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Xu Y, Aung HL, Hesam-Shariati N, Keay L, Sun X, Phu J, Honson V, Tully PJ, Booth A, Lewis E, Anderson CS, Anstey KJ, Peters R. Contrast Sensitivity, Visual Field, Color Vision, Motion Perception, and Cognitive Impairment: A Systematic Review. J Am Med Dir Assoc 2024; 25:105098. [PMID: 38908397 DOI: 10.1016/j.jamda.2024.105098] [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: 07/23/2023] [Revised: 02/07/2024] [Accepted: 05/12/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVES To examine relationships between visual function (ie, contrast sensitivity, visual field, color vision, and motion perception) and cognitive impairment, including any definition of "cognitive impairment," mild cognitive impairment, or dementia. DESIGN Systematic review and meta-analyses. SETTING AND PARTICIPANTS Any settings; participants with (cases) or without (controls) cognitive impairment. METHODS We searched 4 databases (to January 2024) and included published studies that compared visual function between cases and controls. Standardized mean differences (SMD) with 95% CIs were calculated where data were available. Data were sufficient for meta-analyses when cases were people with dementia. The Joanna Briggs Institute checklists were used for quality assessment. RESULTS Fifty-one studies/69 reports were included. Cross-sectional evidence shows that people with dementia had worse contrast sensitivity function and color vision than controls: measured by contrast sensitivity (log units) on letter charts, SMD -1.22 (95% CI -1.98, -0.47), or at varied spatial frequencies, -0.92 (-1.28, -0.57); and by pseudoisochromatic plates, -1.04 (-1.59, -0.49); color arrangement, -1.30 (-2.31, -0.29); or matching tests, -0.51 (-0.78, -0.24). They also performed more poorly on tests of motion perception, -1.20 (-1.73, -0.67), and visual field: mean deviation, -0.87 (-1.29, -0.46), and pattern standard deviation, -0.69 (-1.24, -0.15). Results were similar when cases were limited to participants with clinically diagnosed Alzheimer disease. Sources of bias included lack of clarity on study populations or settings and definitions of cognitive impairment. The 2 included longitudinal studies with follow-ups of approximately 10 years were of good quality but reported inconsistent results. CONCLUSIONS AND IMPLICATIONS In the lack of longitudinal data, cross-sectional studies indicate that individuals with cognitive impairment have poorer visual function than those with normal cognition. Additional longitudinal data are needed to understand whether poor visual function precedes cognitive impairment and the most relevant aspects of visual function, dementia pathologies, and domains of cognition.
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Affiliation(s)
- Ying Xu
- Neuroscience Research Australia, Sydney, Australia; School of Psychology, Faculty of Science, UNSW Sydney, Sydney, Australia; The George Institute for Global Health, UNSW Sydney, Sydney, Australia; Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia; Ageing Futures Institute, UNSW Sydney, Sydney, Australia; Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.
| | - Htein Linn Aung
- Neuroscience Research Australia, Sydney, Australia; Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
| | - Negin Hesam-Shariati
- Neuroscience Research Australia, Sydney, Australia; School of Psychology, Faculty of Science, UNSW Sydney, Sydney, Australia
| | - Lisa Keay
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia; Ageing Futures Institute, UNSW Sydney, Sydney, Australia; School of Optometry and Vision Science, UNSW Sydney, Sydney, Australia
| | - Xiaodong Sun
- Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Shanghai Key Laboratory of Fundus Diseases, Shanghai, China; Shanghai Engineering Center for Visual Science and Photomedicine, Shanghai, China; National Clinical Research Center for Ophthalmic Diseases, Shanghai, China
| | - Jack Phu
- School of Optometry and Vision Science, UNSW Sydney, Sydney, Australia; Center for Eye Health, UNSW Sydney, Sydney, Australia; Faculty of Medicine and Health, University of Sydney, Sydney, Australia; Concord Clinical School, Concord Repatriation General Hospital, Sydney, Australia
| | - Vanessa Honson
- School of Optometry and Vision Science, UNSW Sydney, Sydney, Australia
| | - Phillip J Tully
- School of Psychology, The University of New England, Armidale, Australia
| | - Andrew Booth
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Ebony Lewis
- Neuroscience Research Australia, Sydney, Australia; School of Psychology, Faculty of Science, UNSW Sydney, Sydney, Australia; Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia; Ageing Futures Institute, UNSW Sydney, Sydney, Australia
| | - Craig S Anderson
- The George Institute for Global Health, UNSW Sydney, Sydney, Australia; Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia; The George Institute China, Peking University Health Science Center, Beijing, China; Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
| | - Kaarin J Anstey
- Neuroscience Research Australia, Sydney, Australia; School of Psychology, Faculty of Science, UNSW Sydney, Sydney, Australia; Ageing Futures Institute, UNSW Sydney, Sydney, Australia
| | - Ruth Peters
- Neuroscience Research Australia, Sydney, Australia; School of Psychology, Faculty of Science, UNSW Sydney, Sydney, Australia; The George Institute for Global Health, UNSW Sydney, Sydney, Australia; Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia; Ageing Futures Institute, UNSW Sydney, Sydney, Australia; School of Public Health, Imperial College London, London, United Kingdom
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Gaire BP, Koronyo Y, Fuchs DT, Shi H, Rentsendorj A, Danziger R, Vit JP, Mirzaei N, Doustar J, Sheyn J, Hampel H, Vergallo A, Davis MR, Jallow O, Baldacci F, Verdooner SR, Barron E, Mirzaei M, Gupta VK, Graham SL, Tayebi M, Carare RO, Sadun AA, Miller CA, Dumitrascu OM, Lahiri S, Gao L, Black KL, Koronyo-Hamaoui M. Alzheimer's disease pathophysiology in the Retina. Prog Retin Eye Res 2024; 101:101273. [PMID: 38759947 PMCID: PMC11285518 DOI: 10.1016/j.preteyeres.2024.101273] [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: 02/11/2023] [Revised: 04/23/2024] [Accepted: 05/10/2024] [Indexed: 05/19/2024]
Abstract
The retina is an emerging CNS target for potential noninvasive diagnosis and tracking of Alzheimer's disease (AD). Studies have identified the pathological hallmarks of AD, including amyloid β-protein (Aβ) deposits and abnormal tau protein isoforms, in the retinas of AD patients and animal models. Moreover, structural and functional vascular abnormalities such as reduced blood flow, vascular Aβ deposition, and blood-retinal barrier damage, along with inflammation and neurodegeneration, have been described in retinas of patients with mild cognitive impairment and AD dementia. Histological, biochemical, and clinical studies have demonstrated that the nature and severity of AD pathologies in the retina and brain correspond. Proteomics analysis revealed a similar pattern of dysregulated proteins and biological pathways in the retina and brain of AD patients, with enhanced inflammatory and neurodegenerative processes, impaired oxidative-phosphorylation, and mitochondrial dysfunction. Notably, investigational imaging technologies can now detect AD-specific amyloid deposits, as well as vasculopathy and neurodegeneration in the retina of living AD patients, suggesting alterations at different disease stages and links to brain pathology. Current and exploratory ophthalmic imaging modalities, such as optical coherence tomography (OCT), OCT-angiography, confocal scanning laser ophthalmoscopy, and hyperspectral imaging, may offer promise in the clinical assessment of AD. However, further research is needed to deepen our understanding of AD's impact on the retina and its progression. To advance this field, future studies require replication in larger and diverse cohorts with confirmed AD biomarkers and standardized retinal imaging techniques. This will validate potential retinal biomarkers for AD, aiding in early screening and monitoring.
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Affiliation(s)
- Bhakta Prasad Gaire
- Department of Neurosurgery, Maxine Dunitz Neurosurgical Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Yosef Koronyo
- Department of Neurosurgery, Maxine Dunitz Neurosurgical Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Dieu-Trang Fuchs
- Department of Neurosurgery, Maxine Dunitz Neurosurgical Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Haoshen Shi
- Department of Neurosurgery, Maxine Dunitz Neurosurgical Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Altan Rentsendorj
- Department of Neurosurgery, Maxine Dunitz Neurosurgical Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ron Danziger
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jean-Philippe Vit
- Department of Neurosurgery, Maxine Dunitz Neurosurgical Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nazanin Mirzaei
- Department of Neurosurgery, Maxine Dunitz Neurosurgical Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jonah Doustar
- Department of Neurosurgery, Maxine Dunitz Neurosurgical Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Julia Sheyn
- Department of Neurosurgery, Maxine Dunitz Neurosurgical Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Harald Hampel
- Sorbonne University, Alzheimer Precision Medicine (APM), AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Andrea Vergallo
- Sorbonne University, Alzheimer Precision Medicine (APM), AP-HP, Pitié-Salpêtrière Hospital, Paris, France
| | - Miyah R Davis
- Department of Neurosurgery, Maxine Dunitz Neurosurgical Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ousman Jallow
- Department of Neurosurgery, Maxine Dunitz Neurosurgical Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Filippo Baldacci
- Sorbonne University, Alzheimer Precision Medicine (APM), AP-HP, Pitié-Salpêtrière Hospital, Paris, France; Department of Clinical and Experimental Medicine, Neurology Unit, University of Pisa, Pisa, Italy
| | | | - Ernesto Barron
- Department of Ophthalmology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA; Doheny Eye Institute, Los Angeles, CA, USA
| | - Mehdi Mirzaei
- Department of Clinical Medicine, Health and Human Sciences, Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
| | - Vivek K Gupta
- Department of Clinical Medicine, Health and Human Sciences, Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
| | - Stuart L Graham
- Department of Clinical Medicine, Health and Human Sciences, Macquarie Medical School, Macquarie University, Sydney, NSW, Australia; Department of Clinical Medicine, Macquarie University, Sydney, NSW, Australia
| | - Mourad Tayebi
- School of Medicine, Western Sydney University, Campbelltown, NSW, Australia
| | - Roxana O Carare
- Department of Clinical Neuroanatomy, University of Southampton, Southampton, UK
| | - Alfredo A Sadun
- Department of Ophthalmology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA; Doheny Eye Institute, Los Angeles, CA, USA
| | - Carol A Miller
- Department of Pathology Program in Neuroscience, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Shouri Lahiri
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Liang Gao
- Department of Bioengineering, University of California Los Angeles, Los Angeles, CA, USA
| | - Keith L Black
- Department of Neurosurgery, Maxine Dunitz Neurosurgical Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Maya Koronyo-Hamaoui
- Department of Neurosurgery, Maxine Dunitz Neurosurgical Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Biomedical Sciences, Division of Applied Cell Biology and Physiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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3
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Piano MEF, Nguyen BN, Gocuk SA, Joubert L, McKendrick AM. Primary eyecare provision for people living with dementia: what do we need to know? Clin Exp Optom 2023; 106:711-725. [PMID: 36375138 DOI: 10.1080/08164622.2022.2140032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 10/10/2022] [Accepted: 10/11/2022] [Indexed: 11/16/2022] Open
Abstract
Dementia comprises a group of brain disorders characterised by loss of cognitive function. Sensory loss, predominantly vision (the focus of this review) and hearing, is a significant problem for people living with dementia. Eyecare practitioners such as optometrists therefore play an important role in identifying and addressing vision-related care needs. To support provision of high quality "dementia-friendly" eyecare, this scoping review summarises recent primary research findings and available clinical practice guidelines, to identify research gaps relating to vision and dementia, and make recommendations for future research and clinical practice. The review set a priori guidelines for the population, concept and context based on the review questions. Primary research papers (2016-2021) were included via 3-step search strategy: preliminary search to index terms, full search, search reference lists of included articles for further inclusions. Additionally, websites of eyecare professional bodies in English-speaking countries were searched to identify current clinical eyecare practice guidelines relating to dementia. Study characteristics (e.g. country, study design) were reported descriptively. Patterns within findings/recommendations from included sources were identified using thematic analysis and reported as themes. 1651 titles/abstracts and 161 full-text articles were screened for eligibility. Three clinical practice guidelines were also identified. The final review included 21 sources: 18 primary research papers and 3 clinical practice guidelines. The thematic analysis reported five key themes: Diagnosis/Screening, dementia progression, findings on clinical visual testing, tailored approach to care, improving care. This scoping review demonstrated limited information about current practices of optometrists working with people living with dementia. Recent evidence reinforces the continuing need for improved eyecare for people living with dementia, taking into account their specific needs with an individualised approach. Up-to-date practical recommendations are synthesised for eyecare providers before, during and after a consultation with a person living with dementia, to better support their care.
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Affiliation(s)
- Marianne E F Piano
- Department of Optometry and Vision Sciences, School of Health Sciences, The University of Melbourne, Melbourne, Australia
- National Vision Research Institute, Australian College of Optometry, Carlton, Australia
| | - Bao N Nguyen
- Department of Optometry and Vision Sciences, School of Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Sena A Gocuk
- Department of Optometry and Vision Sciences, School of Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Lynette Joubert
- Department of Social Work, School of Health Sciences, The University of Melbourne, Melbourne, Australia
| | - Allison M McKendrick
- Department of Optometry and Vision Sciences, School of Health Sciences, The University of Melbourne, Melbourne, Australia
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Constable PA, Lim JKH, Thompson DA. Retinal electrophysiology in central nervous system disorders. A review of human and mouse studies. Front Neurosci 2023; 17:1215097. [PMID: 37600004 PMCID: PMC10433210 DOI: 10.3389/fnins.2023.1215097] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/17/2023] [Indexed: 08/22/2023] Open
Abstract
The retina and brain share similar neurochemistry and neurodevelopmental origins, with the retina, often viewed as a "window to the brain." With retinal measures of structure and function becoming easier to obtain in clinical populations there is a growing interest in using retinal findings as potential biomarkers for disorders affecting the central nervous system. Functional retinal biomarkers, such as the electroretinogram, show promise in neurological disorders, despite having limitations imposed by the existence of overlapping genetic markers, clinical traits or the effects of medications that may reduce their specificity in some conditions. This narrative review summarizes the principal functional retinal findings in central nervous system disorders and related mouse models and provides a background to the main excitatory and inhibitory retinal neurotransmitters that have been implicated to explain the visual electrophysiological findings. These changes in retinal neurochemistry may contribute to our understanding of these conditions based on the findings of retinal electrophysiological tests such as the flash, pattern, multifocal electroretinograms, and electro-oculogram. It is likely that future applications of signal analysis and machine learning algorithms will offer new insights into the pathophysiology, classification, and progression of these clinical disorders including autism, attention deficit/hyperactivity disorder, bipolar disorder, schizophrenia, depression, Parkinson's, and Alzheimer's disease. New clinical applications of visual electrophysiology to this field may lead to earlier, more accurate diagnoses and better targeted therapeutic interventions benefiting individual patients and clinicians managing these individuals and their families.
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Affiliation(s)
- Paul A. Constable
- College of Nursing and Health Sciences, Caring Futures Institute, Flinders University, Adelaide, SA, Australia
| | - Jeremiah K. H. Lim
- Discipline of Optometry, School of Allied Health, University of Western Australia, Perth, WA, Australia
| | - Dorothy A. Thompson
- The Tony Kriss Visual Electrophysiology Unit, Clinical and Academic Department of Ophthalmology, Great Ormond Street Hospital for Children NHS Trust, London, United Kingdom
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
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5
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Retinal Neurodegeneration Measured With Optical Coherence Tomography and Neuroimaging in Alzheimer Disease: A Systematic Review. J Neuroophthalmol 2023; 43:116-125. [PMID: 36255105 DOI: 10.1097/wno.0000000000001673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Optical coherence tomography (OCT) has enabled several retinal alterations to be detected in patients with Alzheimer disease (AD), alterations that could be potential biomarkers. However, the relationship between the retina and other biomarkers of AD has been underresearched. We gathered and analyzed the literature about the relationship between retinal and cerebral alterations detected via neuroimaging in patients with AD, mild cognitive impairment (MCI), and preclinical AD. METHODS This systematic review followed the PRISMA Statement guidelines through the 27 items on its checklist. We searched in PubMed, BVS, Scopus, and the Cochrane Library, using the keywords: Alzheimer's disease, optical coherence tomography, white matter, cortex, atrophy, cortical thickness, neuroimaging, magnetic resonance imaging, and positron emission tomography. We included articles that studied the retina in relation to neuroimaging in patients with AD, MCI, and preclinical AD. We excluded studies without OCT, without neuroimaging, clinical cases, opinion articles, systematic reviews, and animal studies. RESULTS Of a total of 35 articles found, 23 were finally included. Although mixed results were found, most of these corroborate the relationship between retinal and brain disorders. CONCLUSIONS More rigorous research is needed in the field, including homogenized, longitudinal, and prolonged follow-up studies, as well as studies that include all stages of AD. This will enable better understanding of the retina and its implications in AD, leading to the discovery of retinal biomarkers that reflect brain alterations in AD patients in an accessible and noninvasive manner.
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Wang X, Jiao B, Liu H, Wang Y, Hao X, Zhu Y, Xu B, Xu H, Zhang S, Jia X, Xu Q, Liao X, Zhou Y, Jiang H, Wang J, Guo J, Yan X, Tang B, Zhao R, Shen L. Machine learning based on Optical Coherence Tomography images as a diagnostic tool for Alzheimer's disease. CNS Neurosci Ther 2022; 28:2206-2217. [PMID: 36089740 PMCID: PMC9627364 DOI: 10.1111/cns.13963] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/03/2022] [Accepted: 08/23/2022] [Indexed: 02/06/2023] Open
Abstract
AIMS We mainly evaluate retinal alterations in Alzheimer's disease (AD) patients, investigate the associations between retinal changes with AD biomarkers, and explore an optimal machine learning (ML) model for AD diagnosis based on retinal thickness. METHODS A total of 159 AD patients and 299 healthy controls were enrolled. The retinal parameters of each participant were measured using optical coherence tomography (OCT). Additionally, cognitive impairment severity, brain atrophy, and cerebrospinal fluid (CSF) biomarkers were measured in AD patients. RESULTS AD patients demonstrated a significant decrease in the average, superior, and inferior quadrant peripapillary retinal nerve fiber layer, macular retinal nerve fiber layer, ganglion cell layer (GCL), inner plexiform layer (IPL) thicknesses, as well as total macular volume (TMV) (all p < 0.05). Moreover, TMV was positively associated with Mini-Mental State Examination and Montreal Cognitive Assessment scores, IPL thickness was correlated negatively with the medial temporal lobe atrophy score, and the GCL thickness was positively correlated with CSF Aβ42 /Aβ40 and negatively associated with p-tau level. Based on the significantly decreased OCT variables between both groups, the XGBoost algorithm exhibited the best diagnostic performance for AD, whose four references, including accuracy, area under the curve, f1 score, and recall, ranged from 0.69 to 0.74. Moreover, the macular retinal thickness exhibited an absolute superiority for AD diagnosis compared with other enrolled variables in all ML models. CONCLUSION We identified the retinal alterations in AD patients and found that macular thickness and volume were associated with AD severity and biomarkers. Furthermore, we confirmed that OCT combined with ML could serve as a potential diagnostic tool for AD.
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Affiliation(s)
- Xin Wang
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaChina
| | - Bin Jiao
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaChina,National Clinical Research Center for Geriatric DisordersCentral South UniversityChangshaChina,Engineering Research Center of Hunan Province in Cognitive Impairment DisordersCentral South UniversityChangshaChina,Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic DiseasesChangshaChina,Key Laboratory of Hunan Province in Neurodegenerative DisordersCentral South UniversityChangshaChina
| | - Hui Liu
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaChina
| | - Yaqin Wang
- Health Management Center, the Third Xiangya HospitalCentral South UniversityChangshaChina
| | - Xiaoli Hao
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaChina
| | - Yuan Zhu
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaChina
| | - Bei Xu
- Eye Center of Xiangya HospitalCentral South UniversityChangshaChina
| | - Huizhuo Xu
- Eye Center of Xiangya HospitalCentral South UniversityChangshaChina
| | - Sizhe Zhang
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaChina
| | - Xiaoliang Jia
- School of Computer Science and EngineeringCentral South UniversityChangshaChina
| | - Qian Xu
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaChina,National Clinical Research Center for Geriatric DisordersCentral South UniversityChangshaChina,Engineering Research Center of Hunan Province in Cognitive Impairment DisordersCentral South UniversityChangshaChina,Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic DiseasesChangshaChina,Key Laboratory of Hunan Province in Neurodegenerative DisordersCentral South UniversityChangshaChina
| | - Xinxin Liao
- National Clinical Research Center for Geriatric DisordersCentral South UniversityChangshaChina,Engineering Research Center of Hunan Province in Cognitive Impairment DisordersCentral South UniversityChangshaChina,Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic DiseasesChangshaChina,Key Laboratory of Hunan Province in Neurodegenerative DisordersCentral South UniversityChangshaChina,Department of Geriatrics, Xiangya HospitalCentral South UniversityChangshaChina
| | - Yafang Zhou
- National Clinical Research Center for Geriatric DisordersCentral South UniversityChangshaChina,Engineering Research Center of Hunan Province in Cognitive Impairment DisordersCentral South UniversityChangshaChina,Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic DiseasesChangshaChina,Key Laboratory of Hunan Province in Neurodegenerative DisordersCentral South UniversityChangshaChina,Department of Geriatrics, Xiangya HospitalCentral South UniversityChangshaChina
| | - Hong Jiang
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaChina,National Clinical Research Center for Geriatric DisordersCentral South UniversityChangshaChina,Engineering Research Center of Hunan Province in Cognitive Impairment DisordersCentral South UniversityChangshaChina,Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic DiseasesChangshaChina,Key Laboratory of Hunan Province in Neurodegenerative DisordersCentral South UniversityChangshaChina
| | - Junling Wang
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaChina,National Clinical Research Center for Geriatric DisordersCentral South UniversityChangshaChina,Engineering Research Center of Hunan Province in Cognitive Impairment DisordersCentral South UniversityChangshaChina,Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic DiseasesChangshaChina,Key Laboratory of Hunan Province in Neurodegenerative DisordersCentral South UniversityChangshaChina
| | - Jifeng Guo
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaChina,National Clinical Research Center for Geriatric DisordersCentral South UniversityChangshaChina,Engineering Research Center of Hunan Province in Cognitive Impairment DisordersCentral South UniversityChangshaChina,Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic DiseasesChangshaChina,Key Laboratory of Hunan Province in Neurodegenerative DisordersCentral South UniversityChangshaChina
| | - Xinxiang Yan
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaChina,National Clinical Research Center for Geriatric DisordersCentral South UniversityChangshaChina,Engineering Research Center of Hunan Province in Cognitive Impairment DisordersCentral South UniversityChangshaChina,Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic DiseasesChangshaChina,Key Laboratory of Hunan Province in Neurodegenerative DisordersCentral South UniversityChangshaChina
| | - Beisha Tang
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaChina,National Clinical Research Center for Geriatric DisordersCentral South UniversityChangshaChina,Engineering Research Center of Hunan Province in Cognitive Impairment DisordersCentral South UniversityChangshaChina,Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic DiseasesChangshaChina,Key Laboratory of Hunan Province in Neurodegenerative DisordersCentral South UniversityChangshaChina
| | - Rongchang Zhao
- School of Computer Science and EngineeringCentral South UniversityChangshaChina
| | - Lu Shen
- Department of Neurology, Xiangya HospitalCentral South UniversityChangshaChina,National Clinical Research Center for Geriatric DisordersCentral South UniversityChangshaChina,Engineering Research Center of Hunan Province in Cognitive Impairment DisordersCentral South UniversityChangshaChina,Hunan International Scientific and Technological Cooperation Base of Neurodegenerative and Neurogenetic DiseasesChangshaChina,Key Laboratory of Hunan Province in Neurodegenerative DisordersCentral South UniversityChangshaChina,Key Laboratory of Organ InjuryAging and Regenerative Medicine of Hunan ProvinceChangshaChina
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Jeevakumar V, Sefton R, Chan J, Gopinath B, Liew G, Shah TM, Siette J. Association between retinal markers and cognition in older adults: a systematic review. BMJ Open 2022; 12:e054657. [PMID: 35728906 PMCID: PMC9214387 DOI: 10.1136/bmjopen-2021-054657] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To appraise the existing literature reporting an association between retinal markers and cognitive impairment in adults aged 65 years and over and to provide directions for future use of retinal scanning as a potential tool for dementia diagnosis. DESIGN Systematic review of peer-reviewed empirical articles investigating the association of retinal markers in assessing cognitive impairment. DATA SOURCES Three electronic databases, Medline, PsycINFO and EMBASE were searched from inception until March 2022. ELIGIBILITY CRITERIA All empirical articles in English investigating the association between retinal markers and cognition in humans aged ≥65 years using various retinal scanning methodologies were included. Studies with no explicit evaluation of retinal scanning and cognitive outcomes were excluded. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool. DATA EXTRACTION AND SYNTHESIS Data extraction was conducted by two authors (VJ, RS) and reviewed by another author (JS). Results were synthesised and described narratively. RESULTS Sixty-seven eligible studies examining 6815 older adults were included. Majority of studies were cross-sectional (n=60; 89.6%). Optical coherence tomography (OCT) was the most commonly used retinal scanning methodology to measure the thickness of retinal nerve fibre layer, the ganglion cell complex, choroid and macula. 51.1% of cross-sectional studies using OCT reported an association between the thinning of at least one retinal parameter and poor cognition. Longitudinal studies (n=6) using OCT also mostly identified significant reductions in retinal nerve fibre layer thickness with cognitive decline. Study quality was overall moderate. CONCLUSION Retinal nerve fibre layer thickness is linked with cognitive performance and therefore may have the potential to detect cognitive impairment in older adults. Further longitudinal studies are required to validate our synthesis and understand underlying mechanisms before recommending implementation of OCT as a dementia screening tool in clinical practice. PROSPERO REGISTRATION NUMBER CRD42020176757.
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Affiliation(s)
- Varshanie Jeevakumar
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Rebekah Sefton
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Joyce Chan
- New Look Eyewear, Maitland, New South Wales, Australia
| | - Bamini Gopinath
- Department of Linguistics, Australian Hearing Hub, Macquarie University, Macquarie Park, New South Wales, Australia
| | - Gerald Liew
- Centre for Vision Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Tejal M Shah
- Macquarie Medical School, Macquarie University, North Ryde, New South Wales, Australia
| | - Joyce Siette
- Australian Institute of Health Innovation, Macquarie University, Macquarie Park, New South Wales, Australia
- MARCS Institute for Brain, Behaviour and Development, Western Sydney University, Westmead, New South Wales, Australia
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8
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Sen S, Mandal S, Banerjee M, Gk R, Saxena A, Aalok SP, Saxena R. Ethambutol-induced optic neuropathy: Functional and structural changes in the retina and optic nerve. Semin Ophthalmol 2022; 37:730-739. [PMID: 35699333 DOI: 10.1080/08820538.2022.2085517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUD Ethambutol hydrochloride (EMB) is used in the treatment of tuberculosis and is used as first line modality in combination with other medications. Ethambutol optic neuropathy (EON) is a rare but well-recognised adverse ocular event in patients who receive ethambutol for the treatment of mycobacterial infections and may be potentially devastating with reversible to irreversible changes in visual acuity. KEY FINDINGS Optical coherence tomography has been used to evaluate the thickness of retinal nerve fibre and ganglion cell layers to look for degenerative changes and early markers. Electrophysiological tests like multifocal electroretinogram, visual evoked potentials and visual fields have been used to understand the functional changes associated with established EON and also whether these can be used to detect subclinical EON and correlate them with the structural changes. In this review, we have summarised evidence published till December 2021 related to evaluation of structural and functional changes in the retina and optic nerve in eyes with EON.
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Affiliation(s)
- Sagnik Sen
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Sohini Mandal
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Mousumi Banerjee
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | - Ranjitha Gk
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
| | | | | | - Rohit Saxena
- Dr Rajendra Prasad Centre for Ophthalmic Sciences, AIIMS, New Delhi, India
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Shen T, Sheriff S, You Y, Jiang J, Schulz A, Francis H, Mirzaei M, Saks D, Chitranshi N, Gupta V, Singh MF, Klistorner A, Wen W, Sachdev P, Gupta VK, Graham SL. Evaluating associations of RNFL thickness and multifocal VEP with cognitive assessment and brain MRI volumes in older adults: Optic nerve decline and cognitive change (ONDCC) initiative. AGING BRAIN 2022; 2:100049. [PMID: 36908892 PMCID: PMC9997126 DOI: 10.1016/j.nbas.2022.100049] [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: 12/06/2021] [Revised: 07/31/2022] [Accepted: 08/09/2022] [Indexed: 11/20/2022] Open
Abstract
To examine the relationships of retinal structural (optical coherence tomography) and visual functional (multifocal visual evoked potentials, mfVEP) indices with neuropsychological and brain structural measurements in healthy older subjects. 95 participants (mean (SD) age 68.1 (9.0)) years were recruited in the Optic Nerve Decline and Cognitive Change (ONDCC) study in this observational clinical investigation. OCT was conducted for retinal nerve fibre layer (RNFL) and mfVEP for amplitude and latency measurements. Participants undertook neuropsychological tests for cognitive performance and MRI for volumetric evaluation of various brain regions. Generalised estimating equation models were used for association analysis (p < 0.05). The brain volumetric measures including total grey matter (GM), cortex, thalamus, hippocampal and fourth ventricular volumes were significantly associated with global and sectoral RNFL. RNFL thickness correlated with delayed recalls of California verbal learning test (CVLT) and Rey complex figure test (RCFT). The mfVEP amplitudes associated with cerebral white matter (WM) and cingulate GM volumes in MRI and CVLT, RCFT and trail making test outcomes. A significant association of mfVEP latency with logical memory delayed recall and thalamus volume was also observed. Our results suggested significant association of specific RNFL and mfVEP measures with distinctive brain region volumes and cognitive tests reflecting performance in memory, visuospatial and executive functional domains. These findings indicate that the mfVEP and RNFL measurements may parallel brain structural and neuropsychological measures in the older population.
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Affiliation(s)
- Ting Shen
- Department of Ophthalmology, Shanghai General Hospital (Shanghai First People’s Hospital), School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
- Save Sight Institute, The University of Sydney, Sydney, NSW, Australia
- Corresponding authors at: Department of Ophthalmology, Shanghai General Hospital (Shanghai First People's hospital), School of Medicine, Shanghai Jiao Tong University and Macquarie University.
| | - Samran Sheriff
- Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
| | - Yuyi You
- Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
- Save Sight Institute, The University of Sydney, Sydney, NSW, Australia
| | - Jiyang Jiang
- Centre for Healthy Brain Ageing and the Neuropsychiatric Institute, University of New South Wales, Sydney, NSW, Australia
| | - Angela Schulz
- Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
| | - Heather Francis
- Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
| | - Mehdi Mirzaei
- Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
| | - Danit Saks
- Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
| | - Nitin Chitranshi
- Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
| | - Veer Gupta
- Faculty of Health, Deakin University, VIC, Australia
| | | | - Alexander Klistorner
- Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
- Save Sight Institute, The University of Sydney, Sydney, NSW, Australia
| | - Wei Wen
- Centre for Healthy Brain Ageing and the Neuropsychiatric Institute, University of New South Wales, Sydney, NSW, Australia
| | - Perminder Sachdev
- Centre for Healthy Brain Ageing and the Neuropsychiatric Institute, University of New South Wales, Sydney, NSW, Australia
| | - Vivek K. Gupta
- Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
- Corresponding authors at: Department of Ophthalmology, Shanghai General Hospital (Shanghai First People's hospital), School of Medicine, Shanghai Jiao Tong University and Macquarie University.
| | - Stuart L. Graham
- Macquarie Medical School, Macquarie University, Sydney, NSW, Australia
- Save Sight Institute, The University of Sydney, Sydney, NSW, Australia
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A novel system for measuring visual potentials evoked by passive head-mounted display stimulators. Doc Ophthalmol 2021; 144:125-135. [PMID: 34661850 DOI: 10.1007/s10633-021-09856-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The objective of this work is to evaluate the performances of a novel integrated device, based on passive head-mounted display (HMD), for the pattern reversal visual evoked potential (PR-VEP) clinical test. METHODS Google Cardboard® is used as passive HMD to generate the checkerboard pattern stimuli through an Android® application. Electroencephalographic signals are retrieved and processed over 20 subjects, 12 females and 8 males between 20 and 26 years. Morphological PR-VEPs and frequency response were compared with previous literature results, to test the reproducibility and the efficacy of the proposed solution. RESULTS PR-VEPs evoked by our novel prototype showed typical triphasic waveforms in moderate agreement with those obtained with other more expensive HMDs and standard commercial devices. Statistical analysis did not highlight strong differences among the systems over the features analyzed except for the P100 amplitude and peak time (**p < 0.005). CONCLUSION The proposed solution opens the door for a new generation of non-invasive first-level diagnostic devices of optic nerve pathologies inexpensive and easy to access.
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Ge YJ, Xu W, Ou YN, Qu Y, Ma YH, Huang YY, Shen XN, Chen SD, Tan L, Zhao QH, Yu JT. Retinal biomarkers in Alzheimer's disease and mild cognitive impairment: A systematic review and meta-analysis. Ageing Res Rev 2021; 69:101361. [PMID: 34000463 DOI: 10.1016/j.arr.2021.101361] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/27/2021] [Accepted: 05/12/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Retinal changes may reflect the pathophysiological processes in the central nervous system and can be assessed by imaging modalities non-invasively. We aim to localize candidate retinal biomarkers in Alzheimer's disease (AD), mild cognitive impairment (MCI), and preclinical AD. METHODS We systematically searched PubMed, EMBASE, Scopus, and Web of Science from inception to January 2021 for observational studies that investigated retinal imaging and electrophysiological markers in AD, MCI, and preclinical AD. Between-groups standardized mean differences (SMDs) with 95 % confidence intervals were computed using random-effects models. RESULTS Of 19,727 citations identified, 126 articles were eligible for inclusion. Compared with healthy controls, the thickness of peripapillary retinal nerve fiber layer (pRNFL; SMD = -0.723, p < 0.001), total macular (SMD = -0.612, p < 0.001), and subfoveal choroid (SMD = -0.888, p < 0.001) were significantly reduced in patients with AD. Compared with healthy controls, patients with MCI also had lower thickness of pRNFL (SMD = -0.324, p < 0.001), total macular (SMD = -0.302, p < 0.001), and subfoveal choroid (SMD = -0.462, p = 0.020). Other candidate biomarkers included the optic nerve head morphology, retinal amyloid deposition, microvascular morphology and densities, blood flow, and electrophysiological markers. CONCLUSIONS Retinal structural, vascular, and electrophysiological biomarkers hold great potential for the diagnosis, prognosis and risk assessment of AD and MCI. These biomarkers warrant further development in the future, especially in diagnostic test accuracy and longitudinal studies.
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Past, present and future role of retinal imaging in neurodegenerative disease. Prog Retin Eye Res 2021; 83:100938. [PMID: 33460813 PMCID: PMC8280255 DOI: 10.1016/j.preteyeres.2020.100938] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 12/11/2020] [Accepted: 12/17/2020] [Indexed: 02/08/2023]
Abstract
Retinal imaging technology is rapidly advancing and can provide ever-increasing amounts of information about the structure, function and molecular composition of retinal tissue in humans in vivo. Most importantly, this information can be obtained rapidly, non-invasively and in many cases using Food and Drug Administration-approved devices that are commercially available. Technologies such as optical coherence tomography have dramatically changed our understanding of retinal disease and in many cases have significantly improved their clinical management. Since the retina is an extension of the brain and shares a common embryological origin with the central nervous system, there has also been intense interest in leveraging the expanding armamentarium of retinal imaging technology to understand, diagnose and monitor neurological diseases. This is particularly appealing because of the high spatial resolution, relatively low-cost and wide availability of retinal imaging modalities such as fundus photography or OCT compared to brain imaging modalities such as magnetic resonance imaging or positron emission tomography. The purpose of this article is to review and synthesize current research about retinal imaging in neurodegenerative disease by providing examples from the literature and elaborating on limitations, challenges and future directions. We begin by providing a general background of the most relevant retinal imaging modalities to ensure that the reader has a foundation on which to understand the clinical studies that are subsequently discussed. We then review the application and results of retinal imaging methodologies to several prevalent neurodegenerative diseases where extensive work has been done including sporadic late onset Alzheimer's Disease, Parkinson's Disease and Huntington's Disease. We also discuss Autosomal Dominant Alzheimer's Disease and cerebrovascular small vessel disease, where the application of retinal imaging holds promise but data is currently scarce. Although cerebrovascular disease is not generally considered a neurodegenerative process, it is both a confounder and contributor to neurodegenerative disease processes that requires more attention. Finally, we discuss ongoing efforts to overcome the limitations in the field and unmet clinical and scientific needs.
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Rod pathway and cone pathway retinal dysfunction in the 5xFAD mouse model of Alzheimer's disease. Sci Rep 2021; 11:4824. [PMID: 33649406 PMCID: PMC7921657 DOI: 10.1038/s41598-021-84318-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/09/2021] [Indexed: 01/02/2023] Open
Abstract
To characterize rod- and cone-pathway function in the 5xFAD mouse model of Alzheimer’s disease (AD) using the full-field electroretinogram (ERG). Dark-adapted (DA; rod-pathway) and light-adapted (LA; cone-pathway) ERGs were recorded from three-month-old 5xFAD and wild type (WT) mice. ERGs were elicited by achromatic flashes (0.01–25 cd-s-m−2). Amplitude and implicit time (IT) of the a-wave, b-wave, and oscillatory potentials (OPs) were calculated according to convention. In addition, the amplitude and IT of the photopic negative response (PhNR) were measured from the LA recordings. Amplitude and IT differences between the 5xFAD and WT groups were evaluated using quantile regression models. Under DA conditions, there were significant differences between the 5xFAD and WT groups in post-receptor function, whereas photoreceptor function did not differ significantly. Specifically, the DA a-wave amplitude did not differ between groups (p = 0.87), whereas the b-wave amplitude was reduced in the 5xFAD mice (p = 0.003). There were significant OP (p < 0.001) and a-wave (p = 0.04) delays, but the a-wave delay may be attributable to a post-receptor abnormality. Under LA conditions, the only 5xFAD abnormalities were in the PhNR, which was reduced (p = 0.009) and delayed (p = 0.04). The full-field ERG can be abnormal in the 5xFAD model of AD, with the greatest effects on post-receptor rod pathway function. These results indicate that retinal electrophysiology may be a useful tool for evaluating neural dysfunction in AD.
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Zhang Y, Wang Y, Shi C, Shen M, Lu F. Advances in retina imaging as potential biomarkers for early diagnosis of Alzheimer's disease. Transl Neurodegener 2021; 10:6. [PMID: 33517891 PMCID: PMC7849105 DOI: 10.1186/s40035-021-00230-9] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 01/07/2021] [Indexed: 12/20/2022] Open
Abstract
As the most common form of dementia, Alzheimer’s disease (AD) is characterized by progressive cognitive impairments and constitutes a major social burden. Currently, the invasiveness and high costs of tests have limited the early detection and intervention of the disease. As a unique window of the brain, retinal changes can reflect the pathology of the brain. In this review, we summarize current understanding of retinal structures in AD, mild cognitive impairment (MCI) and preclinical AD, focusing on neurodegeneration and microvascular changes measured using optical coherence tomography (OCT) and optical coherence tomography angiography (OCTA) technologies. The literature suggests that the impairment of retinal microvascular network and neural microstructure exists in AD, MCI and even preclinical AD. These findings provide valuable insights into a better understanding of disease pathogenesis and demonstrate that retinal changes are potential biomarkers for early diagnosis of AD and monitoring of disease progression.
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Affiliation(s)
- Ying Zhang
- School of Ophthalmology and Optometry, Wenzhou Medical College, Wenzhou, 325027, China
| | - Yanjiang Wang
- Department of Neurology, Daping Hospital, Third Military Medical University, Chongqing, 400042, China
| | - Ce Shi
- School of Ophthalmology and Optometry, Wenzhou Medical College, Wenzhou, 325027, China
| | - Meixiao Shen
- School of Ophthalmology and Optometry, Wenzhou Medical College, Wenzhou, 325027, China.
| | - Fan Lu
- School of Ophthalmology and Optometry, Wenzhou Medical College, Wenzhou, 325027, China.
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Sen S, Saxena R. Re: Varin et al.: Age-related eye disease and cognitive function: the search for mediators (Ophthalmology. 2020;127:660-666). Ophthalmology 2020; 127:e89-e90. [DOI: 10.1016/j.ophtha.2020.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 05/06/2020] [Indexed: 11/25/2022] Open
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