (H.K.)
| | - Christopher Holmes
- Moorfields Eye Hospital, London EC1V 2PD, UK; (W.-S.T.); (A.M.K.); (C.H.); (D.K.); (S.C.); (H.K.)
| | - Dimitrios Kazantzis
- Moorfields Eye Hospital, London EC1V 2PD, UK; (W.-S.T.); (A.M.K.); (C.H.); (D.K.); (S.C.); (H.K.)
| | - Swati Chandak
- Moorfields Eye Hospital, London EC1V 2PD, UK; (W.-S.T.); (A.M.K.); (C.H.); (D.K.); (S.C.); (H.K.)
| | - Heena Kubravi
- Moorfields Eye Hospital, London EC1V 2PD, UK; (W.-S.T.); (A.M.K.); (C.H.); (D.K.); (S.C.); (H.K.)
| | - Sobha Sivaprasad
- UCL Institute of Ophthalmology, London EC1V 9EL, UK;
- Moorfields Eye Hospital, London EC1V 2PD, UK; (W.-S.T.); (A.M.K.); (C.H.); (D.K.); (S.C.); (H.K.)
| |
Collapse
|
18
|
Nanji K, Sarohia GS, Xie J, Patil NS, Phillips M, Zeraatkar D, Thabane L, Guymer RH, Kaiser PK, Sivaprasad S, Sadda SR, Wykoff CC, Chaudhary V. Anti-vascular endothelial growth factor therapy and retinal non-perfusion in diabetic retinopathy: A meta-analysis of randomised trials. Acta Ophthalmol 2024; 102:e31-e41. [PMID: 37042340 DOI: 10.1111/aos.15673] [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: 01/08/2023] [Revised: 02/19/2023] [Accepted: 03/27/2023] [Indexed: 04/13/2023]
Abstract
PURPOSE Retinal non-perfusion (RNP) is fundamental to disease onset and progression in diabetic retinopathy (DR). Whether anti-vascular endothelial growth factor (anti-VEGF) therapy can modify RNP progression is unclear. This investigation quantified the impact of anti-VEGF therapy on RNP progression compared with laser or sham at 12 months. METHODS A systematic review and meta-analysis of randomised controlled trials (RCTs) were performed; Ovid MEDLINE, EMBASE and CENTRAL were searched from inception to 4th March 2022. The change in any continuous measure of RNP at 12 months and 24 months was the primary and secondary outcomes, respectively. Outcomes were reported utilising standardised mean differences (SMD). The Cochrane Risk of Bias Tool version-2 and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines informed risk of bias and certainty of evidence assessments. RESULTS Six RCTs (1296 eyes) and three RCTs (1131 eyes) were included at 12 and 24 months, respectively. Meta-analysis demonstrated that RNP progression may be slowed with anti-VEGF therapy compared with laser/sham at 12 months (SMD: -0.17; 95% confidence interval [CI]: -0.29, -0.06; p = 0.003; I2 = 0; GRADE rating: LOW) and 24-months (SMD: -0.21; 95% CI: -0.37, -0.05; p = 0.009; I2 = 28%; GRADE rating: LOW). The certainty of evidence was downgraded due to indirectness and due to imprecision. CONCLUSION Anti-VEGF treatment may slightly impact the pathophysiologic process of progressive RNP in DR. The dosing regimen and the absence of diabetic macular edema may impact this potential effect. Future trials are needed to increase the precision of the effect and inform the association between RNP progression and clinically important events. PROSPERO REGISTRATION CRD42022314418.
Collapse
Affiliation(s)
- Keean Nanji
- Department of Surgery, Division of Ophthalmology, McMaster University, 2757 King Street East, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada
| | - Gurkaran S Sarohia
- Department of Ophthalmology and Visual Sciences, University of Alberta, 2319 Active Treatment Centre, 10240 Kingsway Avenue NW, Edmonton, Alberta, Canada, T5H 3V8
| | - Jim Xie
- Department of Surgery, Division of Ophthalmology, McMaster University, 2757 King Street East, Hamilton, Ontario, Canada
| | - Nikhil S Patil
- Department of Surgery, Division of Ophthalmology, McMaster University, 2757 King Street East, Hamilton, Ontario, Canada
| | - Mark Phillips
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada
| | - Dena Zeraatkar
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada
- Biostatistics Unit, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
- Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa
| | - Robyn H Guymer
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
- Department of Surgery (Ophthalmology), the University of Melbourne, Melbourne, Australia
| | - Peter K Kaiser
- Cole Eye Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio, USA
| | - Sobha Sivaprasad
- NIHR Moorfields Biomedical Research Centre, Moorfields Eye Hospital, London, UK
| | - Srinivas R Sadda
- Doheny Eye Institute, David Geffen School of Medicine, University of California - Los Angeles, Los Angeles, California, USA
| | - Charles C Wykoff
- Retina Consultants of Texas, Houston, Texas, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, USA
| | - Varun Chaudhary
- Department of Surgery, Division of Ophthalmology, McMaster University, 2757 King Street East, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, Hamilton, Ontario, Canada
| |
Collapse
|
19
|
Konno A, Ishibazawa A, De Pretto L, Shimouchi A, Omae T, Song YS. Relationship between nonperfusion area from widefield optical coherence tomography angiography and macular vascular parameters in diabetic retinopathy. Int Ophthalmol 2023; 43:4803-4814. [PMID: 37851140 PMCID: PMC10724328 DOI: 10.1007/s10792-023-02882-0] [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: 07/04/2023] [Accepted: 09/27/2023] [Indexed: 10/19/2023]
Abstract
PURPOSE To evaluate the relationship between the nonperfusion area (NPA) from widefield optical coherence tomography angiography (OCTA) and macular vascular parameters in diabetic retinopathy (DR). METHODS In total, 51 eyes from 51 patients with proliferative DR (PDR) or moderate/severe non-PDR were included. Widefield OCTA using the Zeiss Plex Elite 9000 was performed. A semi-automatic algorithm calculated the percentages of the NPA within the total image. Macular OCTA (3 × 3 mm and 6 × 6 mm area) was scanned using the RTVue-XR Avanti. Vessel density (VD) was automatically separated into the superficial (SCP) and deep capillary plexus (DCP), and foveal avascular zone (FAZ) measurements were computed according to the parafoveal (1-3 mm) and perifoveal (3-6 mm) regions. RESULTS A negative correlation was found between the average VD of the SCP and DCP obtained 3 × 3 mm and 6 × 6 mm area and the NPA. Multiple regression analysis revealed that the temporal-perifoveal region most negatively correlated with the NPA (r = - 0.55, p < 0.0001). No correlation was found between FAZ measurements and DR severity (area, p = 0.07; perimeter, p = 0.13). CONCLUSION Diabetic macular nonperfusion was significantly associated with the NPA from widefield OCTA. In particular, the temporal-perifoveal DCP disorder may be a sensitive indicator of wide NPA.
Collapse
Affiliation(s)
- Ami Konno
- Department of Ophthalmology, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, 078-8510, Japan.
| | - Akihiro Ishibazawa
- Department of Ophthalmology, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, 078-8510, Japan
| | - Lucas De Pretto
- Nuclear and Energy Research Institute IPEN-CNEN/SP, Sao Paulo, Brazil
| | - Akito Shimouchi
- Department of Ophthalmology, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, 078-8510, Japan
| | - Tsuneaki Omae
- Department of Ophthalmology, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, 078-8510, Japan
| | - Young-Seok Song
- Department of Ophthalmology, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa, 078-8510, Japan
| |
Collapse
|
20
|
Stino H, Huber KL, Niederleithner M, Mahnert N, Sedova A, Schlegl T, Steiner I, Sacu S, Drexler W, Schmoll T, Leitgeb R, Schmidt-Erfurth U, Pollreisz A. Association of Diabetic Lesions and Retinal Nonperfusion Using Widefield Multimodal Imaging. Ophthalmol Retina 2023; 7:1042-1050. [PMID: 37517798 DOI: 10.1016/j.oret.2023.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/14/2023] [Accepted: 07/24/2023] [Indexed: 08/01/2023]
Abstract
PURPOSE To evaluate the association of microvascular lesions on ultrawidefield (UWF) color fundus (CF) images with retinal nonperfusion (RNP) up to the midperiphery on single-capture widefield (WF) OCT angiography (OCTA) in patients with diabetic retinopathy (DR). DESIGN Cross-sectional study. SUBJECTS Seventy-five eyes of 50 patients with mild to severe nonproliferative DR (NPDR) and proliferative DR (PDR) were included in this analysis. METHODS ETDRS level and presence of predominantly peripheral lesions (PPLs) were assessed on UWF-CF images acquired with a Zeiss Clarus 700. Single-capture 65°-WF-OCTA was performed using a PlexElite prototype (Carl Zeiss Meditec, Inc.). A custom grid consisting of a central ETDRS grid extended by 2 rings reaching up to the midperiphery was overlaid to subdivide retinal areas visible on WF-OCTA en face images. Retinal nonperfusion was measured in each area and in total. Nonperfusion index (NPI) was calculated from total RNP. On UWF-CF images, the number of microaneurysms, hemorrhages, neovascularizations, and areas with intraretinal microvascular abnormalities (IRMAs) were evaluated using the same grid. MAIN OUTCOME MEASURES Association of diabetic lesions with RNP was calculated using Spearman correlations (rs). RESULTS Median RNP on WF-OCTA was 0 mm2 (0-0.9), 4.9 mm2 (1.9-5.4), 23.4 mm2 (17.8-37), and 68.4 mm2 (40.8-91.7) in mild, moderate, and severe NPDR and PDR, respectively. We found a statistically significant correlation (P < 0.01) of overall RNP (rs = 0.96,) and NPI (rs = 0.97) on WF-OCTA with ETDRS level. Number of grid-fields affected by IRMAs on CF images was highly associated with NPI (rs = 0.86, P < 0.01). Intraretinal microvascular abnormalities and RNPs had similar topographic distributions with high correlations in affected areas. Eyes with PPLs (n = 43 eyes, 57%) on CF images had a significantly higher NPI (P = 0.014) than eyes without PPLs. CONCLUSION The combination of UWF-CF imaging and single-capture WF-OCTA allows precise and noninvasive analysis of the retinal vasculature up to the midperiphery in patients with DR. The presence and extent of IRMAs on CF images may serve as an indicator for underlying RNP, which is more pronounced in eyes with PPLs. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
Collapse
Affiliation(s)
- Heiko Stino
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - Kim Lien Huber
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - Michael Niederleithner
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Nikolaus Mahnert
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - Aleksandra Sedova
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - Thomas Schlegl
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Irene Steiner
- Center for Medical Data Science, Institute of Medical Statistics, Medical University of Vienna, Vienna, Austria
| | - Stefan Sacu
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Drexler
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Tilman Schmoll
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria; Carl Zeiss Meditec, Inc., Dublin, California
| | - Rainer Leitgeb
- Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | | | - Andreas Pollreisz
- Department of Ophthalmology, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
21
|
Lee PK, Ra H, Baek J. Automated segmentation of ultra-widefield fluorescein angiography of diabetic retinopathy using deep learning. Br J Ophthalmol 2023; 107:1859-1863. [PMID: 36241374 DOI: 10.1136/bjo-2022-321063] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 09/27/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND/AIMS Retinal capillary non-perfusion (NP) and neovascularisation (NV) are two of the most important angiographic changes in diabetic retinopathy (DR). This study investigated the feasibility of using deep learning (DL) models to automatically segment NP and NV on ultra-widefield fluorescein angiography (UWFA) images from patients with DR. METHODS Retrospective cross-sectional chart review study. In total, 951 UWFA images were collected from patients with severe non-proliferative DR (NPDR) or proliferative DR (PDR). Each image was segmented and labelled for NP, NV, disc, background and outside areas. Using the labelled images, DL models were trained and validated (80%) using convolutional neural networks (CNNs) for automated segmentation and tested (20%) on test sets. Accuracy of each model and each label were assessed. RESULTS The best accuracy from CNN models for each label was 0.8208, 0.8338, 0.9801, 0.9253 and 0.9766 for NP, NV, disc, background and outside areas, respectively. The best Intersection over Union for each label was 0.6806, 0.5675, 0.7107, 0.8551 and 0.924 and mean mean boundary F1 score (BF score) was 0.6702, 0.8742, 0.9092, 0.8103 and 0.9006, respectively. CONCLUSIONS DL models can detect NV and NP as well as disc and outer margins on UWFA with good performance. This automated segmentation of important UWFA features will aid physicians in DR clinics and in overcoming grader subjectivity.
Collapse
Affiliation(s)
- Phil-Kyu Lee
- Department of Ophthalmology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea
| | - Ho Ra
- Department of Ophthalmology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea
| | - Jiwon Baek
- Department of Ophthalmology, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Republic of Korea
- Department of Ophthalmology, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| |
Collapse
|
22
|
Liang GB, Hormel TT, Wei X, Guo Y, Wang J, Hwang T, Jia Y. Single-shot OCT and OCT angiography for slab-specific detection of diabetic retinopathy. BIOMEDICAL OPTICS EXPRESS 2023; 14:5682-5695. [PMID: 38021127 PMCID: PMC10659794 DOI: 10.1364/boe.503476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 12/01/2023]
Abstract
In this study, we present an optical coherence tomographic angiography (OCTA) prototype using a 500 kHz high-speed swept-source laser. This system can generate a 75-degree field of view with a 10.4 µm lateral resolution with a single acquisition. With this prototype we acquired detailed, wide-field, and plexus-specific images throughout the retina and choroid in eyes with diabetic retinopathy, detecting early retinal neovascularization and locating pathology within specific retinal slabs. Our device could also visualize choroidal flow and identify signs of key biomarkers in diabetic retinopathy.
Collapse
Affiliation(s)
- Guangru B. Liang
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S.W. Bond Avenue, Portland, OR 97239, USA
- Casey Eye Institute, Oregon Health & Science University, 515 S.W. Campus Drive, Portland, OR 97239, USA
| | - Tristan T. Hormel
- Casey Eye Institute, Oregon Health & Science University, 515 S.W. Campus Drive, Portland, OR 97239, USA
| | - Xiang Wei
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S.W. Bond Avenue, Portland, OR 97239, USA
- Casey Eye Institute, Oregon Health & Science University, 515 S.W. Campus Drive, Portland, OR 97239, USA
| | - Yukun Guo
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S.W. Bond Avenue, Portland, OR 97239, USA
- Casey Eye Institute, Oregon Health & Science University, 515 S.W. Campus Drive, Portland, OR 97239, USA
| | - Jie Wang
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S.W. Bond Avenue, Portland, OR 97239, USA
- Casey Eye Institute, Oregon Health & Science University, 515 S.W. Campus Drive, Portland, OR 97239, USA
| | - Thomas Hwang
- Casey Eye Institute, Oregon Health & Science University, 515 S.W. Campus Drive, Portland, OR 97239, USA
| | - Yali Jia
- Department of Biomedical Engineering, Oregon Health & Science University, 3303 S.W. Bond Avenue, Portland, OR 97239, USA
- Casey Eye Institute, Oregon Health & Science University, 515 S.W. Campus Drive, Portland, OR 97239, USA
| |
Collapse
|
23
|
Yoshida M, Murakami T, Kawai K, Nishikawa K, Ishihara K, Mori Y, Tsujikawa A. Inference of Capillary Nonperfusion Progression on Widefield OCT Angiography in Diabetic Retinopathy. Invest Ophthalmol Vis Sci 2023; 64:24. [PMID: 37847225 PMCID: PMC10584022 DOI: 10.1167/iovs.64.13.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 09/26/2023] [Indexed: 10/18/2023] Open
Abstract
Purpose The purpose of this study was to explore the spatial patterns of the nonperfusion areas (NPAs) on widefield optical coherence tomography angiography (OCTA) images in diabetic retinopathy (DR) and to investigate their associations with NPA progression and DR severity. Methods We prospectively enrolled 201 eyes from 158 patients with DR. Widefield images were obtained using a swept-source OCTA device (Xephilio OCT-S1), followed by the creation of 20-mm (1614 pixels) en face images. Nonperfusion squares (NPSs) were defined as 10 × 10-pixel squares without retinal vessels. Eyes with high-dimensional spatial data were mapped onto a two-dimensional space using the uniform manifold approximation and projection algorithm and divided by clustering. The patterns of NPA distribution were statistically compared between clusters. Results All eyes were mapped onto a two-dimensional space and divided into six clusters based on the similarity of NPA distribution. Eyes in clusters 1 and 2 had minimal and small NPAs, respectively. Eyes in clusters 3 and 4 exhibited NPAs in the temporal and inferotemporal regions, respectively. Eyes in cluster 5 displayed NPAs in both superonasal and inferonasal areas. The unique NPA distributions in each cluster encouraged us to propose eight possible pathways of NPA progression. DR severity was not equal between clusters (P < 0.001), for example, 8 (15.7%) of 51 eyes and 15 (65.2%) of 23 eyes had PDR in clusters 1 and 5, respectively. Conclusions Dimensionality reduction and subsequent clustering based on the NPA distribution on widefield OCTA enabled the inference of possible NPA progression in DR.
Collapse
Affiliation(s)
- Miyo Yoshida
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Tomoaki Murakami
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kentaro Kawai
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Keiichi Nishikawa
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kenji Ishihara
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yuki Mori
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akitaka Tsujikawa
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| |
Collapse
|
24
|
Zhuang X, Chen R, Liang A, Yao J, Wang Z, Chen Y, Zheng K, Lu P, Zhang L, Cao D. Multimodal imaging analysis for the impact of retinal peripheral lesions on central neurovascular structure and retinal function in type 2 diabetes with diabetic retinopathy. Br J Ophthalmol 2023; 107:1496-1501. [PMID: 35772851 DOI: 10.1136/bjo-2022-321297] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 06/13/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To explore the possible role of peripheral lesions (PLs) detected by ultrawide field (UWF) imaging system on central neurovascular structure and retinal function. METHODS Ninety-seven diabetic patients were included in this cross-sectional study using UWF pseudocolour colour imaging with Optos Daytona (Optos, PLC). UWF images were graded as with predominantly peripheral lesions (PPLs) and without PPL. Macular neurovascular alterations and retinal function were measured by optical coherence tomography angiography (OCTA) and RETeval device, respectively. Central microcirculation and retinal function were compared between eyes with and without PPL. RESULTS The study evaluated 186 eyes (97 patients; 43 females (44.3%)), including 92 eyes without PPL and 94 eyes with PPL. Central retinal vessel density was comparable between eyes with and without PPL. Delayed implicit time and decreased pupil area ratio were found in the PPL group compared with eyes without PPL, and this difference remained unchanged after adjusting for systemic factors (all p<0.01). CONCLUSIONS Our study suggests that retinal function is worse in diabetic eyes with PPL. These findings challenged the conventional ETDRS protocols which ignored peripheral retina in determining DR severity. Furthermore, combining UWF imaging with RETeval system to detect more retinal abnormalities may be helpful in DR management.
Collapse
Affiliation(s)
- Xuenan Zhuang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
- Key Laboratory of Ophthalmology, Zhongshan Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ruoyu Chen
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
| | - Anyi Liang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
| | - Jie Yao
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
- Shantou University Medical College, Shantou, China
| | - Zicheng Wang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
- School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
| | - Yesheng Chen
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Kangyan Zheng
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
- Shantou University Medical College, Shantou, China
| | - Peiyao Lu
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Liang Zhang
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| | - Dan Cao
- Department of Ophthalmology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, China
- Guangdong Cardiovascular Institute, Guangzhou, Guangdong, China
| |
Collapse
|
25
|
Choi J, Kim SJ, Kang SW, Son KY, Hwang S. Local ocular factors associated with the development of diabetic macular edema: an inter-eye study. Sci Rep 2023; 13:14868. [PMID: 37684395 PMCID: PMC10491578 DOI: 10.1038/s41598-023-42038-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 09/04/2023] [Indexed: 09/10/2023] Open
Abstract
To investigate local ocular factors associated with the development of diabetic macular edema (DME), we classified each eye of patients with unilateral DME as the DME eyes or the fellow eyes (without DME). We compared the clinical characteristics, optical coherence tomography (OCT), and OCT angiography (OCTA), ultra-wide field fundus photography, and angiography features of each eye. As a result, fifty-five patients with unilateral DME were enrolled. Although the diabetic retinopathy stage was not different between each group of eyes, DME eyes showed a higher prevalence of venous beading and a larger area of nonperfusion region than did fellow eyes (all P < 0.05). OCTA features of DME eyes also showed a larger foveal avascular zone in the deep capillary plexus and a lower vascular density in both the superficial and deep capillary plexuses (all P < 0.05). This study highlighted ocular features reflecting retinal ischemia, such as venous beading, area of nonperfusion region, and vascular density in the central retinal area, are associated with the development of DME. OCTA and ultra-wide field fluorescein angiography may be useful for evaluating the parameters of retinal ischemia and the risk of DME development.
Collapse
Affiliation(s)
- Jaehwan Choi
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang Jin Kim
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Se Woong Kang
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Ki Young Son
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Department of Ophthalmology, Chungnam National University Sejong Hospital, Sejong, South Korea
| | - Sungsoon Hwang
- Department of Ophthalmology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| |
Collapse
|
26
|
Oganov AC, Seddon I, Jabbehdari S, Uner OE, Fonoudi H, Yazdanpanah G, Outani O, Arevalo JF. Artificial intelligence in retinal image analysis: Development, advances, and challenges. Surv Ophthalmol 2023; 68:905-919. [PMID: 37116544 DOI: 10.1016/j.survophthal.2023.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 04/30/2023]
Abstract
Modern advances in diagnostic technologies offer the potential for unprecedented insight into ophthalmic conditions relating to the retina. We discuss the current landscape of artificial intelligence in retina with respect to screening, diagnosis, and monitoring of retinal pathologies such as diabetic retinopathy, diabetic macular edema, central serous chorioretinopathy, and age-related macular degeneration. We review the methods used in these models and evaluate their performance in both research and clinical contexts and discuss potential future directions for investigation, use of multiple imaging modalities in artificial intelligence algorithms, and challenges in the application of artificial intelligence in retinal pathologies.
Collapse
Affiliation(s)
- Anthony C Oganov
- Department of Ophthalmology, Renaissance School of Medicine, Stony Brook, NY, USA
| | - Ian Seddon
- College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL, USA
| | - Sayena Jabbehdari
- Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Ogul E Uner
- Casey Eye Institute, Department of Ophthalmology, Oregon Health and Science University, Portland, OR, USA
| | - Hossein Fonoudi
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Iranshahr University of Medical Sciences, Iranshahr, Sistan and Baluchestan, Iran
| | - Ghasem Yazdanpanah
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, Chicago, IL, USA
| | - Oumaima Outani
- Faculty of Medicine and Pharmacy of Rabat, Mohammed 5 University, Rabat, Rabat, Morocco
| | - J Fernando Arevalo
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
27
|
Decker NL, Duffy BV, Boughanem GO, Fukuyama H, Castellanos Canales D, Nesper PL, Gill MK, Fawzi AA. Macular Perfusion Deficits on OCT Angiography Correlate with Nonperfusion on Ultrawide-field Fluorescein Angiography in Diabetic Retinopathy. Ophthalmol Retina 2023; 7:692-702. [PMID: 37061036 PMCID: PMC10524214 DOI: 10.1016/j.oret.2023.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 03/16/2023] [Accepted: 04/07/2023] [Indexed: 04/17/2023]
Abstract
OBJECTIVE To evaluate the correlation between nonperfusion parameters on OCT angiography (OCTA) and ultrawide-field fluorescein angiography (UWF-FA) in subjects with diabetes mellitus (DM). DESIGN Prospective, cross-sectional study. SUBJECTS Subjects with DM and a wide range of diabetic retinopathy (DR) severity seen at a tertiary referral center. METHODS We used averaged 3 × 3 mm OCTA scans to measure geometric perfusion deficit (GPD), vessel density, and vessel length density in the full retina, superficial capillary plexuses (SCPs), and deep capillary plexuses (DCPs). Nonperfusion was manually delineated on UWF-FA to quantify central, peripheral, and total retinal nonperfusion (mm2 and % area). MAIN OUTCOME MEASURES Correlation between OCTA parameters and UWF-FA nonperfusion, and accuracy of these OCTA and UWF-FA parameters in detecting clinically referable eyes, using receiver operating characteristic (ROC) curve analysis, sensitivity, specificity, and area under the ROC curve (AUC). RESULTS The study included 67 eyes (12 eyes with no signs of DR, 8 mild, 22 moderate, 14 severe nonproliferative DR, and 11 treatment-naive proliferative DR). There was a fair-to-moderate correlation between either central or total retinal nonperfusion on UWF-FA (mm2) and GPD in the SCP (r = 0.482 and r = 0.464, respectively) and DCP (r = 0.470 and r = 0.456, respectively). Receiver operating characteristic analysis showed the DCP GPD significantly superior to other OCTA parameters at the DCP with the largest overall AUC on OCTA for distinguishing referable DR (0.905). Furthermore, the GPD parameter had the largest AUC in each respective capillary layer compared with other parameters. Overall, the total UWF-FA nonperfusion area showed a comparable AUC (0.907) and performed significantly better than peripheral nonperfusion (P = 0.041). Comparing the AUC values between GPD and UWF-FA nonperfusion parameters showed no significant difference in discerning referable DR. CONCLUSIONS Nonperfusion as quantified on OCTA (3 × 3 mm) correlated with UWF-FA parameters and both were comparable in detecting referable DR. These macular OCTA metrics, particularly DCP GPD, have the potential for gauging the overall ischemic status of the retina, with an important clinical role in identifying eyes with clinically referable DR. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
Collapse
Affiliation(s)
- Nicole L Decker
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Brandon V Duffy
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ghazi O Boughanem
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Hisashi Fukuyama
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Peter L Nesper
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Manjot K Gill
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Amani A Fawzi
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| |
Collapse
|
28
|
Sivaprasad S, Sen S, Cunha-Vaz J. Perspectives of diabetic retinopathy-challenges and opportunities. Eye (Lond) 2023; 37:2183-2191. [PMID: 36494431 PMCID: PMC10366207 DOI: 10.1038/s41433-022-02335-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 09/16/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022] Open
Abstract
Diabetic retinopathy (DR) may lead to vision-threatening complications in people living with diabetes mellitus. Decades of research have contributed to our understanding of the pathogenesis of diabetic retinopathy from non-proliferative to proliferative (PDR) stages, the occurrence of diabetic macular oedema (DMO) and response to various treatment options. Multimodal imaging has paved the way to predict the impact of peripheral lesions and optical coherence tomography-angiography is starting to provide new knowledge on diabetic macular ischaemia. Moreover, the availability of intravitreal anti-vascular endothelial growth factors has changed the treatment paradigm of DMO and PDR. Areas of research have explored mechanisms of breakdown of the blood-retinal barrier, damage to pericytes, the extent of capillary non-perfusion, leakage and progression to neovascularisation. However, knowledge gaps remain. From this perspective, we highlight the challenges and future directions of research in this field.
Collapse
Affiliation(s)
- Sobha Sivaprasad
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.
| | - Sagnik Sen
- Department of Retina and Vitreous, Aravind Eye Hospital and Aravind Medical Research Foundation, Madurai, India
- Moorfields Eye Hospital, NHS Foundation Trust, London, United Kingdom
| | - José Cunha-Vaz
- AIBILI - Association for Innovation and Biomedical Research on Light and Image, Coimbra, Portugal
- University of Coimbra, Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, Coimbra, Portugal
| |
Collapse
|
29
|
Chaudhary V. The need for a pragmatic, individualized treat-and-extend (T&E) treatment paradigm for centre-involving diabetic macular oedema. Eye (Lond) 2023; 37:2431-2433. [PMID: 36849826 PMCID: PMC10397213 DOI: 10.1038/s41433-023-02455-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/10/2023] [Accepted: 02/13/2023] [Indexed: 03/01/2023] Open
Affiliation(s)
- Varun Chaudhary
- Department of Surgery, McMaster University, Hamilton, ON, Canada.
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| |
Collapse
|
30
|
Kim K, Kim ES, Yu SY. PREDICTION OF DIABETIC RETINOPATHY SEVERITY USING A COMBINATION OF RETINAL NEURODEGENERATION AND CAPILLARY NONPERFUSION ON OPTICAL COHERENCE TOMOGRAPHY ANGIOGRAPHY. Retina 2023; 43:1291-1300. [PMID: 37116460 DOI: 10.1097/iae.0000000000003820] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
PURPOSE To generate a prediction model of diabetic retinopathy (DR) severity stages based on retinal neurodegeneration and capillary nonperfusion area (NPA) detected using optical coherence tomography (OCT) and OCT angiography (OCTA). METHODS A total of 155 treatment-naïve eyes were retrospectively included. Macular ganglion cell/inner plexiform layer (mGCIPL) thickness in six macular regions was measured. A custom algorithm was used to calculate capillary NPA from 3 × 3 mm 2 and 12 × 12 mm 2 field OCTA images. The region of interest was selected as circular areas of 3 mm and 12 mm diameter and divided into six subsections. Classification and regression tree analysis identified the best predictors to discriminate between the five DR stages. RESULTS Inferotemporal sector showed the largest mean NPA, and the inferior hemispheric NPA was significantly larger compared with the superior hemisphere. The mean mGCIPL thickness was significantly correlated with NPA of 12 × 12 mm 2 field in participants with early stage DR. Inferior hemispheric NPA of 12 × 12 mm 2 field and mean mGCIPL thickness were the two best variables to discriminate no DR versus mild nonproliferative DR (NPDR) and mild versus moderate NPDR (accuracy: 88.8% and 93.5%). Meanwhile, a combination of NPA of 12 × 12 mm 2 and 3 × 3 mm 2 fields was the best prediction model to discriminate moderate versus severe NPDR and severe NPDR versus PDR (accuracy: 91.8% and 94.1%). CONCLUSION A combination model of capillary NPA and mGCIPL thickness may be a novel biomarker for predicting DR severity. Capillary nonperfusion seems to initially occur in the midperipheral retina with macular neurodegeneration and progress posteriorly.
Collapse
Affiliation(s)
- Kiyoung Kim
- Department of Ophthalmology, Kyung Hee University Medical Center, Kyung Hee University, Seoul, South Korea
| | | | | |
Collapse
|
31
|
Salongcay RP, Aquino LAC, Salva CMG, Peto T, Silva PS. Comparison of Diabetic Retinopathy Lesions Identified Using Ultrawide Field Imaging and Optical Coherence Tomography Angiography. Ophthalmic Res 2023; 66:1053-1062. [PMID: 37379803 PMCID: PMC10614530 DOI: 10.1159/000531723] [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: 06/21/2022] [Accepted: 06/11/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Optical coherence tomography (OCT) angiography (OCTA) has the potential to influence the diagnosis and management of diabetic eye disease. This study aims to determine the correlation between diabetic retinopathy (DR) findings on ultrawide field (UWF) color photography (UWF-CP), UWF fluorescein angiography (UWF-FA), and OCTA. METHODS This is a cross-sectional, prospective study. One hundred and fourteen eyes from 57 patients with diabetes underwent mydriatic UWF-CP, UWF-FA, and OCTA. DR severity was assessed. Ischemic areas were identified on UWF-FA using ImageJ and the nonperfusion index (NPI) was calculated. Diabetic macular edema (DME) was assessed using OCT. Superficial capillary plexus vessel density (VD), vessel perfusion (VP), and foveal avascular zone (FAZ) area were automatically measured on OCTA. Pearson correlation coefficient between the imaging modalities was determined. RESULTS Forty-five eyes were excluded due to non-DR findings or prior laser photocoagulation; 69 eyes were analyzed. DR severity was associated with larger NPI (r = 0.55944, p < 0.0001) even after distinguishing between cones (Cone Nonperfusion Index [CPI]: r = 0.55617, p < 0.0001) and rods (Rod Nonperfusion Index [RPI]: r = 0.55285, p < 0.0001). In eyes with nonproliferative DR (NPDR), NPI is correlated with DME (r = 0.51156, p = 0.0017) and central subfield thickness (CST) (r = 0.67496, p < 0.0001). UWF-FA macular nonperfusion correlated with NPI (r = 0.42899, p = 0.0101), CPI (r = 0.50028, p = 0.0022), and RPI (r = 0.49027, p = 0.0028). Central VD and VP correlated with the DME presence (r = 0.52456, p < 0.0001; r = 0.51952, p < 0.0001) and CST (r = 0.50133, p < 0.0001; r = 0.48731, p < 0.0001). Central VD and VP were correlated with macular nonperfusion (r = 0.44503, p = 0.0065; r = 0.44239, p = 0.0069) in eyes with NPDR. Larger FAZ was correlated with decreased central VD (r = -0.60089, p = 0.0001) and decreased central VP (r = -0.59224, p = 0.0001). CONCLUSION UWF-CP, UWF-FA, and OCTA findings provide relevant clinical information on diabetic eyes. Nonperfusion on UWF-FA is correlated with DR severity and DME. OCTA metrics of the superficial capillary plexus correlate with the incidence of DME and macular ischemia.
Collapse
Affiliation(s)
- Recivall P. Salongcay
- Centre for Public Health, Queen’s University Belfast, Belfast, UK
- Eye and Vision Institute, The Medical City, Pasig, Metro Manila, Philippines
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | - Lizzie Anne C. Aquino
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | | | - Tunde Peto
- Centre for Public Health, Queen’s University Belfast, Belfast, UK
| | - Paolo S. Silva
- Eye and Vision Institute, The Medical City, Pasig, Metro Manila, Philippines
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
32
|
Sarici K, Yordi S, Martin A, Lunasco L, Mugnaini C, Chu K, Moini H, Vitti R, Srivastava SK, Ehlers JP. Longitudinal Quantitative Ultrawide-field Fluorescein Angiography Dynamics in the RUBY Diabetic Macular Edema Study. Ophthalmol Retina 2023; 7:543-552. [PMID: 36736895 DOI: 10.1016/j.oret.2023.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/17/2022] [Accepted: 01/23/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate the longitudinal change in quantitative ultrawide-field angiographic (UWFA) parameters and correlate them with functional outcomes and spectral domain-OCT metrics. DESIGN This study is a post hoc analysis of the phase II RUBY study: a prospective, randomized trial of patients with diabetic macular edema (DME) treated with either intravitreal aflibercept injection (IAI) or combined IAI/nesvacumab (antiangiopoietin 2 mAb). SUBJECTS Subjects with DME that underwent UWFA across all treatment groups (n = 44). METHODS A machine learning-enabled feature extraction system generated panretinal quantitative UWFA metrics, including leakage, ischemia, and microaneurysm (MA) burden. Zonal assessments were performed corresponding to the macula, midperiphery, and far periphery. MAIN OUTCOME MEASURES Changes in ischemic area and index (proportion of nonperfusion in analyzable retina), leakage area and index (proportion of leakage in analyzable retina), and MA count at baseline, week 12, week 24, and week 36 were analyzed. Spectral-domain-OCT quantitative metrics, such as central subfield thickness, ellipsoid zone (EZ) integrity parameters, intraretinal fluid (IRF) volume, and subretinal fluid (SRF) volume were extracted via a machine learning-enhanced OCT feature extraction platform and analyzed. Additionally, the effect of these changes on best-corrected visual acuity (BCVA) was evaluated. RESULTS Mean panretinal leakage index, zonal leakage area, and panretinal MA count improved significantly between baseline and week 36. Panretinal ischemic index decreased between baseline and week 36, with some aspects showing significant improvement. Mean BCVA significantly improved from baseline to week 36. There was a significant inverse correlation between change in BCVA and change in macular leakage area. A direct correlation was observed between both baseline macular leakage area and panretinal leakage index with IRF volume, SRF volume, and EZ disruption on OCT. CONCLUSIONS Assessment of UWFA parameters demonstrates a significant improvement in panretinal leakage index, leakage area, and MA burden in eyes treated with IAI with or without nesvacumab. A numeric reduction in panretinal ischemic index and area was noted. The analysis also shows the critical association of leakage with visual and OCT features. This highlights the potential role of UWFA in disease burden assessment, with leakage parameters serving as a primary end point. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
Collapse
Affiliation(s)
- Kubra Sarici
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Sari Yordi
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alison Martin
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Leina Lunasco
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christopher Mugnaini
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Karen Chu
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York
| | - Hadi Moini
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York
| | - Robert Vitti
- Regeneron Pharmaceuticals, Inc., Tarrytown, New York
| | - Sunil K Srivastava
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
| | - Justis P Ehlers
- The Tony and Leona Campane Center for Excellence in Image-Guided Surgery and Advanced Imaging Research, Cleveland Clinic, Cleveland, Ohio; Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio.
| |
Collapse
|
33
|
Kalaw FGP, Sharma P, Kako RN, Walker E, Borooah S. Peripheral retinal vessel whitening in patients with diabetes mellitus. Sci Rep 2023; 13:7981. [PMID: 37198200 DOI: 10.1038/s41598-023-35124-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/12/2023] [Indexed: 05/19/2023] Open
Abstract
This study aimed to identify retinal vessel whitening outside the standard Early Treatment Diabetic Retinopathy Study (ETDRS) fields and to correlate the findings with vision and severity of diabetic retinopathy. Patients with diabetes mellitus who were seen in the retinal clinic to assess diabetic retinopathy status were included. Retinal vessel whitening was identified using ultra-widefield imaging. Four hundred and forty-five eyes of 260 patients were included. Thirty-five eyes in 24 patients (7.9%) were noted to have peripheral retinal vessel whitening. Thirty-one eyes with peripheral retinal vessel whitening did not have vessel whitening within the standard 7 ETDRS fields (p < 0.001). The proportion of whitening increased as DR severity increased, from 4.0% for patients with no DR (OR 0.249) to 33.3% for those with severe NPDR and PDR (OR 6.430 and 7.232, respectively). In addition, patients with peripheral retinal vessel whitening had worse visual acuity (logMAR = 0.34) compared to those without (logMAR = 0.15) (p < 0.001). In conclusion, we found an association between peripheral retinal vessel whitening in diabetic patients which correlated with diabetic retinopathy severity. Additionally, we found an association between vessel whitening and reduced vision, suggesting that vessel whitening identified using ultra-widefield imaging may be a prognostic indicator of vision in diabetic retinopathy.
Collapse
Affiliation(s)
- Fritz Gerald P Kalaw
- Jacobs Retina Center, University of California San Diego, San Diego, CA, 92093, USA
- Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, 9415 Campus Point Dr, La Jolla, San Diego, CA, 92093, USA
- Division of Ophthalmology Informatics and Data Science, Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, San Diego, CA, 92093, USA
| | - Paripoorna Sharma
- Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, 9415 Campus Point Dr, La Jolla, San Diego, CA, 92093, USA
| | - Rasha Nabil Kako
- Jacobs Retina Center, University of California San Diego, San Diego, CA, 92093, USA
| | - Evan Walker
- Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, 9415 Campus Point Dr, La Jolla, San Diego, CA, 92093, USA
| | - Shyamanga Borooah
- Jacobs Retina Center, University of California San Diego, San Diego, CA, 92093, USA.
- Viterbi Family Department of Ophthalmology and Shiley Eye Institute, University of California San Diego, 9415 Campus Point Dr, La Jolla, San Diego, CA, 92093, USA.
| |
Collapse
|
34
|
Murakami T, Ishihara K, Terada N, Nishikawa K, Kawai K, Tsujikawa A. Pathological Neurovascular Unit Mapping onto Multimodal Imaging in Diabetic Macular Edema. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050896. [PMID: 37241128 DOI: 10.3390/medicina59050896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 05/01/2023] [Accepted: 05/06/2023] [Indexed: 05/28/2023]
Abstract
Diabetic retinopathy is a form of diabetic microangiopathy, and vascular hyperpermeability in the macula leads to retinal thickening and concomitant reduction of visual acuity in diabetic macular edema (DME). In this review, we discuss multimodal fundus imaging, comparing the pathogenesis and interventions. Clinicians diagnose DME using two major criteria, clinically significant macular edema by fundus examination and center-involving diabetic macular edema using optical coherence tomography (OCT), to determine the appropriate treatment. In addition to fundus photography, fluorescein angiography (FA) is a classical modality to evaluate morphological and functional changes in retinal capillaries, e.g., microaneurysms, capillary nonperfusion, and fluorescein leakage. Recently, optical coherence tomography angiography (OCTA) has allowed us to evaluate the three-dimensional structure of the retinal vasculature and newly demonstrated that lamellar capillary nonperfusion in the deep layer is associated with retinal edema. The clinical application of OCT has accelerated our understanding of various neuronal damages in DME. Retinal thickness measured by OCT enables us to quantitatively assess therapeutic effects. Sectional OCT images depict the deformation of neural tissues, e.g., cystoid macular edema, serous retinal detachment, and sponge-like retinal swelling. The disorganization of retinal inner layers (DRIL) and foveal photoreceptor damage, biomarkers of neurodegeneration, are associated with visual impairment. Fundus autofluorescence derives from the retinal pigment epithelium (RPE) and its qualitative and quantitative changes suggest that the RPE damage contributes to the neuronal changes in DME. These clinical findings on multimodal imaging help to elucidate the pathology in the neurovascular units and lead to the next generation of clinical and translational research in DME.
Collapse
Affiliation(s)
- Tomoaki Murakami
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
| | - Kenji Ishihara
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
| | - Noriko Terada
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
| | - Keiichi Nishikawa
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
| | - Kentaro Kawai
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
| | - Akitaka Tsujikawa
- Department of Ophthalmology and Visual Sciences, Kyoto University Graduate School of Medicine, Kyoto 606-8507, Japan
| |
Collapse
|
35
|
Ong CJT, Wong MYZ, Cheong KX, Zhao J, Teo KYC, Tan TE. Optical Coherence Tomography Angiography in Retinal Vascular Disorders. Diagnostics (Basel) 2023; 13:diagnostics13091620. [PMID: 37175011 PMCID: PMC10178415 DOI: 10.3390/diagnostics13091620] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 04/28/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023] Open
Abstract
Traditionally, abnormalities of the retinal vasculature and perfusion in retinal vascular disorders, such as diabetic retinopathy and retinal vascular occlusions, have been visualized with dye-based fluorescein angiography (FA). Optical coherence tomography angiography (OCTA) is a newer, alternative modality for imaging the retinal vasculature, which has some advantages over FA, such as its dye-free, non-invasive nature, and depth resolution. The depth resolution of OCTA allows for characterization of the retinal microvasculature in distinct anatomic layers, and commercial OCTA platforms also provide automated quantitative vascular and perfusion metrics. Quantitative and qualitative OCTA analysis in various retinal vascular disorders has facilitated the detection of pre-clinical vascular changes, greater understanding of known clinical signs, and the development of imaging biomarkers to prognosticate and guide treatment. With further technological improvements, such as a greater field of view and better image quality processing algorithms, it is likely that OCTA will play an integral role in the study and management of retinal vascular disorders. Artificial intelligence methods-in particular, deep learning-show promise in refining the insights to be gained from the use of OCTA in retinal vascular disorders. This review aims to summarize the current literature on this imaging modality in relation to common retinal vascular disorders.
Collapse
Affiliation(s)
- Charles Jit Teng Ong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore 168751, Singapore
| | - Mark Yu Zheng Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore 168751, Singapore
| | - Kai Xiong Cheong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore 168751, Singapore
| | - Jinzhi Zhao
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore 168751, Singapore
| | - Kelvin Yi Chong Teo
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore 168751, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program (EYE ACP), Duke-NUS Medical School, Singapore 169857, Singapore
| | - Tien-En Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore 168751, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program (EYE ACP), Duke-NUS Medical School, Singapore 169857, Singapore
| |
Collapse
|
36
|
Ashraf M, AbdelAl O, Shokrollahi S, Pitoc CM, Aiello LP, Silva PS. Evaluation of diabetic retinopathy severity on ultrawide field colour images compared with ultrawide fluorescein angiograms. Br J Ophthalmol 2023; 107:534-539. [PMID: 36669774 DOI: 10.1136/bjo-2022-322163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 12/22/2022] [Indexed: 01/21/2023]
Abstract
PURPOSE To compare Early Treatment Diabetic Retinopathy Study (ETDRS) diabetic retinopathy (DR) severity on ultrawide field (UWF) colour imaging (CI) and UWF fluorescein angiography (FA). DESIGN Cross-sectional retrospective review. SUBJECTS Patients with diabetes mellitus and at least mild non-proliferative DR on UWF-CI. METHODS UWF-CI and UWF-FA images acquired within 1 month of each other were evaluated independently using ETDRS DR Severity Scale (DRSS) for colour photography adapted for UWF-CI and UWF-FA. Extent of non-perfusion (NP, mm2) was determined from UWF-FA images. MAIN OUTCOME MEASURES Agreement rate between DRSS on UWF-CI and UWF-FA. RESULTS Images from 218 eyes of 137 patients with diabetes were evaluated. Agreement rate for DRSS between UWF-CI and UWF-FA was moderate to substantial (K=0.46, Kw=0.65). Over-all, DRSS was worse in 73 (33.5%) eyes on UWF-FA and in 16 (7.3%) on UWF-CI. Compared to UWF-CI, UWF-FA identified more severe DRSS in 26.5% (1 step) and 7.34% (≥2 steps) of eyes. DRSS was worse than UWF-FA in 56 (51.4%) in early DR (ETDRS levels 20-47, N=109) and 17 (15.6%) in eyes with severe DR (53 and higher, N=109). In this cohort, the extent of NP significantly increased as eyes approach moderate non-proliferative DR (levels 43-47, p=0.0065). CONCLUSION When evaluating UWF-FA images using the ETDRS colour severity scale, DRSS is graded as more severe in a substantial number of eyes than when evaluating UWF-CI. It is uncertain how the DRSS levels using UWF-FA translate to clinical outcomes, but the additional lesions detected might provide added prognostic value. These and other recent data emphasise the need of obtaining outcome data based on UWF-FA and the potential need to develop DRSS specifically tailored for UWF-FA images.
Collapse
Affiliation(s)
- Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Ophthlamology Department, Harvard Medical School, Boston, MA, USA
- Ophthalmology Department, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Omar AbdelAl
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
| | | | - Cloyd M Pitoc
- University of the Philippines Manila, Manila, Philippines
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Ophthlamology Department, Harvard Medical School, Boston, MA, USA
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Ophthlamology Department, Harvard Medical School, Boston, MA, USA
- University of the Philippines Manila, Manila, Philippines
| |
Collapse
|
37
|
Szeto SKH, Hui VWK, Siu V, Mohamed S, Chan CKM, Cheung CYL, Hsieh YT, Tan CS, Chhablani J, Lai TYY, Ng DSC. Recent Advances in Clinical Applications of Imaging in Retinal Diseases. Asia Pac J Ophthalmol (Phila) 2023; 12:252-263. [PMID: 36650100 DOI: 10.1097/apo.0000000000000584] [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: 09/24/2022] [Accepted: 10/24/2022] [Indexed: 01/19/2023] Open
Abstract
Many diseases that cause visual impairment, as well as systemic conditions, manifest in the posterior segment of the eye. With the advent of high-speed, high-resolution, reliable, and noninvasive imaging techniques, ophthalmologists are becoming more dependent on ocular imaging for disease diagnosis, classification, and management in clinical practice. There are rapid advances on the indications of multimodal retinal imaging techniques, including the application of ultra-widefield fundus angiography, fundus autofluorescence, optical coherence tomography, as well as optical coherence tomography angiography. This review summarizes and highlights the clinical applications, latest indications, and interpretations of multimodal imaging in age-related macular degeneration, polypoidal choroidal vasculopathy, diabetic macular edema, central serous chorioretinopathy, diabetic retinopathy, retinal vein occlusion, and uveitis.
Collapse
Affiliation(s)
- Simon Ka-Ho Szeto
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
- Hong Kong Eye Hospital, Hong Kong, China
| | - Vivian Wing Ki Hui
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
- Hong Kong Eye Hospital, Hong Kong, China
| | - Vivianna Siu
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Shaheeda Mohamed
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
- Hong Kong Eye Hospital, Hong Kong, China
| | - Carmen K M Chan
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
- Hong Kong Eye Hospital, Hong Kong, China
| | - Carol Yim Lui Cheung
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Yi Ting Hsieh
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
| | - Colin S Tan
- National Healthcare Group Eye Institute, Tan Tock Seng Hospital, Singapore
| | - Jay Chhablani
- Department of Ophthalmology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Timothy Y Y Lai
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
- Hong Kong Eye Hospital, Hong Kong, China
- 2010 Retina and Macula Centre, Hong Kong, China
| | - Danny Siu-Chun Ng
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
- Hong Kong Eye Hospital, Hong Kong, China
| |
Collapse
|
38
|
Fan W, Uji A, Wykoff CC, Brown DM, van Hemert J, Falavarjani KG, Wang K, Sadda SR, Ip M. Baseline retinal vascular bed area on ultra-wide field fluorescein angiography correlates with the anatomical outcome of diabetic macular oedema to ranibizumab therapy: two-year analysis of the DAVE Study. Eye (Lond) 2023; 37:678-683. [PMID: 35332289 PMCID: PMC9998428 DOI: 10.1038/s41433-021-01777-7] [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: 09/10/2020] [Revised: 09/07/2021] [Accepted: 09/15/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To determine the relationship between baseline retinal non-perfusion area (NPA) and retinal vascular bed area (RVBA) on ultra-wide field fluorescein angiography (UWF FA) and long-term response to intravitreal ranibizumab therapy in diabetic macular oedema (DMO). METHODS A post-hoc, 2-year observational case series. Baseline UWF FA images (Optos 200Tx) of 40 eyes from 29 patients with diabetes mellitus and treatment naïve DMO in the DAVE (NCT01552408) study were montaged and stereographically projected at the Doheny Image Reading Center to adjust for peripheral distortion. The retinal vasculature was automatically extracted to calculate RVBA. NPA was manually delineated by two masked certified graders. RVBA and NPA were computed in mm2 automatically by adjusting for peripheral distortion and then correlated with the severity of DMO. RESULTS While global NPA at baseline was not correlated to retinal thickness measurements, baseline NPA in the superior retina was associated with the macular volume (MV) improvement (P = 0.022). Multivariate analysis revealed a smaller RVBA at baseline was correlated with a better MV outcome at two-year follow-up after adjusting for confounding factors (P = 0.049). CONCLUSION Eyes with smaller baseline RVBA appear to have a better long-term anatomic outcome of DMO.
Collapse
Affiliation(s)
- Wenying Fan
- Beijing Tongren Eye Center, Beijing Tongren Hospital, Beijing Ophthalmology and Visual Sciences Key Laboratory, Capital Medical University, Beijing, China
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, CA, USA
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Akihito Uji
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, CA, USA
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Charles C Wykoff
- Retina Consultants of Houston, Houston, TX, USA
- Blanton Eye Institute, Houston Methodist Hospital & Weill Cornell Medical College, Houston, TX, USA
| | - David M Brown
- Retina Consultants of Houston, Houston, TX, USA
- Blanton Eye Institute, Houston Methodist Hospital & Weill Cornell Medical College, Houston, TX, USA
| | | | - Khalil Ghasemi Falavarjani
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, CA, USA
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Kang Wang
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, CA, USA
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - SriniVas R Sadda
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, CA, USA
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Michael Ip
- Doheny Image Reading Center, Doheny Eye Institute, Los Angeles, CA, USA.
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
| |
Collapse
|
39
|
Estaji M, Hosseini B, Bozorg-Qomi S, Ebrahimi B. Pathophysiology and diagnosis of diabetic retinopathy: a narrative review. J Investig Med 2023; 71:265-278. [PMID: 36718824 DOI: 10.1177/10815589221145040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Diabetes is an endocrine disorder which is known by abnormal high blood glucose levels. There are two main categories of diabetes: type I (10%-15%) and type II (85%-90%). Although type II is more common, type I is the most common form in children. Diabetic retinopathy (DR), which remains the foremost cause of losing vision in working-age populations, can be considered as the main complication of diabetes mellitus. So choosing the best method for diagnosing, tracking, and treating the DR is vital to enhance the quality of life and decrease the medical expenses. Each method for diagnosing DR has some advantages and the best way must be selected according to the points that we need to find. For writing this manuscript, we made a list of relevant keywords including diabetes, DR, pathophysiology, ultrawide field imaging, fluorescein angiography, optical coherence tomography, and optical coherence tomography-angiography, and then we started searching for studies in PubMed, Scopus, and Web of Science databases. This review article covers the pathophysiology of DR and medical imaging techniques to monitor DR. First, we introduce DR and its pathophysiology and then we present the medical imaging techniques to monitor it.
Collapse
Affiliation(s)
- Mohadese Estaji
- Department of Medical Physics and Biomedical Engineering, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Bita Hosseini
- Bioscience Research Group, School of Health and Life Sciences, Aston University, Birmingham, UK
| | - Saeed Bozorg-Qomi
- Department of Medical Genetics, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Babak Ebrahimi
- Department of Anatomy, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
40
|
Morel JB, Fajnkuchen F, Amari F, Sritharan N, Bloch-Queyrat C, Giocanti-Aurégan A. Ultra-Wide-Field Fluorescein Angiography Assessment of Non-Perfusion in Patients with Diabetic Retinopathy Treated with Anti-Vascular Endothelial Growth Factor Therapy. J Clin Med 2023; 12:jcm12041365. [PMID: 36835902 PMCID: PMC9963628 DOI: 10.3390/jcm12041365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 01/25/2023] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
Purpose: To follow the evolution of peripheral ischemia by fluorescein angiography (FA) on ultra-wide-field (UWF) images in diabetic patients treated with anti-vascular endothelial growth factor (anti-VEGF) for macular edema. Methods: Prospective, non-interventional cohort study analyzing UWF-FA images of 48 patients with diabetic retinopathy (48 eyes) treated for diabetic macular edema. UWF-FA was performed at baseline and after one year of anti-VEGF therapy (M12). The primary endpoint was the change in the non-perfusion index. Results: Of the 48 patients included in this study, 25 completed the one-year follow-up, and 20 had FA images of sufficient quality to be interpreted. The non-perfusion index did not significantly change from baseline after one year of anti-VEGF treatment (0.7% of the non-perfused area at baseline versus 0.5% at M12; p = 0.29). In contrast, the diabetic retinopathy severity score improved significantly between baseline and M12. Conclusions: Anti-VEGF treatment with aflibercept for diabetic macular edema had no impact on the retinal perfusion assessed by FA, but it allowed for artificially improving diabetic retinopathy severity scores.
Collapse
Affiliation(s)
- Jean-Baptiste Morel
- Ophthalmology Department, Paris Seine Saint Denis Hospital, Sorbonne Paris Nord University, 125 Rue de Stalingrad, 93000 Bobigny, France
| | - Franck Fajnkuchen
- Ophthalmology Department, Paris Seine Saint Denis Hospital, Sorbonne Paris Nord University, 125 Rue de Stalingrad, 93000 Bobigny, France
| | - Fatima Amari
- Ophthalmology Department, Paris Seine Saint Denis Hospital, Sorbonne Paris Nord University, 125 Rue de Stalingrad, 93000 Bobigny, France
| | - Nanthara Sritharan
- Department of Clinical Research, Paris Seine Saint Denis Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), 93000 Bobigny, France
| | - Coralie Bloch-Queyrat
- Department of Clinical Research, Paris Seine Saint Denis Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), 93000 Bobigny, France
| | - Audrey Giocanti-Aurégan
- Ophthalmology Department, Paris Seine Saint Denis Hospital, Sorbonne Paris Nord University, 125 Rue de Stalingrad, 93000 Bobigny, France
- Correspondence:
| |
Collapse
|
41
|
Ashraf M, Sun JK, Silva PS, Aiello LP. Using Ultrawide Field-Directed Optical Coherence Tomography for Differentiating Nonproliferative and Proliferative Diabetic Retinopathy. Transl Vis Sci Technol 2023; 12:7. [PMID: 36745439 PMCID: PMC9910382 DOI: 10.1167/tvst.12.2.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 11/25/2022] [Indexed: 02/07/2023] Open
Abstract
Purpose To evaluate the ability of ultrawide field (UWF)-directed optical coherence tomography (OCT) to detect retinal neovascularization in eyes thought to have severe nonproliferative diabetic retinopathy (NPDR). Methods Retrospective study of 20 consecutive patients diagnosed with severe NPDR by clinical examination. All patients underwent UWF color imaging (UWF-CI) and UWF-directed OCT following a prespecified imaging protocol to assess the mid periphery, 15/32 (46.9%) eyes underwent UWF-fluorescein angiography (FA). On OCT, new vessels elsewhere (NVE) were defined when vessels breached the internal limiting membrane. Results A total of 32 eyes of 20 patients were evaluated. Of the 45 suspected areas of intraretinal microvascular abnormalities (IRMA) on UWF-CI, 38 (84.4%) were imaged by UWF-directed OCT, and 9/38 IRMA (23.7%) were NVE by OCT. Furthermore, UWF-directed OCT identified seven additional NVE in three eyes not seen on UWF-CI. This resulted in a change in diabetic retinopathy (DR) severity from severe NPDR to PDR in 8/32 eyes (25.0%). Among the 46.9% of eyes with UWF-FA, UWF-directed OCT agreed with the UWF-FA findings in 80% (12/15 eyes), missing only one peripheral NVE outside the UWF-OCT scanning area. Two eyes had subtle NVD that were not evident on UWF-directed OCT. Conclusions This pilot study suggests that UWF-directed OCT may help differentiate IRMA from NVE and detect unrecognized NVE in eyes with advanced DR in a clinical practice setting. Future prospective studies in larger cohorts could determine whether this rapid and noninvasive method is clinically relevant in determining NVE presence or retinopathy progression and complication risk. Translational Relevance UWF-directed OCT may offer a noninvasive alternative to detect NVE in eyes with DR.
Collapse
Affiliation(s)
- Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- Ophthalmology Department, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Jennifer K. Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Paolo S. Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
42
|
Khalili Pour E, Rezaee K, Azimi H, Mirshahvalad SM, Jafari B, Fadakar K, Faghihi H, Mirshahi A, Ghassemi F, Ebrahimiadib N, Mirghorbani M, Bazvand F, Riazi-Esfahani H, Riazi Esfahani M. Automated machine learning-based classification of proliferative and non-proliferative diabetic retinopathy using optical coherence tomography angiography vascular density maps. Graefes Arch Clin Exp Ophthalmol 2023; 261:391-399. [PMID: 36050474 DOI: 10.1007/s00417-022-05818-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 08/07/2022] [Accepted: 08/23/2022] [Indexed: 01/17/2023] Open
Abstract
PURPOSE The study aims to classify the eyes with proliferative diabetic retinopathy (PDR) and non-proliferative diabetic retinopathy (NPDR) based on the optical coherence tomography angiography (OCTA) vascular density maps using a supervised machine learning algorithm. METHODS OCTA vascular density maps (at superficial capillary plexus (SCP), deep capillary plexus (DCP), and total retina (R) levels) of 148 eyes from 78 patients with diabetic retinopathy (45 PDR and 103 NPDR) was used to classify the images to NPDR and PDR groups based on a supervised machine learning algorithm known as the support vector machine (SVM) classifier optimized by a genetic evolutionary algorithm. RESULTS The implemented algorithm in three different models reached up to 85% accuracy in classifying PDR and NPDR in all three levels of vascular density maps. The deep retinal layer vascular density map demonstrated the best performance with a 90% accuracy in discriminating between PDR and NPDR. CONCLUSIONS The current study on a limited number of patients with diabetic retinopathy demonstrated that a supervised machine learning-based method known as SVM can be used to differentiate PDR and NPDR patients using OCTA vascular density maps.
Collapse
Affiliation(s)
- Elias Khalili Pour
- Retina Service, Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Karegar Street, Tehran, Iran
| | - Khosro Rezaee
- Department of Biomedical Engineering, Meybod University, Meybod, Iran
| | - Hossein Azimi
- Faculty of Mathematical Sciences and Computer, Kharazmi University, Tehran, Iran
| | - Seyed Mohammad Mirshahvalad
- Retina Service, Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Karegar Street, Tehran, Iran
| | - Behzad Jafari
- Retina Service, Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Karegar Street, Tehran, Iran
| | - Kaveh Fadakar
- Retina Service, Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Karegar Street, Tehran, Iran
| | - Hooshang Faghihi
- Retina Service, Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Karegar Street, Tehran, Iran
| | - Ahmad Mirshahi
- Retina Service, Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Karegar Street, Tehran, Iran
| | - Fariba Ghassemi
- Retina Service, Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Karegar Street, Tehran, Iran
| | - Nazanin Ebrahimiadib
- Retina Service, Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Karegar Street, Tehran, Iran
| | - Masoud Mirghorbani
- Retina Service, Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Karegar Street, Tehran, Iran
| | - Fatemeh Bazvand
- Retina Service, Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Karegar Street, Tehran, Iran
| | - Hamid Riazi-Esfahani
- Retina Service, Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Qazvin Square, South Karegar Street, Tehran, Iran.
| | - Mohammad Riazi Esfahani
- Department of Ophthalmology, Gavin Herbert Eye Institute, University of California Irvine, Irvine, CA, USA
| |
Collapse
|
43
|
Häner NU, Dysli C, Munk MR. Imaging in retinal vascular disease: A review. Clin Exp Ophthalmol 2023; 51:217-228. [PMID: 36597823 DOI: 10.1111/ceo.14203] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/06/2022] [Accepted: 12/09/2022] [Indexed: 01/05/2023]
Abstract
Retinal vascular diseases represent a broad field of ocular pathologies. Retinal imaging is an important tool for diagnosis, prognosis and follow up of retinal vascular diseases. It includes a wide variety of imaging techniques ranging from colour fundus photography and optical coherence tomography to dynamic diagnostic options such as fluorescein angiography, and optical coherence tomography angiography. The newest developments in respective imaging techniques include widefield imaging to assess the retinal periphery, which is of especial interest in retinal vascular diseases. Automatic image analysis and artificial intelligence may support the image analysis and may prove valuable for prognostic purposes. This review provides a broad overview of the imaging techniques that have been used in the past, today and maybe in the future to stage and monitor retinal vascular disease with focus on the main disease entities including diabetic retinopathy, retinal vein occlusion, and retinal artery occlusion.
Collapse
Affiliation(s)
- Nathanael U Häner
- Department of Ophthalmology, Inselspital University Hospital, Bern, Switzerland
| | - Chantal Dysli
- Department of Ophthalmology, Inselspital University Hospital, Bern, Switzerland
| | - Marion R Munk
- Department of Ophthalmology, Inselspital University Hospital, Bern, Switzerland
| |
Collapse
|
44
|
Antropoli A, Arrigo A, La Franca L, Bianco L, Barlocci E, Fusi E, Bandello F, Battaglia Parodi M. Peripheral and central capillary non-perfusion in diabetic retinopathy: An updated overview. Front Med (Lausanne) 2023; 10:1125062. [PMID: 37035306 PMCID: PMC10076599 DOI: 10.3389/fmed.2023.1125062] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/07/2023] [Indexed: 04/11/2023] Open
Abstract
Capillary non-perfusion (CNP) is one of the key hallmarks of diabetic retinopathy (DR), which may develop both in the periphery and at the posterior pole. Our perspectives on CNP have extended with the introduction of optical coherence tomography angiography (OCTA) and ultra-widefield imaging, and the clinical consequences of peripheral and macular CNP have been well characterized. Fluorescein angiography (FA) continues to be the gold standard for detecting and measuring CNP, particularly when ultra-widefield imaging is available. OCTA, on the other hand, is a quicker, non-invasive approach that allows for a three-dimensional examination of CNP and may soon be regarded as an useful alternative to FA. In this review, we provide an updated scenario regarding the characteristics, clinical impact, and management of central and peripheral CNP in DR.
Collapse
|
45
|
Inoda S, Takahashi H, Yamagata H, Hisadome Y, Kondo Y, Tampo H, Sakamoto S, Katada Y, Kurihara T, Kawashima H, Yanagi Y. Deep-learning-based AI for evaluating estimated nonperfusion areas requiring further examination in ultra-widefield fundus images. Sci Rep 2022; 12:21826. [PMID: 36528737 PMCID: PMC9759556 DOI: 10.1038/s41598-022-25894-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022] Open
Abstract
We herein propose a PraNet-based deep-learning model for estimating the size of non-perfusion area (NPA) in pseudo-color fundus photos from an ultra-wide-field (UWF) image. We trained the model with focal loss and weighted binary cross-entropy loss to deal with the class-imbalanced dataset, and optimized hyperparameters in order to minimize validation loss. As expected, the resultant PraNet-based deep-learning model outperformed previously published methods. For verification, we used UWF fundus images with NPA and used Bland-Altman plots to compare estimated NPA with the ground truth in FA, which demonstrated that bias between the eNPA and ground truth was smaller than 10% of the confidence limits zone and that the number of outliers was less than 10% of observed paired images. The accuracy of the model was also tested on an external dataset from another institution, which confirmed the generalization of the model. For validation, we employed a contingency table for ROC analysis to judge the sensitivity and specificity of the estimated-NPA (eNPA). The results demonstrated that the sensitivity and specificity ranged from 83.3-87.0% and 79.3-85.7%, respectively. In conclusion, we developed an AI model capable of estimating NPA size from only an UWF image without angiography using PraNet-based deep learning. This is a potentially useful tool in monitoring eyes with ischemic retinal diseases.
Collapse
Affiliation(s)
- Satoru Inoda
- grid.410804.90000000123090000Department of Ophthalmology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-Shi, Tochigi 329-0498 Japan
| | - Hidenori Takahashi
- grid.410804.90000000123090000Department of Ophthalmology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-Shi, Tochigi 329-0498 Japan ,grid.410804.90000000123090000DeepEyeVision, Inc, Jichi Medical University, Shimotsuke-Shi, Tochigi 329-0498 Japan
| | - Hitoshi Yamagata
- grid.410804.90000000123090000DeepEyeVision, Inc, Jichi Medical University, Shimotsuke-Shi, Tochigi 329-0498 Japan
| | - Yoichiro Hisadome
- grid.410804.90000000123090000DeepEyeVision, Inc, Jichi Medical University, Shimotsuke-Shi, Tochigi 329-0498 Japan
| | - Yusuke Kondo
- grid.410804.90000000123090000DeepEyeVision, Inc, Jichi Medical University, Shimotsuke-Shi, Tochigi 329-0498 Japan
| | - Hironobu Tampo
- grid.410804.90000000123090000DeepEyeVision, Inc, Jichi Medical University, Shimotsuke-Shi, Tochigi 329-0498 Japan
| | - Shinichi Sakamoto
- grid.410804.90000000123090000Department of Ophthalmology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-Shi, Tochigi 329-0498 Japan
| | - Yusaku Katada
- grid.26091.3c0000 0004 1936 9959Department of Ophthalmology, Keio University, Tokyo, 160-8582 Japan
| | - Toshihide Kurihara
- grid.26091.3c0000 0004 1936 9959Department of Ophthalmology, Keio University, Tokyo, 160-8582 Japan
| | - Hidetoshi Kawashima
- grid.410804.90000000123090000Department of Ophthalmology, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke-Shi, Tochigi 329-0498 Japan
| | - Yasuo Yanagi
- grid.410804.90000000123090000DeepEyeVision, Inc, Jichi Medical University, Shimotsuke-Shi, Tochigi 329-0498 Japan
| |
Collapse
|
46
|
Wang XN, Cai X, Li SW, Li T, Long D, Wu Q. Wide-field swept-source OCTA in the assessment of retinal microvasculature in early-stage diabetic retinopathy. BMC Ophthalmol 2022; 22:473. [PMID: 36474199 PMCID: PMC9727974 DOI: 10.1186/s12886-022-02724-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND To perform a quantitative analysis of retinal microvasculature in patients with early-stage diabetic retinopathy (DR) using wide-field swept-source optical coherence tomography angiography (SS-OCTA). METHODS: One hundred nineteen eyes of 119 patents (67 eyes with no DR and 52 eyes with mild-moderate nonproliferative diabetic retinopathy (NPDR)) were enrolled in this observational and cross-sectional cohort study, and an age-matched group consisting of 39 eyes of 39 non-diabetic subjects were set as the control. Each participant underwent a full ophthalmic examination, including wide-field SS-OCTA imaging. On OCTA scans (12 mm * 12 mm), the mean perfusion area (PA) and vessel density (VD) were independently measured in all 16 Early Treatment Diabetic Retinopathy Study (ETDRS) sectors. Linear regression analyses were conducted to evaluate the influences of PA. RESULTS In the central ring, there were no significant differences in the average PA and VD among the groups. In the 3 mm radius, the PA and VD of the no DR and mild-moderate NPDR were significantly decreased compared with the control group in superior and inferior quadrants. In the wide-field scans (9 and 12 mm radius), there was no significant difference in average PA and VD between the groups in each sectors (p > 0.05). Regression analysis found that the effect of VD on PA was statistically different (b = 1.311, p < 0.001). CONCLUSION Wide-field OCTA imaging is useful for evaluating peripheral capillary perfusion in eyes with early-stage DR. Decrease in PA and VD was greater in the S3 and I3 sectors, and reductions in PA and VD were uneven in wide-filed sectors (9 and 12 mm radius).
Collapse
Affiliation(s)
- Xiang-ning Wang
- grid.412528.80000 0004 1798 5117Department of Ophthalmology, Shanghai Sixth People’s Hospital, 600 Yishan Road, Shanghai, 200233 Xuhui District China
| | - Xuan Cai
- grid.412528.80000 0004 1798 5117Department of Ophthalmology, Shanghai Sixth People’s Hospital, 600 Yishan Road, Shanghai, 200233 Xuhui District China
| | - Shi-wei Li
- grid.412528.80000 0004 1798 5117Department of Ophthalmology, Shanghai Sixth People’s Hospital, 600 Yishan Road, Shanghai, 200233 Xuhui District China
| | - Tingting Li
- grid.412528.80000 0004 1798 5117Department of Ophthalmology, Shanghai Sixth People’s Hospital, 600 Yishan Road, Shanghai, 200233 Xuhui District China
| | - Da Long
- grid.412528.80000 0004 1798 5117Department of Ophthalmology, Shanghai Sixth People’s Hospital, 600 Yishan Road, Shanghai, 200233 Xuhui District China
| | - Qiang Wu
- grid.412528.80000 0004 1798 5117Department of Ophthalmology, Shanghai Sixth People’s Hospital, 600 Yishan Road, Shanghai, 200233 Xuhui District China ,grid.16821.3c0000 0004 0368 8293Shanghai Key Laboratory of Diabetes Mellitus, Shanghai, 200233 China
| |
Collapse
|
47
|
Fonda SJ, Bursell SE, Lewis DG, Clary D, Shahon D, Silva PS. Prevalence of Diabetic Eye Diseases in American Indians and Alaska Natives (AI/AN) as Identified by the Indian Health Service's National Teleophthalmology Program Using Ultrawide Field Imaging (UWFI). Ophthalmic Epidemiol 2022; 29:672-680. [PMID: 34726132 DOI: 10.1080/09286586.2021.1996611] [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: 05/18/2021] [Revised: 09/16/2021] [Accepted: 10/15/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Estimates of diabetic eye disease in American Indian and Alaska Natives (AI/AN) vary over time, region, and methods. This article reports recent prevalence of diabetic retinopathy (DR) and diabetic macular edema (DME) in AI/AN served by the Indian Health Services' (IHS) teleophthalmology program, as identified using ultrawide field imaging (UWFI). METHODS This was a retrospective analysis of 2016-2019 clinical data (n = 53,900). UWF images were acquired by certified imagers using a validated protocol, and graded by licensed, certified optometrists supervised by an ophthalmologist. Graders evaluated the extent/severity of retinal lesions in comparison to standard photographs. DR lesions predominantly in any peripheral field were considered "predominantly peripheral lesions" (PPL). The analyses calculated prevalence of any DR, any DME, DR and DME severity, sight-threatening disease, and PPL. RESULTS Patients averaged 56 years of age with a 68 mmol/mol A1c and 55% had had diabetes for 5+ years. Prevalence of any DR, any DME, and sight-threatening disease was 28.6%, 3.0%, and 3.0%. In patients with mild nonproliferative DR, PPL was seen in 25.3%. PPL suggested a more severe level of DR in 8.7% of patients. DR increased with age. DME decreased with age. Males and patients in the Nashville IHS area had more diabetic eye disease. CONCLUSION AI/AN have a high burden of diabetes and its complications. The IHS is resource-constrained, making accurate disease estimates necessary for resource allocation and budget justifications to Congress. These data update the estimates of diabetic eye disease in Indian Country and suggest that UWFI identifies early DR.
Collapse
Affiliation(s)
| | - Sven-Erik Bursell
- Telehealth Research Institute, John A. Burns School of Medicine, University of Hawaii, Honolulu, USA
| | | | - Dawn Clary
- Indian Health Service-Joslin Vision Network, Phoenix Indian Medical Center, Phoenix, AZ, USA
| | - Dara Shahon
- Indian Health Service-Joslin Vision Network, Phoenix Indian Medical Center, Phoenix, AZ, USA
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
48
|
Kawai K, Murakami T, Mori Y, Ishihara K, Dodo Y, Terada N, Nishikawa K, Morino K, Tsujikawa A. Clinically Significant Nonperfusion Areas on Widefield OCT Angiography in Diabetic Retinopathy. OPHTHALMOLOGY SCIENCE 2022; 3:100241. [PMID: 36545265 PMCID: PMC9762190 DOI: 10.1016/j.xops.2022.100241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/26/2022] [Accepted: 10/26/2022] [Indexed: 12/14/2022]
Abstract
Purpose To investigate the distribution of clinically significant nonperfusion areas (NPAs) on widefield OCT angiography (OCTA) images in patients with diabetes. Design Prospective, cross-sectional, observational study. Participants One hundred and forty-four eyes of 114 patients with diabetes. Methods Nominal 20 × 23 mm OCTA images were obtained using a swept-source OCTA device (Xephilio OCT-S1), followed by the creation of en face images 20-mm (1614 pixels) in diameter centering on the fovea. The nonperfusion squares (NPSs) were defined as the 10 × 10 pixel squares without retinal vessels, and the ratio of eyes with the NPSs to all eyes in each square was referred to as the NPS ratio. The areas with probabilistic differences (APD) for proliferative diabetic retinopathy (PDR) and nonproliferative diabetic retinopathy (NPDR) (APD[PDR] and APD[NPDR]) were defined as sets of squares with higher NPS ratios in eyes with PDR and NPDR, respectively. The P ratio (NPSs within APD[PDR] but not APD[NPDR]/all NPSs) was also calculated. Main Outcome Measures The probabilistic distribution of the NPSs and the association with diabetic retinopathy (DR) severity. Results The NPSs developed randomly in eyes with mild and moderate NPDR and were more prevalent in the extramacular areas and the temporal quadrant in eyes with severe NPDR and PDR. The APD(PDR) was distributed mainly in the extramacular areas, sparing the areas around the vascular arcades and radially peripapillary capillaries. The APD(PDR) contained retinal neovascularization more frequently than the non-APD(PDR) (P = 0.023). The P ratio was higher in eyes with PDR than in those with NPDR (P < 0.001). The multivariate analysis designated the P ratio (odds ratio, 8.293 × 107; 95% confidence interval, 6.529 × 102-1.053 × 1013; P = 0.002) and the total NPSs (odds ratio, 1.002; 95% confidence interval, 1.001-1.003; P < 0.001) as independent risk factors of PDR. Most eyes with NPDR and 4-2-1 rule findings of DR severity had higher P ratios but not necessarily greater NPS numbers. Conclusions The APD(PDR) is uniquely distributed on widefield OCTA images, and the NPA location patterns are associated with DR severity, independent of the entire area of NPAs. Financial Disclosures Proprietary or commercial disclosure may be found after the references.
Collapse
Key Words
- APD, areas with probabilistic differences
- DR, diabetic retinopathy
- Diabetic retinopathy
- FA, fluorescein angiography
- IQR, interquartile range
- IRMA, intraretinal microvascular abnormality
- NPA, nonperfusion area
- NPDR, nonproliferative diabetic retinopathy
- NPS, nonperfusion square
- NV, neovascularization
- NVD, neovascularization of the disc
- NVE, retinal neovascularization
- Neovascularization
- Nonperfusion areas
- OCTA, OCT angiography
- PDR, proliferative diabetic retinopathy
- PRP, panretinal photocoagulation
- RPC, radial peripapillary capillary
- Semiautomatic quantification
- VA, visual acuity
- Widefield OCT angiography
Collapse
Affiliation(s)
| | - Tomoaki Murakami
- Correspondence: Tomoaki Murakami, MD, PhD, 54 Shougoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan.
| | | | | | | | | | | | | | | |
Collapse
|
49
|
Li J, Wei D, Mao M, Li M, Liu S, Li F, Chen L, Liu M, Leng H, Wang Y, Ning X, Liu Y, Dong W, Zhong J. Ultra-widefield color fundus photography combined with high-speed ultra-widefield swept-source optical coherence tomography angiography for non-invasive detection of lesions in diabetic retinopathy. Front Public Health 2022; 10:1047608. [PMID: 36408020 PMCID: PMC9667033 DOI: 10.3389/fpubh.2022.1047608] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022] Open
Abstract
Purpose To compare the detection rate of diabetic retinopathy (DR) lesions and the agreement of DR severity grading using the ultra-widefield color fundus photography (UWF CFP) combined with high-speed ultra-widefield swept-source optical coherence tomography angiography (UWF SS-OCTA) or fluorescein angiography (FFA). Methods This prospective, observational study recruited diabetic patients who had already taken the FFA examination from November 2021 to June 2022. These patients had either no DR or any stage of DR. All participants were imaged with a 200° UWF CFP and UWF SS-OCTA using a 24 × 20 mm scan model. Images were independently evaluated for the presence or absence of DR lesions including microaneurysms (MAs), intraretinal hemorrhage (IRH), non-perfusion areas (NPAs), intraretinal microvascular abnormalities (IRMAs), venous beading (VB), neovascularization elsewhere (NVE), neovascularization of the optic disc (NVD), and vitreous or preretinal hemorrhage (VH/PRH). Agreement of DR severity grading based on UWF CFP plus UWF SS-OCTA and UWF CFP plus FFA was compared. All statistical analyses were performed using SPSS V.26.0. Results One hundred and fifty-three eyes of 86 participants were enrolled in the study. The combination of UWF CFP with UWF SS-OCTA showed a similar detection rate compared with UWF CFP plus FFA for all the characteristic DR lesions (p>0.05), except NPAs (p = 0.039). Good agreement was shown for the identification of VB (κ = 0.635), and very good agreement for rest of the DR lesions between the two combination methods (κ-value ranged from 0.858 to 0.974). When comparing the grading of DR severity, very good agreement was achieved between UWF CFP plus UWF SS-OCTA and UWF CFP plusr FFA (κ = 0.869). Conclusion UWF CFP plus UWF SS-OCTA had a very good agreement in detecting DR lesions and determining the severity of DR compared with UWF CFP plus FFA. This modality has the potential to be used as a fast, reliable, and non-invasive method for DR screening and monitoring in the future.
Collapse
Affiliation(s)
- Jie Li
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China,School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Dingyang Wei
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China,Eye School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Mingzhu Mao
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China,Eye School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Mengyu Li
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China,School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Sanmei Liu
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Fang Li
- Health Management Medical Center, Chengdu First People's Hospital, Chengdu, China
| | - Li Chen
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China,Eye School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Miao Liu
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China,School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Hongmei Leng
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China,Eye School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yiya Wang
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China,Eye School, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xinru Ning
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China,Department of Ophthalmology, Southwest Medical University, Luzhou, China
| | - Yi Liu
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China,School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Wentao Dong
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China,Wentao Dong
| | - Jie Zhong
- Department of Ophthalmology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China,School of Medicine, University of Electronic Science and Technology of China, Chengdu, China,*Correspondence: Jie Zhong
| |
Collapse
|
50
|
Ramtohul P, Iovino C, Au A, Bacci T, Pichi F, Corradetti G, Corvi F, Manoharan N, Marin AI, Tadayoni R, Sadda S, Freund KB, Sarraf D. Clinical and Morphologic Characteristics of Perivenular Fernlike Leakage on Ultrawide-field Fluorescein Angiography. Ophthalmol Retina 2022; 6:1070-1079. [PMID: 35545196 DOI: 10.1016/j.oret.2022.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 05/02/2022] [Accepted: 05/03/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE To analyze the spectrum of the perivenular fernlike leakage on ultrawide-field fluorescein angiography (UWFA) and discuss its potential implications in the current understanding of the retinal venous outflow. DESIGN Retrospective, observational case series. PARTICIPANTS Eyes presenting with fernlike patterns of dye leakage on UWFA were included in this study. METHODS Analysis of the clinical characteristics and multimodal imaging findings using UWFA and wide-angle swept-source OCT-angiography (SS-OCTA). MAIN OUTCOME MEASURES The disease spectrum, anatomic origin, and clinical implications of this fernlike leakage. RESULTS Multimodal retinal images from 40 eyes of 29 patients with fernlike leakage on UWFA were studied. The underlying etiologies included a wide range of inflammatory disorders, including pars planitis (18 eyes) and central retinal vein occlusion (2 eyes). On UWFA, the fernlike leakage originated from the retinal capillaries and venules directly adjacent to the veins and spared the periarterial zone. This perivenular fernlike leakage involved the far periphery in all cases and progressed more diffusely and centripetally in cases with more severe intraocular inflammation. On wide-angle SS-OCTA, the impairment of deep capillary plexus (DCP) flow signals precisely colocalized with the perivenular fernlike leakages identified on UWFA. CONCLUSIONS The fernlike leakage on UWFA refers to the distinctive perivenular dye leakage that originates from the retinal capillaries and venules. Multimodal imaging correlation suggests that the predominant impairment is at the level of the DCP. The axial symmetry of the fernlike leakage with the veins and sparing of the periarterial zone may support the dominant venous role of the DCP.
Collapse
Affiliation(s)
- Prithvi Ramtohul
- Centre Hospitalier Universitaire de l'Hôpital Nord, chemin des Bourrely, Marseille, France; Vitreous Retina Macula Consultants of New York, New York, New York
| | - Claudio Iovino
- Eye Clinic, Multidisciplinary Department of Medical, Surgical and Dental Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Adrian Au
- Stein Eye Institute, University of California Los Angeles, Los Angeles, California
| | - Tommaso Bacci
- Vitreous Retina Macula Consultants of New York, New York, New York; Ophthalmology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena University Hospital, Siena, Italy
| | - Francesco Pichi
- Eye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Giulia Corradetti
- Department of Ophthalmology, Doheny Image Reading Center, Doheny Eye Institute, University of California Los Angeles (UCLA) Affiliated, Los Angeles, California
| | - Federico Corvi
- Department of Ophthalmology, Doheny Image Reading Center, Doheny Eye Institute, University of California Los Angeles (UCLA) Affiliated, Los Angeles, California
| | - Niranjan Manoharan
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado
| | - Alejandro Itzam Marin
- Department of Ophthalmology, University of Colorado School of Medicine, Aurora, Colorado
| | - Ramin Tadayoni
- Université de Paris, Ophthalmology Department, AP-HP, Hôpital Lariboisière, Paris, France; Hôpital Fondation Adolphe de Rothschild, 75019, Paris, France
| | - SriniVas Sadda
- Department of Ophthalmology, Doheny Image Reading Center, Doheny Eye Institute, University of California Los Angeles (UCLA) Affiliated, Los Angeles, California
| | - K Bailey Freund
- Vitreous Retina Macula Consultants of New York, New York, New York; Department of Ophthalmology, NYU Grossman School of New York, New York, New York
| | - David Sarraf
- Stein Eye Institute, University of California Los Angeles, Los Angeles, California.
| |
Collapse
|