Analysing the impact of myopia on the Stiles-Crawford effect of the first kind using a digital micromirror device

Retinal neurovascular assessment and choroidal vascularity index in patients with keratoconus

This study aims to evaluate the macular and the optic nerve head thickness and vascular profiles in KC patients and compare them with two groups of healthy emmetrope and subjects with myopic-astigmatism. This cross-sectional study was conducted at Khatam-Al-Anbia Eye Hospital between 2022 and 2023. Subjects aged 18 to 40 were prone to be included in the study. The participants in this study were grouped into three categories: emmetrope (E), myopic-astigmatic (MA), and keratoconus (KC). All participants underwent a comprehensive ocular examination, as well as macular and optic nerve head (ONH) optical coherence tomography angiography (OCTA). In this study, 143 subjects, 50 cases in the KCN group, 46 cases in the E group, and 47 cases in the MA group, enrolled. There was no difference between the three groups regarding age (p = 0.123) and gender (p = 0.632). The superficial and deep capillary densities at the fovea, parafovea, and perifovea were significantly lower in KC patients than in the control groups (p < 0.01). The radial peripapillary capillary (RPC)- all vessels' density is significantly lower in the KC group (p < 0.001). Besides, the choroidal vascularity index (CVI) and choroidal luminal area (CLA) were considerably higher in KC patients (p < 0.001). The macular and ONH vascular profile in KC patients significantly differs from the vascular profile of healthy controls. Further scientific evidence regarding the systemic implications of keratoconus on the vascular system would be desirable to understand the connections between KC and vascular disease.

Evaluation of Retinal Layer Thicknesses in Patients with Keratoconus Using Retinal Layer Segmentation Analysis

OBJECTIVE

To conduct an evaluation of the effects of irregular astigmatism on the retinal nerve fiber layer (RNFL) and the retinal layers observed using spectral-domain optical coherence tomography (SD-OCT) in patients who had keratoconus (KC).

MATERIALS AND METHODS

A total of 255 eyes from 255 individuals, comprising 72 eyes of KC patients, 70 eyes of patients with astigmia, and 113 eyes of healthy controls were included in the analysis. RNFL scan maps (comprising global, temporal, superotemporal, inferotemporal, nasal, inferonasal, and superonasal maps) and macular thickness (MT) maps of a standard from the Early Treatment Diabetic Retinopathy Study (ETDRS) grid were assessed. The measurements were segmented automatically using Spectralis software, and included the RNFL, inner and outer plexiform layers (IPL, OPL), inner and outer nuclear layers (INL, ONL), ganglion cell layer, retinal pigment epithelium (RPE) in the central 6-mm ETDRS subfield.

RESULTS

The RNFL thickness in the KC group was lower when compared with the other two groups; however, statistically significant differences were noted in the global, temporal, superotemporal, and inferotemporal sectors (p < 0.05 for all). All of the central MT parameters showed significant variation among the groups, while a statistically significant decrease was noted in the KC group, except in the inferior outer sector (p = 0.741). In the segmentation analysis, the KC group had the significantly lowest IPL, ONL, RPE, and outer retinal layer (ORL) thickness among the groups (p < 0.05 for each). The astigmatic group was similar to the control group with regard to these parameters (p > 0.05 for each).

CONCLUSION

The eyes in the KC group appeared to have a thinner RNFL and MT when compared to those in the astigmatic and control groups. The ORLs, especially the ONL and RPE, were the most affected component of the macula in the KC group.

Factors associated with reduced visual acuity in myopes with and without ocular pathologies after optical correction

PURPOSE

Considering that a certain proportion of high myopes have reduced visual acuity even after full optical correction, this study aimed to investigate the association between various refractive error components (sphere, cylinder and axis orientation) and reduced visual acuity in individuals with low to high myopia with and without pathologic myopia lesions.

METHODS

We analysed data from randomly selected eyes of 11,258 individuals with myopia (mean ± SD spherical equivalent (SE) -3.2 ± 2.9D; range: -0.5D to -21.5D). In total, 10,528 individuals had no pathologic myopia lesions. Sphere, cylinder and SE refraction were classified into mild, moderate and high categories. Astigmatism was defined as with-the-rule, against-the-rule or oblique based on the axis orientation. Reduced best-corrected visual acuity was defined as ≥0.18 logMAR. Logistic regression was performed to test factors associated with reduced visual acuity with and without pathologic myopia lesions.

RESULT

Overall, 6.4% (N = 720/11,258) of myopes had reduced best-corrected visual acuity. High sphere (≤-6.0D; Odd ratios [OR]: 16.1; 95% CI: 2.1-126.5), high cylinder (<-2.0 DC; OR: 2.5; 95% CI: 1.8-3.4), against-the-rule (OR: 1.5; 95% CI: 1.1-2.0) and oblique astigmatism (OR: 1.6; 95% CI: 1.2-2.1) were significantly (p ≤ 0.008) associated with reduced visual acuity in the absence of pathologic myopia lesions. Both moderate SE and high myopic SE were also associated with reduced visual acuity. In the presence of pathologic myopia lesions, tessellated fundus (OR: 6.9; 95% CI: 3.5-14.1), chorioretinal atrophy (OR: 7.7; 95% CI: 2.6-19.9) and choroidal neovascularisation (OR: 37.4; 95% CI: 3.3-419.3) were significantly (p ≤ 0.003) associated with reduced visual acuity.

CONCLUSION

Even after full optical correction, both refractive components and pathologic myopia lesions can independently cause reduced visual acuity, regardless of the degree of myopia.

The link between Keratoconus and posterior segment parameters: An updated, comprehensive review

Keratoconus (KCN) has been typically known as a disorder with effects limited to the cornea. Because of this viewpoint, less attention has been devoted to its effects on the posterior segment structures. We aimed to provide a comprehensive review of the literature to understand the potential link between KCN and posterior segment structures and their functions. It is clear from the extensive evidence in the literature that KCN can be associated with morphological and functional changes in different parts of the posterior segment. It is worth noting that anatomical changes have been not only noted in several layers of the retina but also in the optic nerve head and the choroid. Several mechanisms have been proposed to explain this observation, including incidents induced by oxidative stress in keratoconic corneas and retinal adaptions to the distorted image that lands on the retina. Consequently, when KCN has been diagnosed, it seems practical to consider assessing the retinal and choroidal profile using optical coherence tomography and potentially functional abnormalities through electrophysiology procedures.

Geometrical scaling of the developing eye and photoreceptors and a possible relation to emmetropization and myopia

In this study the role of vergence in relation to age-dependent scaling of eye and photoreceptor parameters is studied. The underlying hypothesis is that the size and packing of outer segments is matched to the pupil size outdoors in photopic conditions. Vergence is analysed in relation to the angular spectrum of waves being incident using age-dependent data from the literature for the actual geometry and density of photoreceptor cones and rods. This approach is used to derive simple relations for the angular confinement of light along outer segments. Only with a small photopic pupil can leakage and crosstalk for both central and peripheral photoreceptors be entirely ruled out due to the finite length of the outer segments. A limiting 3 mm pupil size is found for children in the school age. Larger pupils will increase the likelihood of leakage and crosstalk that may therefore impact on emmetropization. This study has introduced a new paradigm in myopia research by considering vergence across the 3-D retina as being matched to the angular spectrum of waves being incident from the eye pupil. Emmetropization suggests a delicate balance between photoreceptor outer segment length and density in relation to pupil size. Only when balanced will leakage and crosstalk between adjacent outer segments be effectively suppressed thereby ensuring the highest possible light capture efficiency by visual pigments in the outer segments whether an image is formed on the retina or not.

Emmetropic, But Not Myopic Human Eyes Distinguish Positive Defocus From Calculated Blur

Purpose

Defocus blur imposed by positive lenses can induce hyperopia, whereas blur imposed by diffusers induces deprivation myopia. It is unclear whether the retina can distinguish between both conditions when the magnitude of blur is matched.

Methods

Ten emmetropic (average 0.0 ± 0.3 diopters [D]) and 10 subjects with myopia (−2.7 ± 0.9 D; 24 ± 4 years) watched a movie on a large screen (65 inches at 2 meters (m) distance. The movie was presented either unfiltered (“control”), with calculated low-pass filtering equivalent to a defocus of 2.5 D, or with binocular real optical defocus of +2.5 D. Spatial filtering was done in real-time by software written in Visual C++. Axial length was followed with the Lenstar LS-900 with autopositioning system.

Results

Watching unfiltered movies (“control”) caused no changes in axial length. In emmetropes, watching movies with calculated defocus caused axial eye elongation (+9.8 ± 7.6 µm) while watching movies with real positive defocus caused shorter eyes (−8.8 ± 9.2 µm; difference between both P < 0.0001). In addition, in myopes, calculated defocus caused longer eyes (+8.4 ± 9.0 µm, P = 0.001). Strikingly, myopic eyes became also longer with positive defocus (+9.1 ± 11.2 µm, P = 0.02). The difference between emmetropic and myopic eyes was highly significant (−8.8 ± 9.2 µm vs. +9.1 ± 11.2 µm, respectively, P = 0.001).

Conclusions

(1) In emmetropic human subjects, the retina is able to distinguish between real positive defocus and calculated defocus even when the modulation transfer function was matched, (2) in myopic eyes, the retina no longer distinguishes between both conditions because the eyes became longer in both cases. Results suggest that the retina in a myopic eye has reduced ability to detect positive defocus.

Subjective measurement of the Stiles-Crawford effect of the first kind with variation in accommodation

PURPOSE

To measure the Stiles-Crawford effect of the first kind (SCE-I), corresponding to central vision, with innovative technology to evaluate changes in the directionality and photoreceptor alignment with accommodation.

METHODS

A uniaxial Maxwellian system (spot size in pupil 0.5 mm diameter) was employed, incorporating a spatial light modulator to flicker at 2 Hz between two 2.3° fields corresponding to test (peripheral pupil) and reference (pupil centre) positions. Participants determined thresholds at 13 positions along the horizontal pupil meridian by indicating if the test field was brighter or dimmer than the reference field. Thresholds were determined by a staircase procedure after four reversals at each pupil location. After pupil dilation, seven emmetropes were tested at 0 D to 6 D accommodation stimulus levels in 2 D intervals. Data were fit by the Gaussian function, both when the fits were unforced or forced to pass through the sensitivity expected for the reference point. Directionality (ρ) and peak location values ( x max ) were determined for unforced and forced fits.

RESULTS

Regression slopes for ρ as a function of accommodation stimulus were not significant. There was a tendency for x max to shift temporally with increasing accommodation across the 6 D stimulus range. This was not significant for regression fitting (-0.059 mm/D, R²  = 0.06, p = 0.20), but a paired t-test for 0 and 6 D stimuli showed a weakly significant change of 0.62 mm (p = 0.05). The differences between the two fitting approaches were small and non-significant.

CONCLUSIONS

Directionality did not change with accommodation, but the pupil peak location showed a significant temporal shift of approximately 0.62 mm with 6 D accommodation stimulus. It is possible that substantial changes in the directionality and a shift in the direction of peak location might occur at very high levels of accommodation.

Subjective measurement of the Stiles-Crawford effect with different field sizes

The Stiles-Crawford effect of the first kind (SCE) is the phenomenon in which light entering the eye near the center of the pupil appears brighter than light entering near the edge. Previous investigations have found an increase in the directionality (steepness) of the effect as the testing location moves from the center of the visual field to parafoveal positions, but the effect of central field size has not been considered. The influence of field size on the SCE was investigated using a uniaxial Maxwellian system in which stimulus presentation was controlled by an active-matrix liquid crystal display. SCE directionality increased as field size increased from 0.5° to 4.7° diameter, although this was noted in four mild myopes and not in two emmetropes. The change with field size was supported by a geometric optics absorption model.

Functional integration of eye tissues and refractive eye development: Mechanisms and pathways

Refractive eye development is a tightly coordinated developmental process. The general layout of the eye and its various components are established during embryonic development, which involves a complex cross-tissue signaling. The eye then undergoes a refinement process during the postnatal emmetropization process, which relies heavily on the integration of environmental and genetic factors and is controlled by an elaborate genetic network. This genetic network encodes a multilayered signaling cascade, which converts visual stimuli into molecular signals that guide the postnatal growth of the eye. The signaling cascade underlying refractive eye development spans across all ocular tissues and comprises multiple signaling pathways. Notably, tissue-tissue interaction plays a key role in both embryonic eye development and postnatal eye emmetropization. Recent advances in eye biometry, physiological optics and systems genetics of refractive error have significantly advanced our understanding of the biological processes involved in refractive eye development and provided a framework for the development of new treatment options for myopia. In this review, we summarize the recent data on the mechanisms and signaling pathways underlying refractive eye development and discuss new evidence suggesting a wide-spread signal integration across different tissues and ocular components involved in visually guided eye growth.

Ambient Light Regulates Retinal Dopamine Signaling and Myopia Susceptibility

Purpose

Exposure to high-intensity or outdoor lighting has been shown to decrease the severity of myopia in both human epidemiological studies and animal models. Currently, it is not fully understood how light interacts with visual signaling to impact myopia. Previous work performed in the mouse retina has demonstrated that functional rod photoreceptors are needed to develop experimentally-induced myopia, alluding to an essential role for rod signaling in refractive development.

Methods

To determine whether dim rod-dominated illuminance levels influence myopia susceptibility, we housed male C57BL/6J mice under 12:12 light/dark cycles with scotopic (1.6 × 10⁻³ candela/m²), mesopic (1.6 × 10¹ cd/m²), or photopic (4.7 × 10³ cd/m²) lighting from post-natal day 23 (P23) to P38. Half the mice received monocular exposure to −10 diopter (D) lens defocus from P28–38. Molecular assays to measure expression and content of DA-related genes and protein were conducted to determine how illuminance and lens defocus alter dopamine (DA) synthesis, storage, uptake, and degradation and affect myopia susceptibility in mice.

Results

We found that mice exposed to either scotopic or photopic lighting developed significantly less severe myopic refractive shifts (lens treated eye minus contralateral eye; –1.62 ± 0.37D and −1.74 ± 0.44D, respectively) than mice exposed to mesopic lighting (–3.61 ± 0.50D; P < 0.005). The 3,4-dihydroxyphenylacetic acid /DA ratio, indicating DA activity, was highest under photopic light regardless of lens defocus treatment (controls: 0.09 ± 0.011 pg/mg, lens defocus: 0.08 ± 0.008 pg/mg).

Conclusions

Lens defocus interacted with ambient conditions to differentially alter myopia susceptibility and DA-related genes and proteins. Collectively, these results show that scotopic and photopic lighting protect against lens-induced myopia, potentially indicating that a broad range of light levels are important in refractive development.

Posterior pole retinal thickness distribution pattern in keratoconus

PURPOSE

To evaluate the pattern of retinal thickness distribution in patients with keratoconus (KCN) and its correlation with disease severity.

METHODS

For this cross-sectional cohort study, the study subjects with documented keratoconus and normal eyes were prospectively enrolled. All subjects had anterior segment (Pentacam HR) and posterior segment (Spectralis) imaging. Posterior segment imaging by optical coherence tomography included the posterior pole asymmetry analysis map. Data were analyzed with multiple linear regression models and correlation tests to examine the mean and variance of the measured thickness of the retina and its distribution relative to the presence and severity of KCN.

RESULTS

A total of 24 subjects with keratoconus (48 eyes) and 14 normal subjects (28 eyes) enrolled in this study. The posterior pole retinal thickness, both superior and inferior hemifields, as well as the overall retinal thickness in KCN patients was greater than the control group. There was a direct correlation between the overall retinal thickness of the posterior pole and the severity of KCN (R² = 0.422, P < 0.001). However, the variability of the retinal thickness showed no difference between KCN-afflicted and healthy eyes.

CONCLUSION

Although KCN is a disease of the anterior segment of the eye, we found an orderly increase in posterior pole retinal thickness that is correlated with the severity of disease in KCN eyes compared to control. These findings suggest that the retina may maintain some degree of plasticity to respond to the degraded optical system of the eye.

Directional light-capture efficiency of the foveal and parafoveal photoreceptors at different luminance levels: an experimental and analytical study

A gradual drop in visibility with obliquely incident light on retinal photoreceptors is namely described by the Stiles-Crawford effect of the first kind and characterized by a directionality parameter. Using a digital micromirror device in a uniaxial flicker system, here we report on variations of this effect with luminance levels, wavelengths within the visible and near-infrared spectrum and retinal regions ranging from the fovea to 7.5° parafoveal. Results show a consistent directionality in mesopic and photopic conditions. Higher directionality is measured for longer wavelengths, and a decrease with retinal eccentricity is observed. Results are discussed in relation to an absorption model for the visual pigments taking the outer-segment packing and thickness of the neural retina into account. Good correspondence is found without enforcing photoreceptor waveguiding.

Measuring Ocular Aberrations Sequentially Using a Digital Micromirror Device

The Hartmann–Shack wavefront sensor is widely used to measure aberrations in both astronomy and ophthalmology. Yet, the dynamic range of the sensor is limited by cross-talk between adjacent lenslets. In this study, we explore ocular aberration measurements with a recently-proposed variant of the sensor that makes use of a digital micromirror device for sequential aperture scanning of the pupil, thereby avoiding the use of a lenslet array. We report on results with the sensor using two different detectors, a lateral position sensor and a charge-coupled device (CCD) scientific camera, and explore the pros and cons of both. Wavefront measurements of a highly aberrated artificial eye and of five real eyes, including a highly myopic subject, are demonstrated, and the role of pupil sampling density, CCD pixel binning, and scanning speed are explored. We find that the lateral position sensor is mostly suited for high-power applications, whereas the CCD camera with pixel binning performs consistently well both with the artificial eye and for real-eye measurements, and can outperform a commonly-used wavefront sensor with highly aberrated wavefronts.

QD laser eyewear as a visual field aid in a visual field defect model

Visual field defects interfere with free actions and influence the quality of life of patients with retinitis pigmentosa; the prevalence of this disease is increasing in aging societies. Patients with progressive disease may require visual aids; however, no such devices are currently available. We utilized a retinal projection eyewear system, QD laser eyewear, which includes a projector inside the spectacle frame, to draw the image taken by a connected portable camera with a wide field lens. The images are projected onto the retina using a Maxwellian view optical system, which is not influenced by refractive error or the amount of incident light. Goldmann perimetry and figure recognition tests with the QD laser eyewear showed increased visual field areas and angles, and shortened the time for recognition of the number of figures in a sheet, in a limited visual field model that we developed by using a pin-hole system to simulate the tunnel vision of retinitis pigmentosa in 19 healthy adults. The device supported the quality of vision. Additionally, the visual field defect model used in healthy adults was useful for validating the device in the development stage of the study, to clarify both advantages and future goals for improving the device.

Lack of cone mediated retinal function increases susceptibility to form-deprivation myopia in mice

Retinal photoreceptors are important in visual signaling for normal eye growth in animals. We used Gnat2^cplf3/cplf3 (Gnat2^-/-) mice, a genetic mouse model of cone dysfunction to investigate the influence of cone signaling in ocular refractive development and myopia susceptibility in mice. Refractive development under normal visual conditions was measured for Gnat2^-/- and age-matched Gnat2^+/+ mice, every 2 weeks from 4 to 14 weeks of age. Weekly measurements were performed on a separate cohort of mice that underwent monocular form-deprivation (FD) in the right eye from 4 weeks of age using head-mounted diffusers. Refraction, corneal curvature, and ocular biometrics were obtained using photorefraction, keratometry and optical coherence tomography, respectively. Retinas from FD mice were harvested, and analyzed for dopamine (DA) and 3,4-dihydroxyphenylacetate (DOPAC) using high-performance liquid chromatography. Under normal visual conditions, Gnat2^+/+ and Gnat2^-/- mice showed similar refractive error, axial length, and corneal radii across development (p > 0.05), indicating no significant effects of the Gnat2 mutation on normal ocular refractive development in mice. Three weeks of FD produced a significantly greater myopic shift in Gnat2^-/- mice compared to Gnat2^+/+ controls (-5.40 ± 1.33 D vs -2.28 ± 0.28 D, p = 0.042). Neither the Gnat2 mutation nor FD altered retinal levels of DA or DOPAC. Our results indicate that cone pathways needed for high acuity vision in primates are not as critical for normal refractive development in mice, and that both rods and cones contribute to visual signalling pathways needed to respond to FD in mammalian eyes.

Hartmann-Shack wavefront sensing without a lenslet array using a digital micromirror device

The common Hartmann-Shack wavefront sensor makes use of a lenslet array to sample in-parallel optical wavefronts. Here, we introduce a Hartmann-Shack wavefront sensor that employs a digital micromirror device in combination with a single lens for serial sampling by scanning. Sensing is analyzed numerically and validated experimentally using a deformable mirror operated in closed-loop adaptive optics with a conventional Hartmann-Shack wavefront sensor, as well as with a set of ophthalmic trial lenses, to generate controllable amounts of monochromatic aberrations. The new sensor is free of crosstalk and can potentially operate at kilohertz speed. It offers a reconfigurable aperture that can exclude unwanted parts of the wavefront.