Optomap ultrawide field imaging for detecting peripheral retinal lesions in 1725 high myopic eyes before implantable collamer lens surgery

Complications of high myopia: An update from clinical manifestations to underlying mechanisms

Background

High myopia is one of the major causes of visual impairment and has an ever-increasing prevalence, especially in East Asia. It is characterized by excessive axial elongation, leading to various blinding complications that extend beyond mere refractive errors and persist immovably after refractive surgery, presenting substantial public health challenge.

Main text

High myopia-related complications include lens pathologies, atrophic and tractional maculopathy, choroidal neovascularization, peripheral retinal degenerations and retinal detachment, and glaucoma and heightened susceptibility to intraocular pressure (IOP) elevation. Pathological lens changes characteristic of high myopia include early cataractogenesis, overgrowth of lens, weakened zonules, and postoperative capsular contraction syndrome, possibly driven by inflammatory pathogenesis, etc. Dome-shaped macula and cilioretinal arteries are two newly identified protective factors for central vision of highly myopic patients. These patients also face risks of open-angle glaucoma and IOP spike following intraocular surgery. Morphologic alternations of optic nerve in high myopia can complicate early glaucoma detection, necessitating comprehensive examinations and close follow-up. Anatomically, thinner trabecular meshwork increases this risk; conversely lamina cribrosa defects may offer a fluid outlet, potentially mitigating the pressure. Notably, anxiety has emerged as the first recognized extra-ocular complication in high myopia, with an underlying inflammatory pathogenesis that connects visual stimulus, blood and brain.

Conclusions

High myopia induces multiple ocular and potential mental health complications, underscoring the need to develop more effective strategies to improve both physical and emotional well-being of these patients, among which anti-inflammation might possibly represent a promising new target.

Design of ultra-wide-field scanning laser fundus imaging system with cascaded conicoid mirrors

We propose and design a multi-stage cascaded scanning laser ophthalmoscope (SLO) for ultra-wide field (UWF), which uses conicoid mirrors, constructed by conjugation of pupil plane. The vergence uniformity and the angular magnification of a cascaded conicoid mirrors (CCM) system are analyzed recursively and optimized preliminarily to achieve high quality imaging with UWF, and the optimal system with the model eye are obtained by simulation and optimization. Two-stage and three-stage cascaded systems are designed with this method, and the formulas of beam vergence and angular magnification are obtained by theoretical derivation. As compared to the two-stage CCM system, the proposed three-stage cascaded UWF SLO has superior performance in imaging quality. Its average RMS radius of spot diagram is calculated to be 26.372 µm, close to the diffractive limit resolution. The image resolution of human retina can be up to 30 µm with 135° FOV in theory. The three-stage cascaded SLO is more suitable for UWF fundus imaging. This study will be helpful for early screening and accurate diagnosis of various diseases in the peripheral retina.

EVALUATING ULTRA-WIDEFIELD IMAGING UTILITY IN THE DETECTION OF TREATMENT-REQUIRING PERIPHERAL RETINAL TEARS AND HOLES

PURPOSE

To determine the utility of ultra-widefield (UWF) imaging in detecting pathologic peripheral retinal tears and holes.

METHODS

This was a retrospective, observational study. One-hundred ninety-eight eyes of 198 patients diagnosed with acute posterior vitreous detachment were included. Eyes were divided into two groups: 89 eyes with peripheral retinal holes and tears treated with laser retinopexy (treatment group) and 109 control eyes. Patients underwent UWF imaging and indirect ophthalmoscopy with scleral depression. UWF images from both groups were reviewed by two blinded graders and then compared with funduscopic examination and medical records.

RESULTS

UWF imaging identified 60 of the 89 eyes (sensitivity of 67.4%) found to have treatment-requiring peripheral retinal lesions and 107 of the 109 control eyes (specificity of 98.2%).The distribution of misses based on octant location did reach statistical significance ( P = 0.004). Lesions anterior to the equator were more likely to be missed (21/41 eyes, 51.2%) compared with those located posterior to the equator (4/20 eyes, 25.0%) and at the equator (4/28, 14.3%), P = 0.002. The combined discordance rate between graders in the entire cohort was 12.1% (24/198 eyes) yielding an interrater agreement of 87.9%.

CONCLUSION

UWF imaging showed a moderate sensitivity and high specificity in detecting treatment-requiring retinal tears and holes, with high interrater agreement. Given there is only a moderate sensitivity in identifying treatment-requiring retinal tears and holes, UWF imaging can assist with clinical examination, but a 360-degree scleral depressed examination should remain the gold standard.

A new diagnostic method for retinal breaks in patients with posterior vitreous detachment: Ultra-wide-field imaging with the Zeiss Clarus 700

PURPOSE

This study was performed with the aim of finding a more convenient and less time-consuming method to diagnose retinal breaks in posterior vitreous detachment (PVD) patients.

METHODS

A prospective double-blind observational case study was performed with patients who were admitted to the Eye Emergency Department Sahlgrenska University Hospital with PVD symptoms and approved to participate in the study (n = 128). Standard slit lamp examination was compared with images from a Zeiss Clarus 700 ultra-wide-field camera (UWFC). Patients were examined and photographed by an independent operator. Data and image review was performed by three independent reviewers with varying experience. Retinal break detection with the two different methods (detailed eye examination by well-trained ophthalmologist and UWFC evaluations) was analysed statistically.

RESULTS

After excluding diagnoses other than PVD as well as unclear images due to cataracts, vitreous bleeding, etc., a total of 103 eyes with PVD were evaluated. A total of 38 ruptures in 25 patients were detected by routine examination and were subjected to laser treatment. UWFC images were reviewed by three ophthalmology consultants and compared with routine examinations. Sensitivity values in detecting retinal ruptures in UWFC images of the three reviewers were 0.89, 0.87 and 0.79, and specificity values were 0.88, 0.86 and 0.93 (kappa values: 0.742, 0.689 and 0.728) respectively.

CONCLUSION

Although there have been rapid developments in imaging with UWFC in recent years and it is a very promising method for the future, routine clinical examination is still the only valid method for the detection of retinal tears today.

Spotlight on Lattice Degeneration Imaging Techniques

Lattice degeneration (LD), routinely diagnosed with indirect ophthalmoscopy, is one of the most common and clinically significant peripheral retinal findings. In this review, we have summarized the data on currently available imaging techniques which help to improve diagnosis and our understanding of LD pathogenesis. Ultra-wide field imaging provides reliable color fundus capturing for the primary diagnosis of LD and may also be used as a screening tool. Wide-field imaging can be used for targeted documentation of LD lesions using true colors and with minimal optical distortions. Information on the status of the vitreoretinal interface, including detection of retinal holes, detachments, and vitreous tractions, can be obtained with peripheral structural optical coherence tomography (OCT) or scanning laser ophthalmoscopy in retro-mode. These techniques clarify the associated risks of rhegmatogenous retinal detachment. Fundus autofluorescence can provide details on atrophic changes. However, the risk of retinal detachment by means of this technique requires further investigation. OCT angiography may be successfully performed for some lesions. Taken together, OCT and OCT angiography demonstrate thinning of the choroid, alteration of local choroidal microcirculation, and, in severe lesions, involvement of the sclera. OCT angiography confirms loss of retinal microcirculation within LD lesion, which was previously shown with fluorescein angiography. In conclusion, despite relatively simple primary diagnosis, imaging of LD lesions remains challenging due to their peripheral localization. However, several new strategies, including ultra-wide field imaging, peripheral OCT, and scanning laser ophthalmoscopy, make LD imaging possible on a routine basis, improving diagnosis and understanding of LD pathogenesis.

Application of mydriasis and eye steering in ultrawide field imaging for detecting peripheral retinal lesions in myopic patients

PURPOSE

To compare mydriatic and eye-steering ultrawide field imaging (UWFI) with standard non-mydriatic UWFI examination in detecting peripheral retinal lesions in myopic patients.

METHODS

Cross-sectional, observational study. 220 eyes of 110 myopic patients with known peripheral retinal lesions in at least one eye under Goldmann three mirror contact lens examination were recruited. Non-mydriatic standard and eye-steering UWFI images were taken centrally and with eye-steering technique in upper, lower, nasal and temporal gazes under Optomap UWFI (Daytona, Optos, UK). Mydriatic standard and eye-steering UWFI was captured in central gaze and four different peripheral gazes. Sensitivity of detecting peripheral retinal lesions under different UWFI settings was compared.

RESULTS

141 (64.09%) eyes were with peripheral retinal lesions. The sensitivity for detecting peripheral lesions from low to high was 41.84% (95% CI 33.62% to 50.54%) under non-mydriatic standard UWFI setting, 52.48% (95% CI 44.08% to 60.75%) under mydriatic standard setting, 75.18% (95% CI 67.21% to 82.06%) under non-mydriatic eye-steering setting and 86.52% (95% CI 79.76% to 91.69%) under mydriatic eye-steering setting. Both mydriasis and eye-steering technique increased sensitivity of detecting peripheral lesions with statistical significance (p<0.001). By applying eye-steering technique, sensitivity of detecting lesions located in superior and inferior quadrants witnessed a greater increase compared with other two quadrants (p<0.05). Neither spherical equivalence (p>0.05) nor axial length (p>0.05) was an independent influence factor for detecting peripheral lesions.

CONCLUSIONS

Eye-steering technique and mydriasis could both efficiently improve the sensitivity of detecting peripheral retinal lesions in myopic patients. Lesions of superior and inferior quadrants benefited more from eye-steering technique.

A method for the automatic detection of myopia in Optos fundus images based on deep learning

Myopia detection is significant for preventing irreversible visual impairment and diagnosing myopic retinopathy. To improve the detection efficiency and accuracy, a Myopia Detection Network (MDNet) that combines the advantages of dense connection and Residual Squeeze-and-Excitation attention is proposed in this paper to automatically detect myopia in Optos fundus images. First, an automatic optic disc recognition method is applied to extract the Regions of Interest and remove the noise disturbances; then, data augmentation techniques are implemented to enlarge the data set and prevent overfitting; moreover, an MDNet composed of Attention Dense blocks is constructed to detect myopia in Optos fundus images. The results show that the Mean Absolute Error of the Spherical Equivalent detected by this network can reach 1.1150 D (diopter), which verifies the feasibility and applicability of this method for the automatic detection of myopia in Optos fundus images.

Ultra-Widefield Imaging for Evaluation of the Myopic Eye

Topic: Ultra-widefield (UWF) imaging of the myopic eye. Clinical Relevance: Myopes, and particularly high and pathologic myopes, present a unique challenge in fundoscopic imaging. Critical pathology is often located in the anteriormost portion of the retina, variations in posterior segment contour are difficult to capture in two-dimensional images, and extremes in axial length make simply focusing imaging devices difficult. Methods: We review the evolution of modalities for ophthalmic imaging (color fundus photography [CFP], optical coherence topography [OCT], angiography, artificial intelligence [AI]) to present day UWF technology and its impact on our understanding of myopia. Results: Advances in UWF technology address many of the challenges in fundoscopic imaging of myopes, providing new insights into the structure and function of the myopic eye. UWF CFP improves our ability to detect and document anterior peripheral pathology prevalent in approximately half of all high myopes. UWF OCT better captures the staphylomatous contour of the myopic eye, providing enhanced visualization of the vitreoretinal interface and progressive development of myopic traction maculopathy. UWF angiography highlights the posterior vortex veins, thin choriocapillaris, far peripheral avascularity, and peripheral retinal capillary microaneurysms more prevalent in the myopic eye. Researchers have demonstrated the ability of AI algorithms to predict refractive error, and great potential remains in the use of AI technology for the screening and prevention of myopic disease. Conclusion: We note significant progress in our ability to capture anterior pathology and improved image quality of the posterior segment of high and pathologic myopes. The next jump forward for UWF imaging will be the ability to capture a high quality ora to ora multimodal fundoscopic image in a single scan that will allow for sensitive AI-assisted screening of myopic disease.

Screening and prophylaxis of retinal degenerations prior to refractive surgery

The need and demand for surgical correction of refractive errors, particularly myopia, has been increasing. Degenerations involving the peripheral retina are common in myopes and can result in a rhegmatogenous retinal detachment. There are no clear guidelines for retinal screening and management of asymptomatic retinal degenerations prior to refractive surgery or for follow-up of these patients. This article aims to provide a set of guidelines for the management of retinal degenerations in eyes undergoing refractive surgeries.

Inter-observer agreement and sensitivity of Optomap images for screening peripheral retinal lesions in patients undergoing refractive surgery

Purpose:

The aim of this study was to compute the sensitivity, specificity and inter-reader variability of ultra-widefield retinal imaging (Optomap 200Tx) for screening retinal lesions before myopic refractive surgery.

Methods:

Two hundred and eight eyes of 109 consecutive refractive surgery candidates were included in this study. All subjects underwent Optomap 200Tx, mydriatic slit-lamp lens examination and dilated retinal examination with scleral indentation by a retinal specialist. Retinal findings by indirect dilated examination by retinal specialist was considered as the gold-standard. Sensitivity analyses for the readers were calculated between the Optomap images and the gold-standard retinal examination.

Results:

Seventy-three of the 208 eyes (35.1%) had peripheral retinal lesions diagnosed by the retinal specialist on dilated fundus examination. Peripheral lesions were seen on the Optomap images in 111 (53.4%) eyes. Compared to the dilated retinal examination, the detection rate with the Optomap 200Tx was 78.1% and specificity rate was 60%. The accuracy rate between the 3 readers ranged from 72% to 87%. The highest accuracy was noted with the reader post 1 year of retinal training (86.54%).

Conclusion:

The Optomap 200Tx showed a high sensitivity and moderate specificity for identifying peripheral retinal lesions in eyes undergoing refractive surgery. The Optomap examination is a convenient, fast and feasible method for detecting the pathological fundus changes in myopic eyes. The reliability of the examination improves when the images are interpreted by a reader with prior retinal training.