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Żmijewska MA, Wawrzyniak ZM, Janiszewski M, Zaleska-Żmijewska A. Retinal Microcirculation Measurements in Response to Endurance Exercises Analysed by Adaptive Optics Retinal Camera. Diagnostics (Basel) 2024; 14:710. [PMID: 38611623 PMCID: PMC11012106 DOI: 10.3390/diagnostics14070710] [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: 03/05/2024] [Revised: 03/23/2024] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
This study aimed to precisely investigate the effects of intensive physical exercise on retinal microvascular regulation in healthy volunteers through adaptive optics retinal camera (AO) measurement. We included healthy volunteers (11 men and 14 women) aged 20.6 ± 0.9. The heart rate (HR) and systolic and diastolic blood pressures (SBP, DBP) were recorded before and after a submaximal physical exertion of continuously riding a training ergometer. The superior temporal retinal artery measurements were captured using the AO-rtx1TM (Imagine Eyes, Orsay, France) without pupil dilation. We compared measures of vessel diameter (VD), lumen diameter (LD), two walls (Wall 1, 2), wall-to-lumen ratio (WLR), and wall cross-sectional analysis (WCSA) before and immediately after the cessation of exercise. Cardiovascular parameter results: After exercise, SBP, DBP, and HR changed significantly from 130.2 ± 13.2 to 159.7 ± 15.6 mm Hg, 81.2 ± 6.3 to 77.1 ± 8.2 mm Hg, and 80.8 ± 16.1 to 175.0 ± 6.2 bpm, respectively (p < 0.002). Retinal microcirculation analysis showed no significant decrease in LD, Wall 1 after exercise: from 96.0 ± 6.8 to 94.9 ± 6.7 (p = 0.258), from 11.0 ± 1.5 to 10.4 ± 1.5 (p = 0.107), respectively, and significant reduction in VD from 118.5 ± 8.3 to 115.9 ± 8.3 (p = 0.047), Wall 2 from 11.5 ± 1.0 to 10.7 ± 1.3 (p = 0.017), WLR from 0.234 ± 0.02 to 0.222 ± 0.010 (p = 0.046), WCSA from 3802.8 ± 577.6 to 3512.3 ± 535.3 (p = 0.016). The AO is a promising technique for investigating the effects of exercise on microcirculation, allowing for the tracking of changes throughout the observation. Intensive dynamic physical exertion increases blood pressure and heart rate and causes the vasoconstriction of small retinal arterioles due to the autoregulation mechanism.
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Affiliation(s)
- Maria Anna Żmijewska
- Faculty of Medicine, Student Scientific Society “Eye”, Medical University of Warsaw, 02-097 Warsaw, Poland;
| | - Zbigniew M. Wawrzyniak
- Faculty of Electronics and Information Technology, Warsaw University of Technology, 00-065 Warsaw, Poland
| | - Maciej Janiszewski
- Faculty of Medicine and Dentistry, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Anna Zaleska-Żmijewska
- Department of Ophthalmology, Public Ophthalmic Clinical Hospital (SPKSO), Medical University of Warsaw, 00-576 Warsaw, Poland;
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Schanner C, Hautala N, Rauscher FG, Falck A. The impact of the image conversion factor and image centration on retinal vessel geometric characteristics. Front Med (Lausanne) 2023; 10:1112652. [PMID: 37007779 PMCID: PMC10063888 DOI: 10.3389/fmed.2023.1112652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/02/2023] [Indexed: 03/19/2023] Open
Abstract
BackgroundThis study aims to use fundus image material from a long-term retinopathy follow-up study to identify problems created by changing imaging modalities or imaging settings (e.g., image centering, resolution, viewing angle, illumination wavelength). Investigating the relationship of image conversion factor and imaging centering on retinal vessel geometric characteristics (RVGC), offers solutions for longitudinal retinal vessel analysis for data obtained in clinical routine.MethodsRetinal vessel geometric characteristics were analyzed in scanned fundus photographs with Singapore-I-Vessel-Assessment using a constant image conversion factor (ICF) and an individual ICF, applying them to macula centered (MC) and optic disk centered (ODC) images. The ICF is used to convert pixel measurements into μm for vessel diameter measurements and to establish the size of the measuring zone. Calculating a constant ICF, the width of all analyzed optic disks is included, and it is used for all images of a cohort. An individual ICF, in turn, uses the optic disk diameter of the eye analyzed. To investigate agreement, Bland-Altman mean difference was calculated between ODC images analyzed with individual and constant ICF and between MC and ODC images.ResultsWith constant ICF (n = 104 eyes of 52 patients) the mean central retinal equivalent was 160.9 ± 17.08 μm for arteries (CRAE) and 208.7 ± 14.7.4 μm for veins (CRVE). The individual ICFs resulted in a mean CRAE of 163.3 ± 15.6 μm and a mean CRVE of 219.0 ± 22.3 μm. On Bland–Altman analysis, the individual ICF RVGC are more positive, resulting in a positive mean difference for most investigated parameters. Arteriovenous ratio (p = 0.86), simple tortuosity (p = 0.08), and fractal dimension (p = 0.80) agreed well between MC and ODC images, while the vessel diameters were significantly smaller in MC images (p < 0.002).ConclusionScanned images can be analyzed using vessel assessment software. Investigations of individual ICF versus constant ICF point out the asset of utilizing an individual ICF. Image settings (ODC vs. MC) were shown to have good agreement.
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Affiliation(s)
- Carolin Schanner
- Department of Ophthalmology and Medical Research Center, Oulu University Hospital, Oulu, Finland
- PEDEGO Research Unit, University of Oulu, Oulu, Finland
- Institute for Medical Informatics, Statistics, and Epidemiology, Leipzig University, Leipzig, Germany
| | - Nina Hautala
- Department of Ophthalmology and Medical Research Center, Oulu University Hospital, Oulu, Finland
- PEDEGO Research Unit, University of Oulu, Oulu, Finland
| | - Franziska G. Rauscher
- Institute for Medical Informatics, Statistics, and Epidemiology, Leipzig University, Leipzig, Germany
| | - Aura Falck
- Department of Ophthalmology and Medical Research Center, Oulu University Hospital, Oulu, Finland
- PEDEGO Research Unit, University of Oulu, Oulu, Finland
- *Correspondence: Aura Falck,
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Ding Q, Wu H, Wang W, Xiong K, Gong X, Yuan G, Li T, Li Y, Liu H, Wang L, Huang W. Association of Body Mass Index and Waist-to-Hip Ratio With Retinal Microvasculature in Healthy Chinese Adults: An Optical Coherence Tomography Angiography Study. Am J Ophthalmol 2023; 246:96-106. [PMID: 36240858 DOI: 10.1016/j.ajo.2022.09.012] [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: 12/17/2021] [Revised: 09/14/2022] [Accepted: 09/20/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE To investigate the association of body mass index (BMI) and waist-to-hip ratio (WHR) with macular vessel density (VD) and foveal avascular zone (FAZ), using optical coherence tomography angiography (OCTA), in healthy Chinese adults. DESIGN Cross-sectional study. METHODS A total of 1555 Chinese adults aged ≥ 50 years with no history of ocular disease were recruited from communities in Guangzhou, China. The OCTA was performed with a 6 × 6 mm macular angiography model. The FAZ of the superficial capillary plexus (SCP), and VD of SCP and deep capillary plexus (DCP) were calculated. Univariable and multivariable linear regression analyses were used to evaluate the effect of BMI and WHR on VD and FAZ. RESULTS The VD of the SCP increased as BMI increased, with average measurements of 39.30 ± 2.14 for normal, 39.52 ± 2.07 for overweight, and 39.76 ± 2.03 for obesity (P = .001). The VD of the DCP also increased with increasing BMI (P = .009). Multiple regression models confirmed a positive association between generalized obesity and superficial VD in the whole image (β = 0.350, P = .008), inner circle (β = 0.431, P = .032), and outer circle (β = 0.368, P = .005). After adjusting for confounders, tertile 3 of the WHR level was positively associated with superficial VD (β = 0.472, P = .033) and deep VD (β = 0.422, P = .034) only in the inner circle. CONCLUSIONS Generalized obesity was associated with increased superficial VD, while abdominal obesity was associated with increased superficial and deep VD only in the inner circle. Different manifestations of the retinal microvasculature may reflect distinct roles of body composition on macular vessel alterations and disease occurrence.
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Affiliation(s)
- Qiong Ding
- From 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 (Q.D, W.W., K.X., X.G., L.W., W.H.); The First People's Hospital of Zhaoqing, Zhaoqing City, China (Q.D., G.Y., T.L., Y.L.)
| | - Huimin Wu
- Shenzhen Children's Hospital, Shenzhen, Guangdong, China (H.W.)
| | - Wei Wang
- From 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 (Q.D, W.W., K.X., X.G., L.W., W.H.)
| | - Kun Xiong
- From 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 (Q.D, W.W., K.X., X.G., L.W., W.H.)
| | - Xia Gong
- From 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 (Q.D, W.W., K.X., X.G., L.W., W.H.)
| | - Guiliang Yuan
- The First People's Hospital of Zhaoqing, Zhaoqing City, China (Q.D., G.Y., T.L., Y.L.)
| | - Tengchao Li
- The First People's Hospital of Zhaoqing, Zhaoqing City, China (Q.D., G.Y., T.L., Y.L.)
| | - Youjia Li
- The First People's Hospital of Zhaoqing, Zhaoqing City, China (Q.D., G.Y., T.L., Y.L.)
| | - Hua Liu
- Department of Ophthalmology, Third Affiliated Hospital of Jinzhou Medical University, Jinzhou, China (H.L.).
| | - Lanhua Wang
- From 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 (Q.D, W.W., K.X., X.G., L.W., W.H.).
| | - Wenyong Huang
- From 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 (Q.D, W.W., K.X., X.G., L.W., W.H.)
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Luo X, Zhang H, Su J, Wong WK, Li J, Xu Y. RV-ESA: A novel computer-aided elastic shape analysis system for retinal vessels in diabetic retinopathy. Comput Biol Med 2023; 152:106406. [PMID: 36521357 DOI: 10.1016/j.compbiomed.2022.106406] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 11/06/2022] [Accepted: 12/03/2022] [Indexed: 12/12/2022]
Abstract
Diabetic retinopathy (DR), one of the most common and serious complications of diabetes, has become one of the main blindness diseases. The retinal vasculature is the only part of the human circulatory system that allows direct noninvasive visualization of the body's microvasculature, which provides the opportunity to detect the structural and functional changes before DR becomes unable to intervene. For decades, as the fundamental step in computer-assisted analysis of retinopathy, retinal vascular extraction methods have been largely developed. However, further research focusing on retinal vascular analysis is still in its infancy. Meanwhile, due to the complexity of retinal vascular structure, the relationship between vascular geometry and DR has never been concluded. This paper aims to provide a novel computer-aided shape analysis system for retinal vessels. To perform retinal vascular shape analysis, a mathematical geometric representation is firstly generated by utilizing the proposed shape modeling method. Then, several useful statistical tools (e.g. Graph Mean, Graph PCA) are adopted to quantitatively analyze the vascular shape. Besides, in order to visualize the changes in vascular shape in the progression of DR, a geodesic tool is used to display the deformation process for ophthalmologists to observe. The efficacy of this analysis system is demonstrated in the EyePACS dataset and the subsequent visit records of 98 patients from the proprietary dataset. The experimental results show that there is a certain correlation between the variation of retinal vascular shape and DR progression, and the Graph PCA scores of retinal vessels are negatively correlated with DR grades. The code of our RV-ESA system can be publicly available at github.com/XiaolingLuo/RV-ESA.
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Affiliation(s)
| | | | - Jingyong Su
- Harbin Institute of Technology, Shenzhen, China.
| | - Wai Keung Wong
- The Hong Kong Polytechnic University, Kowloon, Hong Kong SAR; Laboratory for Artificial Intelligence in Design, Hong Kong SAR.
| | - Jinkai Li
- Harbin Institute of Technology, Shenzhen, China
| | - Yong Xu
- Harbin Institute of Technology, Shenzhen, China; Shenzhen Key Laboratory of Visual Object Detection and Recognition, China
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Sun C, Chen T, Cong J, Wu X, Wang J, Yuan Y. Changes in retinal vascular bifurcation in eyes with myopia. BMC Ophthalmol 2022; 22:408. [PMID: 36271390 PMCID: PMC9585760 DOI: 10.1186/s12886-022-02629-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/06/2022] [Accepted: 10/04/2022] [Indexed: 11/15/2022] Open
Abstract
Objective To evaluate the effect of myopia on retinal vascular bifurcation. Methods A cross-sectional study that retrospectively analyzed the fundus photographs and clinical data of 493 people who participated in routine physical examinations in Huadong Sanatorium. One eye of each subject was included in the analysis. Retinal vascular bifurcation measurements were extracted by using a validated computer program. One-way ANOVA and analysis of covariance were performed to compare the measurements across high myopia, low to moderate myopia, and non-myopia groups. Results The mean age was 41.83 ± 10.43 years and 63.49% were women. The mean spherical equivalent refraction (SER) was − 4.59 ± 3.07 D. Ninety-nine (20.08%) eyes met the definition of high myopia (SER ≤ -6.0 D), along with 234 (47.46%) low to moderate myopia (-6.0 D < SER <-0.5 D), and 160 (32.45%) non-myopia (SER ≥ -0.5 D). The differences in the arteriolar branching angle, venular branching coefficient, venular asymmetry ratio, venular angular asymmetry, and venular junctional exponent among the three groups remained significant (p < 0.05) after multivariate adjustment. Pairwise comparisons showed arteriolar branching angle and venular angular asymmetry in high myopia were significantly lower than low to moderate myopia (p < 0.001, p = 0.014 respectively) and non-myopia (p = 0.007, p = 0.048 respectively). Venular asymmetry ratio and venular branching coefficient in high myopia were significantly higher than low to moderate myopia (p = 0.029, p = 0.001 respectively) and non-myopia (p = 0.041, p = 0.043 respectively). There was a significant difference in venular junctional exponent between high myopia and low to moderate myopia (p = 0.031). Conclusion The vascular bifurcation differs in dependence on the myopic refractive error and a significant increase in the difference can be observed in high myopic eyes.
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Affiliation(s)
- Caixia Sun
- Department of Ophthalmology, Zhongshan Hospital, Fudan University, 200032, Shanghai, China
| | - Tingli Chen
- Department of Ophthalmology, Huadong Sanatorium, Wuxi, Jiangsu Province, China
| | - Jing Cong
- Department of Ophthalmology, Zhongshan Hospital, Fudan University, 200032, Shanghai, China
| | - Xinyuan Wu
- Department of Ophthalmology, Zhongshan Hospital, Fudan University, 200032, Shanghai, China
| | - Jing Wang
- Department of Ophthalmology, Huadong Sanatorium, Wuxi, Jiangsu Province, China
| | - Yuanzhi Yuan
- Department of Ophthalmology, Zhongshan Hospital, Fudan University, 200032, Shanghai, China. .,Department of Ophthalmology, Zhongshan Hospital (Xiamen), Fudan University, Xiamen, Fujian Province, China. .,Center for Evidence-based Medicine, Fudan University, Shanghai, China.
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Tapp RJ, Owen CG, Barman SA, Strachan DP, Welikala RA, Foster PJ, Whincup PH, Rudnicka AR. Retinal microvascular associations with cardiometabolic risk factors differ by diabetes status: results from the UK Biobank. Diabetologia 2022; 65:1652-1663. [PMID: 35852586 PMCID: PMC9477904 DOI: 10.1007/s00125-022-05745-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 03/25/2022] [Indexed: 12/30/2022]
Abstract
AIMS/HYPOTHESIS The aim of the study was to examine the association of retinal vessel morphometry with BP, body composition and biochemistry, and to determine whether these associations differ by diabetes status. METHODS The UK Biobank ocular assessment included 68,550 participants aged 40-70 years who underwent non-mydriatic retinal photography, BP and body composition measurements, and haematological analysis. A fully automated image analysis program provided measurements of retinal vessel diameter and tortuosity. The associations between retinal vessel morphology and cardiometabolic risk factors by diabetes status were examined using multilevel linear regression, to provide absolute differences in vessel diameter and percentage differences in tortuosity (allowing for within-person clustering). RESULTS A total of 50,233 participants (a reduction from 68,550) were included in these analyses. Overall, those with diabetes had significantly more tortuous venules and wider arteriolar diameters compared with those without. Associations between venular tortuosity and cardiometabolic risk factors differed according to diabetes status (p interaction <0.01) for total fat mass index, HbA1c, C-reactive protein, white cell count and granulocyte count. For example, a unit rise in white cell count was associated with a 0.18% increase (95% CI 0.05, 0.32%) in venular tortuosity for those without diabetes and a 1.48% increase (95% CI 0.90, 2.07%) among those with diabetes. For arteriolar diameter, significant interactions were evident for systolic BP, diastolic BP, mean arterial pressure (MAP) and LDL-cholesterol. For example, a 10 mmHg rise in systolic BP was associated with a -0.92 μm difference (95% CI -0.96 to -0.88 μm) in arteriolar diameter for those without diabetes, and a -0.58 μm difference (95% CI -0.76 to -0.41 μm) among those with diabetes. No interactions were observed for arteriolar tortuosity or venular diameters. CONCLUSIONS/INTERPRETATION We provide clear evidence of the modifying effect of diabetes on cardiometabolic risk factor associations with retinal microvascular architecture. These observations suggest the occurrence of preclinical disease processes, and may be a sign of impaired autoregulation due to hyperglycaemia, which has been suggested to play a pivotal role in the development of diabetes-related microvascular complications. DATA AVAILABILITY The data supporting the results reported here are available through the UK Biobank ( https://www.ukbiobank.ac.uk/enable-your-research/apply-for-access ).
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Affiliation(s)
- Robyn J Tapp
- Population Health Research Institute, St George's, University of London, London, UK.
- Research Centre for Intelligent Healthcare, Coventry University, Coventry, UK.
| | - Christopher G Owen
- Population Health Research Institute, St George's, University of London, London, UK
| | - Sarah A Barman
- Faculty of Science, Engineering and Computing, Kingston University, Kingston upon Thames, Surrey, UK
| | - David P Strachan
- Population Health Research Institute, St George's, University of London, London, UK
| | - Roshan A Welikala
- Faculty of Science, Engineering and Computing, Kingston University, Kingston upon Thames, Surrey, UK
| | - Paul J Foster
- Integrative Epidemiology Research Group, UCL Institute of Ophthalmology, London, UK
- NIHR Biomedical Research Centre at Moorfields Eye Hospital, London, UK
| | - Peter H Whincup
- Population Health Research Institute, St George's, University of London, London, UK
| | - Alicja R Rudnicka
- Population Health Research Institute, St George's, University of London, London, UK.
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Hanssen H, Streese L, Vilser W. Retinal vessel diameters and function in cardiovascular risk and disease. Prog Retin Eye Res 2022; 91:101095. [PMID: 35760749 DOI: 10.1016/j.preteyeres.2022.101095] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/03/2022] [Accepted: 06/13/2022] [Indexed: 12/13/2022]
Abstract
In the last two decades evidence has gradually accumulated suggesting that the eye may be a unique window for cardiovascular risk stratification based on the assessment of subclinical damage of retinal microvascular structure and function. This can be facilitated by non-invasive analysis of static retinal vessel diameters and dynamic recording of flicker light-induced and endothelial function-related dilation of both retinal arterioles and venules. Recent new findings have made retinal microvascular biomarkers strong candidates for clinical implementation as reliable risk predictors. Beyond a review of the current evidence and state of research, the article aims to discuss the methodological benefits and pitfalls and to identify research gaps and future directions. Above all, the potential use for screening and treatment monitoring of cardiovascular disease risk are highlighted. The article provides fundamental comprehension of retinal vessel imaging by explaining anatomical and physiological essentials of the retinal microcirculation leading to a detailed description of the methodological approach. This allows for better understanding of the underlying retinal microvascular pathology associated with the prevalence and development of cardiovascular disease. A body of new evidence is presented on the clinical validity and predictive value of retinal vessel diameters and function for incidence cardiovascular disease and outcome. Findings in children indicate the potential for utility in childhood cardiovascular disease prevention, and the efficacy of exercise interventions highlight the treatment sensitivity of retinal microvascular biomarkers. Finally, coming from the availability of normative data, solutions for diagnostic challenges are discussed and conceptual steps towards clinical implementation are put into perspective.
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Affiliation(s)
- Henner Hanssen
- Department of Sport, Exercise and Health, Preventive Sports Medicine and Systems Physiology, Medical Faculty, University of Basel, Switzerland.
| | - Lukas Streese
- Department of Sport, Exercise and Health, Preventive Sports Medicine and Systems Physiology, Medical Faculty, University of Basel, Switzerland
| | - Walthard Vilser
- Institute of Biomedical Engineering and Informatics, Ilmenau University of Technology, Ilmenau, Germany; Neonatology and Pediatric Intensive Care Unit, Department of Pediatrics, Jena University Hospital, Jena, Germany
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Feng Z, Wang G, Xia H, Li M, Liang G, Dong T, Xiao P, Yuan J. Macular Vascular Geometry Changes With Sex and Age in Healthy Subjects: A Fundus Photography Study. Front Med (Lausanne) 2021; 8:778346. [PMID: 34977079 PMCID: PMC8714757 DOI: 10.3389/fmed.2021.778346] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/17/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: To characterize the sex- and age-related alterations of the macular vascular geometry in a population of healthy eyes using fundus photography. Methods: A cross-sectional study was conducted with 610 eyes from 305 healthy subjects (136 men, 169 women) who underwent fundus photography examination and was divided into four age groups (G1 with age ≤ 25 years, G2 with age 26–35 years, G3 with age 36–45 years, and G4 with age ≥ 46 years). A self-developed automated retinal vasculature analysis system allowed segmentation and separate multiparametric quantification of the macular vascular network according to the Early Treatment Diabetic Retinopathy Study (ETDRS). Vessel fractal dimension (Df), vessel area rate (VAR), average vessel diameter (Dm), and vessel tortuosity (τn) were acquired and compared between sex and age groups. Results: There was no significant difference between the mean age of male and female subjects (32.706 ± 10.372 and 33.494 ± 10.620, respectively, p > 0.05) and the mean age of both sexes in each age group (p > 0.05). The Df, VAR, and Dm of the inner ring, the Df of the outer ring, and the Df and VAR of the whole macula were significantly greater in men than women (p < 0.001, p < 0.001, p < 0.05, respectively). There was no significant change of τn between males and females (p > 0.05). The Df, VAR, and Dm of the whole macula, the inner and outer rings associated negatively with age (p < 0.001), whereas the τn showed no significant association with age (p > 0.05). Comparison between age groups observed that Df started to decrease from G2 compared with G1 in the inner ring (p < 0.05) and Df, VAR, and Dm all decreased from G3 compared with the younger groups in the whole macula, inner and outer rings (p < 0.05). Conclusion: In the healthy subjects, macular vascular geometric parameters obtained from fundus photography showed that Df, VAR, and Dm are related to sex and age while τn is not. The baseline values of the macular vascular geometry were also acquired for both sexes and all age groups.
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Affiliation(s)
- Ziqing Feng
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Gengyuan Wang
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Honghui Xia
- Department of Ophthalmology, Zhaoqing Gaoyao People's Hospital, Zhaoqing, China
| | - Meng Li
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
| | - Guoxia Liang
- Department of Ophthalmology, Zhaoqing Gaoyao People's Hospital, Zhaoqing, China
| | - Tingting Dong
- Department of Ophthalmology, Zhaoqing Gaoyao People's Hospital, Zhaoqing, China
| | - Peng Xiao
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
- *Correspondence: Peng Xiao
| | - Jin Yuan
- State Key Laboratory of Ophthalmology, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Diseases, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China
- Jin Yuan
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Autoimmune Rheumatic Diseases and Vascular Function: The Concept of Autoimmune Atherosclerosis. J Clin Med 2021; 10:jcm10194427. [PMID: 34640445 PMCID: PMC8509415 DOI: 10.3390/jcm10194427] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 12/18/2022] Open
Abstract
Autoimmune rheumatic diseases (AIRDs) with unknown etiology are increasing in incidence and prevalence. Up to 5% of the population is affected. AIRDs include rheumatoid arthritis, system lupus erythematosus, systemic sclerosis, and Sjögren's syndrome. In patients with autoimmune diseases, the immune system attacks structures of its own body, leading to widespread tissue and organ damage, which, in turn, is associated with increased morbidity and mortality. One third of the mortality associated with autoimmune diseases is due to cardiovascular diseases. Atherosclerosis is considered the main underlying cause of cardiovascular diseases. Currently, because of finding macrophages and lymphocytes at the atheroma, atherosclerosis is considered a chronic immune-inflammatory disease. In active inflammation, the liberation of inflammatory mediators such as tumor necrotic factor alpha (TNFa), interleukine-6 (IL-6), IL-1 and other factors like T and B cells, play a major role in the atheroma formation. In addition, antioxidized, low-density lipoprotein (LDL) antibodies, antinuclear antibodies (ANA), and rheumatoid factor (RF) are higher in the atherosclerotic patients. Traditional risk factors like gender, age, hypercholesterolemia, smoking, diabetes mellitus, and hypertension, however, do not alone explain the risk of atherosclerosis present in autoimmune diseases. This review examines the role of chronic inflammation in the etiology-and progression-of atherosclerosis in autoimmune rheumatic diseases. In addition, discussed here in detail are the possible effects of autoimmune rheumatic diseases that can affect vascular function. We present here the current findings from studies that assessed vascular function changes using state-of-the-art techniques and innovative endothelial function biomarkers.
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The Relation between Body Mass Index and Retinal Photoreceptor Morphology and Microvascular Changes Measured with Adaptive Optics (rtx1) High-Resolution Imaging. J Ophthalmol 2021; 2021:6642059. [PMID: 33728057 PMCID: PMC7935605 DOI: 10.1155/2021/6642059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 02/11/2021] [Accepted: 02/17/2021] [Indexed: 11/20/2022] Open
Abstract
Background Overweight and obese patients are at risk for diabetes, cardiovascular disorders, and microvascular complications. The rtx1TM (Imagine Eyes, France) is a microscope that allows near histological visualizations of cones and retinal microcirculation. Objective This study analysed the cones and retinal microvascular changes in a group of 47 healthy women with different BMI values. Participants were divided into 2 groups: the BMI group (28 women with BMI >/25) and the control group (19 lean women with BMI <25). Results The lumen and diameter of retinal arteries were not significantly different between groups. There were significant differences in the thickness of arteriole walls. The WLR and WCSA values differed significantly between the control and BMI groups (for WLR 0.25 ± 0.03 vs. 0.29 ± 0.03, p < 0.001; for WCSA 4136.7 ± 1140.0 vs. 5217.3 ± 944.0, respectively, p < 0.001). In healthy eyes, cone density and morphology were not affected by weight. Conclusions Retinal image analysis with rtx1 offers a novel noninvasive measurement of early changes in retinal vasculature that are not detectable during routine clinical examination. Abnormalities of retinal arterioles found by rtx1™examination should be considered as a strong risk factor for cardiovascular changes resulting from overweight and obesity.
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Tapp RJ, Owen CG, Barman SA, Welikala RA, Foster PJ, Whincup PH, Strachan DP, Rudnicka AR. Retinal Vascular Tortuosity and Diameter Associations with Adiposity and Components of Body Composition. Obesity (Silver Spring) 2020; 28:1750-1760. [PMID: 32725961 PMCID: PMC7116641 DOI: 10.1002/oby.22885] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 03/18/2020] [Accepted: 05/06/2020] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The aim of this study was to assess whether adiposity or body composition relates to microvascular characteristics of the retina, indicative of cardiometabolic function. METHODS A fully automated QUARTZ software processed retinal images from 68,550 UK Biobank participants (aged 40-69 years). Differences in retinal vessel diameter and tortuosity with body composition measures from the Tanita analyzer were obtained by using multilevel regression analyses adjusted for age, sex, ethnicity, clinic, smoking, and Townsend deprivation index. RESULTS Venular tortuosity and diameter increased by approximately 2% (P < 10-300 ) and 0.6 μm (P < 10-6 ), respectively, per SD increase in BMI, waist circumference index, waist-hip ratio, total body fat mass index, and fat-free mass index (FFMI). Venular associations with adiposity persisted after adjustment for FFMI, whereas associations with FFMI were weakened by FMI adjustment. Arteriolar diameter (not tortuosity) narrowing with FFMI was independent of adiposity (-0.6 μm; -0.7 to -0.4 μm per SD increment of FFMI), while adiposity associations with arteriolar diameter were largely nonsignificant after adjustment for FFMI. CONCLUSIONS This demonstrates, on an unprecedented scale, that venular tortuosity and diameter are more strongly associated with adiposity, whereas arteriolar diameter relates more strongly to fat-free mass. Different attributes of the retinal microvasculature may reflect distinct roles of body composition and fatness on the cardiometabolic system.
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Affiliation(s)
- Robyn J Tapp
- Population Health Research Institute, St George's, University of London, London, UK
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Christopher G Owen
- Population Health Research Institute, St George's, University of London, London, UK
| | - Sarah A Barman
- Faculty of Science, Engineering and Computing, Kingston University, Surrey, UK
| | - Roshan A Welikala
- Faculty of Science, Engineering and Computing, Kingston University, Surrey, UK
| | - Paul J Foster
- Integrative Epidemiology Research Group, UCL Institute of Ophthalmology, London, UK
- NIHR Biomedical Research Centre at Moorfields Eye Hospital, London, UK
| | - Peter H Whincup
- Population Health Research Institute, St George's, University of London, London, UK
| | - David P Strachan
- Population Health Research Institute, St George's, University of London, London, UK
| | - Alicja R Rudnicka
- Population Health Research Institute, St George's, University of London, London, UK
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McKay GJ, McCarter RV, Hogg RE, Higbee DH, Bajaj MPK, Burrage DR, Ruickbie S, Baker EH, Jones PW, Dodd JW. Simple non-mydriatic retinal photography is feasible and demonstrates retinal microvascular dilation in Chronic Obstructive Pulmonary Disease (COPD). PLoS One 2020; 15:e0227175. [PMID: 31923188 PMCID: PMC6953864 DOI: 10.1371/journal.pone.0227175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 12/05/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Chronic Obstructive Pulmonary Disease (COPD) is associated with an increased risk of myocardial infarction and stroke but it remains unclear how to identify microvascular changes in this population. OBJECTIVES We hypothesized that simple non-mydriatic retinal photography is feasible and can be used to assess microvascular damage in COPD. METHODS Novel Vascular Manifestations of COPD was a prospective study comparing smokers with and without COPD, matched for age. Non-mydriatic, retinal fundus photographs were assessed using semi-automated software. RESULTS Retinal images from 24 COPD and 22 control participants were compared. Cases were of similar age to controls (65.2 vs. 63.1 years, p = 0.38), had significantly lower Forced Expiratory Volume in one second (FEV1) (53.4 vs 100.1% predicted; p < 0.001) and smoked more than controls (41.7 vs. 29.6 pack years; p = 0.04). COPD participants had wider mean arteriolar (155.6 ±15 uM vs. controls [142.2 ± 12 uM]; p = 0.002) and venular diameters (216.8 ±20.7 uM vs. [201.3± 19.1 uM]; p = 0.012). Differences in retinal vessel caliber were independent of confounders, odds ratios (OR) = 1.08 (95% confidence intervals [CI] = 1.02, 1.13; p = 0.007) and OR = 1.05 (CI = 1.01, 1.09; p = 0.011) per uM increase in arteriolar and venular diameter respectively. FEV1 remained significantly associated with retinal vessel dilatation r = -0.39 (p = 0.02). CONCLUSIONS Non-mydriatic retinal imaging is easily facilitated. We found significant arteriole and venous dilation in COPD compared to age-matched smokers without COPD associated with lung function independent of standard cardiovascular risk factors. Retinal microvascular changes are known to be strongly associated with future vascular events and retinal photography offers potential to identify this risk. TRIAL REGISTRATION clinicaltrials.gov NCT02060292.
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Affiliation(s)
- G. J. McKay
- Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland
| | - R. V. McCarter
- Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland
| | - R. E. Hogg
- Centre for Public Health, Queen’s University Belfast, Belfast, Northern Ireland
| | - D. H. Higbee
- Academic Respiratory Unit, Southmead Hospital, Bristol, United Kingdom
| | - M-P. K. Bajaj
- Clinical Pharmacology, Institute of Infection and Immunity Institute, St George’s, University of London, London, United Kingdom
| | - D. R. Burrage
- Neuroscience Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
- Clinical Pharmacology, Institute of Infection and Immunity Institute, St George’s, University of London, London, United Kingdom
| | - S. Ruickbie
- Neuroscience Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
- Clinical Pharmacology, Institute of Infection and Immunity Institute, St George’s, University of London, London, United Kingdom
| | - E. H. Baker
- Neuroscience Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, London, United Kingdom
| | - P. W. Jones
- Academic Respiratory Unit, Southmead Hospital, Bristol, United Kingdom
| | - J. W. Dodd
- Academic Respiratory Unit, Southmead Hospital, Bristol, United Kingdom
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Appaji A, Nagendra B, Chako DM, Padmanabha A, Jacob A, Hiremath CV, Varambally S, Kesavan M, Venkatasubramanian G, Rao SV, Webers CAB, Berendschot TTJM, Rao NP. Retinal vascular tortuosity in schizophrenia and bipolar disorder. Schizophr Res 2019; 212:26-32. [PMID: 31466896 DOI: 10.1016/j.schres.2019.08.020] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/23/2019] [Accepted: 08/18/2019] [Indexed: 11/20/2022]
Abstract
The micro-vasculature of retina and brain share common morphological, physiological, and pathological properties. Retina being easily accessible, retinal vascular examination provides an indirect assessment of cerebral vasculature. Considering the high prevalence of vascular morbidity in SCZ and BD a few studies have examined retinal vascular caliber and have reported increased retinal venular caliber in schizophrenia (SCZ). Retinal vascular tortuosity could serve as a better structural measure than caliber as it is static and less susceptible to pulse period variations. However, to date, no study has examined retinal vascular tortuosity in SCZ and bipolar disorder (BD). Hence, we examined retinal vascular tortuosity in comparison with healthy volunteers (HV). We included 255 subjects (78 HV, 79 SCZ, and 86 BD) in the age range of 18 to 50 years. Trained personnel acquired images using a non-mydriatic fundus camera. To measure the average retinal arteriolar tortuosity index (RATI) and retinal venular tortuosity index (RVTI), we used a previously validated, semi-automatic algorithm. The results showed significant differences across the three groups in RATI but not in RVTI; both BD and SCZ had significantly increased RATI compared to HV. There was also a significant difference between SCZ and BD, with BD having higher RATI. If shown to be of predictive utility in future longitudinal studies, it has the potential to identify patients at risk of development of adverse vascular events. As retinal vascular imaging is non-invasive and inexpensive, it could serve as a proxy marker and window to cerebral vasculature.
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Affiliation(s)
- Abhishek Appaji
- Department of Medical Electronics, B.M.S. College of Engineering, Bangalore, India; University Eye Clinic Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Bhargavi Nagendra
- Dept. of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Dona Maria Chako
- Dept. of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Ananth Padmanabha
- Department of Medical Electronics, B.M.S. College of Engineering, Bangalore, India
| | - Arpitha Jacob
- Dept. of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Chaitra V Hiremath
- Dept. of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Shivarama Varambally
- Dept. of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Muralidharan Kesavan
- Dept. of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India
| | | | - Shyam Vasudeva Rao
- Department of Medical Electronics, B.M.S. College of Engineering, Bangalore, India; University Eye Clinic Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Carroll A B Webers
- University Eye Clinic Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Tos T J M Berendschot
- University Eye Clinic Maastricht, Maastricht University, Maastricht, the Netherlands
| | - Naren P Rao
- Dept. of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, India.
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Tapp RJ, Hughes AD, Kähönen M, Wong TY, Witt N, Lehtimäki T, Hutri-Kähönen N, Sahota P, Juonala M, Raitakari OT. Cardiometabolic Health Among Adult Offspring of Hypertensive Pregnancies: The Cardiovascular Risk in Young Finns Study. J Am Heart Assoc 2018; 7:JAHA.117.006284. [PMID: 29306901 PMCID: PMC5778953 DOI: 10.1161/jaha.117.006284] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background Cardiometabolic health among adult offspring of hypertensive disorders of pregnancy (HDP) is relatively unknown. We hypothesized that offspring of HDP would have abnormalities in the retinal microvasculature and cardiac structure by midadulthood. Methods and Results The Cardiovascular Risk in Young Finns Study included randomly selected children from 5 Finnish university cities. The mean age of participants was 40 years (range 34–49 years) at the time of retinal photography and cardiac assessment. Offspring born ≥37 weeks of gestation and appropriate for gestational age (n=1006) were included. Offspring of HDP had higher systolic blood pressure (β=4.68, P<0.001), body mass index (β=1.25, P=0.009), and waist circumference (β=0.25, P=0.042), compared with offspring of normotensive pregnancies. However, no differences in fasting glucose, insulin, lipid profile, carotid intima media thickness, or brachial artery flow‐mediated dilatation were shown. Retinal arteriolar diameters were narrower (β=−0.43, P=0.009) and longer (β=32.5, P=0.023) and the arteriolar length‐to‐diameter ratio was higher (β=2.32, P=0.006) among offspring of HDP, after adjustment for age and sex. Left atrial volume indexed to body surface area (β=1.34, P=0.040) was increased. Adjustment for the confounding effects of birth weight, body mass index, smoking and socioeconomic status, and the mediating effect of hypertension had little impact on the associations. Conclusions Abnormalities of the retinal microvasculature and cardiac structure are seen in offspring of HDP in midadulthood. These findings may need to be considered in future primary prevention strategies of cardiovascular disease among offspring of HDP.
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Affiliation(s)
- Robyn J Tapp
- Melbourne School of Population and Global Health University of Melbourne, Australia .,School of Clinical and Applied Sciences, Leeds Beckett University, Leeds, United Kingdom.,Department of Optometry and Vision Sciences, The University of Melbourne, Australia
| | - Alun D Hughes
- Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Mika Kähönen
- Department of Clinical Physiology, Tampere University Hospital and the University of Tampere, Finland
| | - Tien Yin Wong
- Singapore National Eye Center, Singapore & Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, National University of Singapore, Singapore
| | - Nicholas Witt
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Terho Lehtimäki
- Department of Clinical Chemistry, Fimlab Laboratories and School of Medicine, University of Tampere, Finland
| | - Nina Hutri-Kähönen
- Department of Pediatrics, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Pinki Sahota
- School of Clinical and Applied Sciences, Leeds Beckett University, Leeds, United Kingdom
| | - Markus Juonala
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Finland.,Turku University Hospital, Turku, Finland
| | - Olli T Raitakari
- Research Centre of Applied and Preventive Cardiovascular Medicine, University of Turku, Finland.,Department of Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku, Finland
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15
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Chan VTT, Tso THK, Tang F, Tham C, Mok V, Chen C, Wong TY, Cheung CY. Using Retinal Imaging to Study Dementia. J Vis Exp 2017. [PMID: 29155753 DOI: 10.3791/56137] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The retina offers a unique "window" to study pathophysiological processes of dementia in the brain, as it is an extension of the central nervous system (CNS) and shares prominent similarities with the brain in terms of embryological origin, anatomical features and physiological properties. The vascular and neuronal structure in the retina can now be visualized easily and non-invasively using retinal imaging techniques, including fundus photography and optical coherence tomography (OCT), and quantified semi-automatically using computer-assisted analysis programs. Studying the associations between vascular and neuronal changes in the retina and dementia could improve our understanding of dementia and, potentially, aid in diagnosis and risk assessment. This protocol aims to describe a method of quantifying and analyzing retinal vasculature and neuronal structure, which are potentially associated with dementia. This protocol also provides examples of retinal changes in subjects with dementia, and discusses technical issues and current limitations of retinal imaging.
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Affiliation(s)
- Victor T T Chan
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong
| | - Tiffany H K Tso
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong
| | - Fangyao Tang
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong
| | - Clement Tham
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong
| | - Vincent Mok
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong; Therese Pei Fong Chow Research Centre for Prevention of Dementia, The Chinese University of Hong Kong; Gerald Choa Neuroscience Centre, The Chinese University of Hong Kong
| | - Christopher Chen
- Memory Aging and Cognition Centre, National University Health System; Department of Pharmacology, National University of Singapore
| | - Tien Y Wong
- Singapore Eye Research Institute, Singapore National Eye Centre; Duke-NUS Medical School, National University of Singapore
| | - Carol Y Cheung
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong;
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16
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Houben AJHM, Martens RJH, Stehouwer CDA. Assessing Microvascular Function in Humans from a Chronic Disease Perspective. J Am Soc Nephrol 2017; 28:3461-3472. [PMID: 28904002 DOI: 10.1681/asn.2017020157] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Microvascular dysfunction (MVD) is considered a crucial pathway in the development and progression of cardiometabolic and renal disease and is associated with increased cardiovascular mortality. MVD often coexists with or even precedes macrovascular disease, possibly due to shared mechanisms of vascular damage, such as inflammatory processes and oxidative stress. One of the first events in MVD is endothelial dysfunction. With the use of different physiologic or pharmacologic stimuli, endothelium-dependent (micro)vascular reactivity can be studied. This reactivity depends on the balance between various mediators, including nitric oxide, endothelin, and prostanoids, among others. The measurement of microvascular (endothelial) function is important to understand the pathophysiologic mechanisms that contribute to MVD and the role of MVD in the development and progression of cardiometabolic/renal disease. Here, we review a selection of direct, noninvasive techniques for measuring human microcirculation, with a focus on methods, interpretation, and limitations from the perspective of chronic cardiometabolic and renal disease.
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Affiliation(s)
- Alfons J H M Houben
- Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands; and .,CARIM School for Cardiovascular Diseases and
| | - Remy J H Martens
- Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands; and.,School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Coen D A Stehouwer
- Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands; and.,CARIM School for Cardiovascular Diseases and
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Cheung CYL, Sabanayagam C, Law AKP, Kumari N, Ting DSW, Tan G, Mitchell P, Cheng CY, Wong TY. Retinal vascular geometry and 6 year incidence and progression of diabetic retinopathy. Diabetologia 2017. [PMID: 28623387 DOI: 10.1007/s00125-017-4333-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIMS/HYPOTHESIS We aimed to examine prospectively the association between a range of retinal vascular geometric variables measured from retinal photographs and the 6 year incidence and progression of diabetic retinopathy. METHODS We conducted a prospective, population-based cohort study of Asian Malay individuals aged 40-80 years at baseline (n = 3280) who returned for a 6 year follow-up. Retinal vascular geometric variables (tortuosity, branching, fractal dimension, calibre) were measured from baseline retinal photographs using a computer-assisted program (Singapore I Vessel Assessment). Diabetic retinopathy was graded from baseline and follow-up photographs using the modified Airlie House classification system. Incidence of diabetic retinopathy was defined as a severity of ≥15 at follow-up among those without diabetic retinopathy at baseline. Incidence of referable diabetic retinopathy was defined as moderate or severe non-proliferative diabetic retinopathy, proliferative diabetic retinopathy or diabetic macular oedema at follow-up in participants who had had no or mild non-proliferative diabetic retinopathy at baseline. Progression of diabetic retinopathy was defined as an increase in severity of ≥2 steps at follow-up. Log-binomial models with an expectation-maximisation algorithm were used to estimate RR adjusting for age, sex, diabetes duration, HbA1c level, BP, BMI, estimated GFR and total and HDL-cholesterol at baseline. RESULTS A total of 427 individuals with diabetes participated in the baseline and 6 year follow-up examinations. Of these, 19.2%, 7.57% and 19.2% developed incidence of diabetic retinopathy, incidence of referable diabetic retinopathy and diabetic retinopathy progression, respectively. After multivariate adjustment, greater arteriolar simple tortuosity (mean RR [95% CI], 1.34 [1.04, 1.74]), larger venular branching angle (RR 1.26 [1.00, 1.59]) and larger venular branching coefficient (RR 1.26 [1.03, 1.56]) were associated with incidence of diabetic retinopathy. Greater arteriolar simple tortuosity (RR 1.82 [1.32, 2.52]), larger venular branching coefficient (RR 1.46 [1.03, 2.07]), higher arteriolar fractal dimension (RR 1.59 [1.08, 2.36]) and larger arteriolar calibre (RR 1.83 [1.15, 2.90]) were associated with incidence of referable diabetic retinopathy. Greater arteriolar simple tortuosity (RR 1.34 [1.12, 1.61]) was associated with diabetic retinopathy progression. Addition of retinal vascular variables improved discrimination (C-statistic 0.796 vs 0.733, p = 0.031) and overall reclassification (net reclassification improvement 18.8%, p = 0.025) of any diabetic retinopathy risk beyond established risk factors. CONCLUSIONS/INTERPRETATION Retinal vascular geometry measured from fundus photographs predicted the incidence and progression of diabetic retinopathy in adults with diabetes, beyond established risk factors.
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Affiliation(s)
- Carol Yim-Lui Cheung
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, 168751, Singapore, Republic of Singapore
- Department of Ophthalmology and Visual Sciences, Chinese University of Hong Kong, Hong Kong, Special Administrative Region, People's Republic of China
| | - Charumathi Sabanayagam
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, 168751, Singapore, Republic of Singapore
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Republic of Singapore
| | - Antony Kwan-Pui Law
- Department of Ophthalmology and Visual Sciences, Chinese University of Hong Kong, Hong Kong, Special Administrative Region, People's Republic of China
| | - Neelam Kumari
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, 168751, Singapore, Republic of Singapore
| | - Daniel Shu-Wei Ting
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, 168751, Singapore, Republic of Singapore
| | - Gavin Tan
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, 168751, Singapore, Republic of Singapore
| | - Paul Mitchell
- Centre for Vision Research, University of Sydney, Sydney, NSW, Australia
| | - Ching Yu Cheng
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, 168751, Singapore, Republic of Singapore
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Republic of Singapore
- Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, National University of Singapore, Singapore, Republic of Singapore
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, 11 Third Hospital Avenue, 168751, Singapore, Republic of Singapore.
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Republic of Singapore.
- Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, National University of Singapore, Singapore, Republic of Singapore.
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Abstract
OBJECTIVE To investigate associations of central retinal arteriolar equivalent (CRAE), a measure of retinal arteriolar width, and central retinal venular equivalents (CRVE), a measure of retinal venular width, with shiftwork in 199 police officers (72.9% men). METHODS Shiftwork (day, afternoon, night) was assessed using electronic payroll records. Four digital retinal images per officer were taken. Mean diameters of the retinal vasculature were compared across shifts using analysis of variance (ANOVA)/analysis of covariance (ANCOVA). RESULTS Among all officers (mean age = 46.6 ± 6.8 years), shiftwork was not significantly associated with CRAE or CRVE. However, among current and former smokers, night-shift officers had a wider mean (±standard error [SE]) CRVE (230.0 ± 4.5 μm) compared with day shift officers (215.1 ± 3.5 μm); adjusted P = 0.014. CONCLUSIONS Night shift schedule in current and former smokers is associated with wider retinal venules. Reasons for this association are not known. Longitudinal studies are warranted.
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Cheung CYL, Ikram MK, Chen C, Wong TY. Imaging retina to study dementia and stroke. Prog Retin Eye Res 2017; 57:89-107. [PMID: 28057562 DOI: 10.1016/j.preteyeres.2017.01.001] [Citation(s) in RCA: 165] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/07/2016] [Accepted: 01/01/2017] [Indexed: 02/07/2023]
Abstract
With increase in life expectancy, the number of persons suffering from common age-related brain diseases, including neurodegenerative (e.g., dementia) and cerebrovascular (e.g., stroke) disease is expected to rise substantially. As current neuro-imaging modalities such as magnetic resonance imaging may not be able to detect subtle subclinical changes (resolution <100-500 μm) in dementia and stroke, there is an urgent need for other complementary techniques to probe the pathophysiology of these diseases. The retina - due to its anatomical, embryological and physiological similarities with the brain - offers a unique and accessible "window" to study correlates and consequences of subclinical pathology in the brain. Retinal components such as the microvasculature and retinal ganglion cell axons can now be visualized non-invasively using different retinal imaging techniques e.g., ocular fundus photography and optical coherence tomography. Advances in retinal imaging may provide new and potentially important insights into cerebrovascular neurodegenerative processes in addition to what is currently possible with neuro-imaging. In this review, we present an overview of the current literature on the application of retinal imaging in the study of dementia and stroke. We discuss clinical implications of these studies, novel state-of-the-art retinal imaging techniques and future directions aimed at evaluating whether retinal imaging can be an additional investigation tool in the study of dementia and stroke.
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Affiliation(s)
- Carol Yim-Lui Cheung
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong.
| | - M Kamran Ikram
- Duke-NUS Graduate Medical School, National University of Singapore, Singapore; Departments of Neurology & Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Christopher Chen
- Memory Aging and Cognition Centre, National University Health System, Singapore; Department of Pharmacology, National University of Singapore, Singapore
| | - Tien Yin Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore; Duke-NUS Graduate Medical School, National University of Singapore, Singapore
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20
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Predicting bifurcation angle effect on blood flow in the microvasculature. Microvasc Res 2016; 108:22-8. [DOI: 10.1016/j.mvr.2016.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 04/25/2016] [Accepted: 07/02/2016] [Indexed: 11/20/2022]
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Cheung CY, Ikram MK, Klein R, Wong TY. The clinical implications of recent studies on the structure and function of the retinal microvasculature in diabetes. Diabetologia 2015; 58:871-85. [PMID: 25669631 DOI: 10.1007/s00125-015-3511-1] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/12/2015] [Indexed: 12/26/2022]
Abstract
The retinal blood vessels provide the opportunity to study early structural and functional changes in the microvasculature prior to clinically significant microvascular and macrovascular complications of diabetes. Advances in digital retinal photography and computerised assessment of the retinal vasculature have provided more objective and precise measurements of retinal vascular changes. Clinic- and population-based studies have reported that these quantitatively measured retinal vascular changes (e.g. retinal arteriolar narrowing and venular widening) are associated with preclinical structural changes in other microvascular systems (e.g. infarct in the cerebral microcirculation), as well as diabetes and diabetic complications, suggesting that they are markers of early microvascular dysfunction. In addition, there are new retinal imaging techniques to further assess alterations in retinal vascular function (e.g. flicker-induced vasodilatory response, blood flow and oxygen saturation) in diabetes and complications that result from the effects of chronic hyperglycaemia, inflammation and endothelial dysfunction. In this review, we summarise the latest findings on the relationships between quantitatively measured structural and functional retinal vascular changes with diabetes and diabetic complications. We also discuss clinical implications and future research to evaluate whether detection of retinal vascular changes has additional value beyond that achieved with methods currently used to stratify the risk of diabetes and its complications.
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Affiliation(s)
- Carol Yimlui Cheung
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, 11 Third Hospital Avenue, Singapore, 168751, Republic of Singapore
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Prabhakar P, Zhang H, Chen D, Faber JE. Genetic variation in retinal vascular patterning predicts variation in pial collateral extent and stroke severity. Angiogenesis 2015; 18:97-114. [PMID: 25369734 PMCID: PMC4422395 DOI: 10.1007/s10456-014-9449-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 10/27/2014] [Indexed: 01/21/2023]
Abstract
The presence of a native collateral circulation in tissues lessens injury in occlusive vascular diseases. However, differences in genetic background cause wide variation in collateral number and diameter in mice, resulting in large variation in protection. Indirect estimates of collateral perfusion suggest that wide variation also exists in humans. Unfortunately, methods used to obtain these estimates are invasive and not widely available. We sought to determine whether differences in genetic background in mice result in variation in branch patterning of the retinal arterial circulation, and whether these differences predict strain-dependent differences in pial collateral extent and severity of ischemic stroke. Retinal patterning metrics, collateral extent, and infarct volume were obtained for 10 strains known to differ widely in collateral extent. Multivariate regression was conducted, and model performance was assessed using K-fold cross-validation. Twenty-one metrics varied with strain (p<0.01). Ten metrics (e.g., bifurcation angle, lacunarity, optimality) predicted collateral number and diameter across seven regression models, with the best model closely predicting (p<0.0001) number (±1.2-3.4 collaterals, K-fold R2=0.83-0.98), diameter (±1.2-1.9 μm, R2=0.73-0.88), and infarct volume (±5.1 mm3, R2=0.85-0.87). An analogous set of the most predictive metrics, obtained for the middle cerebral artery (MCA) tree in a subset of the above strains, also predicted (p<0.0001) collateral number (±3.3 collaterals, K-fold R2=0.78) and diameter (±1.6 μm, R2=0.86). Thus, differences in arterial branch patterning in the retina and the MCA trees are specified by genetic background and predict variation in collateral extent and stroke severity. If also true in human, and since genetic variation in cerebral collaterals extends to other tissues at least in mice, a similar "retinal predictor index" could serve as a non- or minimally invasive biomarker for collateral extent in brain and other tissues. This could aid prediction of severity of tissue injury in the event of an occlusive event or development of obstructive disease and in patient stratification for treatment options and clinical studies.
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Affiliation(s)
- Pranay Prabhakar
- Department of Cell Biology and Physiology and the McAllister Heart Institute, University of North Carolina
| | - Hua Zhang
- Department of Cell Biology and Physiology and the McAllister Heart Institute, University of North Carolina
| | - De Chen
- Optical Microscopy and Analysis Laboratory Leidos Biomedical Research, Inc, Frederick National Laboratory for Cancer Research, Frederick, Maryland
| | - James E. Faber
- Department of Cell Biology and Physiology and the McAllister Heart Institute, University of North Carolina
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MacCormick IJC, Beare NAV, Taylor TE, Barrera V, White VA, Hiscott P, Molyneux ME, Dhillon B, Harding SP. Cerebral malaria in children: using the retina to study the brain. ACTA ACUST UNITED AC 2014; 137:2119-42. [PMID: 24578549 PMCID: PMC4107732 DOI: 10.1093/brain/awu001] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Cerebral malaria is a dangerous complication of Plasmodium falciparum infection, which takes a devastating toll on children in sub-Saharan Africa. Although autopsy studies have improved understanding of cerebral malaria pathology in fatal cases, information about in vivo neurovascular pathogenesis is scarce because brain tissue is inaccessible in life. Surrogate markers may provide insight into pathogenesis and thereby facilitate clinical studies with the ultimate aim of improving the treatment and prognosis of cerebral malaria. The retina is an attractive source of potential surrogate markers for paediatric cerebral malaria because, in this condition, the retina seems to sustain microvascular damage similar to that of the brain. In paediatric cerebral malaria a combination of retinal signs correlates, in fatal cases, with the severity of brain pathology, and has diagnostic and prognostic significance. Unlike the brain, the retina is accessible to high-resolution, non-invasive imaging. We aimed to determine the extent to which paediatric malarial retinopathy reflects cerebrovascular damage by reviewing the literature to compare retinal and cerebral manifestations of retinopathy-positive paediatric cerebral malaria. We then compared retina and brain in terms of anatomical and physiological features that could help to account for similarities and differences in vascular pathology. These comparisons address the question of whether it is biologically plausible to draw conclusions about unseen cerebral vascular pathogenesis from the visible retinal vasculature in retinopathy-positive paediatric cerebral malaria. Our work addresses an important cause of death and neurodisability in sub-Saharan Africa. We critically appraise evidence for associations between retina and brain neurovasculature in health and disease, and in the process we develop new hypotheses about why these vascular beds are susceptible to sequestration of parasitized erythrocytes.
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Affiliation(s)
- Ian J C MacCormick
- 1 Malawi-Liverpool-Wellcome Trust Clinical Research Programme, PO Box 30096, Chichiri, Blantyre 3, Malawi2 University of Liverpool, Department of Eye and Vision Science, Faculty of Health & Life Sciences, University of Liverpool Room 356, 4th Floor, UCD Building, Daulby Street, Liverpool L69 3GA, UK
| | - Nicholas A V Beare
- 2 University of Liverpool, Department of Eye and Vision Science, Faculty of Health & Life Sciences, University of Liverpool Room 356, 4th Floor, UCD Building, Daulby Street, Liverpool L69 3GA, UK3 Royal Liverpool University Hospital, St. Paul's Eye Unit, Prescot St, Liverpool, Merseyside L7 8XP, UK
| | - Terrie E Taylor
- 5 Blantyre Malaria Project, Blantyre, Malawi6 Michigan State University, Department of Osteopathic Medical Specialities, West Fee Hall, 909 Fee Road, Room B305, East Lansing, MI 48824, USA
| | - Valentina Barrera
- 2 University of Liverpool, Department of Eye and Vision Science, Faculty of Health & Life Sciences, University of Liverpool Room 356, 4th Floor, UCD Building, Daulby Street, Liverpool L69 3GA, UK
| | - Valerie A White
- 7 Vancouver General Hospital, Department of Pathology and Laboratory Medicine, Vancouver, B.C. V5Z1M9, Canada
| | - Paul Hiscott
- 2 University of Liverpool, Department of Eye and Vision Science, Faculty of Health & Life Sciences, University of Liverpool Room 356, 4th Floor, UCD Building, Daulby Street, Liverpool L69 3GA, UK
| | - Malcolm E Molyneux
- 1 Malawi-Liverpool-Wellcome Trust Clinical Research Programme, PO Box 30096, Chichiri, Blantyre 3, Malawi4 University of Malawi College of Medicine, College of Medicine, P/Bag 360 Chichiri, Blantyre 3 Malawi8 Liverpool School of Tropical Medicine, Liverpool School of Tropical Medicine, Pembroke Place , Liverpool, L3 5QA , UK
| | - Baljean Dhillon
- 9 University of Edinburgh, Department of Ophthalmology, Edinburgh, UK10 Princess Alexandra Eye Pavilion, Edinburgh, UK
| | - Simon P Harding
- 2 University of Liverpool, Department of Eye and Vision Science, Faculty of Health & Life Sciences, University of Liverpool Room 356, 4th Floor, UCD Building, Daulby Street, Liverpool L69 3GA, UK3 Royal Liverpool University Hospital, St. Paul's Eye Unit, Prescot St, Liverpool, Merseyside L7 8XP, UK
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Sasongko MB, Wong TY, Wang JJ. Retinal microvascular structure: determinants and potential utility of novel imaging measurements. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.10.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Tapp RJ, Ness A, Williams C, Howe LD, Tilling K, Witt N, Chaturvedi N, McG Thom SA, Hughes AD. Differential Effects of Adiposity and Childhood Growth Trajectories on Retinal Microvascular Architecture. Microcirculation 2013; 20:609-16. [DOI: 10.1111/micc.12060] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 03/17/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | - Andrew Ness
- School of Oral and Dental Sciences; University of Bristol; Bristol; UK
| | - Cathy Williams
- Centre for Child and Adolescent Health; University of Bristol; Bristol; UK
| | | | - Kate Tilling
- School of Social and Community Medicine; University of Bristol; Bristol; UK
| | - Nicholas Witt
- International Centre for Circulatory Health; NHLI; St Mary's Hospital & Imperial College London; London; UK
| | - Nish Chaturvedi
- International Centre for Circulatory Health; NHLI; St Mary's Hospital & Imperial College London; London; UK
| | - Simon A. McG Thom
- International Centre for Circulatory Health; NHLI; St Mary's Hospital & Imperial College London; London; UK
| | - Alun D. Hughes
- International Centre for Circulatory Health; NHLI; St Mary's Hospital & Imperial College London; London; UK
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Hughes AD, Bathula R, Park C, Tillin T, Wit N, McG Thom S, Chaturvedi N. Microcirculatory rarefaction in South Asians - a potential mechanism for increased cardiovascular risk and diabetes. PLoS One 2013; 8:e76680. [PMID: 24116136 PMCID: PMC3792020 DOI: 10.1371/journal.pone.0076680] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Accepted: 08/30/2013] [Indexed: 12/15/2022] Open
Abstract
People of South Asian descent have an increased risk of cardiovascular disease (CVD) and diabetes, but little is known about the microcirculation in South Asian people despite evidence that this plays an important role in the aetiology of CVD. We compared the retinal microcirculation in a population-based sample of 287 middle-aged adults (144 European 143 South Asian) matched for age and sex. Retinal photographs were taken and analysed using a validated semi-automated program and microvascular measures were compared. Blood pressure, anthropometry and fasting bloods were also measured. South Asians had significantly fewer arteriolar and venular vessels and bifurcations. Arterioles and venules were longer and venules were also more tortuous in South Asians. These differences were not explained by adjustment for traditional risk factors including blood pressure, body mass index, diabetes or measures of insulin resistance. People of South Asian descent have rarefaction of the retinal microcirculation compared to age-sex matched individuals of European descent. Reduced microvascular density could contribute to the elevated risk of CVD and impaired glucose tolerance in South Asian people.
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Affiliation(s)
- Alun D. Hughes
- International Centre for Circulatory Health, NHLI Division, Faculty of Medicine, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
- * E-mail:
| | - Raj Bathula
- International Centre for Circulatory Health, NHLI Division, Faculty of Medicine, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Chloe Park
- International Centre for Circulatory Health, NHLI Division, Faculty of Medicine, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Therese Tillin
- International Centre for Circulatory Health, NHLI Division, Faculty of Medicine, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Nicholas Wit
- International Centre for Circulatory Health, NHLI Division, Faculty of Medicine, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Simon McG Thom
- International Centre for Circulatory Health, NHLI Division, Faculty of Medicine, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Nish Chaturvedi
- International Centre for Circulatory Health, NHLI Division, Faculty of Medicine, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
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Bachmayer C, Kemmer A, Ehrmann N, Hasenberg T, Lammert A, Hammes HP. Adipokines and endothelial dysfunction in obesity WHO°III. Microvasc Res 2013; 89:129-33. [DOI: 10.1016/j.mvr.2013.04.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2013] [Revised: 04/12/2013] [Accepted: 04/28/2013] [Indexed: 12/26/2022]
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Obesity and the microvasculature: a systematic review and meta-analysis. PLoS One 2013; 8:e52708. [PMID: 23405065 PMCID: PMC3566162 DOI: 10.1371/journal.pone.0052708] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 11/20/2012] [Indexed: 11/23/2022] Open
Abstract
Background Overweight and obesity are thought to significantly influence a person's risk of cardiovascular disease, possibly via its effect on the microvasculature. Retinal vascular caliber is a surrogate marker of microvascular disease and a predictor of cardiovascular events. The aim of this systematic review and meta-analysis was to determine the association between body mass index (BMI) and retinal vascular caliber. Methods and Findings Relevant studies were identified by searches of the MEDLINE and EMBASE databases from 1966 to August 2011. Standardized forms were used for data extraction. Among over 44,000 individuals, obese subjects had narrower arteriolar and wider venular calibers when compared with normal weight subjects, independent of conventional cardiovascular risk factors. In adults, a 1 kg/m2 increase in BMI was associated with a difference of 0.07 μm [95% CI: −0.08; −0.06] in arteriolar caliber and 0.22 μm [95% CI: 0.21; 0.23] in venular caliber. Similar results were found for children. Conclusions Higher BMI is associated with narrower retinal arteriolar and wider venular calibers. Further prospective studies are needed to examine whether a causative relationship between BMI and retinal microcirculation exists.
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Kalitzeos AA, Lip GYH, Heitmar R. Retinal vessel tortuosity measures and their applications. Exp Eye Res 2012; 106:40-6. [PMID: 23146682 DOI: 10.1016/j.exer.2012.10.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Revised: 10/05/2012] [Accepted: 10/30/2012] [Indexed: 10/27/2022]
Abstract
Structural retinal vascular characteristics, such as vessel calibers, tortuosity and bifurcation angles are increasingly quantified in an objective manner, slowly replacing subjective qualitative disease classification schemes. This paper provides an overview of the current methodologies and calculations used to compute retinal vessel tortuosity. We set out the different parameter calculations and provide an insight into the clinical applications, while critically reviewing its pitfalls and shortcomings.
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Affiliation(s)
- Angelos A Kalitzeos
- Aston University, School of Life and Health Sciences, Aston Triangle, Birmingham B4 7ET, UK
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Cheung CYL, Ikram MK, Sabanayagam C, Wong TY. Retinal microvasculature as a model to study the manifestations of hypertension. Hypertension 2012; 60:1094-103. [PMID: 23045470 DOI: 10.1161/hypertensionaha.111.189142] [Citation(s) in RCA: 168] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The retinal vasculature allows direct noninvasive visualization of the body's mircrovasculature. Because the retina and other end organs (brain and kidney) share similar anatomical features and physiological properties, the retinal vessels offer a unique and easily accessible window to study the health and disease of the human microcirculation. Advanced retinal vascular imaging technologies have been developed to allow a more objective and precise assessment of retinal vascular changes. The changes in the retinal vasculature associated with hypertension can be broadly divided into 3 groups: (1) classic retinal vascular changes in response to blood pressure (referred to as hypertensive retinopathy signs), (2) changes in retinal vascular caliber, and (3) changes in more global geometrical patterns of the retina. In this review, we summarize the current understanding of the relationship between retinal vascular changes and blood pressure, the evidence for the retinal vasculature as a biological model to study the manifestation and early pathogenic correlates of hypertension, the latest advances in retinal vascular imaging technologies, and the future opportunities and challenges of retinal vascular imaging. We suggest that further development of retinal vascular analyses and standardized measurement protocols, evaluation of the clinical use of retinal vascular imaging in assessing cardiovascular risk prediction, and using retinal vascular imaging to test antihypertensive treatments will allow the translation of retinal vascular imaging as a tool to improve the diagnosis, prognosis, and management of hypertension in clinical practice.
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Affiliation(s)
- Carol Yim-lui Cheung
- Singapore Eye Research Institute, 11 Third Hospital Ave, Singapore 168751, Singapore
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Kandasamy Y, Smith R, Wright IMR. Retinal microvascular changes in low-birth-weight babies have a link to future health. J Perinat Med 2012; 40:209-14. [PMID: 22150014 DOI: 10.1515/jpm.2011.116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In utero insults that result in low-birth-weight (LBW) infants are now recognized risk factors for the development of vascular-related diseases in adulthood. Microcirculatory pathologies are believed to form a mechanistic link between fetal insult and the manifestation of illness in adulthood. OBJECTIVES The challenge has been to investigate microcirculatory changes in vivo. The objective of this review is to determine whether LBW infants and individuals undergo abnormal microvascular changes and, if so, whether these changes can be objectively identified and measured by investigating retinal vessels. METHODS An online publication search was carried out using the following keywords to identify and review relevant articles: retinal microvasculature, retinal vessels, small for gestation age, growth restriction, and intrauterine growth restriction. Articles published from 1980 to 2011 were considered. CONCLUSIONS The ability of retinal imaging technology to assess and measure retinal microvasculature makes it a valuable assessment tool. The current tool is, however, unsuitable for non-invasive assessment in infants and young children. Once this hurdle has been overcome, a longitudinal study of LBW individuals from infancy to adulthood, with regular retinal microvascular assessments, would help prove the mechanistic link between LBW and cardiovascular disease in adulthood.
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Liu D, Wood NB, Witt N, Hughes AD, Thom SA, Xu XY. Assessment of Energy Requirement for the Retinal Arterial Network in Normal and Hypertensive Subjects. J Biomech Eng 2012; 134:014501. [DOI: 10.1115/1.4005529] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The retinal arterial network structure can be altered by systemic diseases such as hypertension and diabetes. In order to compare the energy requirement for maintaining retinal blood flow and vessel wall metabolism between normal and hypertensive subjects, 3D hypothetical models of a representative retinal arterial bifurcation were constructed based on topological features derived from retinal images. Computational analysis of blood flow was performed, which accounted for the non-Newtonian rheological properties of blood and peripheral vessel resistance. The results suggested that the rate of energy required to maintain the blood flow and wall metabolism is much lower for normal subjects than for hypertensives, with the latter requiring 49.2% more energy for an entire retinal arteriolar tree. Among the several morphological factors, length-to-diameter ratio was found to have the most significant influence on the overall energy requirement.
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Affiliation(s)
- D. Liu
- Department of Chemical Engineering, Imperial College London, South Kensington Campus, London SW7 2AB, UK
| | - N. B. Wood
- Department of Chemical Engineering, Imperial College London, South Kensington Campus, London SW7 2AB, UK
| | - N. Witt
- Faculty of Medicine, Clinical Pharmacology, NHLI Division, International Centre for Circulatory Health, Imperial College London, St Mary’s Campus, London W2 1NY, UK
| | - A. D. Hughes
- Faculty of Medicine, Clinical Pharmacology, NHLI Division, International Centre for Circulatory Health, Imperial College London, St Mary’s Campus, London W2 1NY, UK
| | - S. A. Thom
- Faculty of Medicine, Clinical Pharmacology, NHLI Division, International Centre for Circulatory Health, Imperial College London, St Mary’s Campus, London W2 1NY, UK
| | - X. Y. Xu
- Department of Chemical Engineering, Imperial College London, South Kensington Campus, London SW7 2AB, UK
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Crosby-Nwaobi R, Heng LZ, Sivaprasad S. Retinal Vascular Calibre, Geometry and Progression of Diabetic Retinopathy in Type 2 Diabetes Mellitus. Ophthalmologica 2012; 228:84-92. [DOI: 10.1159/000337252] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 02/02/2012] [Indexed: 11/19/2022]
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Kandasamy Y, Smith R, Wright IM. Retinal microvasculature measurements in full-term newborn infants. Microvasc Res 2011; 82:381-4. [DOI: 10.1016/j.mvr.2011.07.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 07/27/2011] [Accepted: 07/28/2011] [Indexed: 10/17/2022]
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Benitez-Aguirre P, Craig ME, Sasongko MB, Jenkins AJ, Wong TY, Wang JJ, Cheung N, Donaghue KC. Retinal vascular geometry predicts incident retinopathy in young people with type 1 diabetes: a prospective cohort study from adolescence. Diabetes Care 2011; 34:1622-7. [PMID: 21593293 PMCID: PMC3120178 DOI: 10.2337/dc10-2419] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine the association between retinal vascular geometry and subsequent development of incident retinopathy in young patients with type 1 diabetes. RESEARCH DESIGN AND METHODS A prospective cohort study of 736 people with type 1 diabetes aged 12 to 20 years, retinopathy-free at baseline, attending an Australian tertiary care hospital. Retinopathy was determined from seven-field retinal photographs according to the modified Airlie House Classification. Retinal vascular geometry, including length/diameter ratio (LDR) and simple tortuosity (ST), was quantified in baseline retinal photographs. Generalized estimating equations were used to determine risk of retinopathy associated with baseline LDR and ST, adjusting for other factors. RESULTS After a median 3.8 (interquartile range 2.4-6.1) years of follow-up, incident retinopathy developed in 287 of 736 (39%). In multivariate analysis, lower arteriolar LDR (odds ratio 1.8 [95% CI 1.2-2.6]; 1st vs. 4th quartile) and greater arteriolar ST (1.5 [1.0-2.2]; 4th vs. 1st quartile) predicted incident retinopathy after adjusting for diabetes duration, sex, A1C, blood pressure, total cholesterol, and BMI. In subgroup analysis by sex, LDR predicted incident retinopathy in male and female participants (2.1 [1.1-4.0] and 1.7 [1.1-2.7]; 1st vs. 4th quartiles, respectively) and greater arteriolar ST predicted incident retinopathy in male participants (2.4 [1.1-4.4]; 4th vs. 1st quartile) only. CONCLUSIONS Lower arteriolar LDR and greater ST were independently associated with incident retinopathy in young people with type 1 diabetes. These vascular geometry measures may serve as risk markers for diabetic retinopathy and provide insights into the early structural changes in diabetic microvascular complications.
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Cheung CMG, Cheung CYL, Yang EL, Mitchell P, Wang JJ, Wong TY. Retinal arteriolar wall signs and early age-related macular degeneration: the singapore malay eye study. Am J Ophthalmol 2011; 152:108-113.e1. [PMID: 21570050 DOI: 10.1016/j.ajo.2011.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Revised: 01/09/2011] [Accepted: 01/10/2011] [Indexed: 11/18/2022]
Abstract
PURPOSE To determine whether retinal arteriolar wall signs are associated with early age-related macular degeneration (AMD). DESIGN Population-based cross-sectional study. METHODS The Singapore Malay Eye Study (SiMES) is a population-based eye survey including 3,280 (78.7% response) persons aged 40 to 80 years. Retinal arteriolar wall signs and AMD were assessed from photographs by trained technicians, according to standardized protocols. Data on major cardiovascular risk factors and blood pressure were collected. RESULTS Of the 3,280 participants, 2,541 had photographs that were gradable for both AMD and retinal arteriolar wall signs. Early AMD was present in 76 subjects. There were no significant associations of any retinal arteriolar wall signs with early AMD. For specific AMD signs, retinal arteriolar wall opacification was associated with presence of soft distinct drusen (odds ratio [OR] 1.58, 95% confidence interval [CI]: 1.06, 2.35). This association was most significant among non-statin users (OR 1.90, 95% CI: 1.23, 2.93). Focal arteriolar narrowing was associated with retinal hypopigmentation (OR 1.67, 95% CI: 1.02, 2.73). Arteriovenous nicking was not associated with soft drusen (OR 0.89, 95% CI: 0.51, 1.57), hyperpigmentation (OR 0.49, 95% CI: 0.22, 1.08), or hypopigmentation (OR 0.86, 95% CI: 0.46, 1.61). CONCLUSIONS Retinal arteriolar wall signs are not consistently associated with early AMD. We report a new association of retinal arteriolar wall opacification and the presence of soft drusen. This finding could support the hypothesis of a link between lipids and drusen formation.
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Li LJ, Cheung CYL, Liu Y, Chia A, Selvaraj P, Lin XY, Chan YM, Varma R, Mitchell P, Wong TY, Saw SM. Influence of blood pressure on retinal vascular caliber in young children. Ophthalmology 2011; 118:1459-65. [PMID: 21444115 DOI: 10.1016/j.ophtha.2010.12.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Revised: 10/26/2010] [Accepted: 12/07/2010] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE Prior studies have reported that blood pressure (BP) has a significant influence on retinal vascular caliber both in adults and children aged 6 years and older. This study aimed to examine the association between BP and retinal vascular caliber in Singapore Chinese preschoolers 4 to 5 years of age. DESIGN Population-based, cross-sectional study. PARTICIPANTS A total of 385 eligible and healthy Singapore Chinese children 4 to 5 years of age who were recruited in The Strabismus, Amblyopia and Refractive Error Study in Singaporean Chinese Preschoolers from May 2006 through October 2008 underwent BP measurements and retinal photography. METHODS According to standard protocols, BP was measured with an automatic Omron sphygmomanometer (Omron HEM 705 LP, Omron Healthcare, Inc., Bannockburn, IL) and a retinal photograph was obtained with a Canon 45° digital retinal camera (Model CR6-NM45, Canon, Inc., Tokyo, Japan) after pupil dilation. Anthropometric and optical biometric measurements such as height, weight, and axial length were obtained also. Information regarding sociodemographic status and child birth information was supplied by parents in either English or Chinese questionnaires. MAIN OUTCOME MEASURES The computer imaging program was used to measure the caliber of all retinal arterioles and venules located in zone B. The central retinal arteriolar equivalent and central retinal venular equivalent were estimated by using a revised Knudtson-Parr-Hubbard formula. RESULTS The mean retinal arteriolar and venular calibers were 156.19 μm and 220.01 μm in boys and 161.97 μm and 224.22 μm in girls. Higher systolic BP was associated with narrower retinal arterioles. After adjusting for age, gender, father's education, body mass index, birth weight, axial length, and caliber of the fellow retinal vessel, each 10-mmHg increase in systolic BP was associated with 2.00 μm (95% confidence interval, 0.39-3.61; P = 0.02) of retinal arteriolar narrowing and 2.51 μm (95% confidence interval, 0.35-4.68; P = 0.02) of retinal venular widening. However, neither diastolic BP nor mean arterial BP was associated with retinal arteriolar or venular caliber. CONCLUSIONS In very young children 4 to 5 years of age, higher systolic BP was associated with narrower retinal arterioles and wider retinal venules. This suggests that elevated BP may affect the retinal microvasculature from early childhood.
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Affiliation(s)
- Ling-Jun Li
- Department of Epidemiology & Public Health, National University of Singapore, Singapore, Republic of Singapore
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Sasongko MB, Wang JJ, Donaghue KC, Cheung N, Benitez-Aguirre P, Jenkins A, Hsu W, Lee ML, Wong TY. Alterations in retinal microvascular geometry in young type 1 diabetes. Diabetes Care 2010; 33:1331-6. [PMID: 20299479 PMCID: PMC2875449 DOI: 10.2337/dc10-0055] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To describe retinal microvascular geometric parameters in young patients with type 1 diabetes. RESEARCH DESIGN AND METHODS Patients with type 1 diabetes (aged 12-20 years) had clinical assessments and retinal photography following standardized protocol at a tertiary-care hospital in Sydney. Retinal microvascular geometry, including arteriolar and venular tortuosity, branching angles, optimality deviation, and length-to-diameter ratio (LDR), were measured from digitized photographs. Associations of these geometric characteristics with diabetes duration, A1C level, systolic blood pressure (SBP), and other risk factors were assessed. RESULTS Of 1,159 patients enrolled, 944 (81.4%) had gradable photographs and 170 (14.7%) had retinopathy. Older age was associated with decreased arteriolar (P = 0.024) and venular (P = 0.002) tortuosity, and female subjects had larger arteriolar branching angle than male subjects (P = 0.03). After adjusting for age and sex, longer diabetes duration was associated with larger arteriolar branching angle (P <or= 0.001) and increased arteriolar optimality deviation (P = 0.018), higher A1C was associated with increased arteriolar tortuosity (>8.5 vs. <or=8.5%, P = 0.008), higher SBP was associated with decreased arteriolar LDR (P = 0.002), and higher total cholesterol levels were associated with increased arteriolar LDR (P = 0.044) and decreased venular optimality deviation (P = 0.044). These associations remained after controlling for A1C, retinal vessel caliber, and retinopathy status and were seen in subjects without retinopathy. CONCLUSIONS Key diabetes-related factors affect retinal microvascular geometry in young type 1 diabetes, even in those without evidence of retinopathy. These early retinal alterations may be markers of diabetes microvascular complications.
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Affiliation(s)
- Muhammad Bayu Sasongko
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, University of Melbourne, Melbourne, Australia
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SASONGKO MUHAMMADBAYU, WONG TIENYIN, WANG JIEJIN. Retinal Arteriolar Changes: Intermediate Pathways Linking Early Life Exposures to Cardiovascular Disease? Microcirculation 2010; 17:21-31. [DOI: 10.1111/j.1549-8719.2009.00007.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Thom S, Stettler C, Stanton A, Witt N, Tapp R, Chaturvedi N, Allemann S, Mayet J, Sever P, Poulter N, O'Brien E, Hughes A. Differential Effects of Antihypertensive Treatment on the Retinal Microcirculation. Hypertension 2009; 54:405-8. [DOI: 10.1161/hypertensionaha.109.133819] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Simon Thom
- From the International Centre for Circulatory Health (S.T., C.S., N.W., R.T., N.C., J.M., P.S., N.P., A.H.), National Heart and Lung Institute, St Mary’s Hospital and Imperial College London, London, United Kingdom; Division of Endocrinology, Diabetes, and Clinical Nutrition (C.S., S.A.), University Hospital and University of Bern, Bern, Switzerland; Molecular and Cellular Therapeutics (A.S.), RCSI Research Institute, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Epidemiology
| | - Christoph Stettler
- From the International Centre for Circulatory Health (S.T., C.S., N.W., R.T., N.C., J.M., P.S., N.P., A.H.), National Heart and Lung Institute, St Mary’s Hospital and Imperial College London, London, United Kingdom; Division of Endocrinology, Diabetes, and Clinical Nutrition (C.S., S.A.), University Hospital and University of Bern, Bern, Switzerland; Molecular and Cellular Therapeutics (A.S.), RCSI Research Institute, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Epidemiology
| | - Alice Stanton
- From the International Centre for Circulatory Health (S.T., C.S., N.W., R.T., N.C., J.M., P.S., N.P., A.H.), National Heart and Lung Institute, St Mary’s Hospital and Imperial College London, London, United Kingdom; Division of Endocrinology, Diabetes, and Clinical Nutrition (C.S., S.A.), University Hospital and University of Bern, Bern, Switzerland; Molecular and Cellular Therapeutics (A.S.), RCSI Research Institute, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Epidemiology
| | - Nicholas Witt
- From the International Centre for Circulatory Health (S.T., C.S., N.W., R.T., N.C., J.M., P.S., N.P., A.H.), National Heart and Lung Institute, St Mary’s Hospital and Imperial College London, London, United Kingdom; Division of Endocrinology, Diabetes, and Clinical Nutrition (C.S., S.A.), University Hospital and University of Bern, Bern, Switzerland; Molecular and Cellular Therapeutics (A.S.), RCSI Research Institute, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Epidemiology
| | - Robyn Tapp
- From the International Centre for Circulatory Health (S.T., C.S., N.W., R.T., N.C., J.M., P.S., N.P., A.H.), National Heart and Lung Institute, St Mary’s Hospital and Imperial College London, London, United Kingdom; Division of Endocrinology, Diabetes, and Clinical Nutrition (C.S., S.A.), University Hospital and University of Bern, Bern, Switzerland; Molecular and Cellular Therapeutics (A.S.), RCSI Research Institute, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Epidemiology
| | - Nish Chaturvedi
- From the International Centre for Circulatory Health (S.T., C.S., N.W., R.T., N.C., J.M., P.S., N.P., A.H.), National Heart and Lung Institute, St Mary’s Hospital and Imperial College London, London, United Kingdom; Division of Endocrinology, Diabetes, and Clinical Nutrition (C.S., S.A.), University Hospital and University of Bern, Bern, Switzerland; Molecular and Cellular Therapeutics (A.S.), RCSI Research Institute, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Epidemiology
| | - Sabin Allemann
- From the International Centre for Circulatory Health (S.T., C.S., N.W., R.T., N.C., J.M., P.S., N.P., A.H.), National Heart and Lung Institute, St Mary’s Hospital and Imperial College London, London, United Kingdom; Division of Endocrinology, Diabetes, and Clinical Nutrition (C.S., S.A.), University Hospital and University of Bern, Bern, Switzerland; Molecular and Cellular Therapeutics (A.S.), RCSI Research Institute, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Epidemiology
| | - Jamil Mayet
- From the International Centre for Circulatory Health (S.T., C.S., N.W., R.T., N.C., J.M., P.S., N.P., A.H.), National Heart and Lung Institute, St Mary’s Hospital and Imperial College London, London, United Kingdom; Division of Endocrinology, Diabetes, and Clinical Nutrition (C.S., S.A.), University Hospital and University of Bern, Bern, Switzerland; Molecular and Cellular Therapeutics (A.S.), RCSI Research Institute, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Epidemiology
| | - Peter Sever
- From the International Centre for Circulatory Health (S.T., C.S., N.W., R.T., N.C., J.M., P.S., N.P., A.H.), National Heart and Lung Institute, St Mary’s Hospital and Imperial College London, London, United Kingdom; Division of Endocrinology, Diabetes, and Clinical Nutrition (C.S., S.A.), University Hospital and University of Bern, Bern, Switzerland; Molecular and Cellular Therapeutics (A.S.), RCSI Research Institute, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Epidemiology
| | - Neil Poulter
- From the International Centre for Circulatory Health (S.T., C.S., N.W., R.T., N.C., J.M., P.S., N.P., A.H.), National Heart and Lung Institute, St Mary’s Hospital and Imperial College London, London, United Kingdom; Division of Endocrinology, Diabetes, and Clinical Nutrition (C.S., S.A.), University Hospital and University of Bern, Bern, Switzerland; Molecular and Cellular Therapeutics (A.S.), RCSI Research Institute, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Epidemiology
| | - Eoin O'Brien
- From the International Centre for Circulatory Health (S.T., C.S., N.W., R.T., N.C., J.M., P.S., N.P., A.H.), National Heart and Lung Institute, St Mary’s Hospital and Imperial College London, London, United Kingdom; Division of Endocrinology, Diabetes, and Clinical Nutrition (C.S., S.A.), University Hospital and University of Bern, Bern, Switzerland; Molecular and Cellular Therapeutics (A.S.), RCSI Research Institute, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Epidemiology
| | - Alun Hughes
- From the International Centre for Circulatory Health (S.T., C.S., N.W., R.T., N.C., J.M., P.S., N.P., A.H.), National Heart and Lung Institute, St Mary’s Hospital and Imperial College London, London, United Kingdom; Division of Endocrinology, Diabetes, and Clinical Nutrition (C.S., S.A.), University Hospital and University of Bern, Bern, Switzerland; Molecular and Cellular Therapeutics (A.S.), RCSI Research Institute, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Epidemiology
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