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Negi R, Kalivemula M, Bisht K, Bhate M, Sachdeva V, Bharadwaj SR. Diagnostic accuracy of a modularized, virtual-reality-based automated pupillometer for detection of relative afferent pupillary defect in unilateral optic neuropathies. FRONTIERS IN OPHTHALMOLOGY 2024; 4:1396511. [PMID: 39290775 PMCID: PMC11405164 DOI: 10.3389/fopht.2024.1396511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 08/07/2024] [Indexed: 09/19/2024]
Abstract
Purpose To describe the construction and diagnostic accuracy of a modularized, virtual reality (VR)-based, pupillometer for detecting relative afferent pupillary defect (RAPD) in unilateral optic neuropathies, vis-à-vis, clinical grading by experienced neuro-ophthalmologists. Methods Protocols for the swinging flashlight test and pupillary light response analysis used in a previous stand-alone pupillometer was integrated into the hardware of a Pico Neo 2 Eye® VR headset with built-in eye tracker. Each eye of 77 cases (mean ± 1SD age: 39.1 ± 14.9yrs) and 77 age-similar controls were stimulated independently thrice for 1sec at 125lux light intensity, followed by 3sec of darkness. RAPD was quantified as the ratio of the direct reflex of the stronger to the weaker eye. Device performance was evaluated using standard ROC analysis. Results The median (25th - 75th quartiles) pupil constriction of the affected eye of cases was 38% (17 - 23%) smaller than their fellow eye (p<0.001), compared to an interocular difference of +/-6% (3 - 15%) in controls. The sensitivity of RAPD detection was 78.5% for the entire dataset and it improved to 85.1% when the physiological asymmetries in the bilateral pupillary miosis were accounted for. Specificity and the area under ROC curve remained between 81 - 96.3% across all analyses. Conclusions RAPD may be successfully quantified in unilateral neuro-ophthalmic pathology using a VR-technology-based modularized pupillometer. Such an objective estimation of RAPD provides immunity against biases and variability in the clinical grading, overall enhancing its value for clinical decision making.
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Affiliation(s)
- Rahul Negi
- Brien Holden Institute of Optometry and Vision Sciences, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Manasa Kalivemula
- Center for Technology Innovation, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Karan Bisht
- Center for Technology Innovation, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Manjushree Bhate
- Child Sight Institute, L V Prasad Eye Institute, Hyderabad, Telangana, India
| | - Virender Sachdeva
- Nimmagadda Prasad Children's Eye Care Centre, L V Prasad Eye Institute, Visakhapatnam, Andhra Pradesh, India
| | - Shrikant R Bharadwaj
- Brien Holden Institute of Optometry and Vision Sciences, L V Prasad Eye Institute, Hyderabad, Telangana, India
- Prof. Brien Holden Eye Research Centre, Hyderabad Eye Research Foundation, L V Prasad Eye Institute, Hyderabad, Telangana, India
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Glassman AR, Elmasry MA, Baskin DE, Brigell M, Chong V, Davis Q, Lesmes L, Levin LA, Maddess T, Taylor LJ, Wenzel A. Visual Function Measurements in Eyes With Diabetic Retinopathy: An Expert Opinion on Available Measures. OPHTHALMOLOGY SCIENCE 2024; 4:100519. [PMID: 38881606 PMCID: PMC11179417 DOI: 10.1016/j.xops.2024.100519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/18/2024] [Accepted: 03/18/2024] [Indexed: 06/18/2024]
Abstract
Clinical Relevance Visual function impairment from diabetic retinopathy can have a considerable impact on patient's quality of life. Best-corrected visual acuity (BCVA) is most commonly used to assess visual function and guide clinical trials. However, BCVA is affected late in the disease process, is not affected in early disease, and does not capture some of the visual disturbances described by patients with diabetes. The goal of this report is to evaluate the relationship between diabetic retinal disease (DRD) and visual function parameters to determine which if any of them may be used in a future DRD staging system. Methods The visual functions working group was 1 of 6 areas of DRD studied as part of the DRD staging system update, a project of the Mary Tyler Moore Vision Initiative. The working group identified 12 variables of possible interest, 7 of which were judged to have sufficient preliminary data to suggest an association with DR to warrant further review: microperimetry, static automated perimetry, electroretinogram (ERG) oscillatory potentials, flicker ERG, low luminance visual acuity (LLVA), contrast sensitivity (CS), and BCVA. The objective field analyzer (OFA) was added after subsequent in-person workshops. Results Currently, the only visual function test available for immediate use is BCVA; the remaining tests are either promising (within 5 years) or have potential (>5 years) use. Besides BCVA, most visual function tests had a limited role in current clinical care; however, LLVA, CS, flicker ERG, and OFA demonstrated potential for screening and research purposes. Conclusions Although current visual function tests are promising, future prospective studies involving patients with early and more advanced retinopathy are necessary to determine if these tests can be used clinically or as endpoints for clinical studies. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
| | - Mohamed Ashraf Elmasry
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
- Joslin Diabetes Center, Boston, Massachusetts
| | - Darrell E Baskin
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | | | | | - Luis Lesmes
- Adaptive Sensory Technology, San Diego, California
| | - Leonard A Levin
- Departments of Ophthalmology & Visual Sciences and Neurology & Neurosurgery, McGill University, Montreal, Canada
| | - Ted Maddess
- John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Laura J Taylor
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Andreas Wenzel
- Roche Pharma Research & Early Development, F. Hoffmann - La Roche Ltd, Basel, Switzerland
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Zhang Z, Deng C, Paulus YM. Advances in Structural and Functional Retinal Imaging and Biomarkers for Early Detection of Diabetic Retinopathy. Biomedicines 2024; 12:1405. [PMID: 39061979 PMCID: PMC11274328 DOI: 10.3390/biomedicines12071405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/27/2024] [Accepted: 06/10/2024] [Indexed: 07/28/2024] Open
Abstract
Diabetic retinopathy (DR), a vision-threatening microvascular complication of diabetes mellitus (DM), is a leading cause of blindness worldwide that requires early detection and intervention. However, diagnosing DR early remains challenging due to the subtle nature of initial pathological changes. This review explores developments in multimodal imaging and functional tests for early DR detection. Where conventional color fundus photography is limited in the field of view and resolution, advanced quantitative analysis of retinal vessel traits such as retinal microvascular caliber, tortuosity, and fractal dimension (FD) can provide additional prognostic value. Optical coherence tomography (OCT) has also emerged as a reliable structural imaging tool for assessing retinal and choroidal neurodegenerative changes, which show potential as early DR biomarkers. Optical coherence tomography angiography (OCTA) enables the evaluation of vascular perfusion and the contours of the foveal avascular zone (FAZ), providing valuable insights into early retinal and choroidal vascular changes. Functional tests, including multifocal electroretinography (mfERG), visual evoked potential (VEP), multifocal pupillographic objective perimetry (mfPOP), microperimetry, and contrast sensitivity (CS), offer complementary data on early functional deficits in DR. More importantly, combining structural and functional imaging data may facilitate earlier detection of DR and targeted management strategies based on disease progression. Artificial intelligence (AI) techniques show promise for automated lesion detection, risk stratification, and biomarker discovery from various imaging data. Additionally, hematological parameters, such as neutrophil-lymphocyte ratio (NLR) and neutrophil extracellular traps (NETs), may be useful in predicting DR risk and progression. Although current methods can detect early DR, there is still a need for further research and development of reliable, cost-effective methods for large-scale screening and monitoring of individuals with DM.
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Affiliation(s)
- Zhengwei Zhang
- Department of Ophthalmology, Jiangnan University Medical Center, Wuxi 214002, China;
- Department of Ophthalmology, Wuxi No.2 People’s Hospital, Wuxi Clinical College, Nantong University, Wuxi 214002, China
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA;
| | - Callie Deng
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA;
| | - Yannis M. Paulus
- Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, MI 48105, USA;
- Department of Biomedical Engineering, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA
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Lorenceau J, Ajasse S, Barbet R, Boucart M, Chavane F, Lamirel C, Legras R, Matonti F, Rateaux M, Rouland JF, Sahel JA, Trinquet L, Wexler M, Vignal-Clermont C. Method to Quickly Map Multifocal Pupillary Response Fields (mPRF) Using Frequency Tagging. Vision (Basel) 2024; 8:17. [PMID: 38651438 PMCID: PMC11036301 DOI: 10.3390/vision8020017] [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: 01/17/2024] [Accepted: 03/27/2024] [Indexed: 04/25/2024] Open
Abstract
We present a method for mapping multifocal Pupillary Response Fields in a short amount of time using a visual stimulus covering 40° of the visual angle divided into nine contiguous sectors simultaneously modulated in luminance at specific, incommensurate, temporal frequencies. We test this multifocal Pupillary Frequency Tagging (mPFT) approach with young healthy participants (N = 36) and show that the spectral power of the sustained pupillary response elicited by 45 s of fixation of this multipartite stimulus reflects the relative contribution of each sector/frequency to the overall pupillary response. We further analyze the phase lag for each temporal frequency as well as several global features related to pupil state. Test/retest performed on a subset of participants indicates good repeatability. We also investigate the existence of structural (RNFL)/functional (mPFT) relationships. We then summarize the results of clinical studies conducted with mPFT on patients with neuropathies and retinopathies and show that the features derived from pupillary signal analyses, the distribution of spectral power in particular, are homologous to disease characteristics and allow for sorting patients from healthy participants with excellent sensitivity and specificity. This method thus appears as a convenient, objective, and fast tool for assessing the integrity of retino-pupillary circuits as well as idiosyncrasies and permits to objectively assess and follow-up retinopathies or neuropathies in a short amount of time.
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Affiliation(s)
- Jean Lorenceau
- Integrative Neuroscience and Cognition Center, UMR8002, Université Paris Cité, 75006 Paris, France; (R.B.); (M.W.)
| | | | - Raphael Barbet
- Integrative Neuroscience and Cognition Center, UMR8002, Université Paris Cité, 75006 Paris, France; (R.B.); (M.W.)
| | - Muriel Boucart
- CNRS, INSERM UMR-S 1172-Lille Neurosciences & Cognition, 59000 Lille, France;
| | - Frédéric Chavane
- Institut des Neurosciences de la Timone-CNRS UMR 7289, 13005 Marseille, France;
| | - Cédric Lamirel
- Hopital Fondation, Adolphe de Rothschild 29, rue Manin, 75019 Paris, France; (C.L.); (C.V.-C.)
| | - Richard Legras
- LuMIn, CNRS, ENS Paris-Saclay, Centrale Supelec, Université Paris-Saclay, 91192 Orsay, France;
| | - Frédéric Matonti
- Centre Monticelli Paradis d’Ophtalmologie, 13008 Marseille, France;
| | - Maxence Rateaux
- Centre BORELLI, Université Paris Cité, ENS Paris-Saclay, CNRS, INSERM, SSA, 75006 Paris, France;
| | - Jean-François Rouland
- Department of Ophthalmology, Hôpital Claude Huriez, CHRU de Lille, 59037 Lille, France;
| | - José-Alain Sahel
- Department of Ophthalmology, University of Pittsburgh, Pittsburgh, PA 15219, USA;
| | - Laure Trinquet
- Faculté des Sciences Médicales et Paramédicales, Aix-Marseille Université, 13385 Marseille, France;
| | - Mark Wexler
- Integrative Neuroscience and Cognition Center, UMR8002, Université Paris Cité, 75006 Paris, France; (R.B.); (M.W.)
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Sabeti F, van Kleef JP, Iyer RM, Carle CF, Nolan CJ, Chia RH, Maddess T. Discriminating early-stage diabetic retinopathy with subjective and objective perimetry. Front Endocrinol (Lausanne) 2024; 14:1333826. [PMID: 38264290 PMCID: PMC10804944 DOI: 10.3389/fendo.2023.1333826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 12/13/2023] [Indexed: 01/25/2024] Open
Abstract
Introduction To prevent progression of early-stage diabetic retinopathy, we need functional tests that can distinguish multiple levels of neural damage before classical vasculopathy. To that end, we compared multifocal pupillographic objective perimetry (mfPOP), and two types of subjective automated perimetry (SAP), in persons with type 2 diabetes (PwT2D) with either no retinopathy (noDR) or mild to-moderate non-proliferative retinopathy (mmDR). Methods Both eyes were assessed by two mfPOP test methods that present stimuli within either the central ±15° (OFA15) or ±30° (OFA30), each producing per-region sensitivities and response delays. The SAP tests were 24-2 Short Wavelength Automated Perimetry and 24-2 Matrix perimetry. Results Five of eight mfPOP global indices were significantly different between noDR and mmDR eyes, but none of the equivalent measures differed for SAP. Per-region mfPOP identified significant hypersensitivity and longer delays in the peripheral visual field, verifying earlier findings. Diagnostic power for discrimination of noDR vs. mmDR, and normal controls vs. PwT2D, was much higher for mfPOP than SAP. The mfPOP per-region delays provided the best discrimination. The presence of localized rather than global changes in delay ruled out iris neuropathy as a major factor. Discussion mfPOP response delays may provide new surrogate endpoints for studies of interventions for early-stage diabetic eye damage.
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Affiliation(s)
- Faran Sabeti
- Eccles Institute for Neuroscience, The John Curtin School of Medical Research, The Australian National University, Canberra, ACT, Australia
- Discipline of Optometry, Faculty of Health, University of Canberra, Canberra, ACT, Australia
| | - Joshua P. van Kleef
- Eccles Institute for Neuroscience, The John Curtin School of Medical Research, The Australian National University, Canberra, ACT, Australia
| | - Rakesh M. Iyer
- Department of Endocrinology, The Canberra Hospital, Garran, ACT, Australia
| | - Corinne F. Carle
- Eccles Institute for Neuroscience, The John Curtin School of Medical Research, The Australian National University, Canberra, ACT, Australia
| | - Christopher J. Nolan
- Department of Endocrinology, The Canberra Hospital, Garran, ACT, Australia
- School of Medicine and Psychology, The Australian National University, Canberra, ACT, Australia
| | - Rong Hui Chia
- School of Medicine, University of Western Australia, Crawley, WA, Australia
| | - Ted Maddess
- Eccles Institute for Neuroscience, The John Curtin School of Medical Research, The Australian National University, Canberra, ACT, Australia
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Rai BB, van Kleef JP, Sabeti F, Vlieger R, Suominen H, Maddess T. Early diabetic eye damage: Comparing detection methods using diagnostic power. Surv Ophthalmol 2024; 69:24-33. [PMID: 37797701 DOI: 10.1016/j.survophthal.2023.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 08/22/2023] [Accepted: 09/06/2023] [Indexed: 10/07/2023]
Abstract
It is now clear that retinal neuropathy precedes classical microvascular retinopathy in diabetes. Therefore, tests that underpin useful new endpoints must provide high diagnostic power well before the onset of moderate diabetic retinopathy. Hence, we compare detection methods of early diabetic eye damage. We reviewed data from a range of functional and structural studies of early diabetic eye disease and computed standardized effect size as a measure of diagnostic power, allowing the studies to be compared quantitatively. We then derived minimum performance criteria for tests to provide useful clinical endpoints. This included the criteria that tests should be rapid and easy so that children with type 1 diabetes can be followed into adulthood with the same tests. We also defined attributes that lend test data to further improve performance using Machine/Deep Learning. Data from a new form of objective perimetry suggested that the criteria are achievable.
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Affiliation(s)
- Bhim B Rai
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia; ANU Eccles Institute of Neuroscience, Australian National University, Canberra, ACT, Australia.
| | - Joshua P van Kleef
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia; ANU Eccles Institute of Neuroscience, Australian National University, Canberra, ACT, Australia
| | - Faran Sabeti
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia; School of Optometry, Faculty of Health, 2 University of Canberra, Canberra, ACT, Australia
| | - Robin Vlieger
- ANU School of Computing, Australian National University, Canberra, ACT, Australia
| | - Hanna Suominen
- ANU Eccles Institute of Neuroscience, Australian National University, Canberra, ACT, Australia; ANU School of Computing, Australian National University, Canberra, ACT, Australia; University of Turku, Turku, Finland
| | - Ted Maddess
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia; ANU Eccles Institute of Neuroscience, Australian National University, Canberra, ACT, Australia
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