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Zhang X, Hu Q, Peng H, Huang J, Sang W, Guan J, Huang Z, Jiang B, Sun D. Therapeutic potential of flavopiridol in diabetic retinopathy: Targeting DDX58. Int Immunopharmacol 2024; 137:112504. [PMID: 38897127 DOI: 10.1016/j.intimp.2024.112504] [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: 04/25/2024] [Revised: 06/02/2024] [Accepted: 06/14/2024] [Indexed: 06/21/2024]
Abstract
Diabetic retinopathy (DR), a common complication of diabetes, is characterized by inflammation and neovascularization, and is intricately regulated by the ubiquitin-proteasome system (UPS). Despite advancements, identifying ubiquitin-related genes and drugs specifically targeting DR remains a significant challenge. In this study, bioinformatics analyses and the Connectivity Map (CMAP) database were utilized to explore the therapeutic potential of genes and drugs for DR. Through these methodologies, flavopiridol was identified as a promising therapeutic candidate. To evaluate flavopiridol's therapeutic potential in DR, an in vitro model using Human Umbilical Vein Endothelial Cells (HUVECs) induced by high glucose (HG) conditions was established. Additionally, in vivo models using mice with streptozotocin (STZ)-induced DR and oxygen-induced retinopathy (OIR) were employed. The current study reveals that flavopiridol possesses robust anti-inflammatory and anti-neovascularization properties. To further elucidate the molecular mechanisms of flavopiridol, experimental validation and molecular docking techniques were employed. These efforts identified DDX58 as a predictive target for flavopiridol. Notably, our research demonstrated that flavopiridol modulates the DDX58/NLRP3 signaling pathway, thereby exerting its therapeutic effects in suppressing inflammation and neovascularization in DR. This study unveils groundbreaking therapeutic agents and innovative targets for DR, and establishes a progressive theoretical framework for the application of ubiquitin-related therapies in DR.
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Affiliation(s)
- Xue Zhang
- Department of Ophthalmology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China; Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China
| | - Qiang Hu
- Department of Ophthalmology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China; Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China
| | - Hongsong Peng
- Department of Ophthalmology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China; Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China
| | - Jiayang Huang
- Department of Ophthalmology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China; Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China
| | - Wei Sang
- Department of Ophthalmology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China; Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China
| | - Jitian Guan
- Department of Ophthalmology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China; Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China
| | - Zhangxin Huang
- Department of Ophthalmology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China; Future Medical Laboratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China
| | - Bo Jiang
- Department of Ophthalmology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China
| | - Dawei Sun
- Department of Ophthalmology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, China.
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Tan B, Chua J, Wong D, Liu X, Ismail M, Schmetterer L. Techniques for imaging the choroid and choroidal blood flow in vivo. Exp Eye Res 2024:110045. [PMID: 39154819 DOI: 10.1016/j.exer.2024.110045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 08/08/2024] [Accepted: 08/13/2024] [Indexed: 08/20/2024]
Abstract
The choroid, which is a highly vascularized layer between the retina and sclera, is essential for supplying oxygen and nutrients to the outer retina. Choroidal vascular dysfunction has been implicated in numerous ocular diseases, including age-related macular degeneration, central serous chorioretinopathy, polypoidal choroidal vasculopathy, and myopia. Traditionally, the in vivo assessment of choroidal blood flow relies on techniques such as laser Doppler flowmetry, laser speckle flowgraphy, pneumotonometry, laser interferometry, and ultrasonic color Doppler imaging. While the aforementioned methods have provided valuable insights into choroidal blood flow regulation, their clinical applications have been limited. Recent advancements in optical coherence tomography and optical coherence tomography angiography have expanded our understanding of the choroid, allowing detailed visualization of the larger choroidal vessels and choriocapillaris, respectively. This review provides an overview of the available techniques that can investigate the choroid and its blood flow in vivo. Future research should combine these techniques to comprehensively image the entire choroidal microcirculation and develop robust methods to quantify choroidal blood flow. The potential findings will provide a better picture of choroidal hemodynamics and its effect on ocular health and disease.
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Affiliation(s)
- Bingyao Tan
- Singapore Eye Research Institute, National Eye Centre, Singapore; SERI-NTU Advanced Ocular Engineering (STANCE) Program, Singapore; Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore
| | - Jacqueline Chua
- Singapore Eye Research Institute, National Eye Centre, Singapore; SERI-NTU Advanced Ocular Engineering (STANCE) Program, Singapore; Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore
| | - Damon Wong
- Singapore Eye Research Institute, National Eye Centre, Singapore; SERI-NTU Advanced Ocular Engineering (STANCE) Program, Singapore; Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore; Institute of Molecular and Clinical Ophthalmology, Basel, Switzerland
| | - Xinyu Liu
- Singapore Eye Research Institute, National Eye Centre, Singapore; SERI-NTU Advanced Ocular Engineering (STANCE) Program, Singapore; Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore
| | - Munirah Ismail
- Singapore Eye Research Institute, National Eye Centre, Singapore
| | - Leopold Schmetterer
- Singapore Eye Research Institute, National Eye Centre, Singapore; SERI-NTU Advanced Ocular Engineering (STANCE) Program, Singapore; Ophthalmology & Visual Sciences Academic Clinical Program (Eye ACP), Duke-NUS Medical School, Singapore; Institute of Molecular and Clinical Ophthalmology, Basel, Switzerland; School of Chemical and Biomedical Engineering, Nanyang Technological University (NTU), Singapore; Centre for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria; Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria; Rothschild Foundation Hospital, Paris, France.
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Luo YQ, Xu ZS, Hu JY, Ge QM, Zou J, Wei H, Zhou XM, Liao X, Ling Q, He LQ, Chen C, Wang XY, Zeng YM, Shao Y. Retinal microvascular changes in patients with pancreatitis and their clinical significance. Sci Rep 2024; 14:18935. [PMID: 39147923 PMCID: PMC11327248 DOI: 10.1038/s41598-024-69493-2] [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: 05/11/2024] [Accepted: 08/05/2024] [Indexed: 08/17/2024] Open
Abstract
Acute pancreatitis, a common exocrine inflammatory disease affecting the pancreas, is characterized by intense abdominal pain and multiple organ dysfunction. However, the alterations in retinal blood vessels among individuals with acute pancreatitis remain poorly understood. This study employed optical coherence tomography angiography (OCTA) to examine the superficial and deep retinal blood vessels in patients with pancreatitis. Sixteen patients diagnosed with pancreatitis (32 eyes) and 16 healthy controls (32 eyes) were recruited from the First Affiliated Hospital of Nanchang University for participation in the study. Various ophthalmic parameters, such as visual acuity, intraocular pressure, and OCTA image for retina consisting of the superficial retinal layer (SRL) and the deep retinal layer (DRL), were recorded for each eye. The study observed the superficial and deep retinal microvascular ring (MIR), macrovascular ring (MAR), and total microvessels (TMI) were observed. Changes in retinal vascular density in the macula through annular partitioning (C1-C6), hemispheric quadrant partitioning (SR, SL, IL, and IR), and early diabetic retinopathy treatment studies (ETDRS) partitioning methods (R, S, L, and I). Correlation analysis was employed to investigate the relationship between retinal capillary density and clinical indicators. Our study revealed that in the superficial retinal layer, the vascular density of TMI, MIR, MAR, SR, IR, S, C2, C3 regions were significantly decreased in patients group compared with the normal group. For the deep retinal layer, the vascular density of MIR, SR, S, C1, C2 regions also reduced in patient group. The ROC analysis demonstrated that OCTA possesses significant diagnostic performance for pancreatitis. In conclusion, patients with pancreatitis may have retinal microvascular dysfunction, and OCTA can be a valuable tool for detecting alterations in ocular microcirculation in pancreatitis patients in clinical practice.
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Affiliation(s)
- Yun-Qing Luo
- Department of Ophthalmology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Zi-Song Xu
- Huankui Academy, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Jin-Yu Hu
- Department of Ophthalmology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Qian-Min Ge
- Department of Ophthalmology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Jie Zou
- Department of Ophthalmology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Hong Wei
- Department of Ophthalmology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Xian-Mei Zhou
- Ophthalmology Department of Affiliated Hospital, Medical School of Ophthalmology and Optometry, North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Xuan Liao
- Ophthalmology Department of Affiliated Hospital, Medical School of Ophthalmology and Optometry, North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Qian Ling
- Department of Ophthalmology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Liang-Qi He
- Department of Ophthalmology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Cheng Chen
- Department of Ophthalmology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Xiao-Yu Wang
- Department of Ophthalmology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China
| | - Yan-Mei Zeng
- Department of Ophthalmology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, Jiangxi, China.
| | - Yi Shao
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200080, China.
- National Clinical Research Center for Eye Diseases, Shanghai, 200080, China.
- Shanghai Key Laboratory of Ocular Fundus Diseases, Shanghai, 200080, China.
- Shanghai Engineering Center for Visual Science and Photomedicine, Shanghai, 200080, China.
- Shanghai Engineering Center for Precise Diagnosis and Treatment of Eye Diseases, Shanghai, 200080, China.
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Tillmann A, Turgut F, Munk MR. Optical coherence tomography angiography in neovascular age-related macular degeneration: comprehensive review of advancements and future perspective. Eye (Lond) 2024:10.1038/s41433-024-03295-8. [PMID: 39147864 DOI: 10.1038/s41433-024-03295-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/09/2024] [Accepted: 08/05/2024] [Indexed: 08/17/2024] Open
Abstract
Optical coherence tomography angiography (OCTA) holds promise in enhancing the care of various retinal vascular diseases, including neovascular age-related macular degeneration (nAMD). Given nAMD's vascular nature and the distinct vasculature of macular neovascularization (MNV), detailed analysis is expected to gain significance. Research in artificial intelligence (AI) indicates that en-face OCTA views may offer superior predictive capabilities than spectral domain optical coherence tomography (SD-OCT) images, highlighting the necessity to identify key vascular parameters. Analyzing vasculature could facilitate distinguishing MNV subtypes and refining diagnosis. Future studies correlating OCTA parameters with clinical data might prompt a revised classification system. However, the combined utilization of qualitative and quantitative OCTA biomarkers to enhance the accuracy of diagnosing disease activity remains underdeveloped. Discrepancies persist regarding the optimal biomarker for indicating an active lesion, warranting comprehensive prospective studies for validation. AI holds potential in extracting valuable insights from the vast datasets within OCTA, enabling researchers and clinicians to fully exploit its OCTA imaging capabilities. Nevertheless, challenges pertaining to data quantity and quality pose significant obstacles to AI advancement in this field. As OCTA gains traction in clinical practice and data volume increases, AI-driven analysis is expected to further augment diagnostic capabilities.
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Affiliation(s)
- Anne Tillmann
- Augenarzt Praxisgemeinschaft Gutblick, Pfäffikon, Switzerland
| | - Ferhat Turgut
- Augenarzt Praxisgemeinschaft Gutblick, Pfäffikon, Switzerland
- Department of Ophthalmology, Stadtspital Zürich, Zürich, Switzerland
- Department of Ophthalmology, Semmelweis University, Budapest, Hungary
| | - Marion R Munk
- Augenarzt Praxisgemeinschaft Gutblick, Pfäffikon, Switzerland.
- Department of Ophthalmology, Inselspital, Bern University Hospital, University of Bern, 3010, Bern, Switzerland.
- Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, Chicago, IL, 60208, USA.
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Yang S, Liu R, Xin Z, Zhu Z, Chu J, Zhong P, Zhu Z, Shang X, Huang W, Zhang L, He M, Wang W. Plasma Metabolomics Identifies Key Metabolites and Improves Prediction of Diabetic Retinopathy: Development and Validation across Multinational Cohorts. Ophthalmology 2024:S0161-6420(24)00415-9. [PMID: 38972358 DOI: 10.1016/j.ophtha.2024.07.004] [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: 02/22/2024] [Revised: 05/13/2024] [Accepted: 07/01/2024] [Indexed: 07/09/2024] Open
Abstract
PURPOSE To identify longitudinal metabolomic fingerprints of diabetic retinopathy (DR) and to evaluate their usefulness in predicting DR development and progression. DESIGN Multicenter, multiethnic cohort study. PARTICIPANTS This study included 17 675 participants from the UK Biobank (UKB) who had baseline prediabetes or diabetes, identified in accordance with the 2021 American Diabetes Association guidelines, and were free of baseline DR and an additional 638 participants with type 2 diabetes mellitus from the Guangzhou Diabetic Eye Study (GDES) for external validation. Diabetic retinopathy was determined by ICD-10 codes in the UKB cohort and revised ETDRS grading criteria in the GDES cohort. METHODS Longitudinal DR metabolomic fingerprints were identified through nuclear magnetic resonance (NMR) assay in UKB participants. The predictive value of these fingerprints for predicting DR development were assessed in a fully withheld test set. External validation and extrapolation analyses of DR progression and microvascular damage were conducted in the GDES cohort using NMR technology. Model assessments included the concordance (C) statistic, net classification improvement (NRI), integrated discrimination improvement (IDI), calibration, and clinical usefulness in both cohorts. MAIN OUTCOME MEASURES DR development and progression and retinal microvascular damage. RESULTS Of 168 metabolites, 118 were identified as candidate metabolomic fingerprints for future DR development. These fingerprints significantly improved the predictability for DR development beyond traditional indicators (C statistic, 0.802 [95% confidence interval (CI), 0.760-0.843] vs. 0.751 [95% CI, 0.706-0.796]; P = 5.56 × 10-4). Glucose, lactate, and citrate were among the fingerprints validated in the GDES cohort. Using these parsimonious and replicable fingerprints yielded similar improvements for predicting DR development (C statistic, 0.807 [95% CI, 0.711-0.903] vs. 0.617 [95% CI, 0.494-0.740]; P = 1.68 × 10-4) and progression (C statistic, 0.797 [95% CI, 0.712-0.882] vs. 0.665 [95% CI, 0.545-0.784]; P = 0.003) in the external GDES cohort. Improvements in NRIs, IDIs, and clinical usefulness also were evident in both cohorts (all P < 0.05). In addition, lactate and citrate were associated with microvascular damage across macular and optic nerve head regions among Chinese GDES (all P < 0.05). CONCLUSIONS Metabolomic profiling may be effective in identifying robust fingerprints for predicting future DR development and progression, providing novel insights into the early and advanced stages of DR pathophysiology. FINANCIAL DISCLOSURE(S) The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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Affiliation(s)
- Shaopeng Yang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Riqian Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Zhuoyao Xin
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland; F. M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, Maryland; Department of Biomedical Engineering, Columbia University, New York, New York
| | - Ziyu Zhu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Jiaqing Chu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Pingting Zhong
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Zhuoting Zhu
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
| | - Xianwen Shang
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia
| | - Wenyong Huang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China
| | - Lei Zhang
- Clinical Medical Research Center, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China; Artificial Intelligence and Modelling in Epidemiology Program, Melbourne Sexual Health Centre, Alfred Health, Melbourne, Australia; Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Mingguang He
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China; Experimental Ophthalmology, The Hong Kong Polytechnic University, Hong Kong, China
| | - Wei Wang
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Guangzhou, China; Hainan Eye Hospital and Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Haikou, Hainan Province, China.
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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.
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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
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Zhang Z, Deng C, Paulus YM. Advances in Structural and Functional Retinal Imaging and Biomarkers for Early Detection of Diabetic Retinopathy. Biomedicines 2024; 12:1405. [PMID: 39061979 PMCID: PMC11274328 DOI: 10.3390/biomedicines12071405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/27/2024] [Accepted: 06/10/2024] [Indexed: 07/28/2024] Open
Abstract
Diabetic retinopathy (DR), a vision-threatening microvascular complication of diabetes mellitus (DM), is a leading cause of blindness worldwide that requires early detection and intervention. However, diagnosing DR early remains challenging due to the subtle nature of initial pathological changes. This review explores developments in multimodal imaging and functional tests for early DR detection. Where conventional color fundus photography is limited in the field of view and resolution, advanced quantitative analysis of retinal vessel traits such as retinal microvascular caliber, tortuosity, and fractal dimension (FD) can provide additional prognostic value. Optical coherence tomography (OCT) has also emerged as a reliable structural imaging tool for assessing retinal and choroidal neurodegenerative changes, which show potential as early DR biomarkers. Optical coherence tomography angiography (OCTA) enables the evaluation of vascular perfusion and the contours of the foveal avascular zone (FAZ), providing valuable insights into early retinal and choroidal vascular changes. Functional tests, including multifocal electroretinography (mfERG), visual evoked potential (VEP), multifocal pupillographic objective perimetry (mfPOP), microperimetry, and contrast sensitivity (CS), offer complementary data on early functional deficits in DR. More importantly, combining structural and functional imaging data may facilitate earlier detection of DR and targeted management strategies based on disease progression. Artificial intelligence (AI) techniques show promise for automated lesion detection, risk stratification, and biomarker discovery from various imaging data. Additionally, hematological parameters, such as neutrophil-lymphocyte ratio (NLR) and neutrophil extracellular traps (NETs), may be useful in predicting DR risk and progression. Although current methods can detect early DR, there is still a need for further research and development of reliable, cost-effective methods for large-scale screening and monitoring of individuals with DM.
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Affiliation(s)
- Zhengwei Zhang
- Department of Ophthalmology, Jiangnan University Medical Center, Wuxi 214002, China;
- Department of Ophthalmology, Wuxi No.2 People’s Hospital, Wuxi Clinical College, Nantong University, Wuxi 214002, China
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA;
| | - Callie Deng
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA;
| | - Yannis M. Paulus
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA;
- Department of Biomedical Engineering, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA
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Maris D, Dastiridou A, Kotoula M, Karathanou A, Tsironi EE, Bargiota A, Androudi S. Macular Ischemia Changes in Patients with Diabetic Macular Edema Treated with Aflibercept and Ranibizumab. Diagnostics (Basel) 2024; 14:1306. [PMID: 38928721 PMCID: PMC11203373 DOI: 10.3390/diagnostics14121306] [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: 05/22/2024] [Revised: 06/12/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
Τhis study aims to assess changes in the fovea avascular zone (FAZ) in treatment naïve patients receiving aflibercept or ranibizumab injections for diabetic macular edema (DME). Best corrected visual acuity (BCVA) testing, OCT, and OCT-angiography imaging were performed at baseline and 1 month after each injection. Injections of either aflibercept or ranibizumab were administered monthly for 6 consecutive months. FAZ in the superficial (SCP) and the deep capillary plexus (DCP) using OCT angiography was recorded for each visit. Fifty eyes from fifty patients with a mean age of 67.0 ± 10.7 years were included in the study. Twenty-five patients received aflibercept and twenty-five received ranibizumab. BCVA was 40.8 ± 10.0 and increased to 52.1 ± 7.9 ETDRS letters at the last visit (p < 0.001). CRT was 295.6 ± 34.0 at baseline and 247.9 ± 29.7 at the last study visit (p < 0.001). SCP FAZ was 350.6 ± 79.5 μm2 at baseline and 339.0 ± 71.3 μm2 after sox monthly injections (p = 0.132). DCP FAZ was 558.6 ± 199.0 μm2 at baseline and 459.5 ± 156.1 μm2 after six monthly injections (p < 0.001). There was no effect of the choice of ranibizumab or aflibercept on DCP FAZ change (p = 0.277). In conclusion, treatment with 6 monthly injections of ranibizumab and aflibercept led to an increase in BCVA and a decrease in CRT and DCP FAZ area. Both drugs led to an improvement in DCP ischemia.
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Affiliation(s)
- Dimitrios Maris
- Ophthalmology Clinic, University of Thessaly, 41335 Larissa, Greece; (D.M.); (A.D.); (M.K.); (A.K.); (E.E.T.)
| | - Anna Dastiridou
- Ophthalmology Clinic, University of Thessaly, 41335 Larissa, Greece; (D.M.); (A.D.); (M.K.); (A.K.); (E.E.T.)
| | - Maria Kotoula
- Ophthalmology Clinic, University of Thessaly, 41335 Larissa, Greece; (D.M.); (A.D.); (M.K.); (A.K.); (E.E.T.)
| | - Aikaterini Karathanou
- Ophthalmology Clinic, University of Thessaly, 41335 Larissa, Greece; (D.M.); (A.D.); (M.K.); (A.K.); (E.E.T.)
| | - Evangelia E. Tsironi
- Ophthalmology Clinic, University of Thessaly, 41335 Larissa, Greece; (D.M.); (A.D.); (M.K.); (A.K.); (E.E.T.)
| | | | - Sofia Androudi
- Ophthalmology Clinic, University of Thessaly, 41335 Larissa, Greece; (D.M.); (A.D.); (M.K.); (A.K.); (E.E.T.)
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Dai Y, Zheng D, Zhao J, Wang K, Fu B, Xu Z, Wang S, Li C, Zhou G. Macular Neural and Microvascular Alterations in Type 2 Diabetes Without Retinopathy: A SS-OCT Study. Am J Ophthalmol 2024; 262:229-236. [PMID: 38428559 DOI: 10.1016/j.ajo.2024.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE To identify specific markers indicative of macular neural and microvascular alterations in individuals with Type 2 Diabetes Mellitus (T2DM) without clinically observable retinopathy. DESIGN Prospective cross-sectional study. METHODS Using the PLEX Elite 9000, all eyes underwent swept-source optical coherence tomography (SS-OCT) angiography. Quantitative analysis of acquired images compared macular neural and microvascular alterations in T2DM patients without retinopathy to age-matched controls. Precise assessments encompassed measuring the thickness of each individual retinal layer and evaluating macular vascular indices within different capillary plexuses. RESULTS Forty-nine T2DM patients and 51 age-matched controls participated. T2DM patients exhibited a significant reduction in the mean macular thickness of the ganglion cell-inner plexiform layer (GC-IPL) (82.5 ± 5.5 µm vs 86.2 ± 5.0 µm, P = .001) and macular retinal nerve fiber layer (RNFL) (45.8 ± 3.0 µm vs 48.1 ± 3.7 µm, P = .001). Furthermore, macular full retinal thickness was significantly lower in diabetic eyes than controls (324.9 ± 16.3 µm vs 332.8 ± 13.7 µm, P = .009). Vascular measurements revealed subtle changes in macular vascular skeleton density within the total capillary plexuses in T2DM patients (0.132 ± 0.005 vs 0.135 ± 0.005, P = .019). CONCLUSIONS Metrics derived from SS-OCT, particularly macular RNFL and GC-IPL thicknesses, emerged as superior indicators for the early detection of diabetic retinal disease in individuals with T2DM without clinically observable retinopathy. Further investigations are warranted to comprehensively understand the clinical implications of these findings.
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Affiliation(s)
- Yining Dai
- Shanxi Eye Hospital Affiliated to Shanxi Medical University (Y.D., D.Z., J.Z., K.W., G.Z.), Taiyuan, Shanxi, China
| | - Dongping Zheng
- Shanxi Eye Hospital Affiliated to Shanxi Medical University (Y.D., D.Z., J.Z., K.W., G.Z.), Taiyuan, Shanxi, China
| | - Juwei Zhao
- Shanxi Eye Hospital Affiliated to Shanxi Medical University (Y.D., D.Z., J.Z., K.W., G.Z.), Taiyuan, Shanxi, China
| | - Kailu Wang
- Shanxi Eye Hospital Affiliated to Shanxi Medical University (Y.D., D.Z., J.Z., K.W., G.Z.), Taiyuan, Shanxi, China
| | - Binzhe Fu
- School of Precision Instruments and Opto-electronics Engineering (B.F., S.W., C.L.), Tianjin University, Tianjin, China
| | - Zhiling Xu
- Department of Life and Health (Z.X.), Tsinghua Shenzhen International Graduate School, Shenzhen, China
| | - Sheng Wang
- School of Precision Instruments and Opto-electronics Engineering (B.F., S.W., C.L.), Tianjin University, Tianjin, China
| | - Chenxi Li
- School of Precision Instruments and Opto-electronics Engineering (B.F., S.W., C.L.), Tianjin University, Tianjin, China
| | - Guohong Zhou
- Shanxi Eye Hospital Affiliated to Shanxi Medical University (Y.D., D.Z., J.Z., K.W., G.Z.), Taiyuan, Shanxi, China.
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Yang F, Zou W, Li Z, Du Y, Gao W, Zhang J, Ji X, Huang J. Optical coherence tomography angiography for detection of microvascular changes in early diabetes: A systematic review and meta-analysis. Diabetes Metab Res Rev 2024; 40:e3812. [PMID: 38738481 DOI: 10.1002/dmrr.3812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 02/04/2024] [Accepted: 03/27/2024] [Indexed: 05/14/2024]
Abstract
AIMS To evaluate the effectiveness of optical coherence tomography angiography (OCTA) in detecting early intraocular microvascular changes in diabetic patients. MATERIALS AND METHODS A systematic study search was performed on PubMed, Medline, Embase, and the Cochrane Library, ranging from January 2012 to March 2023. Controlled studies compared diabetes mellitus (DM) patients with non-diabetic retinopathy (NDR) or patients with mild non-proliferative diabetic retinopathy (mild NPDR) to healthy people. These studies included parameters of OCTA such as foveal avascular zone (FAZ), vessel density of superficial capillary plexus (VDscp), vessel density of deep capillary plexus (VDdcp), and peripapillary VD. The relevant effect model was used according to the heterogeneity, and the mean difference and 95% confidence intervals were calculated. RESULTS A total of 18 studies with 2101 eyes were eventually included in this meta-analysis. Our results demonstrated that early alterations of VDscp, VDdcp, and peripapillary VD in NDR patients had a significant difference compared with healthy people by OCTA (VDscp: WMD = -1.34, 95% CI: -1.99 to -0.68, P < 0.0001. VDdcp: WMD = -2.00, 95% CI: -2.95 to -1.04, P < 0.0001. Peripapillary VD: WMD = -1.07, 95% CI: -1.70 to -0.43, P = 0.0010). However, there was no statistically significant difference in total FAZ between them (WMD = -0.00, 95% CI: -0.02-0.01, P = 0.84). In addition, for patients with mild NPDR, OCTA could illustrate prominent changes in VDscp, VDdcp, and total FAZ compared with healthy people (VDscp: WMD = -6.11, 95% CI: -9.90 to -2.32, P = 0.002. VDdcp: WMD = -4.26, 95% CI: -5.95 to -2.57, P < 0.00001. FAZ: WMD = 0.06, 95% CI: 0.01-0.11, P = 0.03). CONCLUSIONS In diabetic patients with or without retinopathy, the parameters of OCTA such as VDscp, VDdcp, and peripapillary vessel density were demonstrated as potential biomarkers in monitoring the early alterations of retinal microangiopathy, while total FAZ may have no significant changes in diabetic patients without retinopathy.
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Affiliation(s)
- Fan Yang
- Department of Ophthalmology, Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Weijie Zou
- Department of Ophthalmology, Changshu No. 1 People's Hospital, Suzhou, China
| | - Zhiwei Li
- Department of Radiology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yuanyuan Du
- Department of Ophthalmology, Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Weiyun Gao
- Department of Ophthalmology, Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Ji Zhang
- Department of Ophthalmology, Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoyan Ji
- Department of Ophthalmology, Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiang Huang
- Department of Ophthalmology, Second Affiliated Hospital of Soochow University, Suzhou, China
- State Key Laboratory of Radiation Medicine and Protection, Soochow University, Suzhou, China
- Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
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11
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Theelen T, Yzer S. Editorial: Expanded insights into diabetic neovascular glaucoma by widefield swept-source optical coherence tomography angiography. Graefes Arch Clin Exp Ophthalmol 2024; 262:1015-1016. [PMID: 37947820 DOI: 10.1007/s00417-023-06293-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/12/2023] Open
Affiliation(s)
- Thomas Theelen
- Department of Ophthalmology, Radboud University Medical Center (Radboudumc), Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands.
| | - Suzanne Yzer
- Department of Ophthalmology, Radboud University Medical Center (Radboudumc), Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, the Netherlands
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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.
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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.)
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Liu J, Zhang H, Yu H, Xia Y, Liu Q, Geng C, Dong L, Wang Y. Changes in retinal and choroidal thickness and vascular density in patients with systemic lupus erythematosus: Assessed by optical coherence tomography angiography. Lupus 2024; 33:129-136. [PMID: 38158805 DOI: 10.1177/09612033231224771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVE The aim was to investigate the changes in retinal and choroidal thickness and vascular density in patients with systemic lupus erythematosus (SLE) using optical coherence tomography angiography (OCTA). METHODS Twenty-nine patients with SLE (29 eyes) and 25 control subjects (25 eyes) were enrolled. SLE activity was assessed using the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Retinal thickness (RT), inner retinal thickness (IRT), outer retinal thickness (ORT), choroidal thickness (ChT), retinal superficial vascular density (SVD), retinal deep vascular density (DVD), choriocapillary vascular density (CCVD), foveal avascular zone (FAZ), superficial FAZ (sFAZ), and deep FAZ (dFAZ) were measured using OCTA. The retinal and choroidal thickness and vascular density between the control group and SLE group were compared. The relationships between SLEDAI scores and the retinal and choroidal thickness and vascular density in SLE group were analyzed. RESULTS The SVD was significantly increased, and the DVD and CCVD were significantly decreased in the SLE group compared to the control group (p < .05). The results of receiver operating characteristic (ROC) showed that the area under the curve (AUC) values of SVD, DVD, and CCVD were 0.873, 0.729, and 0.727, indicating a high accuracy in discriminating patients with SLE from controls. Correlation analysis showed that the SLEDAI scores were positively correlated with dFAZ (r = 0.589, p = .001) and FAZ (r = 0.451, p = .018), and negatively correlated with DVD (r = -0.491, p = .009) and CCVD (r = -0.521, p = .005). CONCLUSIONS DVD and CCVD were decreased in the SLE and might be related to the disease activity. SVD, DVD, and CCVD may hold promise in the discovery of biomarkers for diagnosing SLE.
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Affiliation(s)
- Jun Liu
- Department of Ophthalmology, Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Hui Zhang
- Department of Ophthalmology, Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Hua Yu
- Department of Ophthalmology, Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Ye Xia
- Department of Ophthalmology, Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Qiang Liu
- Department of Ophthalmology, Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Chao Geng
- Department of Ophthalmology, Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Lihong Dong
- Department of Ophthalmology, Chaohu Hospital of Anhui Medical University, Hefei, China
| | - Yong Wang
- Department of Ophthalmology, The First Affiliated Hospital of Anhui Medical University, Hefei, China
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Haydinger CD, Oliver GF, Ashander LM, Smith JR. Oxidative Stress and Its Regulation in Diabetic Retinopathy. Antioxidants (Basel) 2023; 12:1649. [PMID: 37627644 PMCID: PMC10451779 DOI: 10.3390/antiox12081649] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/09/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023] Open
Abstract
Diabetic retinopathy is the retinal disease associated with hyperglycemia in patients who suffer from type 1 or type 2 diabetes. It includes maculopathy, involving the central retina and characterized by ischemia and/or edema, and peripheral retinopathy that progresses to a proliferative stage with neovascularization. Approximately 10% of the global population is estimated to suffer from diabetes, and around one in 5 of these individuals have diabetic retinopathy. One of the major effects of hyperglycemia is oxidative stress, the pathological state in which elevated production of reactive oxygen species damages tissues, cells, and macromolecules. The retina is relatively prone to oxidative stress due to its high metabolic activity. This review provides a summary of the role of oxidative stress in diabetic retinopathy, including a description of the retinal cell players and the molecular mechanisms. It discusses pathological processes, including the formation and effects of advanced glycation end-products, the impact of metabolic memory, and involvements of non-coding RNA. The opportunities for the therapeutic blockade of oxidative stress in diabetic retinopathy are also considered.
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Affiliation(s)
| | | | | | - Justine R. Smith
- College of Medicine and Public Health, Flinders University, Adelaide, SA 5042, Australia; (C.D.H.); (G.F.O.); (L.M.A.)
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