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Cicinelli MV, Montesano G, Berni A, Scandale P, Ometto G, Introini U, Battaglia Parodi M, Bandello F, Miserocchi E, Marchese A. Photoreceptor Integrity in MEWDS: Longitudinal Structure-Function Correlations. Invest Ophthalmol Vis Sci 2024; 65:28. [PMID: 38630674 PMCID: PMC11033598 DOI: 10.1167/iovs.65.4.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024] Open
Abstract
Purpose The purpose of this study was to investigate structure-function correlations in multiple evanescent white dot syndrome (MEWDS) using microperimetry (MP) and spectral-domain optical coherence tomography (SD-OCT). Methods Single-center prospective observational study including 14 eyes from 13 patients with MEWDS monitored over a median of 49.5 days (interquartile range = 29-92 days). Investigations focused on best-corrected visual acuity (BCVA), foveal granularity, and the Photoreceptor Reflectivity Ratio (PRR) as a measure of photoreceptor integrity. MP assessed average retinal threshold sensitivity (RTS) and bivariate contour ellipse area (BCEA) for fixation stability. A linear mixed model was used to test associations and interactions among RTS, time, and clinical variables. A hierarchical linear mixed model was used to analyze structure-function relationships, addressing both individual and location-specific variations. Results Overall, 2340 MP locations were tested. PRR revealed a transient decrease within 30 days post-presentation, indicative of early photoreceptor disruption, followed by a progressive increase, signaling recovery. Significantly lower foveal sensitivity (RTS = 14.8 ± 7.4 vs. 22.5 ± 4.4 decibel [dB], P = 0.04) and increased fixation spread (63% BCEA = 1.26 ± 0.97 vs. 0.48 ± 0.35 deg2, P = 0.06) were noted in eyes with foveal granularity compared to those without. A significant increase in RTS was demonstrated over time (0.066 dB/day, P < 0.001), with a central-to-peripheral gradient of improvement. The interaction between follow-up time and baseline BCVA (P < 0.001) indicated more rapid improvement in eyes with worse initial vision. There was a robust, nonlinear association between PRR and RTS across all tested locations (P < 0.001), becoming asymptotic for sensitivity losses exceeding 20 dB. Conclusions Photoreceptor reflectivity accurately aligned with visual function in MEWDS on longitudinal examinations. The central-to-peripheral gradient of improvement may suggest specific vulnerabilities underlying the area around the disc.
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Affiliation(s)
- Maria Vittoria Cicinelli
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Montesano
- City, University of London, Optometry and Visual Sciences, London, United Kingdom
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Alessandro Berni
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Giovanni Ometto
- City, University of London, Optometry and Visual Sciences, London, United Kingdom
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
- London Northwest University Healthcare NHS Trust, London, United Kingdom
| | - Ugo Introini
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maurizio Battaglia Parodi
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Bandello
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisabetta Miserocchi
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Marchese
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Saßmannshausen M, Döngelci S, Vaisband M, von der Emde L, Sloan KR, Hasenauer J, Holz FG, Schmitz-Valckenberg S, Ach T. Spatially Resolved Association of Structural Biomarkers on Retinal Function in Non-Exudative Age-Related Macular Degeneration Over 4 Years. Invest Ophthalmol Vis Sci 2024; 65:45. [PMID: 38687492 PMCID: PMC11067547 DOI: 10.1167/iovs.65.4.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 03/26/2024] [Indexed: 05/02/2024] Open
Abstract
Purpose To longitudinally assess the impact of high-risk structural biomarkers for natural disease progression in non-exudative age-related macular degeneration (AMD) on spatially resolved mesopic and scotopic fundus-controlled perimetry testing. Methods Multimodal retinal imaging data and fundus-controlled perimetry stimuli points were semiautomatically registered according to landmark correspondences at each annual visit over a period of up to 4 years. The presence of sub-RPE drusen, subretinal drusenoid deposits, pigment epithelium detachments (PEDs), hyper-reflective foci (HRF), vitelliform lesions, refractile deposits, and incomplete RPE and outer retinal atrophy (iRORA) and complete RPE and outer retinal atrophy (cRORA) were graded at each stimulus position and visit. Localized retinal layer thicknesses were extracted. Mixed-effect models were used for structure-function correlation. Results Fifty-four eyes of 49 patients with non-exudative AMD (mean age, 70.7 ± 9.1 years) and 27 eyes of 27 healthy controls (mean age, 63.4 ± 8.9 years) were included. During study course, presence of PED had the highest functional impact with a mean estimated loss of -1.30 dB (P < 0.001) for mesopic and -1.23 dB (P < 0.001) for scotopic testing, followed by HRF with -0.89 dB (mesopic, P = 0.001) and -0.87 dB (scotopic, P = 0.005). Subretinal drusenoid deposits were associated with a stronger visual impairment (mesopic, -0.38 dB; P = 0.128; scotopic, -0.37 dB; P = 0.172) compared with sub-RPE drusen (-0.22 dB, P = 0.0004; -0.18 dB, P = 0.006). With development of c-RORA, scotopic retinal sensitivity further significantly decreased (-2.15 dB; P = 0.02). Thickening of the RPE-drusen-complex and thinning of the outer nuclear layer negatively impacted spatially resolved retinal sensitivity. Conclusions The presence of PED and HRF had the greatest prognostic impact on progressive point-wise sensitivity losses. Higher predominant rod than cone-mediated localized retinal sensitivity losses with early signs of retinal atrophy development indicate photoreceptor preservation as a potential therapeutic target for future interventional AMD trials.
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Affiliation(s)
| | - Senem Döngelci
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
| | - Marc Vaisband
- Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Leon von der Emde
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
| | - Kenneth R. Sloan
- Department of Computer Science, University of Alabama at Birmingham, Birmingham, Alabama, United States
| | - Jan Hasenauer
- Department of Internal Medicine III With Haematology, Medical Oncology, Haemostaseology, Infectiology and Rheumatology, Oncologic Center, Salzburg, Austria
- Helmholtz Center Munich–German Research Center for Environmental Health, Institute of Computational Biology, Neuherberg, Germany
| | - Frank G. Holz
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
- Life and Medical Sciences Institute, University of Bonn, Bonn, Germany
| | - Steffen Schmitz-Valckenberg
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
- John A. Moran Eye Center, University of Utah, Salt Lake City, Utah, United States
| | - Thomas Ach
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
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Lad EM, Finger RP, Guymer R. Biomarkers for the Progression of Intermediate Age-Related Macular Degeneration. Ophthalmol Ther 2023; 12:2917-2941. [PMID: 37773477 PMCID: PMC10640447 DOI: 10.1007/s40123-023-00807-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 08/30/2023] [Indexed: 10/01/2023] Open
Abstract
Age-related macular degeneration (AMD) is a leading cause of severe vision loss worldwide, with a global prevalence that is predicted to substantially increase. Identifying early biomarkers indicative of progression risk will improve our ability to assess which patients are at greatest risk of progressing from intermediate AMD (iAMD) to vision-threatening late-stage AMD. This is key to ensuring individualized management and timely intervention before substantial structural damage. Some structural biomarkers suggestive of AMD progression risk are well established, such as changes seen on color fundus photography and more recently optical coherence tomography (drusen volume, pigmentary abnormalities). Emerging biomarkers identified through multimodal imaging, including reticular pseudodrusen, hyperreflective foci, and drusen sub-phenotypes, are being intensively explored as risk factors for progression towards late-stage disease. Other structural biomarkers merit further research, such as ellipsoid zone reflectivity and choriocapillaris flow features. The measures of visual function that best detect change in iAMD and correlate with risk of progression remain under intense investigation, with tests such as dark adaptometry and cone-specific contrast tests being explored. Evidence on blood and plasma markers is preliminary, but there are indications that changes in levels of C-reactive protein and high-density lipoprotein cholesterol may be used to stratify patients and predict risk. With further research, some of these biomarkers may be used to monitor progression. Emerging artificial intelligence methods may help evaluate and validate these biomarkers; however, until we have large and well-curated longitudinal data sets, using artificial intelligence effectively to inform clinical trial design and detect outcomes will remain challenging. This is an exciting area of intense research, and further work is needed to establish the most promising biomarkers for disease progression and their use in clinical care and future trials. Ultimately, a multimodal approach may yield the most accurate means of monitoring and predicting future progression towards vision-threatening, late-stage AMD.
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Affiliation(s)
- Eleonora M Lad
- Department of Ophthalmology, Duke University Medical Center, Durham, NC, USA.
| | - Robert P Finger
- Department of Ophthalmology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Robyn Guymer
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, University of Melbourne, Melbourne, Australia
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Schmetterer L, Scholl H, Garhöfer G, Janeschitz-Kriegl L, Corvi F, Sadda SR, Medeiros FA. Endpoints for clinical trials in ophthalmology. Prog Retin Eye Res 2023; 97:101160. [PMID: 36599784 DOI: 10.1016/j.preteyeres.2022.101160] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 12/22/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023]
Abstract
With the identification of novel targets, the number of interventional clinical trials in ophthalmology has increased. Visual acuity has for a long time been considered the gold standard endpoint for clinical trials, but in the recent years it became evident that other endpoints are required for many indications including geographic atrophy and inherited retinal disease. In glaucoma the currently available drugs were approved based on their IOP lowering capacity. Some recent findings do, however, indicate that at the same level of IOP reduction, not all drugs have the same effect on visual field progression. For neuroprotection trials in glaucoma, novel surrogate endpoints are required, which may either include functional or structural parameters or a combination of both. A number of potential surrogate endpoints for ophthalmology clinical trials have been identified, but their validation is complicated and requires solid scientific evidence. In this article we summarize candidates for clinical endpoints in ophthalmology with a focus on retinal disease and glaucoma. Functional and structural biomarkers, as well as quality of life measures are discussed, and their potential to serve as endpoints in pivotal trials is critically evaluated.
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Affiliation(s)
- Leopold Schmetterer
- Singapore Eye Research Institute, Singapore; SERI-NTU Advanced Ocular Engineering (STANCE), Singapore; Academic Clinical Program, Duke-NUS Medical School, Singapore; School of Chemistry, Chemical Engineering and Biotechnology, Nanyang Technological University, Singapore; Department of Clinical Pharmacology, Medical University Vienna, Vienna, Austria; Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria; Institute of Molecular and Clinical Ophthalmology, Basel, Switzerland.
| | - Hendrik Scholl
- Institute of Molecular and Clinical Ophthalmology, Basel, Switzerland; Department of Ophthalmology, University of Basel, Basel, Switzerland
| | - Gerhard Garhöfer
- Department of Clinical Pharmacology, Medical University Vienna, Vienna, Austria
| | - Lucas Janeschitz-Kriegl
- Institute of Molecular and Clinical Ophthalmology, Basel, Switzerland; Department of Ophthalmology, University of Basel, Basel, Switzerland
| | - Federico Corvi
- Eye Clinic, Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Italy
| | - SriniVas R Sadda
- Doheny Eye Institute, Los Angeles, CA, USA; Department of Ophthalmology, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - Felipe A Medeiros
- Vision, Imaging and Performance Laboratory, Department of Ophthalmology, Duke Eye Center, Duke University, Durham, NC, USA
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Rapid Objective Testing of Visual Function Matched to the ETDRS Grid and Its Diagnostic Power in Age-Related Macular Degeneration. OPHTHALMOLOGY SCIENCE 2022; 2:100143. [PMID: 36249701 PMCID: PMC9559873 DOI: 10.1016/j.xops.2022.100143] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/17/2022] [Accepted: 03/14/2022] [Indexed: 11/21/2022]
Abstract
Purpose To study the power of an 80-second multifocal pupillographic objective perimetry (mfPOP) test tailored to the ETDRS grid to diagnose age-related macular degeneration (AMD) by Age-Related Eye Disease Study (AREDS) severity grade. Design Evaluation of a diagnostic technology. Methods We compared diagnostic power of acuity, ETDRS grid retinal thickness data, new 80-second M18 mfPOP test, and two wider-field 6-minute mfPOP tests (Macular-P131, Widefield-P129). The M18 stimuli match the size and shape of bifurcated ETDRS grid regions, allowing easy structure–function comparisons. M18, P129, and P131 stimuli test both eyes concurrently. We recruited 34 patients with early-stage AMD with a mean ± standard deviation (SD) age of 72.6 ± 7.06 years. The M18 and P129 plus P131 stimuli had 26 and 51 control participants, respectively with mean ± SD ages of 73.1 ± 8.17 years and 72.1 ± 5.83 years, respectively. Multifocal pupillographic objective perimetry testing used the Food and Drug Administration-cleared Objective FIELD Analyzer (OFA; Konan Medical USA). Main Outcome Measures Percentage area under the receiver operator characteristic curve (AUC) and Hedge’s g effect size. Results Acuity and OCT ETDRS grid thickness and volume produced reasonable diagnostic power (percentage AUC) for AREDS grade 4 eyes at 83.9 ± 9.98% and 90.2 ± 6.32% (mean ± standard error), respectively, but not for eyes with less severe disease. By contrast, M18 stimuli produced percentage AUCs from 72.8 ± 6.65% (AREDS grade 2) to 92.9 ± 3.93% (AREDS grade 4), and 82.9 ± 3.71% for all eyes. Hedge’s g effect sizes ranged from 0.84 to 2.32 (large to huge). Percentage AUC for P131 stimuli performed similarly and for P129 performed somewhat less well. Conclusions The rapid and objective M18 test provided diagnostic power comparable with that of wider-field 6-minute mfPOP tests. Unlike acuity or OCT ETDRS grid data, OFA tests produced reasonable diagnostic power in AREDS grade 1 to 3 eyes.
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Madheswaran G, Nasim P, Ballae Ganeshrao S, Raman R, Ve RS. Role of microperimetry in evaluating disease progression in age-related macular degeneration: a scoping review. Int Ophthalmol 2022; 42:1975-1986. [PMID: 34994874 PMCID: PMC9156461 DOI: 10.1007/s10792-021-02170-9] [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: 06/27/2021] [Accepted: 12/18/2021] [Indexed: 12/03/2022]
Abstract
Purpose Recent research has found variable evidence on the role of mesopic and dark-adapted scotopic microperimetry assessment in age-related macular degeneration. This scoping review summarises how mesopic and scotopic microperimetry can be used to assess disease progression in age-related macular degeneration and identifies gaps in the literature. Methods A population, concept, and context approach was used to develop the search strategy. Ovid MEDLINE, EMBASE, Cochrane Library, PubMed, CINAHL Plus, Web of Science, and SCOPUS databases were used to conduct the literature search. The key search terms used in the databases were age-related macular degeneration and microperimetry. Results Twelve studies were eligible and included in the review. All the studies (n = 12) were conducted in European countries [Germany (9), Italy (2), and the United Kingdom (1)]. The mesopic and scotopic sensitivities were measured using the Nidek scotopic microperimeter (MP1-S) (n = 6), scotopic Macular Integrity Assessment device (S-MAIA) (n = 5), and both MP1-s and S MAIA (n = 1). 83.3% (n = 10) studied (cross-sectional design) on mesopic, scotopic microperimetry and found reduced rod (scotopic) photoreceptors sensitivities compared to cone (mesopic) photoreceptors sensitivities in patients with small and reticular pseudodrusen despite having good visual acuity. Only 16.7% (n = 2) of studies followed participants with reticular drusen/large drusen for three years (longitudinal design) and found reduced scotopic over mesopic sensitivity at baseline and localized mesopic with profound scotopic sensitivity loss during follow-ups. Conclusion Scotopic sensitivity is a better functional indicator than mesopic sensitivity to understand early and intermediate age-related macular degeneration progression. The evidence from longitudinal studies is debatable due to the limited stimuli range of existing microperimeters, smaller sample size, and lost follow-ups. Supplementary Information The online version contains supplementary material available at 10.1007/s10792-021-02170-9.
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Affiliation(s)
- Gopinath Madheswaran
- Department of Optometry, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Pinaz Nasim
- Department of Optometry, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shonraj Ballae Ganeshrao
- Department of Optometry, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Rajiv Raman
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamilnadu, India
| | - Ramesh S Ve
- Department of Optometry, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India.
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