Report From the National Eye Institute Workshop on Neuro-Ophthalmic Disease Clinical Trial Endpoints: Optic Neuropathies

Sympathetic nervous system activity is associated with choroidal thickness and axial length in school-aged children

BACKGROUND/AIMS

We aim to explore the effect of sympathetic nervous system (SNS) on choroid thickness (ChT) and axial length (AL).

METHODS

Students of grade 2 and 3 from a primary school were included and followed for 1 year. Visual acuity, refraction, AL and ChT were measured. Morning urine samples were collected for determining SNS activity by analysing concentrations of epinephrine, norepinephrine and dopamine using the liquid chromatography-tandem mass spectrometry. The most important factor (factor 1) was calculated using factor analysis to comprehensively indicate the SNS activity.

RESULTS

A total of 273 students were included, with an average age of 7.77±0.69 years, and 150 (54.95%) were boys. Every 1 µg/L increase in epinephrine is associated with 1.60 µm (95% CI 0.30 to 2.90, p=0.02) decrease in average ChT. Every 1 µg/L increase in norepinephrine is associated with 0.53 µm (95% CI 0.08 to 0.98, p=0.02) decrease in the ChT in inner-superior region. The factor 1 was negatively correlated with the ChT in the superior regions. Every 1 µg/L increase in norepinephrine was associated with 0.002 mm (95% CI 0.0004 to 0.004, p=0.016) quicker AL elongation. The factor 1 was positively correlated with AL elongation (coefficient=0.037, 95% CI 0.005 to 0.070, p=0.023).

CONCLUSIONS

We hypothesised that chronic stress characterised by elevated level of the SNS, was associated with significant increase in AL elongation, probably through thinning of the choroid.

Translational roadmap for regenerative therapies of eye disease

The translation of regenerative therapies to neuronal eye diseases requires a roadmap specific to the nature of the target diseases, patient population, methodologies for assessing outcome, and other factors. This commentary focuses on critical issues for translating regenerative eye therapies relevant to retinal neurons to human clinical trials.

A potential primary endpoint for clinical trials in glaucoma neuroprotection

The purpose of this retrospective, longitudinal study is to evaluate the relationship between MD slope from visual field tests collected over a short period of time (2 years) and the current United States' Food and Drug Administration (FDA) recommended endpoints for visual field outcomes. If this correlation is strong and highly predictive, clinical trials employing MD slopes as primary endpoints could be employed in neuroprotection clinical trials with shorter duration and help expedite the development of novel IOP-independent therapies. Visual field tests of patients with or suspected glaucoma were selected from an academic institution and evaluated based on two functional progression endpoints: (A) five or more locations worsening by at least 7 dB, and (B) at least five test locations based upon the GCP algorithm. A total of 271 (57.6%) and 278 (59.1%) eyes reached Endpoints A and B, respectively during the follow up period. The median (IQR) MD slope of eyes reaching vs. not reaching Endpoint A and B were -1.19 (-2.00 to -0.41) vs. 0.36 (0.00 to 1.00) dB/year and -1.16 (-1.98 to -0.40) vs. 0.41 (0.02 to 1.03) dB/year, respectively (P < 0.001). It was found that eyes experiencing rapid 24-2 visual field MD slopes over a 2-year period were on average tenfold more likely to reach one of the FDA accepted endpoints during or soon after that period.

Where's the Vision? The Importance of Visual Outcomes in Neurologic Disorders: The 2021 H. Houston Merritt Lecture

Neurologists have long recognized the importance of the visual system in the diagnosis and monitoring of neurologic disorders. This is particularly true because approximately 50% of the brain's pathways subserve afferent and efferent aspects of vision. During the past 30 years, researchers and clinicians have further refined this concept to include investigation of the visual system for patients with specific neurologic diagnoses, including multiple sclerosis (MS), concussion, Parkinson disease (PD), and conditions along the spectrum of Alzheimer disease (AD, mild cognitive impairment, and subjective cognitive decline). This review highlights the visual "toolbox" that has been developed over the past 3 decades and beyond to capture both structural and functional aspects of vision in neurologic disease. Although the efforts to accelerate the emphasis on structure-function relationships in neurologic disorders began with MS during the early 2000s, such investigations have broadened to recognize the need for outcomes of visual pathway structure, function, and quality of life for clinical trials of therapies across the spectrum of neurologic disorders. This review begins with a patient case study highlighting the importance using the most modern technologies for visual pathway assessment, including optical coherence tomography. We emphasize that both structural and functional tools for vision testing can be used in parallel to detect what might otherwise be subclinical events or markers of visual and, perhaps, more global neurologic decline. Such measures will be critical because clinical trials and therapies become more available across the neurologic disease spectrum.