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Huang RS, Mihalache A, Popovic MM, Munn C, Balas M, Issa M, Melo IM, Friedman A, Wright T, Yan P, Muni RH. ASSOCIATION OF INTRAVENOUS FLUORESCEIN ANGIOGRAPHY AND ADAPTIVE OPTICS IMAGING IN DIABETIC RETINOPATHY: A Prospective Case Series. Retina 2024; 44:689-699. [PMID: 38011843 DOI: 10.1097/iae.0000000000004012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
PURPOSE To our knowledge, we present the first case series investigating the relationship between adaptive optics (AO) imaging and intravenous fluorescein angiography (IVFA) parameters in patients with diabetic retinopathy. METHODS Consecutive patients with diabetic retinopathy older than age 18 years presenting to a single center in Toronto, Canada, from 2020 to 2021 were recruited. Adaptive optics was performed with the RTX1 camera (Imagine Eyes, Orsay, France) at retinal eccentricities of 2° and 4°. Intravenous fluorescein angiography was assessed with the artificial intelligence-based RETICAD system to extract blood flow, perfusion, and blood-retinal-barrier (BRB) permeability at the same retinal locations. Correlations between AO and IVFA parameters were calculated using Pearson's correlation coefficient. RESULTS Across nine cases, a significant positive correlation existed between photoreceptor spacing on AO and BRB permeability (r = 0.303, P = 0.027), as well as perfusion (r = 0.272, P = 0.049) on IVFA. When stratified by location, a significant positive correlation between photoreceptor dispersion and both BRB permeability and perfusion (r = 0.770, P = 0.043; r = 0.846, P = 0.034, respectively) was observed. Cone density was also negatively correlated with BRB permeability (r = -0.819, P = 0.046). CONCLUSION Photoreceptor spacing on AO was significantly correlated with BRB permeability and perfusion on IVFA in patients with diabetic retinopathy. Future studies with larger sample sizes are needed to understand the relationship between AO and IVFA parameters in diverse patient populations.
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Affiliation(s)
- Ryan S Huang
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Mihalache
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marko M Popovic
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Colyn Munn
- Emagix Inc, Halifax, Nova Scotia, Canada
- Department of Medical Neuroscience, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael Balas
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mariam Issa
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Isabela Martins Melo
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Alon Friedman
- Emagix Inc, Halifax, Nova Scotia, Canada
- Department of Medical Neuroscience, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Tom Wright
- Kensington Vision and Research Centre, Kensington Eye Institute, Toronto, Ontario, Canada; and
| | - Peng Yan
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
- Kensington Vision and Research Centre, Kensington Eye Institute, Toronto, Ontario, Canada; and
| | - Rajeev H Muni
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
- Department of Ophthalmology, St. Michael's Hospital/Unity Health Toronto, Toronto, Ontario, Canada
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Tomkins-Netzer O, Niederer R, Greenwood J, Fabian ID, Serlin Y, Friedman A, Lightman S. Mechanisms of blood-retinal barrier disruption related to intraocular inflammation and malignancy. Prog Retin Eye Res 2024; 99:101245. [PMID: 38242492 DOI: 10.1016/j.preteyeres.2024.101245] [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: 09/29/2023] [Revised: 01/16/2024] [Accepted: 01/16/2024] [Indexed: 01/21/2024]
Abstract
Blood-retinal barrier (BRB) disruption is a common accompaniment of intermediate, posterior and panuveitis causing leakage into the retina and macular oedema resulting in vision loss. It is much less common in anterior uveitis or in patients with intraocular lymphoma who may have marked signs of intraocular inflammation. New drugs used for chemotherapy (cytarabine, immune checkpoint inhibitors, BRAF inhibitors, EGFR inhibitors, bispecific anti-EGFR inhibitors, MET receptor inhibitors and Bruton tyrosine kinase inhibitors) can also cause different types of uveitis and BRB disruption. As malignant disease itself can cause uveitis, particularly from breast, lung and gastrointestinal tract cancers, it can be clinically difficult to sort out the cause of BRB disruption. Immunosuppression due to malignant disease and/or chemotherapy can lead to infection which can also cause BRB disruption and intraocular infection. In this paper we address the pathophysiology of BRB disruption related to intraocular inflammation and malignancy, methods for estimating the extent and effect of the disruption and examine why some types of intraocular inflammation and malignancy cause BRB disruption and others do not. Understanding this may help sort and manage these patients, as well as devise future therapeutic approaches.
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Affiliation(s)
- Oren Tomkins-Netzer
- Department of Ophthalmology, Lady Davis Carmel Medical Centre, Haifa, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
| | - Rachael Niederer
- Department of Ophthalmology, Te Whatu Ora, Auckland, New Zealand; Department of Ophthalmology, University of Auckland, Auckland, New Zealand
| | - John Greenwood
- Institute of Ophthalmology, University College London, London, UK
| | - Ido Didi Fabian
- The Goldschleger Eye Institute, Sheba Medical Centre, Tel Hashomer, Tel Aviv University, Tel Aviv, Israel
| | - Yonatan Serlin
- Department of Medical Neuroscience and the Brain Repair Centre, Dalhousie University, Faculty of Medicine, Halifax, NS, Canada
| | - Alon Friedman
- Department of Medical Neuroscience and the Brain Repair Centre, Dalhousie University, Faculty of Medicine, Halifax, NS, Canada; Departments of Physiology and Cell Biology, Brain and Cognitive Sciences, Zlotowski Centre for Neuroscience, Ben- Gurion University of the Negev, Beer-Sheva, Israel
| | - Sue Lightman
- Institute of Ophthalmology, University College London, London, UK
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Abbasnejad A, Tomkins-Netzer O, Winter A, Friedman A, Cruess A, Serlin Y, Levy J. A fluorescein angiography-based computer-aided algorithm for assessing the retinal vasculature in diabetic retinopathy. Eye (Lond) 2023; 37:1293-1301. [PMID: 35643792 PMCID: PMC10170131 DOI: 10.1038/s41433-022-02120-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 04/24/2022] [Accepted: 05/20/2022] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To present a fluorescein angiography (FA)‒based computer algorithm for quantifying retinal blood flow, perfusion, and permeability, in patients with diabetic retinopathy (DR). Secondary objectives were to quantitatively assess treatment efficacy following panretinal photocoagulation (PRP) and define thresholds for pathology based on a new retinovascular function (RVF) score for quantifying disease severity. METHODS FA images of 65 subjects (58 patients and 7 healthy volunteers) were included. Dye intensity kinetics were derived using pixel-wise linear regression as a measure of retinal blood flow, perfusion, and permeability. Maps corresponding to each measure were then generated for each subject and segmented further using an ETDRS grid. Non-parametric statistical analyses were performed between all ETDRS subfields. For 16 patients, the effect of PRP was measured using the same parameters, and an amalgam of RVF was used to create an RVF index. For ten post-treatment patients, the change in FA-derived data was compared to the macular thickness measured using optical coherence tomography. RESULTS Compared to healthy controls, patients had significantly lower retinal and regional perfusion and flow, as well as higher retinal permeability (p < 0.05). Moreover, retinal flow was inversely correlated with permeability (R = -0.41; p < 0.0001). PRP significantly reduced retinal permeability (p < 0.05). The earliest marker of DR was reduced retinal blood flow, followed by increased permeability. FA-based RVF index was a more sensitive indicator of treatment efficacy than macular thickness. CONCLUSIONS Our algorithm can be used to quantify retinovascular function, providing an earlier diagnosis and an objective characterisation of disease state, disease progression, and response to treatment.
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Affiliation(s)
- Amir Abbasnejad
- Faculty of Computer Science, Dalhousie University, Halifax, NS, Canada
- Emagix, Inc., Halifax, NS, Canada
| | - Oren Tomkins-Netzer
- Department of Ophthalmology, Faculty of Medicine, Carmel Medical Center, Technion, Haifa, Israel
| | - Aaron Winter
- Department of Ophthalmology, QEII Hospital, Dalhousie University, Halifax, NS, Canada
| | - Alon Friedman
- Emagix, Inc., Halifax, NS, Canada
- Departments of Medical Neuroscience and Pediatrics, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Alan Cruess
- Department of Ophthalmology, QEII Hospital, Dalhousie University, Halifax, NS, Canada
| | - Yonatan Serlin
- Neurology Residency Training Program and Department of Neurology and Neurosurgery, Jewish General Hospital (J.M.), McGill University, Montreal, QC, Canada
| | - Jaime Levy
- Department of Ophthalmology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.
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MacLean MA, Kamintsky L, Leck ED, Friedman A. The potential role of microvascular pathology in the neurological manifestations of coronavirus infection. Fluids Barriers CNS 2020; 17:55. [PMID: 32912226 PMCID: PMC7481544 DOI: 10.1186/s12987-020-00216-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/27/2020] [Indexed: 02/08/2023] Open
Abstract
Human coronaviruses are highly pathogenic viruses that pose a serious threat to human health. Examples include the severe acute respiratory syndrome outbreak of 2003 (SARS-CoV-1), the Middle East Respiratory Syndrome (MERS-CoV) outbreak of 2012, and the current SARS-CoV-2 (COVID-19) pandemic. Herein, we review the neurological manifestations of coronaviruses and discuss the potential pathogenic role of blood-brain barrier dysfunction. We present the hypothesis that pre-existing vascular damage (due to aging, cardiovascular disease, diabetes, hypertension or other conditions) facilitates infiltration of the virus into the central nervous system (CNS), increasing neuro-inflammation and the likelihood of neurological symptoms. We also discuss the role of a neuroinflammatory cytokine profile in both blood-brain barrier dysfunction and macrovascular disease (e.g. ischemic stroke and thromboembolism). Future studies are needed to better understand the involvement of the microvasculature in coronavirus neuropathology, and to test the diagnostic potential of minimally-invasive screening tools (e.g. serum biomarkers, fluorescein retinal angiography and dynamic-contrast MRI).
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Affiliation(s)
- M. A. MacLean
- Division of Neurosurgery, Dalhousie University, Queen Elizabeth II Health Sciences Centre (Halifax Infirmary), 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - L. Kamintsky
- Department of Medical Neuroscience, Faculty of Medicine, Dalhousie University, Room 12 H, 12th Floor, Sir Charles Tupper Building, 5850 College Street, PO Box 15000, Halifax, NS Canada
| | - E. D. Leck
- Division of Neurosurgery, Dalhousie University, Queen Elizabeth II Health Sciences Centre (Halifax Infirmary), 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - A. Friedman
- Department of Medical Neuroscience, Faculty of Medicine, Dalhousie University, Room 12 H, 12th Floor, Sir Charles Tupper Building, 5850 College Street, PO Box 15000, Halifax, NS Canada
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Angiographic evidence of proliferative retinopathy predicts neuropsychiatric morbidity in diabetic patients. Psychoneuroendocrinology 2016; 67:163-70. [PMID: 26907995 DOI: 10.1016/j.psyneuen.2016.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/09/2016] [Accepted: 02/11/2016] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Diabetic retinopathy (DR) is a common vasculopathy categorized as either non-proliferative (NPDR) or proliferative (PDR),characterized by dysfunctional blood-retinal barrier (BRB) and diagnosed using fluorescein angiography (FA). Since the BRB is similar in structure and function to the blood-brain barrier (BBB) and BBB dysfunction plays a key role in the pathogenesis of brain disorders, we hypothesized that PDR, the severe form of DR, is likely to mirror BBB damage and to predict a worse neuropsychiatric outcome. METHODS A retrospective cohort study was conducted among subjects with diabetes (N=2982) with FA-confirmed NPDR (N=2606) or PDR (N=376). Incidence and probability to develop brain pathologies and mortality were investigated in a 10-year follow-up study. We used Kaplan-Meier, Cox and logistic regression analyses to examine association between DR severity and neuropsychiatric morbidity adjusting for confounders. RESULTS Patients with PDR had significantly higher rates of all-cause brain pathologies (P<0.001), specifically stroke (P=0.005), epilepsy (P=0.006) and psychosis (P=0.024), and a shorter time to develop any neuropsychiatric event (P<0.001) or death (P=0.014) compared to NPDR. Cox adjusted hazard ratio for developing all-cause brain impairments was higher for PDR (HR=1.37, 95% CI 1.16-1.61, P<0.001) which was an independent predictor for all-cause brain impairments (OR 1.30, 95% CI 1.04-1.64, P=0.022), epilepsy (OR 2.16, 95% CI 1.05-4.41, P=0.035) and mortality (HR=1.35, 95% CI 1.06-1.70, P=0.014). CONCLUSIONS This is the first study to confirm that angiography-proven microvasculopathy identifies patients at high risk for neuropsychiatric morbidity and mortality.
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Wigg JP, Zhang H, Yang D. A Quantitative and Standardized Method for the Evaluation of Choroidal Neovascularization Using MICRON III Fluorescein Angiograms in Rats. PLoS One 2015; 10:e0128418. [PMID: 26024231 PMCID: PMC4449229 DOI: 10.1371/journal.pone.0128418] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 04/27/2015] [Indexed: 01/18/2023] Open
Abstract
Introduction In-vivo imaging of choroidal neovascularization (CNV) has been increasingly recognized as a valuable tool in the investigation of age-related macular degeneration (AMD) in both clinical and basic research applications. Arguably the most widely utilised model replicating AMD is laser generated CNV by rupture of Bruch’s membrane in rodents. Heretofore CNV evaluation via in-vivo imaging techniques has been hamstrung by a lack of appropriate rodent fundus camera and a non-standardised analysis method. The aim of this study was to establish a simple, quantifiable method of fluorescein fundus angiogram (FFA) image analysis for CNV lesions. Methods Laser was applied to 32 Brown Norway Rats; FFA images were taken using a rodent specific fundus camera (Micron III, Phoenix Laboratories) over 3 weeks and compared to conventional ex-vivo CNV assessment. FFA images acquired with fluorescein administered by intraperitoneal injection and intravenous injection were compared and shown to greatly influence lesion properties. Utilising commonly used software packages, FFA images were assessed for CNV and chorioretinal burns lesion area by manually outlining the maximum border of each lesion and normalising against the optic nerve head. Net fluorescence above background and derived value of area corrected lesion intensity were calculated. Results CNV lesions of rats treated with anti-VEGF antibody were significantly smaller in normalised lesion area (p<0.001) and fluorescent intensity (p<0.001) than the PBS treated control two weeks post laser. The calculated area corrected lesion intensity was significantly smaller (p<0.001) in anti-VEGF treated animals at 2 and 3 weeks post laser. The results obtained using FFA correlated with, and were confirmed by conventional lesion area measurements from isolectin stained choroidal flatmounts, where lesions of anti-VEGF treated rats were significantly smaller at 2 weeks (p = 0.049) and 3 weeks (p<0.001) post laser. Conclusion The presented method of in-vivo FFA quantification of CNV, including acquisition variable corrections, using the Micron III system and common use software establishes a reliable method for detecting and quantifying CNV enabling longitudinal studies and represents an important alternative to conventional CNV quantification methods.
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Affiliation(s)
- Jonathan P. Wigg
- Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
| | - Hong Zhang
- Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
- Eye Hospital, Harbin Medical University, Nangang District, Harbin, Heilongjiang Province, China
- * E-mail:
| | - Dong Yang
- Centre for Eye Research Australia, University of Melbourne, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
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Schoknecht K, Prager O, Vazana U, Kamintsky L, Harhausen D, Zille M, Figge L, Chassidim Y, Schellenberger E, Kovács R, Heinemann U, Friedman A. Monitoring stroke progression: in vivo imaging of cortical perfusion, blood-brain barrier permeability and cellular damage in the rat photothrombosis model. J Cereb Blood Flow Metab 2014; 34:1791-801. [PMID: 25160672 PMCID: PMC4269756 DOI: 10.1038/jcbfm.2014.147] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 07/15/2014] [Accepted: 07/21/2014] [Indexed: 11/09/2022]
Abstract
Focal cerebral ischemia is among the main causes of death and disability worldwide. The ischemic core often progresses, invading the peri-ischemic brain; however, assessing the propensity of the peri-ischemic brain to undergo secondary damage, understanding the underlying mechanisms, and adjusting treatment accordingly remain clinically unmet challenges. A significant hallmark of the peri-ischemic brain is dysfunction of the blood-brain barrier (BBB), yet the role of disturbed vascular permeability in stroke progression is unclear. Here we describe a longitudinal in vivo fluorescence imaging approach for the evaluation of cortical perfusion, BBB dysfunction, free radical formation and cellular injury using the photothrombosis vascular occlusion model in male Sprague Dawley rats. Blood-brain barrier dysfunction propagated within the peri-ischemic brain in the first hours after photothrombosis and was associated with free radical formation and cellular injury. Inhibiting free radical signaling significantly reduced progressive cellular damage after photothrombosis, with no significant effect on blood flow and BBB permeability. Our approach allows a dynamic follow-up of cellular events and their response to therapeutics in the acutely injured cerebral cortex.
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Affiliation(s)
- Karl Schoknecht
- Institute for Neurophysiology, Charité-University Medicine Berlin, Berlin, Germany
| | - Ofer Prager
- Departments of Physiology and Cell Biology, Cognitive and Brain Sciences, The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Udi Vazana
- Departments of Physiology and Cell Biology, Cognitive and Brain Sciences, The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Lyn Kamintsky
- Departments of Physiology and Cell Biology, Cognitive and Brain Sciences, The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Denise Harhausen
- Department of Experimental Neurology, Center for Stroke Research Berlin (CSB), Charité-University Medicine Berlin, Berlin, Germany
| | - Marietta Zille
- Department of Experimental Neurology, Center for Stroke Research Berlin (CSB), Charité-University Medicine Berlin, Berlin, Germany
| | - Lena Figge
- Department of Radiology, Charité-University Medicine Berlin, Berlin, Germany
| | - Yoash Chassidim
- Departments of Physiology and Cell Biology, Cognitive and Brain Sciences, The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eyk Schellenberger
- Department of Radiology, Charité-University Medicine Berlin, Berlin, Germany
| | - Richard Kovács
- Institute for Neurophysiology, Charité-University Medicine Berlin, Berlin, Germany
| | - Uwe Heinemann
- Institute for Neurophysiology, Charité-University Medicine Berlin, Berlin, Germany
| | - Alon Friedman
- 1] Departments of Physiology and Cell Biology, Cognitive and Brain Sciences, The Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel [2] Department of Medical Neuroscience, Faculty of Medicine, Dalhousie University, Halifax, Canada
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