1
|
Liew G, Xie J, Nguyen H, Keay L, Kamran Ikram M, McGeechan K, Klein BEK, Jin Wang J, Mitchell P, Klaver CCW, Lamoureux EL, Wong TY. Hypertensive retinopathy and cardiovascular disease risk: 6 population-based cohorts meta-analysis. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2023; 17:200180. [PMID: 36936860 PMCID: PMC10020621 DOI: 10.1016/j.ijcrp.2023.200180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 02/13/2023] [Accepted: 02/22/2023] [Indexed: 03/07/2023]
Abstract
Background The cardiovascular risk associated with different levels of hypertensive retinopathy, including mild, remains unclear. We performed an individual participant meta-analysis from 6 population-based cohort studies to determine the relationship of hypertensive retinopathy with incident cardiovascular outcomes. Methods We identified cohort studies that objectively assessed hypertensive retinopathy from photographs, documented incident cardiovascular outcomes, and were population-based. Six studies contributed data from 11,013 individuals at baseline with 5-13 years follow-up. Participants were recruited if they had hypertension and did not have confounding conditions such as diabetic retinopathy. Main outcome measures were incident coronary heart disease (CHD), stroke and a composite endpoint of cardiovascular disease (CHD or stroke). Pooled estimates of incident risk ratios (IRR) were obtained after adjusting for age, gender, systolic blood pressure, serum total cholesterol, high density lipoprotein and smoking. Results Among eligible participants with hypertension and without diabetes, there were 1018/9662 (10.5%) incident CHD events, 708/11,013 (6.4%) incident stroke events and 1317/9378 (14.0%) incident CVD events. Mild hypertensive retinopathy was associated with increased risk of CVD (IRR 1.13, 95% CI 1.00 to 1.27) and CHD (IRR 1.17, 95% CI 1.02 to 1.34) but not stroke; moderate hypertensive retinopathy was associated with increased risk of CVD (IRR 1.25 95% CI 1.02 to 1.53) but not stroke or CHD individually. Conclusions In persons with hypertension, both mild and moderate hypertensive retinopathy were associated with higher CVD risk.
Collapse
Affiliation(s)
- Gerald Liew
- Centre for Vision Research, Department of Ophthalmology, The Westmead Institute for Medical Research, The University of Sydney, Sydney, Australia
- Corresponding author. Centre for Vision Research, The Westmead Institute for Medical Research, The University of Sydney, 176 Hawkesbury Road, Westmead, NSW, 2145, Australia.
| | - Jing Xie
- Centre for Vision Research, Department of Ophthalmology, The Westmead Institute for Medical Research, The University of Sydney, Sydney, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Helen Nguyen
- Centre for Vision Research, Department of Ophthalmology, The Westmead Institute for Medical Research, The University of Sydney, Sydney, Australia
- School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
| | - Lisa Keay
- School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
| | - M. Kamran Ikram
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Duke-NUS Graduate Medical School, National University of Singapore, Singapore
| | - Kevin McGeechan
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, Australia
| | - Barbara EK. Klein
- Department of Ophthalmology & Visual Sciences, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jie Jin Wang
- Centre for Vision Research, Department of Ophthalmology, The Westmead Institute for Medical Research, The University of Sydney, Sydney, Australia
- Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, Australia
| | - Paul Mitchell
- Centre for Vision Research, Department of Ophthalmology, The Westmead Institute for Medical Research, The University of Sydney, Sydney, Australia
| | - Caroline CW. Klaver
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Ophthalmology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ecosse L. Lamoureux
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, Australia
- Centre for Eye Research Australia, University of Melbourne, Melbourne, Australia
| | - Tien Y. Wong
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Screening and Test Evaluation Program, School of Public Health, University of Sydney, Sydney, Australia
- Centre for Eye Research Australia, University of Melbourne, Melbourne, Australia
| |
Collapse
|
2
|
Pachade S, Coronado I, Abdelkhaleq R, Yan J, Salazar-Marioni S, Jagolino A, Green C, Bahrainian M, Channa R, Sheth SA, Giancardo L. Detection of Stroke with Retinal Microvascular Density and Self-Supervised Learning Using OCT-A and Fundus Imaging. J Clin Med 2022; 11:jcm11247408. [PMID: 36556024 PMCID: PMC9788382 DOI: 10.3390/jcm11247408] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/07/2022] [Accepted: 12/08/2022] [Indexed: 12/15/2022] Open
Abstract
Acute cerebral stroke is a leading cause of disability and death, which could be reduced with a prompt diagnosis during patient transportation to the hospital. A portable retina imaging system could enable this by measuring vascular information and blood perfusion in the retina and, due to the homology between retinal and cerebral vessels, infer if a cerebral stroke is underway. However, the feasibility of this strategy, the imaging features, and retina imaging modalities to do this are not clear. In this work, we show initial evidence of the feasibility of this approach by training machine learning models using feature engineering and self-supervised learning retina features extracted from OCT-A and fundus images to classify controls and acute stroke patients. Models based on macular microvasculature density features achieved an area under the receiver operating characteristic curve (AUC) of 0.87-0.88. Self-supervised deep learning models were able to generate features resulting in AUCs ranging from 0.66 to 0.81. While further work is needed for the final proof for a diagnostic system, these results indicate that microvasculature density features from OCT-A images have the potential to be used to diagnose acute cerebral stroke from the retina.
Collapse
Affiliation(s)
- Samiksha Pachade
- Center for Precision Health, School of Biomedical Informatics, University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77030, USA
| | - Ivan Coronado
- Center for Precision Health, School of Biomedical Informatics, University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77030, USA
| | - Rania Abdelkhaleq
- Department of Neurology, UTHealth McGovern Medical School, UTHealth, Houston, TX 77030, USA
| | - Juntao Yan
- Center for Precision Health, School of Biomedical Informatics, University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77030, USA
| | - Sergio Salazar-Marioni
- Department of Neurology, UTHealth McGovern Medical School, UTHealth, Houston, TX 77030, USA
| | - Amanda Jagolino
- Department of Neurology, UTHealth McGovern Medical School, UTHealth, Houston, TX 77030, USA
| | - Charles Green
- Institute for Stroke and Cerebrovascular Diseases, UTHealth, Houston, TX 77030, USA
- Center for Clinical Research and Evidence-Based Medicine, UTHealth McGovern Medical School, UTHealth, Houston, TX 77030, USA
| | - Mozhdeh Bahrainian
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Roomasa Channa
- Department of Ophthalmology and Visual Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Sunil A. Sheth
- Department of Neurology, UTHealth McGovern Medical School, UTHealth, Houston, TX 77030, USA
| | - Luca Giancardo
- Center for Precision Health, School of Biomedical Informatics, University of Texas Health Science Center at Houston (UTHealth), Houston, TX 77030, USA
- Institute for Stroke and Cerebrovascular Diseases, UTHealth, Houston, TX 77030, USA
- Correspondence:
| |
Collapse
|
3
|
Pyatka N, Banks MK, Fotedar N, DeLozier SJ, Morgan M, Preston DC. Nonmydriatic Retinal Photography in the Outpatient Neurology Resident Clinic. J Neuroophthalmol 2022; 42:68-72. [PMID: 34999652 DOI: 10.1097/wno.0000000000001236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The funduscopic examination is an essential component of the neurologic examination. However, examination of the ocular fundus with a direct ophthalmoscope is often difficult. Nonmydriatic ocular fundus photography allows direct visualization of the ocular fundus with high-quality photographs. We used nonmydriatic ocular fundus photography to improve patient care and funduscopy skills of residents in the Neurology Resident Clinic. METHODS At the time of triage, funduscopic photographs of all new neurology resident clinic patients were taken. The images were imported into the hospital's imaging software. The residents completed a full neurologic examination, including a funduscopic examination with a handheld ophthalmoscope. At the time of staffing the patients with the attendings, the residents received immediate feedback and teaching on retina photograph evaluation. RESULTS A total of 255 patients were enrolled. Of those, 230 (90%) had at least one high-quality funduscopic photograph. Retinal photographs were normal in 161 (70%). Out of the 69 abnormal photographs, only 7% of abnormalities were detected by the residents. Ninety-three percent of residents found the retinal photographs useful. CONCLUSIONS Nonmydriatic ocular fundus photography improved the care in patients presenting to a Neurology resident clinic and facilitated residents in recognizing funduscopic findings. Its benefits are clear when one considers (1) the high risk of negative patient outcomes and possible medicolegal consequences due to missed findings, (2) the ease of incorporating retinal photographs into the patients' medical records, and (3) the benefit of improving resident education in regard to the ophthalmologic examination.
Collapse
Affiliation(s)
- Nataliya Pyatka
- Neurology Department, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | | | | | | | | |
Collapse
|
4
|
Zeng Z, Nallan Chakravarthula T, Muralidharan C, Hall A, Linnemann AK, Alves NJ. Fluorescently conjugated annular fibrin clot for multiplexed real-time digestion analysis. J Mater Chem B 2021; 9:9295-9307. [PMID: 34698753 DOI: 10.1039/d1tb02088a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Impaired fibrinolysis has long been considered as a risk factor for venous thromboembolism. Fibrin clots formed at physiological concentrations are promising substrates for monitoring fibrinolytic performance as they offer clot microstructures resembling in vivo. Here we introduce a fluorescently labeled fibrin clot lysis assay which leverages a unique annular clot geometry assayed using a microplate reader. A physiologically relevant fibrin clotting formulation was explored to achieve high assay sensitivity while minimizing labeling impact as fluorescence isothiocyanate (FITC)-fibrin(ogen) conjugations significantly affect both fibrin polymerization and fibrinolysis. Clot characteristics were examined using thromboelastography (TEG), turbidity, scanning electron microscopy, and confocal microscopy. Sample fibrinolytic activities at varying plasmin, plasminogen, and tissue plasminogen activator (tPA) concentrations were assessed in the present study and results were compared to an S2251 chromogenic assay. The optimized physiologically relevant clot substrate showed minimal reporter-conjugation impact with nearly physiological clot properties. The assay demonstrated good reproducibility, wide working range, kinetic read ability, low limit of detection, and the capability to distinguish fibrin binding-related lytic performance. In combination with its ease for multiplexing, it also has applications as a convenient platform for assessing patient fibrinolytic potential and screening thrombolytic drug activities in personalized medical applications.
Collapse
Affiliation(s)
- Ziqian Zeng
- Department of Emergency Medicine, Indiana University School of Medicine, 635 Barnhill Dr Rm. 2063, Indianapolis, IN 46202, USA. .,Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN 47907, USA
| | - Tanmaye Nallan Chakravarthula
- Department of Emergency Medicine, Indiana University School of Medicine, 635 Barnhill Dr Rm. 2063, Indianapolis, IN 46202, USA. .,Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN 47907, USA
| | - Charanya Muralidharan
- Department of Biochemistry & Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Abigail Hall
- Department of Emergency Medicine, Indiana University School of Medicine, 635 Barnhill Dr Rm. 2063, Indianapolis, IN 46202, USA.
| | - Amelia K Linnemann
- Department of Biochemistry & Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.,Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Nathan J Alves
- Department of Emergency Medicine, Indiana University School of Medicine, 635 Barnhill Dr Rm. 2063, Indianapolis, IN 46202, USA. .,Weldon School of Biomedical Engineering, Purdue University, West Lafayette, IN 47907, USA.,Department of Biochemistry & Molecular Biology, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| |
Collapse
|
5
|
Abstract
BACKGROUND Cerebrovascular disease (CeVD), including stroke, is a leading cause of death globally. The retina is an extension of the cerebrum, sharing embryological and vascular pathways. The association between different retinal signs and CeVD has been extensively evaluated. In this review, we summarize recent studies which have examined this association. EVIDENCE ACQUISITION We searched 6 databases through July 2019 for studies evaluating the link between retinal vascular signs and diseases with CeVD. CeVD was classified into 2 groups: clinical CeVD (including clinical stroke, silent cerebral infarction, cerebral hemorrhage, and stroke mortality), and sub-clinical CeVD (including MRI-defined lacunar infarct and white matter lesions [WMLs]). Retinal vascular signs were classified into 3 groups: classic hypertensive retinopathy (including retinal microaneurysms, retinal microhemorrhage, focal/generalized arteriolar narrowing, cotton-wool spots, and arteriovenous nicking), clinical retinal diseases (including diabetic retinopathy [DR], age-related macular degeneration [AMD], retinal vein occlusion, retinal artery occlusion [RAO], and retinal emboli), and retinal vascular imaging measures (including retinal vessel diameter and geometry). We also examined emerging retinal vascular imaging measures and the use of artificial intelligence (AI) deep learning (DL) techniques. RESULTS Hypertensive retinopathy signs were consistently associated with clinical CeVD and subclinical CeVD subtypes including subclinical cerebral large artery infarction, lacunar infarction, and WMLs. Some clinical retinal diseases such as DR, retinal arterial and venous occlusion, and transient monocular vision loss are consistently associated with clinical CeVD. There is an increased risk of recurrent stroke immediately after RAO. Less consistent associations are seen with AMD. Retinal vascular imaging using computer assisted, semi-automated software to measure retinal vascular caliber and other parameters (tortuosity, fractal dimension, and branching angle) has shown strong associations to clinical and subclinical CeVD. Other new retinal vascular imaging techniques (dynamic retinal vessel analysis, adaptive optics, and optical coherence tomography angiography) are emerging technologies in this field. Application of AI-DL is expected to detect subclinical retinal changes and discrete retinal features in predicting systemic conditions including CeVD. CONCLUSIONS There is extensive and increasing evidence that a range of retinal vascular signs and disease are closely linked to CeVD, including subclinical and clinical CeVD. New technology including AI-DL will allow further translation to clinical utilization.
Collapse
|
6
|
Kwapong WR, Yan Y, Hao Z, Wu B. Reduced Superficial Capillary Density in Cerebral Infarction Is Inversely Correlated With the NIHSS Score. Front Aging Neurosci 2021; 13:626334. [PMID: 33716714 PMCID: PMC7947804 DOI: 10.3389/fnagi.2021.626334] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 02/02/2021] [Indexed: 02/05/2023] Open
Abstract
Purpose: The retina and the brain share similar neuronal and microvascular features, therein we aimed to assess the structural and microvascular changes in the macula and choriocapillaris (CC) in patients with cerebral infarction when compared with healthy controls using optical coherence tomography angiography (OCTA). Methods: OCTA was used to image and measure the capillary density in the radial peripapillary capillaries (RPC), superficial capillary plexus (SCP), deep capillary plexus (DCP), choriocapillaris (CC), and mean area of the foveal avascular zone (FAZ) in all participants. Twenty-two cerebral infarction patients based on their magnetic resonance imaging (MRI) and 25 healthy controls were included in our study. Results: Density of the RPC (P < 0.001), SCP (P = 0.001), DCP (P < 0.001) and CC (P < 0.001) were significantly reduced in cerebral infarction patients when compared with healthy controls, respectively. Retinal thickness measurements (P < 0.05) were significantly reduced in cerebral infarction patients when compared with healthy controls. The mean FAZ area was significantly larger (P = 0.012) in cerebral infarction patients when compared with healthy controls. National Institute of HealthStroke Scale (NIHSS) inversely correlated with SCP density in cerebral infarction patients (Rho = −0.409, P = 0.001). Receiver operating characteristics curve analysis showed that the blood flow of the choriocapillaris had the highest index [area under the receiver operatingcharacteristic (AUROC) = 0.964] to discriminate cerebral infarction patients from the healthy controls. Conclusions: Our study suggests that cerebral microcirculation dysfunction which occurs in cerebral infarction is mirrored in the macula and choroidal microcirculation. OCTA has the potential to non-invasively characterize the macula and choroidal changes in cerebral infarction in vivo.
Collapse
Affiliation(s)
| | - Yuying Yan
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Zilong Hao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
7
|
Zhao Y, Yang B, Xu AD, Ruan YW, Xu Y, Hu HL, Tan ZF. Retinal Microvascular Changes in Subtypes of Ischemic Stroke. Front Neurol 2021; 11:619554. [PMID: 33584518 PMCID: PMC7873353 DOI: 10.3389/fneur.2020.619554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 12/23/2020] [Indexed: 12/03/2022] Open
Abstract
Aims: Retinal microvasculature shares prominent similarities with the brain vasculature. We aimed to assess the association between retinal microvasculature and subtypes of ischemic stroke. Method: We consecutively enrolled ischemic stroke patients within 7 days of onset, who met the criteria of subtype of atherothrombosis (AT), small artery disease (SAD), or cardioembolism (CE) according to a modified version of the Trial of Org 10172 in Acute Stroke Treatment (NEW-TOAST). Digital fundus photographs were taken within 72 h of hospital admission using a digital camera (Topcon TRC-50DX), and fundus photographs were semi-automatically measured by software (Canvus 14 and NeuroLucida) for retinal vasculature parameters. Results: A total of 141 patients were enrolled, including 72 with AT, 54 with SAD, and 15 with CE. AT subtype patients had the widest mean venular diameter within 0.5-1.0 disk diameter (MVD0.5-1.0DD) followed by SAD and CE subtypes (86.37 ± 13.49 vs. 83.55 ± 11.54 vs. 77.90 ± 8.50, respectively, P = 0.047); CE subtype patients had the highest mean arteriovenous ratio within 0.5-1.0 disk diameter (MAVR0.5-1.0DD) followed by the AT and SAD subtype groups (0.97 ± 0.03 vs. 0.89 ± 0.99 vs. 0.89 ± 0.11, respectively, P = 0.010); SAD subtype patients were found with the highest mean venular tortuosity within 0.0-2.0 disk diameter (MVT0.0-2.0DD) followed by the AT and CE subtypes (1.0294 ± 0.0081 vs. 1.0259 ± 0.0084 vs. 1.0243 ± 0.0066, respectively, P = 0.024). After adjusting for clinic characteristics, MVD0.5-1.0DD was significantly different among AT, SAD, and CE subtypes (P = 0.033). By receiver operating characteristic curve analysis, MVD0.5-1.0DD predicted the AT subtype (area 0.690, 95% confidence interval, 0.566-0.815), with a cutoff value of 82.23 μm (sensitivity 61.1%, specificity 73.3%). Conclusion: Retinal MVD0.5-1.0DD (>82.23 μm) might be associated with the AT stroke subtype; however, we need large-scale prospective studies in future to explore the underlying mechanism and causal explanation for this finding.
Collapse
Affiliation(s)
- Ying Zhao
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Jinan University, Guangzhou, China
- Clinical Neuroscience Institute, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Bing Yang
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Jinan University, Guangzhou, China
- Clinical Neuroscience Institute, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - An-Ding Xu
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Jinan University, Guangzhou, China
- Clinical Neuroscience Institute, The First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Yi-Wen Ruan
- Department of Central Nervous System Regeneration, Guangdong-Hongkong-Macau Institute of Central Nervous System (CNS) Regeneration (GHMICR), Jinan University, Guangzhou, China
| | - Ying Xu
- Department of Central Nervous System Regeneration, Guangdong-Hongkong-Macau Institute of Central Nervous System (CNS) Regeneration (GHMICR), Jinan University, Guangzhou, China
| | - Hui-Ling Hu
- Shenzhen Key Laboratory of Ophthalmology, Shenzhen Eye Hospital, Shenzhen University School of Medicine, Shenzhen, China
| | - Ze-Feng Tan
- Department of Neurology and Stroke Center, The First Affiliated Hospital, Jinan University, Guangzhou, China
- Clinical Neuroscience Institute, The First Affiliated Hospital, Jinan University, Guangzhou, China
- Department of Neurology, The Affiliated Shunde Hospital of Jinan University, Guangzhou, China
| |
Collapse
|
8
|
Mastropasqua L, Perilli R, D'Aloisio R, Toto L, Mastropasqua A, Donato S, Taraborrelli M, Ginestra F, Porta M, Consoli A. Why Miss the Chance? Incidental Findings while Telescreening for Diabetic Retinopathy. Ophthalmic Epidemiol 2020; 27:237-245. [PMID: 31958252 DOI: 10.1080/09286586.2020.1715450] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE To report on incidental pathological findings met while screening for Diabetic Retinopathy (DR) in Diabetes Clinics (DC) by ophthalmologist-graded digital fundus imaging. METHODS At the DC of Pescara (central Italy), for 3,859 eyes of 1,930 consecutive patients having not undergone fundus examination in the last year, two mydriatic fundus digital images, taken with a CenterVue DRS Digital Retinal Camera, were sent along with Best Corrected Visual Acuity, on a "store-and-forward" basis, to an ophthalmologist trained in DR screening, and graded according to the UK Diabetic Eye Screening Programme. Incidental fundus abnormalities other than DR were reported. RESULTS No adverse event to mydriasis was reported. One hundred and eighty eyes (4.66%) were ungradable. Among the 3,679 gradable ones, 1,105 (30.04%) showed different degrees of DR (R1 to R3), and 126 (3.42%) maculopathy (M1). Any Age-Related Macular Degeneration was present in 387 eyes (10.52%), any optic disc and parapapillary area features suspect for glaucoma in 562 eyes (15.27%), any hypertensive retinopathy in 1,263 eyes (34.33%), vitreoretinal interface disease in 252 eyes (6.84%), myopic choroidopathy in 92 eyes (2.50%), disc pallor in 31 eyes (0.84%). Mean time was 5 min for screening, 2 min for grading. CONCLUSION Teleretinography is a well-established, cost-effective procedure in DR screening. Along with increased attendance, locating a digital camera in a DC with a retina-specialist grader results in finding fundus pathologies also beyond DR, very similarly to fundus examination in an outpatient ophthalmic setting.
Collapse
Affiliation(s)
- Leonardo Mastropasqua
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
| | - Roberto Perilli
- Territorial Ophthalmology Unit, Local Health Authority , Pescara, Italy
| | - Rossella D'Aloisio
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
| | - Lisa Toto
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
| | - Alessandra Mastropasqua
- Ophthalmology Clinic, Department of Medicine and Science of Ageing, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
| | - Simone Donato
- Chair of Endocrinology and Metabolic Diseases, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
| | - Merilda Taraborrelli
- Chair of Endocrinology and Metabolic Diseases, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
| | - Federica Ginestra
- Chair of Endocrinology and Metabolic Diseases, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
| | - Massimo Porta
- Chair of Internal Medicine, Department Of Medical Sciences, University of Turin , Turin, Italy
| | - Agostino Consoli
- Chair of Endocrinology and Metabolic Diseases, University G. d'Annunzio Chieti-Pescara , Chieti, Italy
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Kipli K, Hoque ME, Lim LT, Mahmood MH, Sahari SK, Sapawi R, Rajaee N, Joseph A. A Review on the Extraction of Quantitative Retinal Microvascular Image Feature. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2018; 2018:4019538. [PMID: 30065780 PMCID: PMC6051289 DOI: 10.1155/2018/4019538] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 05/02/2018] [Indexed: 12/31/2022]
Abstract
Digital image processing is one of the most widely used computer vision technologies in biomedical engineering. In the present modern ophthalmological practice, biomarkers analysis through digital fundus image processing analysis greatly contributes to vision science. This further facilitates developments in medical imaging, enabling this robust technology to attain extensive scopes in biomedical engineering platform. Various diagnostic techniques are used to analyze retinal microvasculature image to enable geometric features measurements such as vessel tortuosity, branching angles, branching coefficient, vessel diameter, and fractal dimension. These extracted markers or characterized fundus digital image features provide insights and relates quantitative retinal vascular topography abnormalities to various pathologies such as diabetic retinopathy, macular degeneration, hypertensive retinopathy, transient ischemic attack, neovascular glaucoma, and cardiovascular diseases. Apart from that, this noninvasive research tool is automated, allowing it to be used in large-scale screening programs, and all are described in this present review paper. This paper will also review recent research on the image processing-based extraction techniques of the quantitative retinal microvascular feature. It mainly focuses on features associated with the early symptom of transient ischemic attack or sharp stroke.
Collapse
Affiliation(s)
- Kuryati Kipli
- Department of Electrical and Electronics Engineering, University Malaysia Sarawak (UNIMAS), 94300 Kota Samarahan, Kuching, Malaysia
| | - Mohammed Enamul Hoque
- Department of Electrical and Electronics Engineering, University Malaysia Sarawak (UNIMAS), 94300 Kota Samarahan, Kuching, Malaysia
| | - Lik Thai Lim
- Department of Ophthalmology, Faculty of Medicine and Health Sciences (FMHS), University Malaysia Sarawak (UNIMAS), 94300 Kota Samarahan, Sarawak, Malaysia
| | - Muhammad Hamdi Mahmood
- Department of Para-Clinical Sciences, Faculty of Medicine and Health Sciences (FMHS), University Malaysia Sarawak (UNIMAS), 94300 Kota Samarahan, Sarawak, Malaysia
| | - Siti Kudnie Sahari
- Department of Electrical and Electronics Engineering, University Malaysia Sarawak (UNIMAS), 94300 Kota Samarahan, Kuching, Malaysia
| | - Rohana Sapawi
- Department of Electrical and Electronics Engineering, University Malaysia Sarawak (UNIMAS), 94300 Kota Samarahan, Kuching, Malaysia
| | - Nordiana Rajaee
- Department of Electrical and Electronics Engineering, University Malaysia Sarawak (UNIMAS), 94300 Kota Samarahan, Kuching, Malaysia
| | - Annie Joseph
- Department of Electrical and Electronics Engineering, University Malaysia Sarawak (UNIMAS), 94300 Kota Samarahan, Kuching, Malaysia
| |
Collapse
|
11
|
Neville CE, Montgomery S, Silvestri G, McGowan A, Moore E, Silvestri V, Cardwell C, McEvoy CT, Maxwell AP, Woodside JV, McKay GJ. Dietary Patterns and Retinal Vessel Caliber in the Irish Nun Eye Study. J Nutr Health Aging 2018; 22:751-758. [PMID: 30080215 PMCID: PMC6061240 DOI: 10.1007/s12603-017-0992-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 10/16/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Retinal vessel abnormalities are associated with cardiovascular disease risk. Widening of retinal venules is associated with increased risk of stroke while narrowing of retinal arterioles independently predicts incident hypertension, coronary heart disease and diabetes. Dietary factors are known to play an important role in cardiovascular health. However, few studies have examined the association between dietary patterns (DPs) and retinal microvascular health. OBJECTIVE To examine the association between 'a posteriori'-derived DPs and retinal vascular caliber (RVC) in older women with a restricted lifestyle. METHODS This was a cross-sectional study of 1233 participants (mean age: 76.3 years) from the Irish Nun Eye Study (INES). Computer-assisted software was used to measure RVC from digital eye images using standardized protocols. Dietary intake was assessed using a food frequency questionnaire (FFQ). DP analysis was performed using principal component analysis from completed FFQs. Regression models were used to assess associations between DPs and retinal vessel diameters, adjusting for age, body mass index, refraction, hypertension, diabetes mellitus, ischemic heart disease, cerebrovascular accident and fellow eye RVC. RESULTS Two DPs were identified: a 'healthy' pattern with high factor loadings for fruit, vegetables, wholegrains and oily fish and an 'unhealthy' pattern with high factor loadings for sugar and sweets, chips, high fat dairy products and French fries. Adjusted linear regression analysis revealed that those who adhered most closely to the unhealthy DP had wider central retinal venular equivalent (CRVE) (p=0.03) and narrower central retinal arteriolar equivalent (CRAE) (p=0.01) compared to the least unhealthy DP. No independent relationship was observed between the healthy DP and RVC. CONCLUSION In this cohort of older women with a restricted lifestyle, an unhealthy DP was independently associated with an unfavorable retinal profile, namely a widening of retinal venules and narrowing of retinal arterioles.
Collapse
Affiliation(s)
- C E Neville
- Charlotte E. Neville, Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom,
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Biousse V, Bruce BB, Newman NJ. Ophthalmoscopy in the 21st century: The 2017 H. Houston Merritt Lecture. Neurology 2017; 90:167-175. [PMID: 29273687 DOI: 10.1212/wnl.0000000000004868] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 10/05/2017] [Indexed: 11/15/2022] Open
Abstract
Although the usefulness of viewing the ocular fundus is well-recognized, ophthalmoscopy is infrequently and poorly performed by most nonophthalmologist physicians, including neurologists. Barriers to the practice of ophthalmoscopy by nonophthalmologists include not only the technical difficulty related to direct ophthalmoscopy, but also lack of adequate training and discouragement by preceptors. Recent studies have shown that digital retinal fundus photographs with electronic transmission and remote interpretation of images by an ophthalmologist are an efficient and reliable way to allow examination of the ocular fundus in patients with systemic disorders such as diabetes mellitus. Ocular fundus photographs obtained without pharmacologic dilation of the pupil using nonmydriatic fundus cameras could be of great value in emergency departments (EDs) and neurologic settings. The Fundus Photography vs Ophthalmoscopy Trial Outcomes in the Emergency Department (FOTO-ED) study showed that ED providers consistently failed to correctly identify relevant ocular funduscopic findings using the direct ophthalmoscope, and that nonmydriatic fundus photography was an effective alternate way of providing access to the ocular fundus in the ED. Extrapolating these results to headache clinics, outpatient neurology clinics, and adult and pediatric primary care settings seems self-evident. As technology advances, nonmydriatic ocular fundus imaging systems will be of higher quality and more portable and affordable, thereby circumventing the need to master the use of the ophthalmoscope. Visualizing the ocular fundus is more important than the method used. Ocular fundus photography facilitates nonophthalmologists' performance of this essential part of the physical examination, thus helping to reestablish the value of doing so.
Collapse
Affiliation(s)
- Valérie Biousse
- From the Departments of Ophthalmology (V.B., B.B.B., N.J.N.), Neurology (V.B., B.B.B., N.J.N.), Epidemiology (B.B.B.), and Neurological Surgery (N.J.N.), Emory University School of Medicine, Atlanta, GA
| | - Beau B Bruce
- From the Departments of Ophthalmology (V.B., B.B.B., N.J.N.), Neurology (V.B., B.B.B., N.J.N.), Epidemiology (B.B.B.), and Neurological Surgery (N.J.N.), Emory University School of Medicine, Atlanta, GA
| | - Nancy J Newman
- From the Departments of Ophthalmology (V.B., B.B.B., N.J.N.), Neurology (V.B., B.B.B., N.J.N.), Epidemiology (B.B.B.), and Neurological Surgery (N.J.N.), Emory University School of Medicine, Atlanta, GA.
| |
Collapse
|
13
|
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.
Collapse
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
| |
Collapse
|
14
|
Frost S, Brown M, Stirling V, Vignarajan J, Prentice D, Kanagasingam Y. Utility of Ward-Based Retinal Photography in Stroke Patients. J Stroke Cerebrovasc Dis 2016; 26:600-607. [PMID: 28010951 DOI: 10.1016/j.jstrokecerebrovasdis.2016.11.112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/19/2016] [Accepted: 11/23/2016] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Improvements in acute care of stroke patients have decreased mortality, but survivors are still at increased risk of future vascular events and mitigation of this risk requires thorough assessment of the underlying factors leading to the stroke. The brain and eye share a common embryological origin and numerous similarities exist between the small vessels of the retina and brain. Recent population-based studies have demonstrated a close link between retinal vascular changes and stroke, suggesting that retinal photography could have utility in assessing underlying stroke risk factors and prognosis after stroke. Modern imaging equipment can facilitate precise measurement and monitoring of vascular features. However, use of this equipment is a challenge in the stroke ward setting as patients are frequently unable to maintain the required seated position, and pupil dilatation is often not feasible as it could potentially obscure important neurological signs of stroke progression. MATERIALS AND METHODS This small study investigated the utility of a novel handheld, nonmydriatic retinal camera in the stroke ward and explored associations between retinal vascular features and stroke risk factors. This camera circumvented the practical limitations of conducting retinal photography in the stroke ward setting. RESULTS A positive correlation was found between carotid disease and both mean width of arterioles (r = .40, P = .00571) and venules (r = .30, P = .0381). CONCLUSIONS The results provide further evidence that retinal vascular features are clinically informative about underlying stroke risk factors and demonstrate the utility of handheld retinal photography in the stroke ward.
Collapse
Affiliation(s)
- Shaun Frost
- CSIRO Australian e-Health Research Center/Health and Biosecurity, Perth, Western Australia, Australia.
| | - Michael Brown
- Department of Ophthalmology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Verity Stirling
- Department of Ophthalmology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Janardhan Vignarajan
- CSIRO Australian e-Health Research Center/Health and Biosecurity, Perth, Western Australia, Australia
| | - David Prentice
- Department of Neurology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Yogesan Kanagasingam
- CSIRO Australian e-Health Research Center/Health and Biosecurity, Perth, Western Australia, Australia
| |
Collapse
|
15
|
Cabrera DeBuc D, Somfai GM, Koller A. Retinal microvascular network alterations: potential biomarkers of cerebrovascular and neural diseases. Am J Physiol Heart Circ Physiol 2016; 312:H201-H212. [PMID: 27923786 DOI: 10.1152/ajpheart.00201.2016] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 11/04/2016] [Accepted: 11/11/2016] [Indexed: 12/12/2022]
Abstract
Increasing evidence suggests that the conditions of retinal microvessels are indicators to a variety of cerebrovascular, neurodegenerative, psychiatric, and developmental diseases. Thus noninvasive visualization of the human retinal microcirculation offers an exceptional opportunity for the investigation of not only the retinal but also cerebral microvasculature. In this review, we show how the conditions of the retinal microvessels could be used to assess the conditions of brain microvessels because the microvascular network of the retina and brain share, in many aspects, standard features in development, morphology, function, and pathophysiology. Recent techniques and imaging modalities, such as optical coherence tomography (OCT), allow more precise visualization of various layers of the retina and its microcirculation, providing a "microscope" to brain microvessels. We also review the potential role of retinal microvessels in the risk identification of cerebrovascular and neurodegenerative diseases. The association between vision problems and cerebrovascular and neurodegenerative diseases, as well as the possible role of retinal microvascular imaging biomarkers in cerebrovascular and neurodegenerative screening, their potentials, and limitations, are also discussed.
Collapse
Affiliation(s)
- Delia Cabrera DeBuc
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida;
| | - Gabor Mark Somfai
- Semmelweis University, Budapest, Hungary.,Augenzentrum, Pallas Kliniken, Olten, Switzerland
| | - Akos Koller
- Institute of Natural Sciences, University of Physical Education, Budapest, Hungary; and.,Department of Physiology, New York Medical College, Valhalla, New York
| |
Collapse
|
16
|
Mackay DD, Bruce BB. Non-mydriatic fundus photography: a practical review for the neurologist. Pract Neurol 2016; 16:343-51. [DOI: 10.1136/practneurol-2016-001443] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2016] [Indexed: 11/03/2022]
|
17
|
Vuong LN, Thulasi P, Biousse V, Garza P, Wright DW, Newman NJ, Bruce BB. Ocular fundus photography of patients with focal neurologic deficits in an emergency department. Neurology 2015; 85:256-62. [PMID: 26109710 DOI: 10.1212/wnl.0000000000001759] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 03/26/2015] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES We evaluated the frequency and predictive value of ocular fundus abnormalities among patients who presented to the emergency department (ED) with focal neurologic deficits to determine the utility of these findings in the evaluation of patients with suspected TIA and stroke. METHODS In this cross-sectional pilot study, ocular fundus photographs were obtained using a nonmydriatic fundus camera. Demographic, neuroimaging, and ABCD(2) score components were collected. Photographs were reviewed for retinal microvascular abnormalities. The results were analyzed using univariate statistics and logistic regression modeling. RESULTS Two hundred fifty-seven patients presented to the ED with focal neurologic deficits, of whom 81 patients (32%) had cerebrovascular disease (CVD) and 144 (56%; 95% confidence interval: 50%-62%) had retinal microvascular abnormalities. Focal and general arteriolar narrowing increased the odds of clinically diagnosed CVD by 5.5 and 2.6 times, respectively, after controlling for the ABCD(2) score and diffusion-weighted imaging. These fundus findings also significantly differentiated TIA from non-CVD, even after controlling for the ABCD(2) score. CONCLUSIONS Focal and general arteriolar narrowing were independent predictors of CVD overall, and TIA alone, even after controlling for the ABCD(2) score and diffusion-weighted imaging lesions. The inclusion of nonmydriatic ocular fundus photographs in the evaluation of patients presenting to the ED with focal neurologic deficits may assist in the differentiation of stroke and TIA from other causes of focal neurologic deficits.
Collapse
Affiliation(s)
- Laurel N Vuong
- From the Departments of Ophthalmology (L.N.V., P.T., V.B., P.G., N.J.N., B.B.B.), Neurology (V.B., N.J.N., B.B.B.), Emergency Medicine (D.W.W.), and Neurological Surgery (N.J.N.), Emory University, Atlanta, GA
| | - Praneetha Thulasi
- From the Departments of Ophthalmology (L.N.V., P.T., V.B., P.G., N.J.N., B.B.B.), Neurology (V.B., N.J.N., B.B.B.), Emergency Medicine (D.W.W.), and Neurological Surgery (N.J.N.), Emory University, Atlanta, GA
| | - Valérie Biousse
- From the Departments of Ophthalmology (L.N.V., P.T., V.B., P.G., N.J.N., B.B.B.), Neurology (V.B., N.J.N., B.B.B.), Emergency Medicine (D.W.W.), and Neurological Surgery (N.J.N.), Emory University, Atlanta, GA
| | - Philip Garza
- From the Departments of Ophthalmology (L.N.V., P.T., V.B., P.G., N.J.N., B.B.B.), Neurology (V.B., N.J.N., B.B.B.), Emergency Medicine (D.W.W.), and Neurological Surgery (N.J.N.), Emory University, Atlanta, GA
| | - David W Wright
- From the Departments of Ophthalmology (L.N.V., P.T., V.B., P.G., N.J.N., B.B.B.), Neurology (V.B., N.J.N., B.B.B.), Emergency Medicine (D.W.W.), and Neurological Surgery (N.J.N.), Emory University, Atlanta, GA
| | - Nancy J Newman
- From the Departments of Ophthalmology (L.N.V., P.T., V.B., P.G., N.J.N., B.B.B.), Neurology (V.B., N.J.N., B.B.B.), Emergency Medicine (D.W.W.), and Neurological Surgery (N.J.N.), Emory University, Atlanta, GA
| | - Beau B Bruce
- From the Departments of Ophthalmology (L.N.V., P.T., V.B., P.G., N.J.N., B.B.B.), Neurology (V.B., N.J.N., B.B.B.), Emergency Medicine (D.W.W.), and Neurological Surgery (N.J.N.), Emory University, Atlanta, GA.
| |
Collapse
|
18
|
Mackay DD, Garza PS, Bruce BB, Newman NJ, Biousse V. The demise of direct ophthalmoscopy: A modern clinical challenge. Neurol Clin Pract 2014; 5:150-157. [PMID: 26137422 DOI: 10.1212/cpj.0000000000000115] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ocular funduscopy appears to be a dying art. Physicians and medical students alike lack confidence in the use of an ophthalmoscope. As a result, few clinicians perform ophthalmoscopy, and many who do are unable to reliably detect abnormalities of the ocular fundus. Approaches to remediation in undergraduate medical education have included simulators, longitudinal skill reinforcement, Web-based teaching, and other techniques. Preservation of the ophthalmoscopic art has been hindered by technical difficulty, waning enthusiasm for ophthalmoscopy, and even discouragement from preceptors in medical education. Ocular fundus photography may serve a role in medical education to help improve student confidence in interpretation of ocular fundus findings and improve awareness of the importance of examination of the ocular fundus. Because neurology clerkships and clinical practices remain an important forum for honing ocular funduscopy skills, the neurologist should be familiar with novel alternative techniques that facilitate examination of the ocular fundus.
Collapse
Affiliation(s)
- Devin D Mackay
- Departments of Neurology, Ophthalmology, and Neurosurgery (DDM), Indiana University School of Medicine, Indianapolis, IN. Departments of Ophthalmology (PSG, BBB, NJN, VB), Neurology (BBB, NJN, VB), and Neurological Surgery (NJN), Emory University School of Medicine; and Department of Epidemiology (BBB), Rollins School of Public Health and Laney Graduate School, Emory University, Atlanta, GA
| | - Philip S Garza
- Departments of Neurology, Ophthalmology, and Neurosurgery (DDM), Indiana University School of Medicine, Indianapolis, IN. Departments of Ophthalmology (PSG, BBB, NJN, VB), Neurology (BBB, NJN, VB), and Neurological Surgery (NJN), Emory University School of Medicine; and Department of Epidemiology (BBB), Rollins School of Public Health and Laney Graduate School, Emory University, Atlanta, GA
| | - Beau B Bruce
- Departments of Neurology, Ophthalmology, and Neurosurgery (DDM), Indiana University School of Medicine, Indianapolis, IN. Departments of Ophthalmology (PSG, BBB, NJN, VB), Neurology (BBB, NJN, VB), and Neurological Surgery (NJN), Emory University School of Medicine; and Department of Epidemiology (BBB), Rollins School of Public Health and Laney Graduate School, Emory University, Atlanta, GA
| | - Nancy J Newman
- Departments of Neurology, Ophthalmology, and Neurosurgery (DDM), Indiana University School of Medicine, Indianapolis, IN. Departments of Ophthalmology (PSG, BBB, NJN, VB), Neurology (BBB, NJN, VB), and Neurological Surgery (NJN), Emory University School of Medicine; and Department of Epidemiology (BBB), Rollins School of Public Health and Laney Graduate School, Emory University, Atlanta, GA
| | - Valérie Biousse
- Departments of Neurology, Ophthalmology, and Neurosurgery (DDM), Indiana University School of Medicine, Indianapolis, IN. Departments of Ophthalmology (PSG, BBB, NJN, VB), Neurology (BBB, NJN, VB), and Neurological Surgery (NJN), Emory University School of Medicine; and Department of Epidemiology (BBB), Rollins School of Public Health and Laney Graduate School, Emory University, Atlanta, GA
| |
Collapse
|
19
|
Tang YH, Vital S, Russell J, Seifert H, Senchenkova E, Granger DN. Transient ischemia elicits a sustained enhancement of thrombus development in the cerebral microvasculature: effects of anti-thrombotic therapy. Exp Neurol 2014; 261:417-23. [PMID: 25058045 DOI: 10.1016/j.expneurol.2014.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 06/26/2014] [Accepted: 07/10/2014] [Indexed: 12/22/2022]
Abstract
OBJECTIVE While transient ischemic attack (TIA) is a well-known harbinger of ischemic stroke, the mechanisms that link TIA to subsequent strokes remain poorly understood. The overall aim of this study was to determine whether: 1) brief periods of transient cerebral ischemia render this tissue more vulnerable to thrombus development and 2) antiplatelet agents used in TIA patients alter ischemia-induced thrombogenesis. APPROACH & RESULTS The middle cerebral artery of C57BL/6 mice was occluded for 2.5-10min, followed by reperfusion periods of 1-28days. Intravital microscopy was used to monitor thrombus development in cerebral microvessels induced by light/dye photoactivation. Thrombosis was quantified as the time to platelet aggregation on the vessel wall and the time for complete blood flow cessation. While brief periods of cerebral ischemia were not associated with neurological deficits or brain infarction (evaluated after 1day), it yielded a pronounced and prolonged (up to 28days) acceleration of thrombus formation, compared to control (sham) mice. This prothrombotic phenotype was not altered by pre- and/or post-treatment of mice with either aspirin (A), clopidogrel (C), dipyridamole (D), or atorvastatin (S), or with A+D+S. CONCLUSIONS The increased vulnerability of the cerebral vasculature to thrombus development after a brief period of transient ischemia can be recapitulated in a murine model. Antiplatelet or antithrombotic agents used in patients with TIA show no benefit in this mouse model of brief transient ischemia.
Collapse
Affiliation(s)
- Ya Hui Tang
- Department of Molecular and Cellular Physiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Shantel Vital
- Department of Molecular and Cellular Physiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Janice Russell
- Department of Molecular and Cellular Physiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Hilary Seifert
- Department of Molecular and Cellular Physiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Elena Senchenkova
- Department of Molecular and Cellular Physiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - D Neil Granger
- Department of Molecular and Cellular Physiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA.
| |
Collapse
|
20
|
|
21
|
Is quality of diet associated with the microvasculature? An analysis of diet quality and retinal vascular calibre in older adults. Br J Nutr 2013; 110:739-46. [DOI: 10.1017/s0007114512005491] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
It is unknown whether diet quality is associated with microvascular structure. The present study aimed to investigate the relationship between diet quality, reflecting adherence to dietary guidelines, with retinal microvascular calibre in older adults. The dietary data of 2720 Blue Mountains Eye Study participants, aged 50+ years, were collected using a semi-quantitative FFQ. A modified version of the Healthy Eating Index for Australians was developed to determine total diet scores (TDS). Fundus photographs were taken and retinal vascular calibre measured using computer-assisted techniques and summarised. After adjusting for age, sex, BMI, mean arterial blood pressure, smoking, serum glucose, leucocyte count and history of diagnosed stroke or CHD, persons with higher TDS had healthier retinal vessels cross-sectionally, with wider retinal arteriolar calibre (by approximately 3 μm, comparing the highest with the lowest quartile of TDS, Ptrend= 0·0001) and narrower retinal venular calibre (by approximately 2·5 μm; Ptrend= 0·02). In younger subjects aged ≤ 65 years, increasing TDS (lowest to the highest quartile) was associated with healthier retinal vessels: approximately 4·4 μm wider retinal arteriolar (Ptrend< 0·0001) and approximately 2·3 μm narrower venular calibre (Ptrend= 0·03). After multivariable adjustment, however, baseline TDS were not associated with retinal arteriolar (Ptrend= 0·89) or venular calibre (Ptrend= 0·25), 5 years later. Also, baseline TDS were not associated with the 5-year change in retinal arteriolar (β = 0·14; P= 0·29) or venular calibre (β = − 0·26; P= 0·07). Greater compliance with published dietary guidelines (higher diet quality) was cross-sectionally associated with wider retinal arterioles and narrower venules, indicating better retinal microvascular health.
Collapse
|
22
|
Xiao J, Zhou X, Jiang T, Zhi ZN, Li Q, Qu J, Chen JG. Unilateral cerebral ischemia inhibits optomotor responses of the ipsilateral eye in mice. J Integr Neurosci 2012; 11:193-200. [PMID: 22744825 DOI: 10.1142/s0219635212500148] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 02/03/2012] [Indexed: 11/18/2022] Open
Abstract
A reduction in blood flow to the brain causes stroke and damage to neuronal networks. Cerebral ischemia is frequently associated with loss of visual functions. Because retinal and small cerebral vessels are vulnerable to similar risk factors, the loss of vision could result from concurrent retinal ischemia, and it is not clear if visual functions may be inhibited by cerebral ischemia directly. In this study, the distal middle cerebral artery in the right hemisphere of mice was occluded to produce unilateral cerebral ischemia and subsequent infarction. The layer V neurons expressing YFP in transgenic yellow fluorescent protein in transgenic B6.Cg-Tg(Thy1-YFPH)2Jrs/J mice disappeared in the motor and somatosensory cortex, but not in the visual area. The latencies of flash visual evoked potential recorded from two hemispheres were imbalanced, but did not differ markedly from the latencies recorded in controls. However, the optomotor responses of the ipsilateral eye were significantly reduced by 48 h after occlusion. Our results suggest that focused cerebral ischemia may inhibit ipsilateral eye movement in the absence of damage to the visual cortex. This study may provide a platform for further investigation of the relationship between cortical ischemia and visual function.
Collapse
Affiliation(s)
- Jian Xiao
- State Key Laboratory Cultivation Base, Ministry of Health, School of Ophthalmology and Optometry, Wenzhou Medical College, Zhejiang, PR China
| | | | | | | | | | | | | |
Collapse
|
23
|
|
24
|
Abstract
Hypertension has profound effects on various parts of the eye. Classically, elevated blood pressure results in a series of retinal microvascular changes called hypertensive retinopathy, comprising of generalized and focal retinal arteriolar narrowing, arteriovenous nicking, retinal hemorrhages, microaneurysms and, in severe cases, optic disc and macular edema. Studies have shown that mild hypertensive retinopathy signs are common and seen in nearly 10% of the general adult non-diabetic population. Hypertensive retinopathy signs are associated with other indicators of end-organ damage (for example, left ventricular hypertrophy, renal impairment) and may be a risk marker of future clinical events, such as stroke, congestive heart failure and cardiovascular mortality. Furthermore, hypertension is one of the major risk factors for development and progression of diabetic retinopathy, and control of blood pressure has been shown in large clinical trials to prevent visual loss from diabetic retinopathy. In addition, several retinal diseases such as retinal vascular occlusion (artery and vein occlusion), retinal arteriolar emboli, macroaneurysm, ischemic optic neuropathy and age-related macular degeneration may also be related to hypertension; however, there is as yet no evidence that treatment of hypertension prevents vision loss from these conditions. In management of patients with hypertension, physicians should be aware of the full spectrum of the relationship of blood pressure and the eye.
Collapse
Affiliation(s)
- M Bhargava
- Singapore Eye Research Institute, National University of Singapore, Singapore
| | | | | |
Collapse
|