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Morgan JIW, Chui TYP, Grieve K. Twenty-five years of clinical applications using adaptive optics ophthalmoscopy [Invited]. BIOMEDICAL OPTICS EXPRESS 2023; 14:387-428. [PMID: 36698659 PMCID: PMC9841996 DOI: 10.1364/boe.472274] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 11/22/2022] [Accepted: 11/27/2022] [Indexed: 05/02/2023]
Abstract
Twenty-five years ago, adaptive optics (AO) was combined with fundus photography, thereby initiating a new era in the field of ophthalmic imaging. Since that time, clinical applications of AO ophthalmoscopy to investigate visual system structure and function in both health and disease abound. To date, AO ophthalmoscopy has enabled visualization of most cell types in the retina, offered insight into retinal and systemic disease pathogenesis, and been integrated into clinical trials. This article reviews clinical applications of AO ophthalmoscopy and addresses remaining challenges for AO ophthalmoscopy to become fully integrated into standard ophthalmic care.
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Affiliation(s)
- Jessica I. W. Morgan
- Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania, Philadelphia, PA 19104, USA
- Center for Advanced Retinal and Ocular Therapeutics, University of Pennsylvania, Philadelphia, PA 19104, USA
- Contributed equally
| | - Toco Y. P. Chui
- Department of Ophthalmology, The New York Eye and Ear Infirmary of Mount Sinai, New York, NY 10003, USA
- Contributed equally
| | - Kate Grieve
- Sorbonne Université, INSERM, CNRS, Institut de la Vision, 17 rue Moreau, and CHNO des Quinze-Vingts, INSERM-DGOS CIC 1423, 28 rue de Charenton, F-75012 Paris, France
- Contributed equally
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Balaratnasingam C, An D, Hein M, Yu P, Yu DY. Studies of the retinal microcirculation using human donor eyes and high-resolution clinical imaging: Insights gained to guide future research in diabetic retinopathy. Prog Retin Eye Res 2022; 94:101134. [PMID: 37154065 DOI: 10.1016/j.preteyeres.2022.101134] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 09/18/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
The microcirculation plays a key role in delivering oxygen to and removing metabolic wastes from energy-intensive retinal neurons. Microvascular changes are a hallmark feature of diabetic retinopathy (DR), a major cause of irreversible vision loss globally. Early investigators have performed landmark studies characterising the pathologic manifestations of DR. Previous works have collectively informed us of the clinical stages of DR and the retinal manifestations associated with devastating vision loss. Since these reports, major advancements in histologic techniques coupled with three-dimensional image processing has facilitated a deeper understanding of the structural characteristics in the healthy and diseased retinal circulation. Furthermore, breakthroughs in high-resolution retinal imaging have facilitated clinical translation of histologic knowledge to detect and monitor progression of microcirculatory disturbances with greater precision. Isolated perfusion techniques have been applied to human donor eyes to further our understanding of the cytoarchitectural characteristics of the normal human retinal circulation as well as provide novel insights into the pathophysiology of DR. Histology has been used to validate emerging in vivo retinal imaging techniques such as optical coherence tomography angiography. This report provides an overview of our research on the human retinal microcirculation in the context of the current ophthalmic literature. We commence by proposing a standardised histologic lexicon for characterising the human retinal microcirculation and subsequently discuss the pathophysiologic mechanisms underlying key manifestations of DR, with a focus on microaneurysms and retinal ischaemia. The advantages and limitations of current retinal imaging modalities as determined using histologic validation are also presented. We conclude with an overview of the implications of our research and provide a perspective on future directions in DR research.
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Affiliation(s)
- Chandrakumar Balaratnasingam
- Lions Eye Institute, Nedlands, Western Australia, Australia; Centre for Ophthalmology and Visual Science, University of Western Australia, Perth, Australia; Department of Ophthalmology, Sir Charles Gairdner Hospital, Western Australia, Australia.
| | - Dong An
- Lions Eye Institute, Nedlands, Western Australia, Australia; Centre for Ophthalmology and Visual Science, University of Western Australia, Perth, Australia
| | - Martin Hein
- Lions Eye Institute, Nedlands, Western Australia, Australia; Centre for Ophthalmology and Visual Science, University of Western Australia, Perth, Australia
| | - Paula Yu
- Lions Eye Institute, Nedlands, Western Australia, Australia; Centre for Ophthalmology and Visual Science, University of Western Australia, Perth, Australia
| | - Dao-Yi Yu
- Lions Eye Institute, Nedlands, Western Australia, Australia; Centre for Ophthalmology and Visual Science, University of Western Australia, Perth, Australia
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Zhang Q, Sampani K, Xu M, Cai S, Deng Y, Li H, Sun JK, Karniadakis GE. AOSLO-net: A Deep Learning-Based Method for Automatic Segmentation of Retinal Microaneurysms From Adaptive Optics Scanning Laser Ophthalmoscopy Images. Transl Vis Sci Technol 2022; 11:7. [PMID: 35938881 PMCID: PMC9366726 DOI: 10.1167/tvst.11.8.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/02/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose Accurate segmentation of microaneurysms (MAs) from adaptive optics scanning laser ophthalmoscopy (AOSLO) images is crucial for identifying MA morphologies and assessing the hemodynamics inside the MAs. Herein, we introduce AOSLO-net to perform automatic MA segmentation from AOSLO images of diabetic retinas. Method AOSLO-net is composed of a deep neural network based on UNet with a pretrained EfficientNet as the encoder. We have designed customized preprocessing and postprocessing policies for AOSLO images, including generation of multichannel images, de-noising, contrast enhancement, ensemble and union of model predictions, to optimize the MA segmentation. AOSLO-net is trained and tested using 87 MAs imaged from 28 eyes of 20 subjects with varying severity of diabetic retinopathy (DR), which is the largest available AOSLO dataset for MA detection. To avoid the overfitting in the model training process, we augment the training data by flipping, rotating, scaling the original image to increase the diversity of data available for model training. Results The validity of the model is demonstrated by the good agreement between the predictions of AOSLO-net and the MA masks generated by ophthalmologists and skillful trainees on 87 patient-specific MA images. Our results show that AOSLO-net outperforms the state-of-the-art segmentation model (nnUNet) both in accuracy (e.g., intersection over union and Dice scores), as well as computational cost. Conclusions We demonstrate that AOSLO-net provides high-quality of MA segmentation from AOSLO images that enables correct MA morphological classification. Translational Relevance As the first attempt to automatically segment retinal MAs from AOSLO images, AOSLO-net could facilitate the pathological study of DR and help ophthalmologists make disease prognoses.
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Affiliation(s)
- Qian Zhang
- Division of Applied Mathematics, Brown University, Providence, RI, USA
| | - Konstantina Sampani
- Beetham Eye Institute, Joslin Diabetes Center, Department of Medicine and Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Mengjia Xu
- Division of Applied Mathematics, Brown University, Providence, RI, USA
- McGovern Institute for Brain Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Shengze Cai
- Division of Applied Mathematics, Brown University, Providence, RI, USA
| | - Yixiang Deng
- School of Engineering, Brown University, Providence, RI, USA
| | - He Li
- School of Engineering, Brown University, Providence, RI, USA
| | - Jennifer K. Sun
- Beetham Eye Institute, Joslin Diabetes Center, Department of Medicine and Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - George Em Karniadakis
- Division of Applied Mathematics and School of Engineering, Brown University, Providence, RI, USA
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Abstract
The eye, the photoreceptive organ used to perceive the external environment, is of great importance to humans. It has been proven that some diseases in humans are accompanied by fundus changes; therefore, the health status of people may be interpreted from retinal images. However, the human eye is not a perfect refractive system for the existence of ocular aberrations. These aberrations not only affect the ability of human visual discrimination and recognition, but restrict the observation of the fine structures of human eye and reduce the possibility of exploring the mechanisms of eye disease. Adaptive optics (AO) is a technique that corrects optical wavefront aberrations. Once integrated into ophthalmoscopes, AO enables retinal imaging at the cellular level. This paper illustrates the principle of AO in correcting wavefront aberrations in human eyes, and then reviews the applications and advances of AO in ophthalmology, including the adaptive optics fundus camera (AO-FC), the adaptive optics scanning laser ophthalmoscope (AO-SLO), the adaptive optics optical coherence tomography (AO-OCT), and their combined multimodal imaging technologies. The future development trend of AO in ophthalmology is also prospected.
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Datlinger F, Wassermann L, Reumueller A, Hajdu D, Steiner I, Salas M, Drexler W, Pircher M, Schmidt-Erfurth U, Pollreisz A. Assessment of Detailed Photoreceptor Structure and Retinal Sensitivity in Diabetic Macular Ischemia Using Adaptive Optics-OCT and Microperimetry. Invest Ophthalmol Vis Sci 2021; 62:1. [PMID: 34605880 PMCID: PMC8496411 DOI: 10.1167/iovs.62.13.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose The purpose of this study was to assess density and morphology of cone photoreceptors (PRs) and corresponding retinal sensitivity in ischemic compared to nonischemic retinal capillary areas of diabetic eyes using adaptive optics optical coherence tomography (AO-OCT) and microperimetry (MP). Methods In this cross-sectional, observational study five eyes of four patients (2 eyes with proliferative diabetic retinopathy (DR) and 3 eyes moderate nonproliferative DR) were included. PR morphology and density was manually assessed in AO-OCT en face images both at the axial position of the inner-segment outer segment (IS/OS) and cone outer segment tips (COSTs). Retinal sensitivity was determined by fundus-controlled microperimetry in corresponding areas (MP-3, Nidek). Results In AO-OCT, areas affected by capillary nonperfusion showed severe alterations of cone PR morphology at IS/OS and COST compared to areas with intact capillary perfusion (84% and 87% vs. 9% and 8% of area affected for IS/OS and COST, respectively). Mean reduction of PR signal density in affected areas compared to those with intact superficial capillary plexus (SCP) and deep capillary plexus (DCP) perfusion of similar eccentricity was -38% at the level of IS/OS (P = 0.01) and -39% at the level of COST (P = 0.01). Mean retinal sensitivity was 10.8 ± 5.4 in areas affected by DCP nonperfusion and 28.2 ± 1.5 outside these areas (P < 0.001). Conclusions Cone PR morphology and signal density are severely altered in areas of capillary nonperfusion. These structural changes are accompanied by a severe reduction of retinal sensitivity, indicating the importance of preventing impaired capillary circulation in patients with DR.
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Affiliation(s)
- Felix Datlinger
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Lorenz Wassermann
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Adrian Reumueller
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Dorottya Hajdu
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Irene Steiner
- Center of Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Matthias Salas
- Center of Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Drexler
- Center of Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Michael Pircher
- Center of Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria
| | - Ursula Schmidt-Erfurth
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Andreas Pollreisz
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
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Bakker E, Dikland FA, van Bakel R, Andrade De Jesus D, Sánchez Brea L, Klein S, van Walsum T, Rossant F, Farías DC, Grieve K, Paques M. Adaptive optics ophthalmoscopy: a systematic review of vascular biomarkers. Surv Ophthalmol 2021; 67:369-387. [PMID: 34090882 DOI: 10.1016/j.survophthal.2021.05.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 05/17/2021] [Accepted: 05/24/2021] [Indexed: 12/28/2022]
Abstract
Retinal vascular diseases are a leading cause for blindness and partial sight certifications. By applying adaptive optics (AO) to conventional imaging modalities, the microstructures of the retinal vasculature can be observed with high spatial resolution, hence offering a unique opportunity for the exploration of the human microcirculation. The objective of this systematic review is to describe the current state of retinal vascular biomarkers imaged by AO flood illumination ophthalmoscopy (FIO) and AO scanning laser ophthalmoscopy (SLO). A literature research was conducted in the PubMed and Scopus databases on July 9, 2020. From 217 screened studies, 42 were eligible for this review. All studies underwent a quality check regarding their content. A meta-analysis was performed for the biomarkers reported for the same pathology in at least three studies using the same modality. The most frequently studied vascular biomarkers were the inner diameter (ID), outer diameter (OD), parietal thickness (PT), wall cross-sectional area (WCSA), and wall-to-lumen ratio (WLR). The applicability of AO vascular biomarkers has been mostly explored in systemic hypertension using AO FIO and in diabetes using AO SLO. The result of the meta-analysis for hypertensive patients showed that WLR, PT, and ID were significantly different when compared to healthy controls, while WCSA was not (P < 0.001, P = 0.002, P < 0.001, and P = 0.070, respectively). The presented review shows that, although a substantial number of retinal vascular biomarkers have been explored in AO en face imaging, further clinical research and standardization of procedures is needed to validate such biomarkers for the longitudinal monitoring of arterial hypertension and other diseases.
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Affiliation(s)
- Elise Bakker
- Biomedical Imaging Group Rotterdam, Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands; Clinical Technology, Delft University of Technology, Delft, The Netherlands
| | - Felix Anne Dikland
- Biomedical Imaging Group Rotterdam, Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands; Clinical Technology, Delft University of Technology, Delft, The Netherlands
| | - Roan van Bakel
- Biomedical Imaging Group Rotterdam, Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands; Clinical Technology, Delft University of Technology, Delft, The Netherlands
| | - Danilo Andrade De Jesus
- Biomedical Imaging Group Rotterdam, Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands.
| | - Luisa Sánchez Brea
- Biomedical Imaging Group Rotterdam, Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Stefan Klein
- Biomedical Imaging Group Rotterdam, Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Theo van Walsum
- Biomedical Imaging Group Rotterdam, Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands
| | - Florence Rossant
- ISEP, Institut Supérieur d'Electronique de Paris, Issy-les-Moulineaux, France
| | - Daniela Castro Farías
- Paris Eye Imaging Group, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, INSERM-DHOS Clinical Investigation Center, Paris, France
| | - Kate Grieve
- Paris Eye Imaging Group, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, INSERM-DHOS Clinical Investigation Center, Paris, France
| | - Michel Paques
- Paris Eye Imaging Group, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, INSERM-DHOS Clinical Investigation Center, Paris, France
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Reumueller A, Wassermann L, Salas M, Schranz M, Told R, Kostolna K, Drexler W, Pircher M, Schmidt-Erfurth U, Pollreisz A. Three-dimensional assessment of para- and perifoveal photoreceptor densities and the impact of meridians and age in healthy eyes with adaptive-optics optical coherence tomography (AO-OCT). OPTICS EXPRESS 2020; 28:36723-36739. [PMID: 33379760 DOI: 10.1364/oe.409076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 11/08/2020] [Indexed: 06/12/2023]
Abstract
An adaptive optics optical coherence tomography (AO-OCT) system is used to assess sixty healthy eyes of thirty subjects (age 22 to 75) to evaluate how the outer retinal layers, foveal eccentricity and age effect the mean cone density. The cone mosaics of different retinal planes (the cone inner segment outer segment junction (IS/OS), the cone outer segment combined with the IS/OS (ISOS+), the cone outer segment tips (COST), and the full en-face plane (FEF)) at four main meridians (superior, nasal, inferior, temporal) and para- and perifoveal eccentricities (ecc 2.5° and 6.5°) were analyzed quantitatively. The mean overall cone density was 19,892/mm2 at ecc 2.5° and 13,323/mm2 at ecc 6.5°. A significant impact on cone density was found for eccentricity (up to 6,700/mm2 between ecc 2.5° and 6.5°), meridian (up to 3,700/mm2 between nasal and superior meridian) and layer (up to 1,400/mm2 between FEF and IS/OS). Age showed only a weak negative effect. These factors as well as inter-individual variability have to be taken into account when comparing cone density measurements between healthy and pathologically changed eyes, as their combined effect on density can easily exceed several thousand cones per mm2 even in parafoveal regions.
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Castro Farías D, Matsui Serrano R, Bianchi Gancharov J, de Dios Cuadras U, Sahel J, Graue Wiechers F, Dupas B, Paques M. Indocyanine green angiography for identifying telangiectatic capillaries in diabetic macular oedema. Br J Ophthalmol 2019; 104:509-513. [PMID: 31358497 DOI: 10.1136/bjophthalmol-2019-314355] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/12/2019] [Accepted: 07/12/2019] [Indexed: 12/22/2022]
Abstract
AIMS During diabetic macular oedema (DME), a spectrum of capillary abnormalities is commonly observed, ranging from microaneurysms to large microvascular abnormalities. Clinical evidence suggests that targeted photocoagulation of large microvascular abnormalities may be beneficial, but their detection is not done in a routine fashion. It was reported that they are better identified by indocyanine green angiography (ICGA) than by fluorescein angiography. Here, we investigated the prevalence and ICGA and optical coherence tomography (OCT) features of retinal microvascular abnormalities in a group of patients with DME. METHODS Observational study. The fundus photographs, ICGA and structural and angiographic OCT charts of 35 eyes from 25 consecutive patients with DME were reviewed. RESULTS 22 eyes (63%) had at least one focal area of microvascular abnormalities showing prolonged indocyanine green (ICG) staining (ie, beyond 10 mins after injection). In particular, all eyes (n=9) with circinate hard exudates showed foci of late ICG staining. These areas were either isolated globular capillary ecstasies or a cluster of ill-defined capillary abnormalities. They were located at a median distance of 2708 µm from the fovea (range: 1064-4583 µm). Their diameter ranged from 153 to 307 µm. During ICGA, 91% showed increased their contrast and apparent size in late frames, whereas 79% of microaneurysms showed reduced contrast on late frames. OCT angiography was not contributive for the detection of these lesions. CONCLUSION Late ICG staining revealing large microvascular abnormalities is commonly observed during DME. Because of their specific angiographic and OCT features relative to microaneurysms, we propose to name them telangiectatic capillaries (TelCaps).
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Affiliation(s)
| | | | | | | | - José Sahel
- Clinical Investigation Center 1423, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, Sorbonne University, Paris, France
| | | | | | - Michel Paques
- Clinical Investigation Center 1423, Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, Sorbonne University, Paris, France
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AbdelAl O, Ashraf M, Sampani K, Sun JK. "For Mass Eye and Ear Special Issue" Adaptive Optics in the Evaluation of Diabetic Retinopathy. Semin Ophthalmol 2019; 34:189-197. [PMID: 31188056 DOI: 10.1080/08820538.2019.1620794] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Retinal imaging is a fundamental tool for clinical and research efforts in the evaluation and management of diabetic retinopathy. Adaptive optics (AO) is an imaging technique that enables correction of over 90% of the optical aberrations of an individual eye induced primarily by the tear film, cornea and lens. The two major tasks of any AO system are to measure the optical imperfections of the eye and to then compensate for these aberrations to generate a corrected wavefront of reflected light from the eye. AO scanning laser ophthalmoscopy (AOSLO) provides a theoretical lateral resolution limit of 1.4 μm, allowing the study of microscopic features of the retinal vascular and neural tissue. AOSLO studies have revealed irregularities of the photoreceptor mosaic, vascular loss, and details of vascular lesions in diabetic eyes that may provide new insight into development, regression, and response to therapy of diabetic eye disease.
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Affiliation(s)
- Omar AbdelAl
- a Beetham Eye Institute , Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| | - Mohammed Ashraf
- a Beetham Eye Institute , Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| | - Konstantina Sampani
- a Beetham Eye Institute , Joslin Diabetes Center , Boston , MA , USA.,c Department of Medicine , Harvard Medical School , Boston , MA , USA
| | - Jennifer K Sun
- a Beetham Eye Institute , Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
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