Age- and race-related differences in human scleral material properties

Long-Term Changes in Lamina Cribrosa Curvature Index After Trabeculectomy in Glaucomatous Eyes

Purpose

This study aimed to evaluate both short-term and long-term changes in the lamina cribrosa curvature index (LCCI) following trabeculectomy and investigate the factors influencing these changes.

Methods

In this retrospective, observational study, 40 eyes of 40 patients with glaucoma who underwent trabeculectomy and had a follow-up of at least 2 years were included. Optic nerve head area was scanned by using spectral-domain optical coherence tomography before surgery (Pre_OP), within 6 months postoperatively (Post_OP1), and at the last visit (Post_OP2). LCCI values calculated from B-scan images at six different planes (0°, 30°, 60°, 90°, 120°, and 150°) and their mean values were compared. Univariate and multivariate linear regression analyses were used to identify the clinical factors associated with the amount of LCCI changes.

Results

The mean follow-up time was 38.3 ± 16.8 months. At Post_OP1, the mean LCCI decreased from 9.28 ± 2.58 to 7.91 ± 2.57 (P < 0.001), and the mean intraocular pressure decreased from 22.0 ± 7.6 mm Hg to 12.2 ± 3.8 mm Hg (P = 0.001). At Post_OP2, the mean LCCI was maintained at 7.74 ± 2.49 (P = 0.56 when compared to Post_OP1 and P < 0.001 when compared to Pre_OP). The mean intraocular pressure was 12.6 ± 5.4 mm Hg (P = 0.67 when compared to Post_OP1 and P < 0.001 when compared to Pre_OP). Long-term LCCI changes were associated with baseline age (P = 0.04), spherical equivalent (P = 0.02), mean IOP during follow-ups (P = 0.02), and preoperative LCCI (P = 0.04).

Conclusions

Glaucomatous eyes undergoing trabeculectomy demonstrated reductions in the LCCI after a mean follow-up of over 3 years. Greater long-term LCCI reduction was associated with younger age, lower mean IOP during follow-up period, greater spherical equivalent refractive error, and preoperative LCCI.

Tensile properties of glaucomatous human sclera, optic nerve, and optic nerve sheath

We characterized the tensile behavior of sclera, optic nerve (ON), and ON sheath in eyes from donors with glaucoma, for comparison with published data without glaucoma. Twelve freshly harvested eyes were obtained from donors with history of glaucoma, of average age 86 ± 7 (standard deviation) years. Rectangular samples were taken from anterior, equatorial, posterior, and peripapillary sclera, and ON sheath, while ON was in native form and measured using calipers. Under physiological temperature and humidity, tissues were preconditioned at 5% strain before loading at 0.1 mm/s. Force-displacement data were converted into engineering stress-strain curves fit by reduced polynomial hyperelastic models and analyzed by tangent moduli at 3% and 7% strain. Data were compared with an age-matched sample of 7 published control eyes. Optic atrophy was supported by significant reduction in ON cross section to 73% of normal in glaucomatous eyes. Glaucomatous was significantly stiffer than control in equatorial and peripapillary regions (P < 0.001). However, glaucomatous ON and sheath were significantly less stiff than control, particularly at low strain (P < 0.001). Hyperelastic models were well fit to stress-strain data (R2 > 0.997). Tangent moduli had variability similar to control in most regions, but was abnormally large in peripapillary sclera. Tensile properties were varied independently among various regions of the same eyes. Glaucomatous sclera is abnormally stiff, but the ON and sheath are abnormally compliant. These abnormalities correspond to properties predicted by finite element analysis to transfer potentially pathologic stress to the vulnerable disk and lamina cribrosa region during adduction eye movement.

Racial Differences in Diagnostic Accuracy of Retinal Nerve Fiber Layer Thickness in Primary Open-Angle Glaucoma

Purpose

To evaluate the diagnostic accuracy of retinal nerve fiber layer thickness (RNFLT) by spectral-domain optical coherence tomography (OCT) in primary open-angle glaucoma (POAG) in eyes of African (AD) and European descent (ED).

Design

Comparative diagnostic accuracy analysis by race.

Participants

379 healthy eyes (125 AD and 254 ED) and 442 glaucomatous eyes (226 AD and 216 ED) from the Diagnostic Innovations in Glaucoma Study and the African Descent and Glaucoma Evaluation Study.

Methods

Spectralis (Heidelberg Engineering GmbH) and Cirrus (Carl Zeiss Meditec) OCT scans were taken within one year from each other.

Main Outcome Measures

Diagnostic accuracy of RNFLT measurements.

Results

Diagnostic accuracy for Spectralis-RNFLT was significantly lower in eyes of AD compared to those of ED (area under the receiver operating curve [AUROC]: 0.85 and 0.91, respectively, P=0.04). Results for Cirrus-RNFLT were similar but did not reach statistical significance (AUROC: 0.86 and 0.90 in AD and ED, respectively, P =0.33). Adjustments for age, central corneal thickness, axial length, disc area, visual field mean deviation, and intraocular pressure yielded similar results.

Conclusions

OCT-RNFLT has lower diagnostic accuracy in eyes of AD compared to those of ED. This finding was generally robust across two OCT instruments and remained after adjustment for many potential confounders. Further studies are needed to explore the potential sources of this difference.

A new look at an old problem: 3D modeling of accommodation reveals how age-related biomechanical changes contribute to dysfunction in presbyopia

Presbyopia is an age-related ocular disorder where accommodative ability declines so that an individual's focusing range is insufficient to provide visual clarity for near and distance vision tasks without corrective measures. With age, the eye exhibits changes in biomechanical properties of many components involved in accommodation, including the lens, sclera, and ciliary muscle. Changes occur at different rates, affecting accommodative biomechanics differently, but individual contributions to presbyopia are unknown. We used a finite element model (FEM) of the accommodative mechanism to simulate age-related changes in lens stiffness, scleral stiffness, and ciliary contraction to predict differences in accommodative function. The FEM predicts how ciliary muscle action leads to lens displacement by initializing a tensioned unaccommodated lens (Phase 0) then simulating ciliary muscle contraction in accommodation (Phase 1). Model inputs were calibrated to replicate experimentally measured lens and ciliary muscle in 30-year-old eyes. Predictions of accommodative lens deformation were verified with additional imaging studies. Model variations were created with altered lens component stiffnesses, scleral stiffness, or ciliary muscle section activations, representing fifteen-year incremental age-related changes. Model variations predict significant changes in accommodative function with age-related biomechanical property changes. Lens changes only significantly altered lens thickening with advanced age (46% decrease at 75 years old) while sclera changes produced progressive dysfunction with increasing age (23%, 36%, 49% decrease at 45, 60, and 75 years old). Ciliary muscle changes effected lens position modulation. Model predictions identified potential mechanisms of presbyopia that likely work in combination to reduce accommodative function and could indicate effectiveness of treatment strategies and their dependency on patient age or relative ocular mechanical properties.

Regional differences in electroactive response of the sclera

The sclera exhibits mechanical response when subjected to an external electric stimulation. The scleral electroactive response is a function of its charge density, mechanical properties, thickness, and strength of the applied electric voltage. The primary objective of the present work was to investigate the regional differences in the electroactive response of porcine sclera. To this end, we cut scleral strips in meridional directions from superior-temporal, superior-nasal, inferior-temporal, and inferior-nasal quadrants. In addition, we excised samples circumferentially from the posterior, equatorial, and anterior regions. The electroactive bending response of these samples was measured under 10 and 15 V in 0.15 M NaCl solution. The meridional samples were tested under two different configurations by clamping them either from their anterior or posterior end. It was observed that the scleral electroactive deformation increased with increasing the the electric voltage. Furthermore, regardless of the region from which meridional strips were excised, their electroactive response was considerably larger when they were clamped from their anterior end. Unlike meridional strips, the electroactive response of circumferential samples was significantly dependent on the location, that is, the average maximum bending angle of posterior samples was significantly larger than that of equatorial and anterior strips. The regionally different electroactive bending response of the sclera was discussed in terms of the variation in its biochemical and biomechanical properties throughout the eyeball.

AI-based clinical assessment of optic nerve head robustness superseding biomechanical testing

BACKGROUND/AIMS

To use artificial intelligence (AI) to: (1) exploit biomechanical knowledge of the optic nerve head (ONH) from a relatively large population; (2) assess ONH robustness (ie, sensitivity of the ONH to changes in intraocular pressure (IOP)) from a single optical coherence tomography (OCT) volume scan of the ONH without the need for biomechanical testing and (3) identify what critical three-dimensional (3D) structural features dictate ONH robustness.

METHODS

316 subjects had their ONHs imaged with OCT before and after acute IOP elevation through ophthalmo-dynamometry. IOP-induced lamina cribrosa (LC) deformations were then mapped in 3D and used to classify ONHs. Those with an average effective LC strain superior to 4% were considered fragile, while those with a strain inferior to 4% robust. Learning from these data, we compared three AI algorithms to predict ONH robustness strictly from a baseline (undeformed) OCT volume: (1) a random forest classifier; (2) an autoencoder and (3) a dynamic graph convolutional neural network (DGCNN). The latter algorithm also allowed us to identify what critical 3D structural features make a given ONH robust.

RESULTS

All three methods were able to predict ONH robustness from a single OCT volume scan alone and without the need to perform biomechanical testing. The DGCNN (area under the curve (AUC): 0.76±0.08) outperformed the autoencoder (AUC: 0.72±0.09) and the random forest classifier (AUC: 0.69±0.05). Interestingly, to assess ONH robustness, the DGCNN mainly used information from the scleral canal and the LC insertion sites.

CONCLUSIONS

We propose an AI-driven approach that can assess the robustness of a given ONH solely from a single OCT volume scan of the ONH, and without the need to perform biomechanical testing. Longitudinal studies should establish whether ONH robustness could help us identify fast visual field loss progressors.

PRECIS

Using geometric deep learning, we can assess optic nerve head robustness (ie, sensitivity to a change in IOP) from a standard OCT scan that might help to identify fast visual field loss progressors.

Segmental biomechanics of the normal and glaucomatous human aqueous outflow pathway

The conventional aqueous outflow pathway, encompassing the trabecular meshwork (TM), juxtacanalicular connective tissue (JCT), and inner wall endothelium of Schlemm's canal (SC), governs intraocular pressure (IOP) regulation. This study targets the biomechanics of low-flow (LF) and high-flow (HF) regions within the aqueous humor outflow pathway in normal and glaucomatous human donor eyes, using a combined experimental and computational approach. LF and HF TM/JCT/SC complex tissues from normal and glaucomatous eyes underwent uniaxial tensile testing. Dynamic motion of the TM/JCT/SC complex was recorded using customized green-light optical coherence tomography during SC pressurization in cannulated anterior segment wedges. A hyperviscoelastic model quantified TM/JCT/SC complex properties. A fluid-structure interaction model simulated tissue-aqueous humor interaction. FluoSpheres were introduced into the pathway via negative pressure in the SC, with their motion tracked using two-photon excitation microscopy. Tensile test results revealed that the elastic moduli of the LF and HF regions in glaucomatous eyes are 3.5- and 1.5-fold stiffer than the normal eyes, respectively. The FE results also showed significantly larger shear moduli in the TM, JCT, and SC of the glaucomatous eyes compared to the normal subjects. The LF regions in normal eyes demonstrated larger elastic moduli compared to the HF regions in glaucomatous eyes. The resultant strain in the outflow tissues and velocity of the aqueous humor in the FSI models were in good agreement with the digital volume correlation and 3D particle image velocimetry data, respectively. This study uncovers stiffer biomechanical responses in glaucomatous eyes, with LF regions stiffer than HF regions in both normal and glaucomatous eyes. STATEMENT OF SIGNIFICANCE: This study delves into the biomechanics of the conventional aqueous outflow pathway, a crucial regulator of intraocular pressure and ocular health. By analyzing mechanical differences in low-flow and high-flow regions of normal and glaucomatous eyes, this research unveils the stiffer response in glaucomatous eyes. The distinction between regions' properties offers insights into aqueous humor outflow regulation, while the integration of experimental and computational methods enhances credibility. These findings have potential implications for disease management and present a vital step toward innovative ophthalmic interventions. This study advances our understanding of glaucoma's biomechanical basis and its broader impact on ocular health.

Direct measurements of collagen fiber recruitment in the posterior pole of the eye

Collagen is the main load-bearing component of the peripapillary sclera (PPS) and lamina cribrosa (LC) in the eye. Whilst it has been shown that uncrimping and recruitment of the PPS and LC collagen fibers underlies the macro-scale nonlinear stiffening of both tissues with increased intraocular pressure (IOP), the uncrimping and recruitment as a function of local stretch have not been directly measured. This knowledge is crucial to understanding their functions in bearing loads and maintaining tissue integrity. In this project we measured local stretch-induced collagen fiber bundle uncrimping and recruitment curves of the PPS and LC. Thin coronal samples of PPS and LC of sheep eyes were mounted and stretched biaxially quasi-statically using a custom system. At each step, we imaged the PPS and LC with instant polarized light microscopy and quantified pixel-level (1.5 μm/pixel) collagen fiber orientations. We used digital image correlation to measure the local stretch and quantified collagen crimp by the circular standard deviation of fiber orientations, or waviness. Local stretch-recruitment curves of PPS and LC approximated sigmoid functions. PPS recruited more fibers than the LC at the low levels of stretch. At 10% stretch the curves crossed with 75% bundles recruited. The PPS had higher uncrimping rate and waviness remaining after recruitment than the LC: 0.9º vs. 0.6º and 3.1º vs. 2.7º. Altogether our findings support describing fiber recruitment of both PPS and LC with sigmoid curves, with the PPS recruiting faster and at lower stretch than the LC, consistent with a stiffer tissue. STATEMENT OF SIGNIFICANCE: Peripapillary sclera (PPS) and lamina cribrosa (LC) collagen recruitment behaviors are central to the nonlinear mechanical behavior of the posterior pole of the eye. How PPS and LC collagen fibers recruit under stretch is crucial to develop constitutive models of the tissues but remains unclear. We used image-based stretch testing to characterize PPS and LC collagen fiber bundle recruitment under local stretch. We found that fiber-level stretch-recruitment curves of PPS and LC approximated sigmoid functions. PPS recruited more fibers at a low stretch, but at 10% bundle stretch the two curves crossed with 75% bundles recruited. We also found that PPS and LC fibers had different uncrimping rates and non-zero waviness's when recruited.

Scleral remodeling in early adulthood: the role of FGF-2

Emmetropization, a natural process of ocular elongation, is closely associated with scleral remodeling. The Fibroblast growth factor-2 (FGF-2) was reported involved in scleral remodeling in myopia models. Herein, we aimed to investigate the role of scleral fibroblast-to-myofibroblast differentiation and FGF-2 in scleral remodeling during maturation. Our findings revealed that the posterior scleral fibroblasts (SFs) from mature guinea pigs exhibit increased stiffness compared to those from young guinea pigs. Moreover, mature SFs displayed decreased cell proliferation but increased levels of α-SMA, matrix metalloproteinase 2 (MMP2), and collagen 1, when compared to young SFs. Additionally, the mRNA expression of scleral Fgf-2, Fgf receptor 1 (Fgfr1), Fgfr2, Fgfr3, and Fgfr4 was increased in mature SFs. Notably, exogenous FGF-2 showed increased cell proliferation and led to decreased expression of α-SMA, MMP2, and collagen 1 in mature SFs. Overall, our findings highlight the influence of maturation on SFs from posterior scleral shells, resulting in increased stiffness and the manifestation of fibroblast-to-myofibroblast differentiation during development. Exogenous FGF-2 increased cell proliferation and reversed the age-related fibroblast-to-myofibroblast differentiation, suggesting a potential role of FGF-2 in regulating scleral remodeling.

A direct fiber approach to model sclera collagen architecture and biomechanics

Sclera collagen fiber microstructure and mechanical behavior are central to eye physiology and pathology. They are also complex, and are therefore often studied using modeling. Most models of sclera, however, have been built within a conventional continuum framework. In this framework, collagen fibers are incorporated as statistical distributions of fiber characteristics such as the orientation of a family of fibers. The conventional continuum approach, while proven successful for describing the macroscale behavior of the sclera, does not account for the sclera fibers are long, interwoven and interact with one another. Hence, by not considering these potentially crucial characteristics, the conventional approach has only a limited ability to capture and describe sclera structure and mechanics at smaller, fiber-level, scales. Recent advances in the tools for characterizing sclera microarchitecture and mechanics bring to the forefront the need to develop more advanced modeling techniques that can incorporate and take advantage of the newly available highly detailed information. Our goal was to create a new computational modeling approach that can represent the sclera fibrous microstructure more accurately than with the conventional continuum approach, while still capturing its macroscale behavior. In this manuscript we introduce the new modeling approach, that we call direct fiber modeling, in which the collagen architecture is built explicitly by long, continuous, interwoven fibers. The fibers are embedded in a continuum matrix representing the non-fibrous tissue components. We demonstrate the approach by doing direct fiber modeling of a rectangular patch of posterior sclera. The model integrated fiber orientations obtained by polarized light microscopy from coronal and sagittal cryosections of pig and sheep. The fibers were modeled using a Mooney-Rivlin model, and the matrix using a Neo-Hookean model. The fiber parameters were determined by inversely matching experimental equi-biaxial tensile data from the literature. After reconstruction, the direct fiber model orientations agreed well with the microscopy data both in the coronal plane (adjusted R2 = 0.8234) and in the sagittal plane (adjusted R2 = 0.8495) of the sclera. With the estimated fiber properties (C10 = 5746.9 MPa; C01 = -5002.6 MPa, matrix shear modulus 200 kPa), the model's stress-strain curves simultaneously fit the experimental data in radial and circumferential directions (adjusted R2's 0.9971 and 0.9508, respectively). The estimated fiber elastic modulus at 2.16% strain was 5.45 GPa, in reasonable agreement with the literature. During stretch, the model exhibited stresses and strains at sub-fiber level, with interactions among individual fibers which are not accounted for by the conventional continuum methods. Our results demonstrate that direct fiber models can simultaneously describe the macroscale mechanics and microarchitecture of the sclera, and therefore that the approach can provide unique insight into tissue behavior questions inaccessible with continuum approaches.

Retinal Vessel Pulsatile Characteristics Associated With Vascular Stiffness Can Predict the Rate of Functional Progression in Glaucoma Suspects

Purpose

Tissue stiffening and alterations in retinal blood flow have both been suggested as causative mechanisms of glaucomatous damage. We tested the hypothesis that retinal blood vessels also stiffen, using laser speckle flowgraphy (LSFG) to characterize vascular resistance.

Methods

In the longitudinal Portland Progression Project, 231 eyes of 124 subjects received LSFG scans of the optic nerve head (ONH) and automated perimetry every 6 months for six visits. Eyes were classified as either "glaucoma suspect" or "glaucoma" eyes based on the presence of functional loss on the first visit. Vascular resistance was quantified using the mean values of several instrument-defined parameterizations of the pulsatile waveform measured by LSFG, either in major vessels within the ONH (serving the retina) or in capillaries within ONH tissue, and age-adjusted using a separate group of 127 healthy eyes of 63 individuals. Parameters were compared against the severity and rate of change of functional loss using mean deviation (MD) over the six visits, within the two groups.

Results

Among 118 "glaucoma suspect" eyes (average MD, -0.4 dB; rate, -0.45 dB/y), higher vascular resistance was related to faster functional loss, but not current severity of loss. Parameters measured in major vessels were stronger predictors of rate than parameters measured in tissue. Among 113 "glaucoma" eyes (average MD, -4.3 dB; rate, -0.53 dB/y), higher vascular resistance was related to more severe current loss but not rate of loss.

Conclusions

Higher retinal vascular resistance and, by likely implication, stiffer retinal vessels were associated with more rapid functional loss in eyes without significant existing loss at baseline.

Three-Dimensional Ultrasound Elastography Detects Age-Related Increase in Anterior Peripapillary Sclera and Optic Nerve Head Compression During IOP Elevation

Purpose

High-frequency ultrasound elastography offers a tool to resolve the complex and heterogeneous deformation through the full thickness of the optic nerve head (ONH) and peripapillary sclera (PPS). Using this tool, we quantified the three-dimensional deformation of the ONH and PPS in human donor eyes and evaluated age-associated changes.

Methods

The ONH and PPS in 15 human donor globes were imaged with a 50-MHz ultrasound probe while increasing intraocular pressure (IOP) from 15 to 30 mm Hg. Tissue displacements were obtained using correlation-based ultrasound speckle tracking. Three-dimensional spherical strains (radial, circumferential, meridional, and respective shear strains) were calculated for the ONH and PPS volumes segmented from three-dimensional ultrasound images. Age-related trends of different strains in each region of interest were explored.

Results

The dominant form of IOP-induced deformation in the ONH and PPS was radial compression. High-magnitude localized out-of-plane shear strains were also observed in both regions. Most strains were concentrated in the anterior one-half of the ONH and PPS. The magnitude of radial and volumetric strains increased with age in the anterior ONH and anterior PPS, indicating greater radial compression and volume loss during IOP elevation in older age.

Conclusions

The age-associated increase of radial compression, the predominant form of IOP-induced deformation in anterior ONH and PPS, may underlie age-associated glaucoma risk. High-frequency ultrasound elastography offers a useful tool to quantify all types of deformation comprehensively in all regions of ONH and PPS, which may improve our understanding of the biomechanical factors contributing to glaucoma risk.

Direct measurements of collagen fiber recruitment in the posterior pole of the eye

Collagen is the main load-bearing component of the peripapillary sclera (PPS) and lamina cribrosa (LC) in the eye. Whilst it has been shown that uncrimping and recruitment of the PPS and LC collagen fibers underlies the macro-scale nonlinear stiffening of both tissues with increased intraocular pressure (IOP), the uncrimping and recruitment as a function of local stretch have not been directly measured. This knowledge is crucial for the development of constitutive models associating micro and macro scales. In this project we measured local stretch-induced collagen fiber bundle uncrimping and recruitment curves of the PPS and LC. Thin coronal samples of PPS and LC of sheep eyes were mounted and stretched biaxially quasi-statically using a custom system. At each step, we imaged the PPS and LC with instant polarized light microscopy and quantified pixel-level (1.5 μm/pixel) collagen fiber orientations. We used digital image correlation to measure the local stretch and quantified collagen crimp by the circular standard deviation of fiber orientations, or waviness. Local stretch-recruitment curves of PPS and LC approximated sigmoid functions. PPS recruited more fibers than the LC at the low levels of stretch. At 10% stretch the curves crossed with 75% bundles recruited. The PPS had higher uncrimping rate and waviness remaining after recruitment than the LC: 0.9° vs. 0.6° and 3.1° vs. 2.7°. Altogether our findings support describing fiber recruitment of both PPS and LC with sigmoid curves, with the PPS recruiting faster and at lower stretch than the LC, consistent with a stiffer tissue.

Emmetropization and nonmyopic eye growth

Most eyes start with a hypermetropic refractive error at birth, but the growth rates of the ocular components, guided by visual cues, will slow in such a way that this refractive error decreases during the first 2 years of life. Once reaching its target, the eye enters a period of stable refractive error as it continues to grow by balancing the loss in corneal and lens power with the axial elongation. Although these basic ideas were first proposed over a century ago by Straub, the exact details on the controlling mechanism and the growth process remained elusive. Thanks to the observations collected in the last 40 years in both animals and humans, we are now beginning to get an understanding how environmental and behavioral factors stabilize or disrupt ocular growth. We survey these efforts to present what is currently known regarding the regulation of ocular growth rates.

Glaucoma - 'A Stiff Eye in a Stiff Body'

Glaucoma is a progressive, age-related optic neuropathy, whereby the prevalence increases sharply over the age of 60 and is associated with increased systemic tissue stiffness. On a molecular basis, this is associated with increased deposition of collagen and loss of elastin structure, resulting in aberrant biomechanical compliance and reduced tissue elasticity. Increased tissue stiffness is a known driver of myofibroblast activation and persistence, especially in chronic cellular injuries via mechanotransduction pathways mediated by integrins and focal adhesion kinases. Evidence from histological and imaging studies plus force measurements of glaucomatous eyes show that several ocular tissues are stiffer than normal, healthy age-matched controls including the trabecular meshwork, Schlemm's canal, cornea, sclera and the lamina cribrosa. This is associated with increased extracellular matrix deposition and fibrosis. This review reports on the evidence to support the concept that glaucoma represents 'a stiff eye in a stiff body' and addresses potential mechanisms to attenuate this.

Aging Effects on Optic Nerve Neurodegeneration

Common risk factors for many ocular pathologies involve non-pathologic, age-related damage to the optic nerve. Understanding the mechanisms of age-related changes can facilitate targeted treatments for ocular pathologies that arise at any point in life. In this review, we examine these age-related, neurodegenerative changes in the optic nerve, contextualize these changes from the anatomic to the molecular level, and appreciate their relationship with ocular pathophysiology. From simple structural and mechanical changes at the optic nerve head (ONH), to epigenetic and biochemical alterations of tissue and the environment, multiple age-dependent mechanisms drive extracellular matrix (ECM) remodeling, retinal ganglion cell (RGC) loss, and lowered regenerative ability of respective axons. In conjunction, aging decreases the ability of myelin to preserve maximal conductivity, even with "successfully" regenerated axons. Glial cells, however, regeneratively overcompensate and result in a microenvironment that promotes RGC axonal death. Better elucidating optic nerve neurodegeneration remains of interest, specifically investigating human ECM, RGCs, axons, oligodendrocytes, and astrocytes; clarifying the exact processes of aged ocular connective tissue alterations and their ultrastructural impacts; and developing novel technologies and pharmacotherapies that target known genetic, biochemical, matrisome, and neuroinflammatory markers. Management models should account for age-related changes when addressing glaucoma, diabetic retinopathy, and other blinding diseases.

Application of Decellularized Porcine Sclera in Repairing Corneal Perforations and Lamellar Injuries

Scleras are mainly used for the treatment of glaucoma, eyelid damage, and scleral ulcers. Given that the sclera and cornea collectively constitute the complete external structure of the eyeball and both have the same tissue and cell origin, we attempted to identify scleral materials to treat lamellar and penetrating corneal injuries. Based on research in our center, antigenic components in decellularized porcine sclera (DPS) were removed using a simplified decellularization method, leaving the collagen structure and active components undamaged. DPS preserved the mechanical properties and did not significantly inhibit the proliferation and replication of human corneal epithelial cells. In vivo, the graft epithelium healed well after lamellar and penetrating scleral grafting, and the graft thickness did not change evidently. DPS can resist suture traction during scleral transplantation and maintain anterior chamber stability until day 28 post-operatively, especially in penetrating repairs. No obvious immune rejection of lamellar or penetrating scleral grafts was found 28 days after DPS transplantation. This study shows that DPS could be used as an alternative material for the emergency repair of corneal perforations and lamellar injuries, representing another application of sclera.

Nasal and temporal curvatures of lamina CRIBROSA in myopic eyes

Little is known about the myopic characteristics of lamina cribrosa (LC) curvature. As such, we investigated nasal and temporal LC curvatures in myopia. In this retrospective, cross-sectional study, 144 myopic eyes (refraction < − 2D) and 88 non-myopic eyes (refraction > − 0.5D) underwent swept-source optical coherence tomography scanning of the LC. The anterior border of LC curvature was delineated with 17 points and interpolated with the “cardinal spline” curve-fitting method. The average curvature indices of the temporal and nasal sides were presented as the temporal and nasal curvatures. Myopic eyes had a mean refraction of − 6.7 ± 2.8D, while for non-myopic eyes, the value was 0.3 ± 1.0D. Nasal LC curvature was visible in 54 myopia (37.5%) and 42 non-myopia (47.7%) cases (P = 0.126), and temporal LC curvature was visible in 142 myopia (98.6%) and 68 non-myopia (77.3%) cases (P = 0.001). The nasal LC curvature was significantly larger in myopia than in non-myopia (P < 0.001). Contrastingly, the temporal LC curvature was significantly smaller in myopia than in non-myopia (P < 0.001). Axial length was associated with larger nasal LC curvature, smaller temporal LC curvature, and larger nasal–temporal LC curvature difference (all P’s < 0.05). In myopic relative to non-myopic eyes, LC curvature was decreased temporally and increased nasally.

Remodeling of the Lamina Cribrosa: Mechanisms and Potential Therapeutic Approaches for Glaucoma

Glaucomatous optic neuropathy is the leading cause of irreversible blindness in the world. The chronic disease is characterized by optic nerve degeneration and vision field loss. The reduction of intraocular pressure remains the only proven glaucoma treatment, but it does not prevent further neurodegeneration. There are three major classes of cells in the human optic nerve head (ONH): lamina cribrosa (LC) cells, glial cells, and scleral fibroblasts. These cells provide support for the LC which is essential to maintain healthy retinal ganglion cell (RGC) axons. All these cells demonstrate responses to glaucomatous conditions through extracellular matrix remodeling. Therefore, investigations into alternative therapies that alter the characteristic remodeling response of the ONH to enhance the survival of RGC axons are prevalent. Understanding major remodeling pathways in the ONH may be key to developing targeted therapies that reduce deleterious remodeling.

Biomechanical changes in myopic sclera correlate with underlying changes in microstructure

Myopia alters the microstructural and biomechanical properties of the posterior sclera, which is characterized as a layered structure with potentially different inter-layer collagen fibril characteristics. Scanning acoustic microscopy (SAM) has been used to investigate how the micron-scale bulk mechanical properties of the posterior sclera are affected by myopia. Other investigators have employed second harmonic generation (SHG) imaging to characterize the collagen microstructure of tissues. In the present study, SAM and SHG imaging were used to investigate the existence of biomechanically-distinct scleral layers and identify relationships between mechanical properties and tissue microstructure in myopic guinea pig (GP) eyes. Diffusers were worn over the right eyes of six, 1-week-old GPs for one week to induce unilateral form-deprivation myopia. GPs were euthanized, enucleated, and eyes were cryosectioned. Twelve-micron-thick adjacent vertical cryosections were scanned with SAM or SHG. SAM maps of bulk modulus, mass density, and acoustic attenuation were estimated. A fiber-extraction algorithm applied to SHG images estimated collagen fiber length, width, straightness, alignment, and number density. Results revealed that the posterior sclera may exhibit biomechanically distinct layers that are affected differently in myopia. Specifically, a layered structure was observed in the mechanical-parameter maps of control eyes that was less apparent in myopic eyes. Collagen fibers in myopic eyes had smaller diameters and were more aligned. Myopia-associated biomechanical changes were most significant in the outermost and innermost scleral layers. SAM-measured mechanical parameters were correlated with collagen fiber microstructure, particularly fiber length, alignment, and number density, which may imply the biomechanical parameters estimated from SAM measurements are related to tissue microstructure. Interestingly, some changes were greatest in more-peripheral regions, suggesting interventions to strengthen the sclera may be effective away from the optic nerve and efficacy may be achieved best when intervention is applied to the outermost layer.

Degree of Myopia and Glaucoma Risk: A Dose-Response Meta-analysis

PURPOSE

To verify the dose-response relation between the degree of myopia and open-angle glaucoma (OAG) risk DESIGN: Dose-response meta-analysis.

METHODS

We searched the PubMed, EMBASE, and Cochrane Library databases for population-based studies published until November 30, 2020, and reporting on both myopia and OAG. Random-effect models generated pooled odds ratios (OR) and 95% CIs. Results robustness was confirmed by influence and subgroup analyses. A 2-stage dose-response meta-analysis calculated the OAG risk per unit dose of myopia (spherical equivalent [SE] decrease of 1 diopter [D]) and examined the relationship pattern.

RESULTS

The meta-analysis comprised 24 studies in 11 countries (514,265 individuals). The pooled OR of any myopia degree's association with OAG was 1.88 (95% CI, 1.66-2.13; I² = 53%). The OR differences based on ethnicity (Asians vs Westerners) or 5 geographic areas were not statistically significant (P = .80 and P = .06, respectively). The pooled ORs of the associations between low, moderate, moderate-to-high, high myopia, and OAG were 1.50 (95% CI, 1.29-1.76), 1.69 (95% CI, 1.33-2.15), 2.27 (95% CI, 1.74-2.96), and 4.14 (95% CI, 2.57-6.69), respectively. According to the dose-response meta-analysis, the pooled OR (per SE 1-D change) was 1.21 (95% CI, 1.15-1.28). The OAG risk accelerated at approximately -6 D, and further accelerated from -8 D, showing a nonlinear concave upward slope (P = .03).

CONCLUSIONS

For each unit (1-D) increase in myopia, the risk of glaucoma increases by approximately 20%. The risk more steeply increases in high-degree myopia, representing a significant nonlinear relationship.

Tropocollagen springs allow collagen fibrils to stretch elastically

The mechanical properties of connective tissues are tailored to their specific function, and changes can lead to dysfunction and pathology. In most mammalian tissues the mechanical environment is governed by the micro- and nano-scale structure of collagen and its interaction with other tissue components, however these hierarchical properties remain poorly understood. In this study we use the human cornea as a model system to characterise and quantify the dominant deformation mechanisms of connective tissue in response to cyclic loads of physiological magnitude. Synchronised biomechanical testing, x-ray scattering and 3D digital image correlation revealed the presence of two dominant mechanisms: collagen fibril elongation due to a largely elastic, spring-like straightening of tropocollagen supramolecular twist, and a more viscous straightening of fibril crimp that gradually increased over successive loading cycles. The distinct mechanical properties of the two mechanisms suggest they have separate roles in vivo. The elastic, spring-like mechanism is fast-acting and likely responds to stresses associated with the cardiac cycle, while the more viscous crimp mechanism will respond to slower processes, such as postural stresses. It is anticipated that these findings will have broad applicability to understanding the normal and pathological functioning of other connective tissues such as skin and blood vessels that exhibit both helical structures and crimp.

Statement of significance

The tropocollagen spring mechanism allows collagen fibrils from some tissues to elongate significantly under small loads, and its recent discovery has the potential to change our fundamental understanding of how tissue deforms. This time-resolved study quantifies the contribution of the spring mechanism to the local strain in stretched tissue and compares it to the contribution associated with the straightening of fibril waviness, the widely accepted primary low-load strain mechanism. The spring mechanism contributed more to the local tissue strain than fibril straightening, and was found to be elastic while fibril straightening was more viscous. The results suggest that the viscoelastic behaviour of a biomaterial is controlled, at least in part, by the relative amount of fibril-scale crimp and tropocollagen supramolecular twist.

Morphologic Changes in the Lamina Cribrosa Upon Intraocular Pressure Lowering in Patients With Normal Tension Glaucoma

Purpose

The purpose of this study was to investigate whether the lamina cribrosa (LC) curve changes in response to intraocular pressure (IOP) reduction following administration of topical ocular hypotensive eye drops in eyes with normal tension glaucoma (NTG).

Methods

Ninety-three eyes of 93 patients with treatment naïve NTG at initial examination and with ≥20% reduction from baseline IOP following administration of topical ocular hypotensive eye drops were included. Serial horizontal B-scan images of the optic nerve head (ONH) were obtained from each eye using enhanced depth imaging spectral domain optical coherence tomography (OCT) before and 1 year after IOP-lowering treatment. The LC curvature in each eye was assessed by measuring the LC curvature index (LCCI) in horizontal OCT B-scan images obtained at three (superior, central, and inferior) locations spaced equidistantly across the vertical optic disc diameter before and after IOP-lowering treatment. We evaluated the OCT detectible change in the LC curvature based on the interval change of LCCI to exceed the intersession standard deviation of 1.96 times and factors associated with the magnitude of the LCCI change in the eyes showing significant LC change.

Results

IOP decreased from 15.7 ± 2.5 mm Hg at baseline to 11.2 ± 1.7 mm Hg after topical glaucoma medication. Among the 93 subjects, 62 (66.7%) eyes showed the significant reduction of the LCCI (interssetional change over 1.5) after the treatment; greater interssessional change of the LCCI after IOP reduction was associated with younger age (P = 0.020) and larger baseline LCCI (P < 0.001).

Conclusions

The OCT detectible changes in LC curvature occurred in response to a modest decrease in the IOP in the naïve NTG eyes. The therapeutic benefit of these changes need to be assessed in longitudinal studies.

Association of Optic Disc Tilt and Torsion with Open-Angle Glaucoma Progression Risk: Meta-Analysis and Meta-Regression Analysis

PURPOSE

To evaluate the association of optic disc deformation with open-angle glaucoma (OAG) progression risk.

DESIGN

Meta-analysis and meta-regression analysis.

METHODS

Reports on the association of optic disc tilt and/or torsion with OAG progression published to June 2020 were identified in the PubMed, EMBASE, and Cochrane databases. Tilt ratio was measured as the longest-to-shortest diameter ratio of the optic disc. The angle (in degrees) between the vertical meridian and the disc's long axis was defined as the torsional angle. We used random-effects models to combine the pooled effects. Random-effects meta-regression was used to quantify the study characteristics' potential moderating influences. The protocol was registered in the PROSPERO International Database (CRD42020201151).

RESULTS

Eleven longitudinal studies (1100 participants) were included. For 10 of them evaluated for tilt ratio and glaucoma progression, the pooled hazard ratio (HR) was 0.988 (95% confidence interval [CI] 0.921-1.059; I² = 59%) per 0.1-unit increase. In the meta-regression-based subgroup analysis, risk tended to decrease as the patients' mean age increased (P = .08). For 7 of the studies (605 patients) reporting data on torsion and glaucoma progression, the pooled HR was 0.936 (95% CI 0.860-1.018; I² = 32%) per 10-degree increase. The meta-regression analyses showed that the glaucoma progression assessment methods had a modulating influence (P = .01). In studies assessing just functional glaucomatous progression, the pooled HR was 0.890 (95% CI 0.831-0.952; I² = 0%).

CONCLUSION

Evidence for the effects of optic nerve deformation on glaucoma progression is still lacking. Future research using stratified analysis according to age and tailored diagnostic criteria will allow for more rigorous analyses for this topic.

Ocular biomechanics due to ground blast reinforcement

BACKGROUND AND OBJECTIVE

Bomb blast injuries exerts a shearing force on the air-tissue interfaces, causing devastating ocular injury from the blast wave. Improvised explosive devices (IEDs) are usually placed at different heights from the ground to induce more severe injury through ground blast reinforcement (GBR). However, there is still a lack of knowledge of the role of GBR and IED height from the ground on ocular biomechanics, and how they can affect the intraocular pressure (IOP) in the eye. This study aimed to estimate the IOP due to frontal IED explosion at different heights from the ground using a fluid-structure interaction model with and without GBR effects.

METHODS

A 2 kg IED was placed within 5 m of the victim at 5 different heights from the ground, including 0, 0.42, 0.85, 1.27, and 1.70 m. Two different blast formulations were used to simulate the IED explosion: (a) spherical airburst, with no amplification of the initial shock wave due to interaction with the ground-surface, and (b) hemispherical surface-burst, where the initial blast wave is immediately reflected and reinforced by the ground (GBR).

RESULTS

Results revealed that the blast wave due to GBR reaches to the skull prior to the IED blast itself. The GBR also reached to the skull ∼ 0.6 ms earlier when the IED was on the ground compared to the height of 1.70 m. The highest and lowest IOPs of ∼ 17,000 and ∼ 15,000 mmHg were observed at the IED heights of 1.70 and 0 m from the ground considering GBR. However, when the role of the GBR is ignored, IOP of ∼ 9,000 mmHg was observed regardless of the IED height from the ground. The deformation in the apex of the cornea was higher when considering the GBR (∼ 0.75 cm) versus no GBR (∼ 0.65 cm). Considering GBR led to higher stresses and strains in the sclera.

CONCLUSIONS

When the role of GBR was ignored, the results showed similar patterns and magnitudes of stresses and deformations in the skull and eye regardless of the height of the IED from the ground, which was not the case when GBR was considered. The findings of this study suggest the critical role of GBR in ocular blast simulations.

Modeling the biomechanics of the lamina cribrosa microstructure in the human eye

Glaucoma is among the leading causes of blindness worldwide that is characterized by irreversible damage to the retinal ganglion cell axons in the lamina cribrosa (LC) region of the optic nerve head (ONH), most often associated with elevated intraocular pressure (IOP). The LC is a porous, connective tissue structure that provides mechanical support to the axons as they exit the eye and the biomechanics of the LC microstructure likely play a crucial role in protecting the axons passing through it. There is a limited knowledge of the IOP-driven biomechanics of the LC microstructure, primarily due to its small size and the difficulty with imaging the LC both in vitro and in vivo. We present finite element (FE) models of three human eye posterior poles that include the LC microstructure and interspersed neural tissues (NT) composed of retinal axons that are constructed directly from segmented, binary images of the LC. These models were used to estimate the stresses and strains in the LC and NT for an acute IOP elevation from 0 to 45 mmHg and compared with identical models except that the LC was represented as a homogenized continuum material with either homogeneous isotropic neo-Hookean properties or heterogeneous properties derived from local connective tissue volume fraction (CTVF) and predominant LC beam orientation. Stresses and strains in the LC and NT microstructure were investigated, and results were compared against those from the models wherein the LC was represented as a homogenized continuum. The regionalized volumetric average stresses and strains showed that the microstructural model yielded similar patterns to our prior approach using an LC continuum representation with mapped LC CTVF/anisotropy, but the microstructural modeling approach allows analysis of the stresses and strains in the LC and NT separately. As expected, the LC beams carried most of the IOP load in the microstructural models but exhibited less strain, while the encapsulated NT exhibited lower stresses and much higher strains. Results also revealed that the continuum models underestimate the maximum strains in the LC beams and NT by a factor of 2-3. Microstructural modeling should provide greater insight into the biomechanical factors driving damage to the axons (NT) and LC connective tissue remodeling that occur in glaucoma. The methods presented are ideal for modeling any structure with a complex microstructure composed of different materials, such as trabecular bone, lung, and tissue engineering scaffolds such as decellularized LC. Matlab code for mesh generation from a segmented image stack of the microstructure is included as Supplemental Material. STATEMENT OF SIGNIFICANCE: Glaucoma is among the leading causes of blindness worldwide that is characterized by axon damage in the lamina cribrosa (LC) region of the eye. We present a new approach for finite element modeling the entire eye-specific 3D LC microstructure and the interspersed neural tissues, incorporated into an eye-specific posterior eye model that provides appropriate boundary and loading conditions. Results are presented for three human donor eyes, showing that prior modeling approaches underestimate the stresses and strains in the laminar microstructure. We constructed models from image stacks of the segmented microstructure (Matlab code included) using an approach that is ideal for modeling any structure with a complex microstructure composed of different materials, such as trabecular bone, lung, and tissue engineering scaffolds.

Strain by virtual extensometers and video-imaging optical coherence tomography as a repeatable metric for IOP-Induced optic nerve head deformations

PURPOSE

To determine if in vivo strain response of the Optic Nerve Head (ONH) to IOP elevation visualized using Optical Coherence Tomography (OCT) video imaging and quantified using novel virtual extensometers was able to be provided repeatable measurements of tissue specific deformations.

METHODS

The ONHs of 5 eyes from 5 non-human primates (NHPs) were imaged by Spectralis OCT. A vertical and a horizontal B-scan of the ONH were continuously recorded for 60 s at 6 Hz (video imaging mode) during IOP elevation from 10 to 30 mmHg. Imaging was repeated over three imaging sessions. The 2D normal strain was computed by template-matching digital image correlation using virtual extensometers. ANOVA F-test (F) was used to compare inter-eye, inter-session, and inter-tissue variability for the prelaminar, Bruch's membrane opening (BMO), lamina cribrosa (LC) and choroidal regions (against variance the error term). F-test of the ratio between inter-eye to inter-session variability was used to test for strain repeatability across imaging sessions (FIS).

RESULTS

Variability of strain across imaging session (F = 0.7263, p = 0.4855) and scan orientation was not significant (F = 1.053, p = 0.3066). Inter session variability of strain was significantly lower than inter-eye variability (FIS = 22.63, p = 0.0428) and inter-tissue variability (FIS = 99.33 p = 0.00998). After IOP elevation, strain was highest in the choroid (-18.11%, p < 0.001), followed by prelaminar tissue (-11.0%, p < 0.001), LC (-3.79%, p < 0.001), and relative change in BMO diameter (-0.57%, p = 0.704).

CONCLUSIONS

Virtual extensometers applied to video-OCT were sensitive to the eye-specific and tissue-specific mechanical response of the ONH to IOP and were repeatable across imaging sessions.

Tensile Viscoelastic Properties of the Sclera after Glycosaminoglycan Depletion

PURPOSE

Fibrillar collagen network and glycosaminoglycans (GAGs) are the primary components of extracellular matrix (ECM) of the sclera. The main goal of this study was to investigate the possible structural roles of GAGs in the scleral tensile properties as a function of preconditioning and displacement rate.

METHODS

Four-step uniaxial stress-relaxation tests were used for characterizing the viscoelastic tensile response of the posterior porcine sclera with and without enzymatic GAG removal. The scleral strips were divided into different groups based on the displacement rate and the presence or absence of a preconditioning step in the loading protocol. The groups were (1) displacement rate of 0.2 mm/min without preconditioning, (2) displacement rate of 1 mm/min without preconditioning, (3) displacement rate of 0.2 mm/min with preconditioning, and (4) displacement rate of 1 mm/min with preconditioning. The peak stress, equilibrium stress, and the equilibrium elastic modulus were calculated for all specimens and compared against each other.

RESULTS

Increasing the displacement rate from 0.2 mm/min to 1.0 mm/min was found to cause an insignificant change in the equilibrium stress and equilibrium elastic modulus of porcine scleral strips. Removal of GAGs resulted in an overall stiffer tensile behavior independent of the displacement rate in samples that were not preconditioned (P < .05). The behavior of preconditioned samples with and without GAG removal was not significantly different from each other.

CONCLUSIONS

The experimental measurements of the present study showed that GAGs play an important role in the mechanical properties of the posterior porcine sclera. Furthermore, using a preconditioning step in the uniaxial testing protocol resulted in not being able to identify any significant difference in the tensile behavior of GAG depleted and normal scleral strips.

Optic nerve tortuosity and displacements during horizontal eye movements in healthy and highly myopic subjects

AIMS

(1) To assess the morphology and 3-dimensional (3D) displacements of the eye globe and optic nerve (ON) in adduction/abduction using MRI. (2) To assess differences between healthy emmetropic and highly myopic (HM) subjects.

METHODS

MRI volumes of both eyes from 18 controls and 20 HM subjects in primary gaze, abduction and adduction (15°) were postprocessed. All ONs were manually segmented and fitted to a 3D curve to assess ON tortuosity. ON displacements were evaluated in four quasicoronal planes which were perpendicular to the ON in primary gaze and were 3 mm apart.

RESULTS

Axial length was higher in the HM group (28.62±2.60 vs 22.84±0.89 mm; p<0.0001). Adjusted ON tortuosities (ie, ON tortuosities estimated before myopia onset) were lower in HM eyes (0.9063±0.0591) versus controls (1.0152±0.02981) in primary gaze, adduction (0.9023±0.05538 vs 1.0137±0.0299) and abduction (0.9100±0.0594 vs 1.0182±0.0316); p<0.0001 for all cases. In all eyes, ON displacements in adduction were significantly different from those in abduction in the naso-temporal direction (p<0.0001 in all planes) but not in the supero-inferior direction. ON displacements in the posterior segments of the ON were smaller in the HM group in both gaze directions and were larger in the anterior-most ON segment in adduction only.

CONCLUSION

The adjusted tortuosity of the ON was significantly lower in HM eyes, suggesting that eyes destined towards HM exhibited higher ON traction forces during eye movements before the onset of myopia. Our ON metrics may be valuable to explore a potential link between eye movements and axial elongation.

Semiautomated Assessment of Anterior Segment Structures in Pediatric Glaucoma Using Quantitative Ultrasound Biomicroscopy

The study was a prospective observational study comparing semiautomated to manual quantitative ultrasound biomicroscopy image analysis among 82 images from 41 eyes of 32 subjects (21 controls and 11 glaucoma) enrolled in the Pediatric Anterior Segment Imaging Innovation Study. Intraclass correlation coefficients and correlation coefficients were >0.8 for all parameters, and comparison of respective analysis speed was 7 times faster for the semiautomated method compared with manual image quantification.

Histologic validation of optical coherence tomography-based three-dimensional morphometric measurements of the human optic nerve head: Methodology and preliminary results

PURPOSE

To compare the three-dimensional (3D) morphology of the deep load-bearing structures of the human optic nerve head (ONH) as revealed in vivo by spectral domain optical coherence tomography (SDOCT) with ex vivo quantitative 3D histology.

METHODS

SDOCT imaging of the ONH was performed in six eyes from three brain-dead organ donors on life-support equipment awaiting organ procurement (in vivo conditions). Following organ procurement (ex vivo conditions), the eyes were enucleated and underwent a pars plana vitrectomy followed by pressurization to physiologic IOP and immersion fixation. Ex vivo ONH morphology was obtained from high-fidelity episcopic fluorescent 3D reconstruction. Morphologic parameters of the observed ONH canal geometry and peripapillary choroid, as well as the shape, visibility and depth of the lamina cribrosa were compared between ex vivo and in vivo measurements using custom software to align, scale, and manually delineate the different regions of the ONH.

RESULTS

There was significant correspondence between in vivo and ex vivo measurements of the depth and shape of the lamina cribrosa, along with the size and shape of Bruch's membrane opening (BMO) and anterior scleral canal opening (ASCO). Weaker correspondence was observed for choroidal thickness; as expected, a thinner choroid was seen ex vivo due to loss of blood volume upon enucleation (-79.9%, p < 0.001). In addition, the lamina was shallower (-32.3%, p = 0.0019) and BMO was smaller ex vivo (-3.38%, p = 0.026), suggesting post mortem shrinkage of the fixed tissue. On average, while highly variable, only 31% of the anterior laminar surface was visible in vivo with SDOCT (p < 0.001).

CONCLUSIONS

Morphologic parameters by SDOCT imaging of the deep ONH showed promising correspondence to histology metrics. Small but significant shrinkage artifact, along with large effects of exsanguination of the choroid, was seen in the ex vivo reconstructions of fixed tissues that may impact the quantification of ex vivo histoarchitecture, and this should be considered when developing models and biomarkers based on ex vivo imaging of fixed tissue. Lack of visibly of most of the lamina surface in SDOCT images is an important limitation to metrics and biomarkers based on in vivo images of the ONH deep tissues.

Longitudinal Observation of Border Tissue Configuration During Axial Elongation in Childhood

Purpose

To investigate the change of border tissue configuration during axial elongation in childhood.

Methods

Fifty-four subjects (108 eyes; age range, 29.3–132.5 months) who had undergone a series of swept-source optical coherence tomography scans at intervals of 6 months or longer were classified into stable axial length (AXL) eyes (n = 55; AXL change of ≤0.36 mm) and elongating AXL eyes (n = 53; AXL change of >0.36 mm). The angle between the Bruch's membrane opening (BMO) reference plane and the border tissue of Elschnig was defined as the border tissue angle (BTA). The border tissue angle, BMO distance (BMOD) and minimum rim width (MRW) were measured in the temporal and nasal regions.

Results

During 15.6 ± 7.2 months of follow-up, the AXL significantly increased from 22.8 ± 1.3 mm to 23.3 ± 1.4 mm (P < 0.001). Changes of border tissue angle and AXL showed a significant correlation only in the temporal region of elongating AXL eyes (r = –0.409; P = 0.002), but not in stable AXL eyes. Both BMOD and nasal MRW significantly increased from 1482.5 ± 153.0 to 1506.1 ± 154.6 µm and from 310.6 ± 83.2 to 324.6 ± 95.6 µm, respectively (all Ps < 0.001). The changes of BMOD and nasal MRW showed a significant positive correlation with changes of AXL in elongating AXL eyes but not in stable AXL eyes.

Conclusions

During the axial elongation in childhood, temporal border tissue configuration change, BMO enlargement, and nasal peripapillary tissue elevation showed a significant correlation with changes in the AXL.

Optical Coherence Tomography Imaging of the Lamina Cribrosa: Structural Biomarkers in Nonglaucomatous Diseases

The lamina cribrosa (LC) is an active structure that responds to the strain by changing its morphology. Abnormal changes in LC morphology are usually associated with, and indicative of, certain pathologies such as glaucoma, intraocular hypertension, and myopia. Recent developments in optical coherence tomography (OCT) have enabled detailed in vivo studies about the architectural characteristics of the LC. Structural characteristics of the LC have been widely explored in glaucoma management. However, information about which LC biomarkers could be useful for the diagnosis, and follow-up, of other diseases besides glaucoma is scarce. Hence, this literature review aims to summarize the role of the LC in nonophthalmic and ophthalmic diseases other than glaucoma. PubMed was used to perform a systematic review on the LC features that can be extracted from OCT images. All imaging features are presented and discussed in terms of their importance and applicability in clinical practice. A total of 56 studies were included in this review. Overall, LC depth (LCD) and thickness (LCT) have been the most studied features, appearing in 75% and 45% of the included studies, respectively. These biomarkers were followed by the prelaminar tissue thickness (21%), LC curvature index (5.4%), LC global shape index (3.6%), LC defects (3.6%), and LC strains/deformations (1.8%). Overall, the disease groups showed a thinner LC (smaller LCT) and a deeper ONH cup (larger LCD), with some exceptions. A large variability between approaches used to compute LC biomarkers has been observed, highlighting the importance of having automated and standardized methodologies in LC analysis. Moreover, further studies are needed to identify the pathologies where LC features have a diagnostic and/or prognostic value.

Analysis of the effects of finite element type within a 3D biomechanical model of a human optic nerve head and posterior pole

BACKGROUND AND OBJECTIVE

Biomechanical stresses and strains can be simulated in the optic nerve head (ONH) using the finite element (FE) method, and various element types have been used. This study aims to investigate the effects of element type on the resulting ONH stresses and strains.

METHODS

A single eye-specific model was constructed using 3D delineations of anatomic surfaces in a high-resolution, fluorescent, 3D reconstruction of a human posterior eye, then meshed using our simple meshing algorithm at various densities using 4- and 10-noded tetrahedral elements, as well as 8- and 20-noded hexahedral elements. A mesh-free approach was used to assign heterogeneous, anisotropic, hyperelastic material properties to the lamina cribrosa, sclera and pia. The models were subjected to elevated IOP of 45 mmHg after pre-stressing from 0 to 10 mmHg, and solved in the open-source FE package Calculix; results were then interpreted in relation to computational time and simulation accuracy, using the quadratic hexahedral model as the reference standard.

RESULTS

The 10-noded tetrahedral and 20R-noded hexahedral elements exhibited similar scleral canal and laminar deformations, as well as laminar and scleral stress and strain distributions; the quadratic tetrahedral models ran significantly faster than the quadratic hexahedral models. The linear tetrahedral and hexahedral elements were stiffer compared to the quadratic element types, yielding much lower stresses and strains in the lamina cribrosa.

CONCLUSIONS

Prior studies have shown that 20-noded hexahedral elements yield the most accurate results in complex models. Results show that 10-noded tetrahedral elements yield very similar results to 20-noded hexahedral elements and so they can be used interchangeably, with significantly lower computational time. Linear element types did not yield acceptable results.

Age and Menopause Effects on Ocular Compliance and Aqueous Outflow

Purpose

Glaucoma is the second leading cause of blindness worldwide. Recent work suggests that estrogen and the timing of menopause play a role in modulating the risk of developing glaucoma. Menopause is known to cause modest changes in intraocular pressure; yet, whether this change is mediated through the outflow pathway remains unknown. Menopause also affects tissue biomechanical properties throughout the body; however, the impact of menopause on ocular biomechanical properties is not well characterized.

Methods

Here, we simultaneously assessed the impact of menopause on aqueous outflow facility and ocular compliance, as a measure of corneoscleral shell biomechanics. We used young (3-4 months old) and middle-aged (9-10 months old) Brown Norway rats. Menopause was induced by ovariectomy (OVX), and control animals underwent sham surgery, resulting in the following groups: young sham (n = 5), young OVX (n = 6), middle-aged sham (n = 5), and middle-aged OVX (n = 5). Eight weeks postoperatively, we measured outflow facility and ocular compliance.

Results

Menopause resulted in a 34% decrease in outflow facility and a 19% increase in ocular compliance (P = 0.011) in OVX animals compared with sham controls (P = 0.019).

Conclusions

These observations reveal that menopause affects several key physiological factors known to be associated with glaucoma, suggesting that menopause may contribute to an increased risk of glaucoma in women.

Collagen fiber interweaving is central to sclera stiffness

The mechanical properties of the microstructural components of sclera are central to eye physiology and pathology. Because these parameters are extremely difficult to measure directly, they are often estimated using inverse-modeling matching deformations of macroscopic samples measured experimentally. Although studies of sclera microstructure show collagen fiber interweaving, current models do not account for this interweaving or the resulting fiber-fiber interactions, which might affect parameter estimates. Our goal was to test the hypothesis that constitutive parameters estimated using inverse modeling differ if models account for fiber interweaving and interactions. We developed models with non-interweaving or interweaving fibers over a wide range of volume fractions (36-91%). For each model, we estimated fiber stiffness using inverse modeling matching biaxial experimental data of human sclera. We found that interweaving increased the estimated fiber stiffness. When the collagen volume fraction was 64% or less, the stiffness of interweaving fibers was about 1.25 times that of non-interweaving fibers. For higher volume fractions, the ratio increased substantially, reaching 1.88 for a collagen volume fraction of 91%. Simulating a model (interweaving/non-interweaving) using the fiber stiffness estimated from the other model produced substantially different behavior, far from that observed experimentally. These results show that estimating microstructural component mechanical properties is highly sensitive to the assumed interwoven/non-interwoven architecture. Moreover, the results suggest that interweaving plays an important role in determining the structural stiffness of sclera, and potentially of other soft tissues in which the collagen fibers interweave. STATEMENT OF SIGNIFICANCE: The collagen fibers of sclera are interwoven, but numerical models do not account for this interweaving or the resulting fiber-fiber interactions. To determine if interweaving matters, we examined the differences in the constitutive model parameters estimated using inverse modeling between models with interweaving and non-interweaving fibers. We found that the estimated stiffness of the interweaving fibers was up to 1.88 times that of non-interweaving fibers, and that the estimate increased with collagen volume fraction. Our results suggest that fiber interweaving is a fundamental characteristic of connective tissues, additional to anisotropy, density and orientation. Better characterization of interweaving, and of its mechanical effects is likely central to understanding microstructure and biomechanics of sclera and other soft tissues.

The role of lamina cribrosa tissue stiffness and fibrosis as fundamental biomechanical drivers of pathological glaucoma cupping

The primary biomechanical driver of pathological glaucomatous cupping remains unknown. Finite element modeling indicates that stress and strain play key roles. In this article, primarily a review, we utilize known biomechanical data and currently unpublished results from our lab to propose a three-stage, tissue stiffness-based model to explain glaucomatous cupping occurring at variable levels of translaminar pressure (TLP). In stage 1, a short-term increase in TLP gradient induces a transient increase in lamina cribrosa (LC) strain. Beyond a critical level of strain, the tissue stiffness rises steeply provoking cellular responses via integrin-mediated mechanotransduction. This early mechanoprotective cellular contraction reduces strain, which reduces tissue stiffness by return of the posteriorly deflected LC to baseline. In stage 2 a prolonged period of TLP increase elicits extracellular matrix (ECM) production leading to fibrosis, increasing baseline tissue stiffness and strain and diminishing the contractile ability/ability to return to the baseline LC position. This is supported by our three-dimensional collagen contraction assays, which show significantly reduced capacity to contract in glaucoma compared with normal LC cells. Second, 15% cyclic strain in LC cells over 24 h elicits a typical increase in ECM profibrotic genes in normal LC cells but a highly blunted response in glaucoma LC cells. Stage 3 is characterized by persistent fibrosis causing further stiffening and inducing a feed-forward ECM production cycle. Repeated cycles of increased strain and stiffness with profibrotic ECM deposition prevent optic nerve head (ONH) recoil from the new deflected position. This incremental maladaptive modeling leads to pathological ONH cupping.

Anatomical and physiological considerations in scleral lens wear: Conjunctiva and sclera

While scleral lenses have been fitted using diagnostic lenses or impression moulding techniques for over a century, recent advances in anterior segment imaging such as optical coherence tomography and corneo-scleral profilometry have significantly improved the current understanding of the anatomy of the anterior eye including the morphometry of the conjunctiva, sclera, and corneo-scleral junction, as well as the ocular surface shape and elevation. These technological advances in ocular imaging along with continual improvements and innovations in scleral lens design and manufacturing have led to a global increase in scleral lens prescribing. This review provides a comprehensive overview of the conjunctiva and sclera in the context of modern scleral lens practice, including anatomical variations in healthy and diseased eyes, the physiological impact of scleral lens wear, potential fitting challenges, and current approaches to lens modifications in order to minimise lens-induced complications and adverse ocular effects. Specific topics requiring further research are also discussed.

In vivo measures of anterior scleral resistance in humans with rebound tonometry

PURPOSE

To measure regional variations in anterior scleral resistance (ASR) using a ballistic rebound tonometer (RBT) and examine whether the variations are significantly affected by ethnicity and refractive error (RE).

METHODS

ASR was measured using a RBT (iCare TA01) following calibration against the biomechanical properties of agarose biogels. Eight scleral regions (nasal, temporal, superior, inferior, inferior-nasal, inferior-temporal, superior-nasal and superior-temporal) were measured at locations 4mm from the limbus. Subjects were 130 young adults comprising three ethnic groups whose RE distributions [MSE (D) ± S.D.] incorporated individuals categorised as without-myopia (NM; MSE ≥ -0.50) and with-myopia (WM; MSE < -0.50); British-White (BW): 26 NM + 0.52 ± 1.15D; 22 WM -3.83 ± 2.89D]; British-South-Asian (BSA): [9 NM + 0.49 ± 1.06D; 11 WM -5.07 ± 3.76D; Hong-Kong-Chinese (HKC): [11 NM + 0.39 ± 0.66D; 49 WM -4.46 ± 2.70D]. Biometric data were compiled using cycloplegic open-field autorefraction and the Zeiss IOLMaster. Two- and three-way repeated measures analysis of variances (anovas) tested regional differences for RBT values across both refractive status and ethnicity whilst stepwise forward multiple linear regression was used as an exploratory test.

RESULTS

Significant regional variations in ASR were identified for the BW, BSA and HKC (p < 0.001) individuals; superior-temporal region showed the lowest levels of resistance whilst the inferior-nasal region the highest. Compared to the BW and BSA groups, the HKC subjects displayed a significant increase in mean resistance for each respective region (p < 0.001). With the exception of the inferior region, ethnicity was found to be the chief predictor for variation in the scleral RBT values for all other regions. Mean RE group differences were insignificant.

CONCLUSIONS

The novel application of RBT to the anterior sclera confirm regional variation in ASR. Greater ASR amongst the HKC group than the BW and BSA individuals suggests that ethnic differences in anterior scleral biomechanics may exist.

Biomechanical properties of the rat sclera obtained with inverse finite element modeling

It is widely accepted that biomechanics plays an important role in glaucoma pathophysiology, but the mechanisms involved are largely unknown. Rats are a common animal model of glaucoma, and finite element models are being developed to provide much-needed insight into the biomechanical environment of the posterior rat eye. However, material properties of rat ocular tissues, including the sclera, are currently unknown. Since the sclera plays a major role in posterior ocular biomechanics, our goal was to use inverse finite element modeling to extract rat scleral material properties. We first used digital image correlation to measure scleral surface displacement during whole-globe inflation testing. We modeled the sclera as a nonlinear material with embedded collagen fibers and then fit modeled displacements to experimental data using a differential evolution algorithm. Subject-specific models were constructed in which 3 parameters described the stiffness of the ground substance and collagen fibers in the posterior eye, and 16 parameters defined the primary orientation and alignment of fibers within eight scleral sub-regions. We successfully extracted scleral material properties for eight rat eyes. Model displacements recreated general patterns of the experimental displacements but did not always match local patterns. The fiber directions and fiber concentration parameters were highly variable, but on average, fibers were aligned circumferentially and were more aligned in the peripapillary sclera than in the peripheral sclera. The material properties determined here will be used to inform future finite element models of the rat posterior eye with the goal of elucidating the role of biomechanics in glaucoma pathophysiology.

Translational relevance of the goat as a preclinical model of the human labrum and chondrolabral junction-histological study

The purpose of this study was to evaluate the histologic features of the caprine labrum, with emphasis on the chondrolabral junction, with the goal of informing the feasibility of the goat as an animal model. The left hip joint of six adolescent Spanish goats (Capra pyrenaica) was harvested and subjected to anatomical and histological assessments. Human acetabular and femoral head samples, collected during total hip arthroplasty, served as comparison samples. The caprine labrum was found to consist of mostly type I collagen with uniform crimp, with an average crimp length of 20.8 µm. Upon histological assessment, acetabular articular chondrocytes were found to express substance-P, especially near or in the chondrolabral junction. And the majority of nonvascular cells expressed α-smooth muscle actin (SMA), with no notable elastin and laminin expression. Human labrum demonstrated similar staining patterns. Overall, the goat hip was found to be homologous to the human hip, demonstrating potential as a useful animal model for future studies. This is the first report of a crimped collagen structure in the labrum. Crimped type I collagen at the chondrolabral junction imparts an extension-recovery property which allows for toleration of stress without permanent deformation, underlying the importance of its preservation during surgery. The high expression of substance-P reflects the degree to which the labrum is innervated. Finally, the expression of α-SMA with contractile characteristics could indicate the potential for chondrocyte (i.e., myochondrocytes) modeling of the extracellular matrix. Statement of Clinical Significance: Establishment of a large animal model and deeper knowledge of the histological composition of the hip joint will enhance our study of the acetabular labrum, including repair techniques. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 38:1070-1080, 2020.

Diurnal Cycle of Translaminar Pressure in Nonhuman Primates Quantified With Continuous Wireless Telemetry

Purpose

Recent retrospective clinical studies and animal experiments have suggested that cerebrospinal fluid pressure (CSFP) is important in glaucoma pathogenesis. Intraocular pressure (IOP) and CSFP are the driving components of the translaminar pressure (TLP), which directly effects the optic nerve head. This study measured the diurnal cycle of TLP using continuous wireless telemetry in nonhuman primates (NHPs), a common animal model of glaucoma.

Methods

We have developed an implantable wireless telemetry system based on a small piezoelectric pressure transducer with low drift. Unilateral IOP was measured in the anterior chamber of the eye, and intracranial pressure (ICP, a surrogate measure of CSFP) was measured in the brain parenchyma in four awake, behaving NHPs for periods of 22 to 281 days. IOP and ICP telemetry transducers were calibrated with direct pressure measurements in the eye (every 2 weeks) and brain (monthly). TLP was quantified in real time as IOP-ICP, and hourly means of IOP, ICP, and TLP were analyzed.

Results

Results show that mean ICP is significantly higher by an average of 4.8 ± 0.8 mmHg during sleeping hours in NHPs (P < 0.01). IOP showed a small but significant nocturnal elevation in two of four animals despite NHPs sleeping upright (P < 0.05). TLP was significantly lower during sleep (7.1 ± 0.6 mmHg; P < 0.01) than when the animals were awake and active (11.0 ± 0.9 mmHg), driven primarily by the large increase in ICP during sleep.

Conclusions

The 56% increase in TLP during waking hours in NHPs matches the increase in TLP due to postural change from supine to upright reported previously in humans.

In Vivo Measurements of Prelamina and Lamina Cribrosa Biomechanical Properties in Humans

Purpose

To develop and use a custom virtual fields method (VFM) to assess the biomechanical properties of human prelamina and lamina cribrosa (LC) in vivo.

Methods

Clinical data of 20 healthy, 20 ocular hypertensive (OHT), 20 primary open-angle glaucoma, and 16 primary angle-closure glaucoma eyes were analyzed. For each eye, the intraocular pressure (IOP) and optical coherence tomography (OCT) images of the optic nerve head (ONH) were acquired at the normal state and after acute IOP elevation. The IOP-induced deformation of the ONH was obtained from the OCT volumes using a three-dimensional tracking algorithm and fed into the VFM to extract the biomechanical properties of the prelamina and the LC in vivo. Statistical measurements and P values from the Mann-Whitney-Wilcoxon tests were reported.

Results

The average shear moduli of the prelamina and the LC were 64.2 ± 36.1 kPa and 73.1 ± 46.9 kPa, respectively. The shear moduli of the prelamina of healthy subjects were significantly lower than those of the OHT subjects. Comparisons between healthy and glaucoma subjects could not be made robustly due to a small sample size.

Conclusions

We have developed a methodology to assess the biomechanical properties of human ONH tissues in vivo and provide preliminary comparisons in healthy and OHT subjects. Our proposed methodology may be of interest for glaucoma management.

Connective Tissue Remodeling in Myopia and its Potential Role in Increasing Risk of Glaucoma

Myopia and glaucoma are both increasing in prevalence and are linked by an unknown mechanism as many epidemiologic studies have identified moderate to high myopia as an independent risk factor for glaucoma. Myopia and glaucoma are both chronic conditions that lead to connective tissue remodeling within the sclera and optic nerve head. The mechanobiology underlying connective tissue remodeling differs substantially between both diseases, with different homeostatic control mechanisms. In this article, we discuss similarities and differences between connective tissue remodeling in myopia and glaucoma; selected multi-scale mechanisms that are thought to underlie connective tissue remodeling in both conditions; how asymmetric remodeling of the optic nerve head may predispose a myopic eye for pathological remodeling and glaucoma; and how neural tissue deformations may accumulate throughout both pathologies and increase the risk for mechanical insult of retinal ganglion cell axons.

A Mesh-Free Approach to Incorporate Complex Anisotropic and Heterogeneous Material Properties into Eye-Specific Finite Element Models

Commercial finite element modeling packages do not have the tools necessary to effectively incorporate the complex anisotropic and heterogeneous material properties typical of the biological tissues of the eye. We propose a mesh-free approach to incorporate realistic material properties into finite element models of individual human eyes. The method is based on the idea that material parameters can be estimated or measured at so called control points, which are arbitrary and independent of the finite element mesh. The mesh-free approach approximates the heterogeneous material parameters at the Gauss points of each finite element while the boundary value problem is solved using the standard finite element method. The proposed method was applied to an eye-specific model a human posterior pole and optic nerve head. We demonstrate that the method can be used to effectively incorporate experimental measurements of the lamina cribrosa micro-structure into the eye-specific model. It was convenient to define characteristic material orientations at the anterior and posterior scleral surface based on the eye-specific geometry of each sclera. The mesh-free approach was effective in approximating these characteristic material directions with smooth transitions across the sclera. For the first time, the method enabled the incorporation of the complex collagen architecture of the peripapillary sclera into an eye-specific model including the recently discovered meridional fibers at the anterior surface and the depth dependent width of circumferential fibers around the scleral canal. The model results suggest that disregarding the meridional fiber region may lead to an underestimation of local strain concentrations in the retina. The proposed approach should simplify future studies that aim to investigate collagen remodeling in the sclera and optic nerve head or in other biological tissues with similar challenges.

Differences in Simulated Refractive Outcomes of Photorefractive Keratectomy (PRK) and Laser In-Situ Keratomileusis (LASIK) for Myopia in Same-Eye Virtual Trials

The use of computational mechanics for assessing the structural and optical consequences of corneal refractive procedures is increasing. In practice, surgeons who elect to perform PRK rather than LASIK must often reduce the programmed refractive treatment magnitude to avoid overcorrection of myopia. Building on a recent clinical validation study of finite element analysis (FEA)-based predictions of LASIK outcomes, this study compares predicted responses in the validated LASIK cases to theoretical PRK treatments for the same refractive error. Simulations in 20 eyes demonstrated that PRK resulted in a mean overcorrection of 0.17 ± 0.10 D relative to LASIK and that the magnitude of overcorrection increased as a function of attempted correction. This difference in correction closely matched (within 0.06 ± 0.03 D) observed differences in PRK and LASIK from a historical nomogram incorporating thousands of cases. The surgically induced corneal strain was higher in LASIK than PRK and resulted in more forward displacement of the central stroma and, consequently, less relative flattening in LASIK. This FE model provides structural confirmation of a mechanism of action for the difference in refractive outcomes of these two keratorefractive techniques, and the results were in agreement with empirical clinical data.