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Ponirakis G, Al-Janahi I, Elgassim E, Homssi M, Petropoulos IN, Gad H, Khan A, Zaghloul HB, Ali H, Siddique MA, Mohamed FFS, Ahmed LHM, Dakroury Y, El Shewehy AMM, Saeid R, Mahjoub F, Al-Thani SN, Ahmed F, Hussein R, Mahmoud S, Hadid NH, Al Obaidan A, Salivon I, Mahfoud ZR, Zirie MA, Al-Ansari Y, Atkin SL, Malik RA. Sustained corneal nerve loss predicts the development of diabetic neuropathy in type 2 diabetes. Front Neurosci 2024; 18:1393105. [PMID: 39015377 PMCID: PMC11249546 DOI: 10.3389/fnins.2024.1393105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/05/2024] [Indexed: 07/18/2024] Open
Abstract
Introduction This study was undertaken to investigate whether sustained rather than a single measure of corneal nerve loss was associated with the onset of diabetic peripheral neuropathy (DPN) and the progression of neuropathic symptoms and deficits in individuals with type 2 diabetes (T2D). Methods Participants underwent clinical, metabolic testing and assessment of neuropathic symptoms, vibration perception threshold (VPT), sudomotor function, and corneal confocal microscopy (CCM) at baseline, 1, 2, and 4-7 years. Sustained corneal nerve loss was defined as abnormal corneal nerve fiber density (CNFD, <24 fibers/mm2), corneal nerve branch density (CNBD, <21 branches/mm2), and corneal nerve fiber length (CNFL, <16 mm/mm2) persisting for ≥50% of the study duration. Results A total of 107 participants with a mean duration of T2D of 13.3 ± 7.3 years, aged 54.8 ± 8.5 years, underwent baseline and follow-up assessments over a median duration of 4 years, ranging from 1 to 7 years. The DPN prevalence at baseline was 18/107 (16.8%), and of the 89 participants without DPN at baseline, 13 (14.6%) developed DPN during follow-up. Approximately half of the cohort had sustained corneal nerve damage, and corneal nerve measures were significantly lower in this group than those without sustained damage (p < 0.0001). Sustained corneal nerve damage was associated with the development of DPN (p < 0.0001), a progressive loss of vibration perception (p ≤ 0.05), an increased incidence of burning pain, numbness, or a combination of both (p = 0.01-0.001), and a borderline association with progressive sudomotor dysfunction (p = 0.07). Sustained abnormal CNFL effectively distinguished between participants who developed DPN and those who did not (AUC: 76.3, 95% CI: 65.9-86.8%, p < 0.0001), while baseline and other sustained measures did not predict DPN onset. Conclusion Sustained abnormal CCM is associated with more severe corneal nerve damage, DPN development, and the progression of neuropathic symptoms and deficits. Regular CCM monitoring may enable the identification of those at greater risk of developing and worsening DPN who may benefit from more aggressive risk factor reduction.
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Affiliation(s)
- Georgios Ponirakis
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Ibrahim Al-Janahi
- National Diabetes Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Einas Elgassim
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Moayad Homssi
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | | | - Hoda Gad
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Adnan Khan
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Hadeel B. Zaghloul
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Hamda Ali
- National Diabetes Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mashhood A. Siddique
- National Diabetes Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Fatima F. S. Mohamed
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Lina H. M. Ahmed
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Youssra Dakroury
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | | | - Ruba Saeid
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Fadwa Mahjoub
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Shaikha N. Al-Thani
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Farheen Ahmed
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Rawan Hussein
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Salah Mahmoud
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Nebras H. Hadid
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Aisha Al Obaidan
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Iuliia Salivon
- National Diabetes Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Ziyad R. Mahfoud
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Mahmoud A. Zirie
- National Diabetes Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Yousuf Al-Ansari
- National Diabetes Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | - Rayaz A. Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom
- Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom
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Banerjee M, Mukhopadhyay P, Ghosh S, Basu M, Pandit A, Malik R, Ghosh S. Corneal Confocal Microscopy Abnormalities in Children and Adolescents With Type 1 Diabetes. Endocr Pract 2023; 29:692-698. [PMID: 37343765 DOI: 10.1016/j.eprac.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 06/09/2023] [Accepted: 06/13/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVE Utility of corneal confocal microscopy (CCM) in children and adolescents with type 1 diabetes mellitus (T1DM) without neuropathic symptoms or signs and minimal abnormality in large and small nerve fiber function tests remains largely undetermined. This study aimed to evaluate the performance of CCM in comparison to thermal detection thresholds (TDT) testing and nerve conduction studies (NCS) for detecting neuropathy in children with T1DM. METHODS A cohort of children and adolescents with T1DM (n = 51) and healthy controls (n = 50) underwent evaluation for symptoms and signs of neurological deficits, including warm detection threshold, cold detection threshold, vibration perception threshold, NCS, and CCM. RESULTS Children with T1DM had no or very minimal neuropathic symptoms and deficits based on the Toronto Clinical Neuropathy Score, yet NCS abnormalities were present in 18 (35%), small fiber dysfunction defined by an abnormal TDT was found in 13 (25.5%) and CCM abnormalities were present in 25 (49%). CCM was abnormal in a majority of T1DM children with abnormal TDT (12/13, 92%) and abnormal NCS (16/18, 88%). CCM additionally was able to detect small fiber abnormalities in 13/38 (34%) in T1DM with a normal TDT and in 9/33 (27%) with normal NCS. CONCLUSION CCM was able to detect corneal nerve loss in children with and without abnormalities in TDT and NCS.
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Affiliation(s)
- Mainak Banerjee
- Department of Endocrinology, Senior Resident, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Pradip Mukhopadhyay
- Department of Endocrinology, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Shatabdi Ghosh
- Department of Endocrinology, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Madhurima Basu
- Department of Endocrinology, Institute of Post Graduate Medical Education & Research, Kolkata, India
| | - Alak Pandit
- Department of Neurology, Bangur Institute of Neurology, Kolkata, India
| | - Rayaz Malik
- Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar; Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom
| | - Sujoy Ghosh
- Department of Endocrinology, Institute of Post Graduate Medical Education & Research, Kolkata, India.
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Lim JZM, Burgess J, Ooi C, Ferdousi M, Azmi S, Kalteniece A, Anson M, Cuthbertson DJ, Petropoulos IN, Malik RA, Wilding JPH, Alam U. Corneal Confocal Microscopy Predicts Cardiovascular and Cerebrovascular Events and Demonstrates Greater Peripheral Neuropathy in Patients with Type 1 Diabetes and Foot Ulcers. Diagnostics (Basel) 2023; 13:2793. [PMID: 37685330 PMCID: PMC10486928 DOI: 10.3390/diagnostics13172793] [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: 07/04/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVE In this study, we evaluate small and large nerve fibre pathology in relation to diabetic foot ulceration (DFU) and incident cardiovascular and cerebrovascular events in type 1 diabetes (T1D). METHODS A prospective observational study was conducted on people with T1D without diabetic peripheral neuropathy (DPN) (n = 25), T1D with DPN (n = 28), T1D with DFU (n = 25) and 32 healthy volunteers. ROC analysis of parameters was conducted to diagnose DPN and DFU, and multivariate Cox regression analysis was performed to evaluate the predictive ability of corneal nerves for cardiac and cerebrovascular events over 3 years. RESULTS Corneal nerve fibre length (CNFL), fibre density (CNFD) and branch density (CNBD) were lower in T1D-DPN and T1D-DFU vs. T1D (all p < 0.001). In ROC analysis, CNFD (sensitivity 88%, specificity 87%; AUC 0.93; p < 0.001; optimal cut-off 7.35 no/mm2) and CNFL (sensitivity 76%, specificity 77%; AUC 0.90; p < 0.001; optimal cut-off 7.01 mm/mm2) had good ability to differentiate T1D with and without DFU. Incident cardiovascular events (p < 0.001) and cerebrovascular events (p < 0.001) were significantly higher in T1D-DPN and T1D-DFU. Corneal nerve loss, specifically CNFD predicted incident cardiovascular (HR 1.67, 95% CI 1.12 to 2.50, p = 0.01) and cerebrovascular (HR 1.55, 95% CI 1.06 to 2.26, p = 0.02) events. CONCLUSIONS Our study provides threshold values for corneal nerve fibre metrics for neuropathic foot at risk of DFU and further demonstrates that lower CNFD predicts incident cardiovascular and cerebrovascular events in T1D.
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Affiliation(s)
- Jonathan Z M Lim
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L69 3BX, UK
- Diabetes, Endocrinology, and Metabolism Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK
- Department of Medicine, Clinical Sciences Centre, Aintree University Hospital, Longmoor Lane, Liverpool L9 7AL, UK
| | - Jamie Burgess
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L69 3BX, UK
- Department of Medicine, Clinical Sciences Centre, Aintree University Hospital, Longmoor Lane, Liverpool L9 7AL, UK
| | - Cheong Ooi
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L69 3BX, UK
- Department of Medicine, Clinical Sciences Centre, Aintree University Hospital, Longmoor Lane, Liverpool L9 7AL, UK
| | - Maryam Ferdousi
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester M13 9WL, UK
| | - Shazli Azmi
- Diabetes, Endocrinology, and Metabolism Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester M13 9WL, UK
| | - Alise Kalteniece
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester M13 9WL, UK
| | - Matthew Anson
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L69 3BX, UK
- Department of Medicine, Clinical Sciences Centre, Aintree University Hospital, Longmoor Lane, Liverpool L9 7AL, UK
| | - Daniel J Cuthbertson
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L69 3BX, UK
- Department of Medicine, Clinical Sciences Centre, Aintree University Hospital, Longmoor Lane, Liverpool L9 7AL, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool University NHS Foundation Trust, Liverpool L69 3BX, UK
| | | | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha P.O. Box 24144, Qatar
| | - John P H Wilding
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L69 3BX, UK
- Department of Medicine, Clinical Sciences Centre, Aintree University Hospital, Longmoor Lane, Liverpool L9 7AL, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool University NHS Foundation Trust, Liverpool L69 3BX, UK
| | - Uazman Alam
- Department of Cardiovascular & Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L69 3BX, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool University NHS Foundation Trust, Liverpool L69 3BX, UK
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke-on-Trent ST4 2DF, UK
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Qi Y, Cui L, Zhang L, Yan C, Jiang Y, Ye S, Ji L, Qiu Y, Zhang L. Effect of repeated intravitreal anti-vascular endothelial growth factor drugs on corneal nerves. Medicine (Baltimore) 2023; 102:e34210. [PMID: 37478270 PMCID: PMC10662821 DOI: 10.1097/md.0000000000034210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 06/14/2023] [Indexed: 07/23/2023] Open
Abstract
To investigate the potential effect of repeated intravitreal injection of anti-vascular endothelial growth factor (anti-VEGF) drugs on corneal nerves. A total of 64 patients were treated with intravitreal injection of anti-VEGF drugs. There were 19 cases of neovascular age-related macular degeneration (AMD), 20 cases of diabetic macular edema (DME) and 25 cases of retinal vein occlusion (RVO). Twenty-nine cases were treated with aflibercept (2 mg/0.05 mL) whereas 35 cases were managed with ranibizumab (0.5 mg/0.05 mL). A corneal confocal microscope was used to collect images of corneal subbasal nerve plexus, and Image J was used for image analysis. The changes in corneal nerve were compared between 1 month after each injection and before injection. There were no significant differences in the density and length of corneal nerve at specific time after the surgery in comparison with baseline in patients who were given 3 intravitreal injections. There was no significant correlation between the numbers of injections and the changes of the corneal nerves. After 3rd injection, the nerve length of the DME group was markedly lower than that of AMD and RVO groups, the difference was statistically significant (P < .05). The nerve density of the DME group was not significantly different from that of AMD and RVO groups, whereas the nerve length and nerve density of the AMD and RVO groups were not statistically significant between each other also. The corneal nerve length after the 2nd and 3rd injections of Aflibercept were lower than that before surgery, the difference was statistically significant. There were no significant differences in nerve density and nerve length at each time point after Ranibizumab injection. The length and density of the corneal nerve after multiple injections in contralateral eye displayed no significant changes compared with the baseline. Repeated intravitreal anti-VEGF drug can reduce the length of corneal nerves. For patients who need repeated intravitreal injections of anti-VEGF drugs, especially in DM, attention should be paid on the changes affecting the corneal nerves. It is also needed to strengthen the local anti-inflammatory therapy to avoid infection and to use artificial tears to protect the microenvironment of the ocular surface after the surgery.
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Affiliation(s)
- Yuanyuan Qi
- Department of Ophthalmology, the Third People’s Hospital Affiliated to Dalian Medical University, Dalian, China
- Key Laboratory of Corneal and Ocular Surface Diseases Research of Liaoning Province, Dalian, China
- Dalian Medical University, Dalian, China
| | - Lin Cui
- Department of Ophthalmology, the Third People’s Hospital Affiliated to Dalian Medical University, Dalian, China
- Key Laboratory of Corneal and Ocular Surface Diseases Research of Liaoning Province, Dalian, China
| | - Li Zhang
- Department of Ophthalmology, the Third People’s Hospital Affiliated to Dalian Medical University, Dalian, China
- Key Laboratory of Corneal and Ocular Surface Diseases Research of Liaoning Province, Dalian, China
| | - Chunxiao Yan
- Department of Ophthalmology, the Third People’s Hospital Affiliated to Dalian Medical University, Dalian, China
- Key Laboratory of Corneal and Ocular Surface Diseases Research of Liaoning Province, Dalian, China
| | - Yao Jiang
- Department of Ophthalmology, the Third People’s Hospital Affiliated to Dalian Medical University, Dalian, China
- Key Laboratory of Corneal and Ocular Surface Diseases Research of Liaoning Province, Dalian, China
| | - Shuang Ye
- Department of Ophthalmology, the Third People’s Hospital Affiliated to Dalian Medical University, Dalian, China
- Key Laboratory of Corneal and Ocular Surface Diseases Research of Liaoning Province, Dalian, China
| | - Lili Ji
- Department of Ophthalmology, the Third People’s Hospital Affiliated to Dalian Medical University, Dalian, China
- Key Laboratory of Corneal and Ocular Surface Diseases Research of Liaoning Province, Dalian, China
| | - Yuanyuan Qiu
- Department of Ophthalmology, the Third People’s Hospital Affiliated to Dalian Medical University, Dalian, China
- Key Laboratory of Corneal and Ocular Surface Diseases Research of Liaoning Province, Dalian, China
| | - Lijun Zhang
- Department of Ophthalmology, the Third People’s Hospital Affiliated to Dalian Medical University, Dalian, China
- Key Laboratory of Corneal and Ocular Surface Diseases Research of Liaoning Province, Dalian, China
- Dalian Medical University, Dalian, China
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Guldiken YC, Malik A, Petropoulos IN, Gad H, Elgassim E, Salivon I, Ponirakis G, Alam U, Malik RA. Where Art Thou O treatment for diabetic neuropathy: the sequel. Expert Rev Neurother 2023; 23:845-851. [PMID: 37602687 DOI: 10.1080/14737175.2023.2247163] [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: 06/27/2023] [Accepted: 08/08/2023] [Indexed: 08/22/2023]
Abstract
INTRODUCTION Having lived through a pandemic and witnessed how regulatory approval processes can evolve rapidly; it is lamentable how we continue to rely on symptoms/signs and nerve conduction as primary endpoints for clinical trials in DPN. AREAS COVERED Small (Aδ and C) fibers are key to the genesis of pain, regulate skin blood flow, and play an integral role in the development of diabetic foot ulceration but continue to be ignored. This article challenges the rationale for the FDA insisting on symptoms/signs and nerve conduction as primary endpoints for clinical trials in DPN. EXPERT OPINION Quantitative sensory testing, intraepidermal nerve fiber density, and especially corneal confocal microscopy remain an after-thought, demoted at best to exploratory secondary endpoints in clinical trials of diabetic neuropathy. If pharma are to be given a fighting chance to secure approval for a new therapy for diabetic neuropathy, the FDA needs to reassess the evidence rather than rely on 'opinion' for the most suitable endpoint(s) in clinical trials of diabetic neuropathy.
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Affiliation(s)
- Yigit Can Guldiken
- Department of Neurology, Kocaeli University Research and Application Hospital, İzmit/Kocaeli, Turkey
| | - Ayesha Malik
- Barts and The London School of Medicine and Dentistry - Medicine, London, UK
| | | | - Hoda Gad
- Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Einas Elgassim
- Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Iuliia Salivon
- Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | | | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Rayaz A Malik
- Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
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Sharma S, Rayman G. Frontiers in diagnostic and therapeutic approaches in diabetic sensorimotor neuropathy (DSPN). Front Endocrinol (Lausanne) 2023; 14:1165505. [PMID: 37274325 PMCID: PMC10234502 DOI: 10.3389/fendo.2023.1165505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/01/2023] [Indexed: 06/06/2023] Open
Abstract
Diabetes sensory polyneuropathy (DSPN) is a significant complication of diabetes affecting up to 50% of patients in their lifetime and approximately 20% of patients suffer from painful diabetes neuropathic pain. DSPN - both painless and painful - leads to considerable morbidity including reduction of quality of life, increased lower limb amputations and is associated with worsening mortality. Significant progress has been made in the understanding of pathogenesis of DSPN and the last decade has seen newer techniques aimed at its earlier diagnosis. The management of painful DSPN remains a challenge despite advances made in the unravelling the pathogenesis of pain and its transmission. This article discusses the heterogenous clinical presentation of DSPN and the need to exclude key differential diagnoses. Furthermore, it reviews in detail the current diagnostic techniques involving both large and small neural fibres, their limitations and advantages and current place in the diagnosis of DSPN. Finally, the management of DSPN including newer pharmacotherapies are also discussed.
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Affiliation(s)
- Sanjeev Sharma
- Department of Diabetes and Endocrinology, Ipswich Hospital, East Suffolk and North East Essex NHS Foundation Trust (ESNEFT), Ipswich, United Kingdom
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Gylfadottir SS, Itani M, Kristensen AG, Nyengaard JR, Sindrup SH, Jensen TS, Finnerup NB, Karlsson P. Assessing Corneal Confocal Microscopy and Other Small Fiber Measures in Diabetic Polyneuropathy. Neurology 2023; 100:e1680-e1690. [PMID: 36750383 PMCID: PMC10115507 DOI: 10.1212/wnl.0000000000206902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/23/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Damage to small nerve fibers is common in diabetic polyneuropathy (DPN), and the diagnosis of DPN relies on subjective symptoms and signs in a combination with objective confirmatory tests, typically electrophysiology or intraepidermal nerve fiber density (IENFD) from skin biopsy. Corneal confocal microscopy (CCM) has been introduced as a tool to detect DPN. However, it is unclear if CCM can reliably be used to diagnose DPN and how the technique compares with other commonly used measures of small fiber damage, such as IENFD, cold detection threshold (CDT), and warm detection threshold (WDT). Therefore, we assessed and compared the use of CCM, IENFD, CDT, and WDT in the diagnosis of DPN in patients with type 2 diabetes. METHODS In this cohort study, the participants underwent detailed neurologic examination, electrophysiology, quantification of IENFD, CCM, and quantitative sensory testing. Definition of DPN was made in accordance with the Toronto criteria for diabetic neuropathy (without relying on IENFD and thermal thresholds). RESULTS A total of 214 patients with at least probable DPN, 63 patients without DPN, and 97 controls without diabetes were included. Patients with DPN had lower CCM measures (corneal nerve fiber length [CNFL], nerve fiber density, and branch density), IENFD, CDT, and WDT compared with patients without DPN (p ≤ 0.001, <0.001, 0.002, p < 0.001, p = 0.003, and <0.005, respectively), whereas there was no difference between controls and patients with diabetes without DPN. All 3 CCM measures showed a very low diagnostic sensitivity with CNFL showing the highest (14.4% [95% CI 9.8-18.4]) and a specificity of 95.7% (88.0-99.1). In comparison, the sensitivity of abnormal CDT and/or WDT was 30.5% (24.4-37.0) with a specificity of 84.9% (74.6-92.2). The sensitivity of abnormal IENFD was highest among all measures with a value of 51.1% (43.7-58.5) and a specificity of 90% (79.5-96.2). CCM measures did not correlate with IENFD, CDT/WDT, or neuropathy severity in the group of patients with DPN. DISCUSSION CCM measures showed the lowest sensitivity compared with other small fiber measures in the diagnosis of DPN. This indicates that CCM is not a sensitive method to detect DPN in recently diagnosed type 2 diabetes. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that CCM measures aid in the detection of DPN in recently diagnosed type 2 diabetics but with a low sensitivity when compared with other small fiber measures.
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Affiliation(s)
- Sandra S Gylfadottir
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark
| | - Mustapha Itani
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark
| | - Alexander G Kristensen
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark
| | - Jens R Nyengaard
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark
| | - Søren Hein Sindrup
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark
| | - Troels S Jensen
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark
| | - Nanna B Finnerup
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark
| | - Pall Karlsson
- From the Department of Clinical Medicine (S.S.G., T.S.J., N.B.F., P.K.), Danish Pain Research Centre, and Core Centre for Molecular Morphology (J.R.N., P.K.), Aarhus University; Departments of Neurology (S.S.G, T.S.J., N.B.F.), Clinical Neurophysiology (A.G.K.), and Pathology (J.R.N.), Aarhus University Hospital; and Department of Neurology (M.I., S.H.S.), Odense University Hospital, Denmark.
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8
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Han R, Tang C, Xu M, Lei Z. A Retinex-based variational model for noise suppression and nonuniform illumination correction in corneal confocal microscopy images. Phys Med Biol 2023; 68. [PMID: 36577141 DOI: 10.1088/1361-6560/acaeef] [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: 09/12/2022] [Accepted: 12/28/2022] [Indexed: 12/29/2022]
Abstract
Objective.Corneal confocal microscopy (CCM) image analysis is a non-invasivein vivoclinical technique that can quantify corneal nerve fiber damage. However, the acquired CCM images are often accompanied by speckle noise and nonuniform illumination, which seriously affects the analysis and diagnosis of the diseases.Approach.In this paper, first we propose a variational Retinex model for the inhomogeneity correction and noise removal of CCM images. In this model, the Beppo Levi space is introduced to constrain the smoothness of the illumination layer for the first time, and the fractional order differential is adopted as the regularization term to constrain reflectance layer. Then, a denoising regularization term is also constructed with Block Matching 3D (BM3D) to suppress noise. Finally, by adjusting the uneven illumination layer, we obtain the final results. Second, an image quality evaluation metric is proposed to evaluate the illumination uniformity of images objectively.Main results.To demonstrate the effectiveness of our method, the proposed method is tested on 628 low-quality CCM images from the CORN-2 dataset. Extensive experiments show the proposed method outperforms the other four related methods in terms of noise removal and uneven illumination suppression.SignificanceThis demonstrates that the proposed method may be helpful for the diagnostics and analysis of eye diseases.
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Affiliation(s)
- Rui Han
- School of Electrical and Information Engineering, Tianjin University, Tianjin 300072, People's Republic of China
| | - Chen Tang
- School of Electrical and Information Engineering, Tianjin University, Tianjin 300072, People's Republic of China
| | - Min Xu
- School of Electrical and Information Engineering, Tianjin University, Tianjin 300072, People's Republic of China
| | - Zhenkun Lei
- State Key Laboratory of Structural Analysis for Industrial Equipment, Dalian University of Technology, Dalian 116024, People's Republic of China
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9
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Omega-3 polyunsaturated fatty acids and corneal nerve health: Current evidence and future directions. Ocul Surf 2023; 27:1-12. [PMID: 36328309 DOI: 10.1016/j.jtos.2022.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 11/07/2022]
Abstract
Corneal nerves play a key role in maintaining ocular surface integrity. Corneal nerve damage, from local or systemic conditions, can lead to ocular discomfort, pain, and, if poorly managed, neurotrophic keratopathy. Omega-3 polyunsaturated fatty acids (PUFAs) are essential dietary components that play a key role in neural development, maintenance, and function. Their potential application in modulating ocular and systemic inflammation has been widely reported. Omega-3 PUFAs and their metabolites also have neuroprotective properties and can confer benefit in neurodegenerative disease. Several preclinical studies have shown that topical administration of omega-3 PUFA-derived lipid mediators promote corneal nerve recovery following corneal surgery. Dietary omega-3 PUFA supplementation can also reduce corneal epithelial nerve loss and promote corneal nerve regeneration in diabetes. Omega-3 PUFAs and their lipid mediators thus show promise as therapeutic approaches to modulate corneal nerve health in ocular and systemic disease. This review discusses the role of dietary omega-3 PUFAs in maintaining ocular surface health and summarizes the possible applications of omega-3 PUFAs in the management of ocular and systemic conditions that cause corneal nerve damage. In examining the current evidence, this review also highlights relatively underexplored applications of omega-3 PUFAs in conferring neuroprotection and addresses their therapeutic potential in mediating corneal nerve regeneration.
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10
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Impact of Chronic Kidney Disease on Corneal Neuroimmune Features in Type 2 Diabetes. J Clin Med 2022; 12:jcm12010016. [PMID: 36614815 PMCID: PMC9820846 DOI: 10.3390/jcm12010016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/02/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Aim: To determine the impact of chronic kidney disease on corneal nerve measures and dendritic cell counts in type 2 diabetes. Methods: In vivo corneal confocal microscopy images were used to estimate corneal nerve parameters and compared in people with type 2 diabetes with chronic kidney disease (T2DM-CKD) (n = 29) and those with type 2 diabetes without chronic kidney disease (T2DM-no CKD) (n = 29), along with 30 healthy controls. Corneal dendritic cell densities were compared between people with T2DM-CKD and those with T2DM-no CKD. The groups were matched for neuropathy status. Results: There was a significant difference in corneal nerve fiber density (p < 0.01) and corneal nerve fiber length (p = 0.04) between T2DM-CKD and T2DM-no CKD groups. The two diabetes groups had reduced corneal nerve parameters compared to healthy controls (all parameters: p < 0.01). Immature central dendritic cell density was significantly higher in the T2DM-CKD group compared to the T2DM-no CKD group ((7.0 (3.8−12.8) and 3.5 (1.4−13.4) cells/mm2, respectively, p < 0.05). Likewise, central mature dendritic cell density was significantly higher in the T2DM-CKD group compared to the T2DM-no CKD group (0.8 (0.4−2.2) and 0.4 (0.6−1.1) cells/mm2, respectively, p = 0.02). Additionally, total central dendritic cell density was increased in the T2DM-CKD group compared to T2DM-no CKD group (10.4 (4.3−16.1) and 3.9 (2.1−21.0) cells/mm2, respectively, p = 0.03). Conclusion: The study showed that central corneal dendritic cell density is increased in T2DM-CKD compared to T2DM-no CKD, with groups matched for peripheral neuropathy severity. This is accompanied by a loss of central corneal nerve fibers. The findings raise the possibility of additional local factors exacerbating central corneal nerve injury in people with diabetic chronic kidney disease.
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11
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Cosmo E, Midena G, Frizziero L, Bruno M, Cecere M, Midena E. Corneal Confocal Microscopy as a Quantitative Imaging Biomarker of Diabetic Peripheral Neuropathy: A Review. J Clin Med 2022; 11:jcm11175130. [PMID: 36079060 PMCID: PMC9457345 DOI: 10.3390/jcm11175130] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Distal symmetric polyneuropathy (DPN), particularly chronic sensorimotor DPN, represents one of the most frequent complications of diabetes, affecting 50% of diabetic patients and causing an enormous financial burden. Whilst diagnostic methods exist to detect and monitor this condition, they have significant limitations, mainly due to their high subjectivity, invasiveness, and non-repeatability. Corneal confocal microscopy (CCM) is an in vivo, non-invasive, and reproducible diagnostic technique for the study of all corneal layers including the sub-basal nerve plexus, which represents part of the peripheral nervous system. We reviewed the current literature on the use of CCM as an instrument in the assessment of diabetic patients, particularly focusing on its role in the study of sub-basal nerve plexus alterations as a marker of DPN. CCM has been demonstrated to be a valid in vivo tool to detect early sub-basal nerve plexus damage in adult and pediatric diabetic patients, correlating with the severity of DPN. Despite its great potential, CCM has still limited application in daily clinical practice, and more efforts still need to be made to allow the dissemination of this technique among doctors taking care of diabetic patients.
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Affiliation(s)
| | | | - Luisa Frizziero
- Department of Neuroscience-Ophthalmology, University of Padova, 35128 Padova, Italy
| | | | | | - Edoardo Midena
- IRCCS—Fondazione Bietti, 00198 Rome, Italy
- Department of Neuroscience-Ophthalmology, University of Padova, 35128 Padova, Italy
- Correspondence: ; Tel.: +39-049-821-2110
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12
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Malik RA. Corneal confocal microscopy meets continuous glucose monitoring: a tale of two technologies. Chin Med J (Engl) 2022; 135:1891-1893. [PMID: 36148585 PMCID: PMC9746738 DOI: 10.1097/cm9.0000000000002254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Indexed: 01/26/2023] Open
Affiliation(s)
- Rayaz A. Malik
- Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha, Qatar
- Institute of Cardiovascular Science, University of Manchester, Manchester, UK
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13
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Ponirakis G, Al-Janahi I, Elgassim E, Gad H, Petropoulos IN, Khan A, Ali H, Siddique MA, Gul W, Ferdousi M, Kalteniece A, Mohamed FF, Ahmed LH, Dakroury Y, El Shewehy AM, Al-Mohamedi A, AlMarri F, Homssi M, Qazi M, Hadid NH, Al-Khayat F, Mahfoud ZR, Azmi S, Alam U, Zirie MA, Al-Ansari Y, Jayyousi A, Rigby AS, Kilpatrick ES, Atkin SL, Malik RA. Progressive loss of corneal nerve fibers is associated with physical inactivity and glucose lowering medication associated with weight gain in type 2 diabetes. J Diabetes Investig 2022; 13:1703-1710. [PMID: 35652859 PMCID: PMC9533053 DOI: 10.1111/jdi.13864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/03/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022] Open
Abstract
Aims/Introduction Limited studies have identified risk factors linked to the progression of diabetic peripheral neuropathy (DPN) in type 2 diabetes. This study examined the association of risk factors with change in neuropathy measures over 2 years. Materials and Methods Participants with type 2 diabetes (n = 78) and controls (n = 26) underwent assessment of clinical and metabolic parameters and neuropathy using corneal confocal microscopy (CCM), vibration perception threshold (VPT), and the DN4 questionnaire at baseline and 2 year follow‐up. Results Participants with type 2 diabetes had a lower corneal nerve fiber density (CNFD), branch density (CNBD), and fiber length (CNFL) (P ≤ 0.0001) and a higher VPT (P ≤ 0.01) compared with controls. Over 2 years, despite a modest reduction in HbA1c (P ≤ 0.001), body weight (P ≤ 0.05), and LDL (P ≤ 0.05) the prevalence of DPN (P = 0.28) and painful DPN (P = 0.21) did not change, but there was a significant further reduction in CNBD (P ≤ 0.0001) and CNFL (P ≤ 0.05). CNFD, CNBD, and CNFL decreased significantly in physically inactive subjects (P < 0.05–0.0001), whilst there was no change in CNFD (P = 0.07) or CNFL (P = 0.85) in physically active subjects. Furthermore, there was no change in CNFD (P = 0.82), CNBD (P = 0.08), or CNFL (P = 0.66) in patients treated with glucose lowering medication associated with weight loss, whilst CNBD (P = 0.001) decreased in patients on glucose lowering medication associated with weight gain. Conclusions In participants with type 2 diabetes, despite a modest improvement in HbA1c, body weight, and LDL there was a progressive loss of corneal nerve fibers; except in those who were physically active or on glucose lowering medication associated with weight loss.
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Affiliation(s)
- Georgios Ponirakis
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Ibrahim Al-Janahi
- National Diabetes Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Einas Elgassim
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Hoda Gad
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | | | - Adnan Khan
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Hamda Ali
- National Diabetes Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mashhood A Siddique
- National Diabetes Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Wajiha Gul
- National Diabetes Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Maryam Ferdousi
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Alise Kalteniece
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Fatima Fs Mohamed
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Lina Hm Ahmed
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Youssra Dakroury
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Abeer Mm El Shewehy
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | | | - Fatema AlMarri
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Moayad Homssi
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Murtaza Qazi
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Nebras H Hadid
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Fatima Al-Khayat
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Ziyad R Mahfoud
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar
| | - Shazli Azmi
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Centre for Diabetes, Endocrinology and Metabolism, Manchester University NHS Foundation Trust, Manchester, UK
| | - Uazman Alam
- Department of Cardiovascular & Metabolic Medicine and the Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, and Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Mahmoud A Zirie
- National Diabetes Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Yousuf Al-Ansari
- National Diabetes Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Amin Jayyousi
- National Diabetes Center, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Alan S Rigby
- Centre for Diabetes, Endocrinology and Metabolism, Manchester University NHS Foundation Trust, Manchester, UK.,Hull York Medical School, University of Hull, Kingston Upon Hull, UK
| | - Eric S Kilpatrick
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Centre for Diabetes, Endocrinology and Metabolism, Manchester University NHS Foundation Trust, Manchester, UK.,Hull York Medical School, University of Hull, Kingston Upon Hull, UK
| | - Stephen L Atkin
- Royal College of Surgeons in Ireland Bahrain, Adliya, Kingdom of Bahrain
| | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Doha, Qatar.,Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.,Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
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14
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Petropoulos IN, Bitirgen G, Ferdousi M, Kalteniece A, Azmi S, D'Onofrio L, Lim SH, Ponirakis G, Khan A, Gad H, Mohammed I, Mohammadi YE, Malik A, Gosal D, Kobylecki C, Silverdale M, Soran H, Alam U, Malik RA. Corneal Confocal Microscopy to Image Small Nerve Fiber Degeneration: Ophthalmology Meets Neurology. FRONTIERS IN PAIN RESEARCH 2022; 2:725363. [PMID: 35295436 PMCID: PMC8915697 DOI: 10.3389/fpain.2021.725363] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 07/26/2021] [Indexed: 12/13/2022] Open
Abstract
Neuropathic pain has multiple etiologies, but a major feature is small fiber dysfunction or damage. Corneal confocal microscopy (CCM) is a rapid non-invasive ophthalmic imaging technique that can image small nerve fibers in the cornea and has been utilized to show small nerve fiber loss in patients with diabetic and other neuropathies. CCM has comparable diagnostic utility to intraepidermal nerve fiber density for diabetic neuropathy, fibromyalgia and amyloid neuropathy and predicts the development of diabetic neuropathy. Moreover, in clinical intervention trials of patients with diabetic and sarcoid neuropathy, corneal nerve regeneration occurs early and precedes an improvement in symptoms and neurophysiology. Corneal nerve fiber loss also occurs and is associated with disease progression in multiple sclerosis, Parkinson's disease and dementia. We conclude that corneal confocal microscopy has good diagnostic and prognostic capability and fulfills the FDA criteria as a surrogate end point for clinical trials in peripheral and central neurodegenerative diseases.
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Affiliation(s)
| | - Gulfidan Bitirgen
- Department of Ophthalmology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Maryam Ferdousi
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Alise Kalteniece
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Shazli Azmi
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom.,Centre for Diabetes, Endocrinology and Metabolism, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Luca D'Onofrio
- Department of Experimental Medicine, Sapienza University, Rome, Italy
| | - Sze Hway Lim
- Department of Neurology, Salford Royal National Health System (NHS) Foundation Trust, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | | | - Adnan Khan
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Hoda Gad
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Ibrahim Mohammed
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | - Ayesha Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - David Gosal
- Department of Neurology, Salford Royal National Health System (NHS) Foundation Trust, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | - Christopher Kobylecki
- Department of Neurology, Salford Royal National Health System (NHS) Foundation Trust, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | - Monty Silverdale
- Department of Neurology, Salford Royal National Health System (NHS) Foundation Trust, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom
| | - Handrean Soran
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine, Clinical Sciences Centre, Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool University Hospital National Health System (NHS) Foundation Trust, Liverpool, United Kingdom
| | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar.,Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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15
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Al-Bazz DY, Nelson AJ, Burgess J, Petropoulos IN, Nizza J, Marshall A, Brown E, Cuthbertson DJ, Marshall AG, Malik RA, Alam U. Is Nerve Electrophysiology a Robust Primary Endpoint in Clinical Trials of Treatments for Diabetic Peripheral Neuropathy? Diagnostics (Basel) 2022; 12:diagnostics12030731. [PMID: 35328284 PMCID: PMC8947384 DOI: 10.3390/diagnostics12030731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 12/10/2022] Open
Abstract
There is currently no FDA-approved disease-modifying therapy for diabetic peripheral neuropathy (DPN). Nerve conduction velocity (NCV) is an established primary endpoint of disease-modifying therapies in DPN and clinical trials have been powered with an assumed decline of 0.5 m/s/year. This paper sought to establish the time-dependent change in NCV associated with a placebo, compared to that observed in the active intervention group. A literature search identified twenty-one double-blind, randomised controlled trials in DPN of ≥1 year duration conducted between 1971 and 2021. We evaluated changes in neurophysiology, with a focus on peroneal motor and sural sensory NCV and amplitude in the placebo and treatment groups. There was significant variability in the change and direction of change (reduction/increase) in NCV in the placebo arm, as well as variability influenced by the anatomical site of neurophysiological measurement within a given clinical trial. A critical re-evaluation of efficacy trials should consider placebo-adjusted effects and present the placebo-subtracted change in NCV rather than assume a universal annual decline of 0.5 m/s/year. Importantly, endpoints such as corneal confocal microscopy (CCM) have demonstrated early nerve repair, whilst symptoms and NCV have not changed, and should thus be considered as a viable alternative.
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Affiliation(s)
- Dalal Y. Al-Bazz
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (A.J.N.); (J.B.); (J.N.); (A.M.); (A.G.M.)
- Correspondence: (D.Y.A.-B.); or (U.A.); Tel.: +44-151-529-5920 (U.A.)
| | - Andrew J. Nelson
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (A.J.N.); (J.B.); (J.N.); (A.M.); (A.G.M.)
| | - Jamie Burgess
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (A.J.N.); (J.B.); (J.N.); (A.M.); (A.G.M.)
| | - Ioannis N. Petropoulos
- Research Division, Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha 24144, Qatar; (I.N.P.); (R.A.M.)
| | - Jael Nizza
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (A.J.N.); (J.B.); (J.N.); (A.M.); (A.G.M.)
| | - Anne Marshall
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (A.J.N.); (J.B.); (J.N.); (A.M.); (A.G.M.)
| | - Emily Brown
- Obesity and Endocrinology Research Group, Institute of Life Course and Medical Sciences, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (E.B.); (D.J.C.)
| | - Daniel J. Cuthbertson
- Obesity and Endocrinology Research Group, Institute of Life Course and Medical Sciences, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (E.B.); (D.J.C.)
| | - Andrew G. Marshall
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (A.J.N.); (J.B.); (J.N.); (A.M.); (A.G.M.)
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester M13 9WL, UK
| | - Rayaz A. Malik
- Research Division, Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha 24144, Qatar; (I.N.P.); (R.A.M.)
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester M13 9WL, UK
| | - Uazman Alam
- Institute of Life Course and Medical Sciences and the Pain Research Institute, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool L9 7AL, UK; (A.J.N.); (J.B.); (J.N.); (A.M.); (A.G.M.)
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester, Manchester M13 9PL, UK
- Correspondence: (D.Y.A.-B.); or (U.A.); Tel.: +44-151-529-5920 (U.A.)
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16
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Khan A, Pasquier J, Ramachandran V, Ponirakis G, Petropoulos IN, Chidiac O, Thomas B, Robay A, Jayyousi A, Al Suwaidi J, Rafii A, Menzies RA, Talal TK, Najafi-Shoushtari SH, Abi Khalil C, Malik RA. Altered Circulating microRNAs in Patients with Diabetic Neuropathy and Corneal Nerve Loss: A Pilot Study. J Clin Med 2022; 11:jcm11061632. [PMID: 35329958 PMCID: PMC8956033 DOI: 10.3390/jcm11061632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 02/09/2022] [Accepted: 02/27/2022] [Indexed: 02/05/2023] Open
Abstract
An alteration in circulating miRNAs may have important diagnostic and therapeutic relevance in diabetic neuropathy. Patients with type 2 diabetes mellitus (T2DM) underwent an assessment of neuropathic symptoms using Douleur Neuropathique 4 (DN4), the vibration perception threshold (VPT) using a Neurothesiometer, sudomotor function using the Sudoscan, corneal nerve morphology using corneal confocal microscopy (CCM) and circulating miRNAs using high-throughput miRNA expression profiling. Patients with T2DM, with (n = 9) and without (n = 7) significant corneal nerve loss were comparable in age, gender, diabetes duration, BMI, HbA1c, eGFR, blood pressure, and lipid profile. The VPT was significantly higher (p < 0.05), and electrochemical skin conductance (p < 0.05), corneal nerve fiber density (p = 0.001), corneal nerve branch density (p = 0.013), and corneal nerve fiber length (p < 0.001) were significantly lower in T2DM patients with corneal nerve loss compared to those without corneal nerve loss. Following a q-PCR-based analysis of total plasma microRNAs, we found that miR-92b-3p (p = 0.008) was significantly downregulated, while miR-22-3p (p = 0.0001) was significantly upregulated in T2DM patients with corneal nerve loss. A network analysis revealed that these miRNAs regulate axonal guidance and neuroinflammation genes. These data support the need for more extensive studies to better understand the role of dysregulated miRNAs’ in diabetic neuropathy.
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Affiliation(s)
- Adnan Khan
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha P.O. Box 24144, Qatar; (A.K.); (G.P.); (I.N.P.)
- Faculty of Health Sciences, Khyber Medical University, Peshawar P.O. Box 25100, Pakistan
| | - Jennifer Pasquier
- Epigenetics Cardiovascular Laboratory, Department of Genetic Medicine, Weill Cornell Medicine-Qatar, Doha P.O. Box 24144, Qatar; (J.P.); (O.C.); (B.T.); (A.R.); (A.R.)
| | - Vimal Ramachandran
- MicroRNA Core Laboratory, Research Division, Weill Cornell Medicine-Qatar, Doha P.O. Box 24144, Qatar; (V.R.); (S.H.N.-S.)
- Department of Cell and Developmental Biology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Georgios Ponirakis
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha P.O. Box 24144, Qatar; (A.K.); (G.P.); (I.N.P.)
| | - Ioannis N. Petropoulos
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha P.O. Box 24144, Qatar; (A.K.); (G.P.); (I.N.P.)
| | - Omar Chidiac
- Epigenetics Cardiovascular Laboratory, Department of Genetic Medicine, Weill Cornell Medicine-Qatar, Doha P.O. Box 24144, Qatar; (J.P.); (O.C.); (B.T.); (A.R.); (A.R.)
| | - Binitha Thomas
- Epigenetics Cardiovascular Laboratory, Department of Genetic Medicine, Weill Cornell Medicine-Qatar, Doha P.O. Box 24144, Qatar; (J.P.); (O.C.); (B.T.); (A.R.); (A.R.)
| | - Amal Robay
- Epigenetics Cardiovascular Laboratory, Department of Genetic Medicine, Weill Cornell Medicine-Qatar, Doha P.O. Box 24144, Qatar; (J.P.); (O.C.); (B.T.); (A.R.); (A.R.)
| | - Amin Jayyousi
- Hamad Medical Corporation, Doha P.O. Box 24144, Qatar; (A.J.); (J.A.S.); (R.A.M.); (T.K.T.)
| | - Jassim Al Suwaidi
- Hamad Medical Corporation, Doha P.O. Box 24144, Qatar; (A.J.); (J.A.S.); (R.A.M.); (T.K.T.)
| | - Arash Rafii
- Epigenetics Cardiovascular Laboratory, Department of Genetic Medicine, Weill Cornell Medicine-Qatar, Doha P.O. Box 24144, Qatar; (J.P.); (O.C.); (B.T.); (A.R.); (A.R.)
| | - Robert A. Menzies
- Hamad Medical Corporation, Doha P.O. Box 24144, Qatar; (A.J.); (J.A.S.); (R.A.M.); (T.K.T.)
| | - Talal K. Talal
- Hamad Medical Corporation, Doha P.O. Box 24144, Qatar; (A.J.); (J.A.S.); (R.A.M.); (T.K.T.)
| | - Seyed Hani Najafi-Shoushtari
- MicroRNA Core Laboratory, Research Division, Weill Cornell Medicine-Qatar, Doha P.O. Box 24144, Qatar; (V.R.); (S.H.N.-S.)
- Department of Cell and Developmental Biology, Weill Cornell Medicine, New York, NY 10065, USA
| | - Charbel Abi Khalil
- Epigenetics Cardiovascular Laboratory, Department of Genetic Medicine, Weill Cornell Medicine-Qatar, Doha P.O. Box 24144, Qatar; (J.P.); (O.C.); (B.T.); (A.R.); (A.R.)
- Joan and Sanford I. Weill Department of Medicine, Weill Cornell Medicine, New York, NY 10065, USA
- Correspondence: (C.A.K.); (R.A.M.); Tel.: +974-4492-8484 (C.A.K.); +974-4492-8256 (R.A.M.)
| | - Rayaz A. Malik
- Department of Medicine, Weill Cornell Medicine-Qatar, Doha P.O. Box 24144, Qatar; (A.K.); (G.P.); (I.N.P.)
- Correspondence: (C.A.K.); (R.A.M.); Tel.: +974-4492-8484 (C.A.K.); +974-4492-8256 (R.A.M.)
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Zhou T, Lee A, Lo ACY, Kwok JSWJ. Diabetic Corneal Neuropathy: Pathogenic Mechanisms and Therapeutic Strategies. Front Pharmacol 2022; 13:816062. [PMID: 35281903 PMCID: PMC8905431 DOI: 10.3389/fphar.2022.816062] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/27/2022] [Indexed: 12/27/2022] Open
Abstract
Diabetes mellitus (DM) is a major global public health problem that can cause complications such as diabetic retinopathy, diabetic neuropathy, and diabetic nephropathy. Besides the reporting of reduction in corneal nerve density and decrease in corneal sensitivity in diabetic patients, there may be a subsequent result in delayed corneal wound healing and increased corneal infections. Despite being a potential cause of blindness, these corneal nerve changes have not gained enough attention. It has been proposed that corneal nerve changes may be an indicator for diabetic neuropathy, which can provide a window for early diagnosis and treatment. In this review, the authors aimed to give an overview of the relationship between corneal nerves and diabetic neuropathy as well as the underlying pathophysiological mechanisms of corneal nerve fiber changes caused by DM for improved prediction and prevention of diabetic neuropathy. In addition, the authors summarized current and novel therapeutic methods for delayed corneal wound healing, nerve protection and regeneration in the diabetic cornea.
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Affiliation(s)
- Ting Zhou
- Department of Ophthalmology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Allie Lee
- Department of Ophthalmology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Amy Cheuk Yin Lo
- Department of Ophthalmology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Jeremy Sze Wai John Kwok
- Department of Ophthalmology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
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18
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Malik RA, Efron N. Corneal Confocal Microscopy and the Nervous System: Introduction to the Special Issue. J Clin Med 2022; 11:jcm11061475. [PMID: 35329801 PMCID: PMC8953792 DOI: 10.3390/jcm11061475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/05/2022] [Indexed: 12/07/2022] Open
Affiliation(s)
- Rayaz A. Malik
- Weill Cornell Medicine-Qatar, Research Division, Qatar Foundation, Education City, Doha 24144, Qatar;
| | - Nathan Efron
- School of Optometry and Vision Science, Queensland University of Technology, Kelvin Grove, QLD 4059, Australia
- Correspondence:
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19
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Abstract
Diabetes polyneuropathy is an important complication of diabetes polyneuropathy, and its notable sequelae of foot ulceration, autonomic dysfunction, and neuropathic pain are associated with significant morbidity and mortality. Despite the major impact on quality of life and health economic costs, it remains underdiagnosed until late in its natural history, and there is lack of any intervention that can reverse its clinical progress. Assessment of small fiber neuropathy (SFN) in diabetes offers an opportunity to detect abnormalities at an early stage so that both interventional studies and preventative measures can be enacted to prevent progression to the devastating complications of foot ulceration and cardiac dysautonomic death. Over the last two decades, significant advances have been made in understanding the pathophysiology of diabetes neuropathy and its assessment. In this review, we discuss limitations of the screening methods recommended in current clinical guidelines which are based on large nerve fiber assessments. Thereafter, we discuss in detail the various methods currently available to assess small fiber structure and function and examine their individual strength and limitations. Finally, we discuss the reasons why despite the considerable body of evidence available, legislators and global experts have yet to incorporate the assessment of SFN as routine clinical surveillance in diabetes management. We hope that these insights will stimulate further discussion and be instrumental in the early adoption of these methods so as to reduce the burden of complications arising due to diabetes polyneuropathy.
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Affiliation(s)
- Sanjeev Sharma
- Diabetes Trails unit, Ipswich Hospital
(ESNEFT), Ipswich, UK
| | - Prashanth Vas
- Department of Diabetes, Kings College
Hospital, London, UK
| | - Gerry Rayman
- Diabetes Trails unit, Ipswich Hospital
(ESNEFT), Ipswich, UK
- Gerry Rayman, MD, Diabetes Trials Unit,
Department of Diabetes & Endocrinology, Ipswich Hospital, ESNEFT, Heath
Road, Ipswich, Suffolk IP4 5RH, UK.
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20
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Newlin Lew K, Arnold T, Cantelmo C, Jacque F, Posada-Quintero H, Luthra P, Chon KH. Diabetes Distal Peripheral Neuropathy: Subtypes and Diagnostic and Screening Technologies. J Diabetes Sci Technol 2022; 16:295-320. [PMID: 34994241 PMCID: PMC8861801 DOI: 10.1177/19322968211035375] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Diabetes distal symmetrical peripheral neuropathy (DSPN) is the most prevalent form of neuropathy in industrialized countries, substantially increasing risk for morbidity and pre-mature mortality. DSPN may manifest with small-fiber disease, large-fiber disease, or a combination of both. This review summarizes: (1) DSPN subtypes (small- and large-fiber disease) with attention to clinical signs and patient symptoms; and (2) technological diagnosis and screening for large- and small-fiber disease with inclusion of a comprehensive literature review of published studies from 2015-present (N = 66). Review findings, informed by the most up-to-date research, advance critical understanding of DSPN large- and small-fiber screening technologies, including those designed for point-of-care use in primary care and endocrinology practices.
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Affiliation(s)
- Kelley Newlin Lew
- School of Nursing, University of
Connecticut (UConn), Storrs, CT, USA
- Kelley Newlin Lew, School of Nursing,
University of Connecticut (UConn), 231 Glenbrook Road, Storrs, CT 06269, USA.
| | - Tracey Arnold
- School of Nursing, University of
Connecticut (UConn), Storrs, CT, USA
| | | | - Francky Jacque
- Hispanic Alliance of Southeastern
Connecticut, New London, CT, USA
| | - Hugo Posada-Quintero
- Biomedical Engineering Department,
University of Connecticut (UConn), Storrs, CT, USA
| | - Pooja Luthra
- Division of Endocrinology and
Metabolism, UConn Health, Farmington, CT, USA
| | - Ki H. Chon
- Biomedical Engineering Department,
University of Connecticut (UConn), Storrs, CT, USA
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21
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Gad H, Petropoulos IN, Khan A, Ponirakis G, MacDonald R, Alam U, Malik RA. Corneal confocal microscopy for the diagnosis of diabetic peripheral neuropathy: A systematic review and meta-analysis. J Diabetes Investig 2022; 13:134-147. [PMID: 34351711 PMCID: PMC8756328 DOI: 10.1111/jdi.13643] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/12/2021] [Accepted: 07/15/2021] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Corneal confocal microscopy (CCM) is a rapid non-invasive ophthalmic imaging technique that identifies corneal nerve fiber damage. Small studies suggest that CCM could be used to assess patients with diabetic peripheral neuropathy (DPN). AIM To undertake a systematic review and meta-analysis assessing the diagnostic utility of CCM for sub-clinical DPN (DPN- ) and established DPN (DPN+ ). DATA SOURCES Databases (PubMed, Embase, Central, ProQuest) were searched for studies using CCM in patients with diabetes up to April 2020. STUDY SELECTION Studies were included if they reported on at least one CCM parameter in patients with diabetes. DATA EXTRACTION Corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), corneal nerve fiber length (CNFL), and inferior whorl length (IWL) were compared between patients with diabetes with and without DPN and controls. Meta-analysis was undertaken using RevMan V.5.3. DATA SYNTHESIS Thirty-eight studies including ~4,000 participants were included in this meta-analysis. There were significant reductions in CNFD, CNBD, CNFL, and IWL in DPN- vs controls (P < 0.00001), DPN+ vs controls (P < 0.00001), and DPN+ vs DPN- (P < 0.00001). CONCLUSION This systematic review and meta-analysis shows that CCM detects small nerve fiber loss in subclinical and clinical DPN and concludes that CCM has good diagnostic utility in DPN.
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Affiliation(s)
- Hoda Gad
- Department of MedicineWeill Cornell Medicine‐QatarDohaQatar
| | | | - Adnan Khan
- Department of MedicineWeill Cornell Medicine‐QatarDohaQatar
| | | | | | - Uazman Alam
- Diabetes and Neuropathy ResearchDepartment of Eye and Vision Sciences and Pain Research InstituteInstitute of Ageing and Chronic DiseaseUniversity of Liverpool and Aintree University Hospital NHS Foundation TrustLiverpoolUK
- Department of Diabetes and EndocrinologyRoyal Liverpool and Broadgreen University NHS Hospital TrustLiverpoolUK
- Division of Endocrinology, Diabetes and GastroenterologyUniversity of ManchesterManchesterUK
| | - Rayaz A Malik
- Department of MedicineWeill Cornell Medicine‐QatarDohaQatar
- Institute of Cardiovascular MedicineUniversity of ManchesterManchesterUK
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22
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Carmichael J, Fadavi H, Ishibashi F, Howard S, Boulton AJM, Shore AC, Tavakoli M. Implementation of corneal confocal microscopy for screening and early detection of diabetic neuropathy in primary care alongside retinopathy screening: Results from a feasibility study. Front Endocrinol (Lausanne) 2022; 13:891575. [PMID: 36313738 PMCID: PMC9597366 DOI: 10.3389/fendo.2022.891575] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 09/12/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Screening for diabetic peripheral neuropathy (DPN) is essential for early detection and timely intervention. Quantitative assessment of small nerve fiber damage is key to the early diagnosis and assessment of its progression. Corneal confocal microscopy (CCM) is a non-invasive, in-vivo diagnostic technique that provides an accurate surrogate biomarker for small-fiber neuropathy. In this novel study for the first time, we introduced CCM to primary care as a screening tool for DPN alongside retinopathy screening to assess the level of neuropathy in this novel cohort. RESEARCH DESIGN AND METHODS 450 consecutive subjects with type 1 or type 2 diabetes attending for annual eye screening in primary care optometry settings underwent assessment with CCM to establish the prevalence of sub-clinical diabetic peripheral neuropathy. Subjects underwent assessment for neurological and ocular symptoms of diabetes and a history of diabetic foot disease, neuropathy and diabetic retinopathy (DR). RESULTS CCM examination was completed successfully in 427 (94.9%) subjects, 22% of whom had neuropathy according to Diabetic Neuropathy Symptom (DNS) score. The prevalence of sub-clinical neuropathy as defined by abnormal corneal nerve fiber length (CNFL) was 12.9%. In the subjects with a short duration of type 2 diabetes, 9.2% had abnormal CNFL. CCM showed significant abnormalities in corneal nerve parameters in this cohort of subjects with reduction of corneal nerve fiber density (CNFD, p<0.001), CNFL (p<0.001) and corneal nerve branch density (CNBD, p<0.001) compared to healthy subjects. In subjects who had no evidence of DR (67% of all subjects), 12.0% had abnormal CNFL. CONCLUSIONS CCM may be a sensitive biomarker for early detection and screening of DPN in primary care alongside retinopathy screening.
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Affiliation(s)
- Josie Carmichael
- Exeter Centre of Excellence for Diabetes Research, National Institute for Health and Care Research (NIHR) Exeter Clinical Research Facility, and Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, Exeter, United Kingdom
| | - Hassan Fadavi
- Peripheral Neuropathy Group, Imperial College, London, United Kingdom
- University of Manchester, Division of Diabetes, Endocrinology & Gastroenterology, University of Manchester, Manchester, United Kingdom
| | - Fukashi Ishibashi
- Internal Medicine, Ishibashi Medical and Diabetes Centre, Hiroshima, Japan
| | - Susan Howard
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC), Manchester, United Kingdom
| | - Andrew J. M. Boulton
- University of Manchester, Division of Diabetes, Endocrinology & Gastroenterology, University of Manchester, Manchester, United Kingdom
| | - Angela C. Shore
- Exeter Centre of Excellence for Diabetes Research, National Institute for Health and Care Research (NIHR) Exeter Clinical Research Facility, and Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, Exeter, United Kingdom
| | - Mitra Tavakoli
- Exeter Centre of Excellence for Diabetes Research, National Institute for Health and Care Research (NIHR) Exeter Clinical Research Facility, and Institute of Biomedical and Clinical Sciences, University of Exeter Medical School, Exeter, United Kingdom
- University of Manchester, Division of Diabetes, Endocrinology & Gastroenterology, University of Manchester, Manchester, United Kingdom
- *Correspondence: Mitra Tavakoli,
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23
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Galosi E, Hu X, Michael N, Nyengaard JR, Truini A, Karlsson P. Redefining distal symmetrical polyneuropathy features in type 1 diabetes: a systematic review. Acta Diabetol 2022; 59:1-19. [PMID: 34213655 PMCID: PMC8758619 DOI: 10.1007/s00592-021-01767-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/21/2021] [Indexed: 12/14/2022]
Abstract
Diabetic neuropathy is among the most frequent complications of both type 1 (T1DM) and type 2 diabetes (T2DM) and commonly manifests as a distal symmetrical polyneuropathy (DSPN). Despite evidence that T1DM- and T2DM-related DSPN are separate entities, most of our knowledge on diabetic DSPN derives from studies focused on type 2 diabetes. This systematic review provides an overview of current evidence on DSPN in T1DM, including its epidemiological, pathophysiological and clinical features, along with principal diagnostic tests findings. This review included 182 clinical and preclinical studies. The results indicate that DSPN is a less frequent complication in T1DM compared with T2DM and that distinctive pathophysiological mechanisms underlie T1DM-related DSPN development, with hyperglycemia as a major determinant. T1DM-related DSPN more frequently manifests with non-painful than painful symptoms, with lower neuropathic pain prevalence compared with T2DM-associated DSPN. The overt clinical picture seems characterized by a higher prevalence of large fiber-related clinical signs (e.g., ankle reflexes reduction and vibration hypoesthesia) and to a lesser extent small fiber damage (e.g., thermal or pinprick hypoesthesia). These findings as a whole suggest that large fibers impairment plays a dominant role in the clinical picture of symptomatic T1DM-related DSPN. Nevertheless, small fiber diagnostic testing shows high diagnostic accuracy in detecting early nerve damage and may be an appropriate diagnostic tool for disease monitoring and screening.
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Affiliation(s)
- Eleonora Galosi
- Department of Human Neuroscience, Sapienza University, Rome, Italy.
| | - Xiaoli Hu
- Core Center for Molecular Morphology, Section for Stereology and Microscopy, Aarhus University, Aarhus, Denmark
| | - Nivatha Michael
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Randel Nyengaard
- Core Center for Molecular Morphology, Section for Stereology and Microscopy, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - Andrea Truini
- Department of Human Neuroscience, Sapienza University, Rome, Italy
| | - Páll Karlsson
- Core Center for Molecular Morphology, Section for Stereology and Microscopy, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Danish Pain Research Center, Aarhus University, Aarhus, Denmark
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24
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Verdugo RJ, Matamala JM, Inui K, Kakigi R, Valls-Solé J, Hansson P, Bernhard Nilsen K, Lombardi R, Lauria G, Petropoulos IN, Malik RA, Treede RD, Baumgärtner U, Jara PA, Campero M. Review of techniques useful for the assessment of sensory small fiber neuropathies: Report from an IFCN expert group. Clin Neurophysiol 2022; 136:13-38. [DOI: 10.1016/j.clinph.2022.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 02/09/2023]
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25
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Petropoulos IN, Fitzgerald KC, Oakley J, Ponirakis G, Khan A, Gad H, George P, Deleu D, Canibano BG, Akhtar N, Shuaib A, Own A, Malik T, Russakoff DB, Mankowski JL, Misra SL, McGhee CNJ, Calabresi P, Saidha S, Kamran S, Malik RA. Corneal confocal microscopy demonstrates axonal loss in different courses of multiple sclerosis. Sci Rep 2021; 11:21688. [PMID: 34737384 PMCID: PMC8568943 DOI: 10.1038/s41598-021-01226-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 10/19/2021] [Indexed: 11/19/2022] Open
Abstract
Axonal loss is the main determinant of disease progression in multiple sclerosis (MS). This study aimed to assess the utility of corneal confocal microscopy (CCM) in detecting corneal axonal loss in different courses of MS. The results were confirmed by two independent segmentation methods. 72 subjects (144 eyes) [(clinically isolated syndrome (n = 9); relapsing–remitting MS (n = 20); secondary-progressive MS (n = 22); and age-matched, healthy controls (n = 21)] underwent CCM and assessment of their disability status. Two independent algorithms (ACCMetrics; and Voxeleron deepNerve) were used to quantify corneal nerve fiber density (CNFD) (ACCMetrics only), corneal nerve fiber length (CNFL) and corneal nerve fractal dimension (CNFrD). Data are expressed as mean ± standard deviation with 95% confidence interval (CI). Compared to controls, patients with MS had significantly lower CNFD (34.76 ± 5.57 vs. 19.85 ± 6.75 fibers/mm2, 95% CI − 18.24 to − 11.59, P < .0001), CNFL [for ACCMetrics: 19.75 ± 2.39 vs. 12.40 ± 3.30 mm/mm2, 95% CI − 8.94 to − 5.77, P < .0001; for deepNerve: 21.98 ± 2.76 vs. 14.40 ± 4.17 mm/mm2, 95% CI − 9.55 to − 5.6, P < .0001] and CNFrD [for ACCMetrics: 1.52 ± 0.02 vs. 1.45 ± 0.04, 95% CI − 0.09 to − 0.05, P < .0001; for deepNerve: 1.29 ± 0.03 vs. 1.19 ± 0.07, 95% − 0.13 to − 0.07, P < .0001]. Corneal nerve parameters were comparably reduced in different courses of MS. There was excellent reproducibility between the algorithms. Significant corneal axonal loss is detected in different courses of MS including patients with clinically isolated syndrome.
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Affiliation(s)
- Ioannis N Petropoulos
- Research Division, Qatar Foundation, Weill Cornell Medicine-Qatar of Cornell University, PO Box 24144, Education City, Doha, Qatar
| | - Kathryn C Fitzgerald
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Georgios Ponirakis
- Research Division, Qatar Foundation, Weill Cornell Medicine-Qatar of Cornell University, PO Box 24144, Education City, Doha, Qatar
| | - Adnan Khan
- Research Division, Qatar Foundation, Weill Cornell Medicine-Qatar of Cornell University, PO Box 24144, Education City, Doha, Qatar
| | - Hoda Gad
- Research Division, Qatar Foundation, Weill Cornell Medicine-Qatar of Cornell University, PO Box 24144, Education City, Doha, Qatar
| | - Pooja George
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar
| | - Dirk Deleu
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar
| | | | - Naveed Akhtar
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar
| | - Ashfaq Shuaib
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar.,Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ahmed Own
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar
| | - Taimur Malik
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Joseph L Mankowski
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Molecular and Comparative Pathobiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stuti L Misra
- Department of Ophthalmology, New Zealand National Eye Centre, University of Auckland, Auckland, New Zealand
| | - Charles N J McGhee
- Department of Ophthalmology, New Zealand National Eye Centre, University of Auckland, Auckland, New Zealand
| | - Peter Calabresi
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shiv Saidha
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Saadat Kamran
- Neuroscience Institute, Hamad General Hospital, Doha, Qatar
| | - Rayaz A Malik
- Research Division, Qatar Foundation, Weill Cornell Medicine-Qatar of Cornell University, PO Box 24144, Education City, Doha, Qatar.
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26
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Schenk MS, Wartak A, Buehler V, Zhao J, Tearney GJ, Birngruber R, Kassumeh S. Advances in Imaging of Subbasal Corneal Nerves With Micro-Optical Coherence Tomography. Transl Vis Sci Technol 2021; 10:22. [PMID: 34779835 PMCID: PMC8606792 DOI: 10.1167/tvst.10.13.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose To investigate the most peripheral corneal nerve plexus using high-resolution micro-optical coherence tomography (µOCT) imaging and to assess µOCT's clinical potential as a screening tool for corneal and systemic diseases. Methods An experimental high-resolution (1.5 × 1.5 × 1 µm) µOCT setup was applied for three-dimensional imaging of the subbasal nerve plexus in nonhuman primates (NHPs) and swine within 3 hours postmortem. Morphologic features of subbasal nerves in µOCT were compared to β3 tubulin-stained fluorescence confocal microscopy (FCM). Parameters such as nerve density, nerve distribution, and imaging repeatability were evaluated, using semiautomatic image analysis in form of a custom corneal surface segmentation algorithm and NeuronJ. Results Swine and NHP corneas showed the species-specific nerve morphology in both imaging modalities. Most fibers showed a linear course, forming a highly parallel pattern, converging in a vortex with overall nerve densities varying between 9.51 and 24.24 mm/mm2. The repeatability of nerve density quantification of the µOCT scans as approximately 88% in multiple image recordings of the same cornea. Conclusions Compared to the current gold standard of FCM, µOCT's larger field of view of currently 1 × 1 mm increases the conclusiveness of density measurements, which, coupled with µOCT's feature of not requiring direct contact, shows promise for future clinical application. The nerve density quantification may be relevant for screening for systemic disease (e.g., peripheral neuropathy). Translational Relevance Technological advances in OCT technology may enable a quick assessment of corneal nerve density, which could be valuable evaluating ophthalmic and systemic peripheral innervation.
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Affiliation(s)
- Merle S Schenk
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Ophthalmology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Andreas Wartak
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Dermatology, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Verena Buehler
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.,Institute of Biomedical Optics, University of Luebeck, Luebeck, Germany
| | - Jie Zhao
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Guillermo J Tearney
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Harvard-MIT Division of Health Sciences and Technology, Cambridge, MA, USA
| | - Reginald Birngruber
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.,Institute of Biomedical Optics, University of Luebeck, Luebeck, Germany
| | - Stefan Kassumeh
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Ophthalmology, Ludwig-Maximilians-University Munich, Munich, Germany
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27
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Alotaibi S, Markoulli M, Ozkan J, Papas E. Bio-chemical markers of chronic, non-infectious disease in the human tear film. Clin Exp Optom 2021; 105:166-176. [PMID: 34592130 DOI: 10.1080/08164622.2021.1974282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
The tear film is a thin, moist layer covering the ocular surface and is laden with proteins, peptides, lipids, mucins, electrolytes and cellular debris which function to maintain the healthy status of the ocular surface. In many cases of ocular or systemic disease, the integrity of this layer is changed and/or the balance of its constituents is disturbed. Since tears are easy and quick to collect and can be stored for long periods, they have the potential to be a valuable source of information relevant to many disease states. The purpose of this review is to collate information on the known biomarkers of systemic disease that have been identified in tears. The range of conditions covered includes diabetes mellitus, diabetic retinopathy, diabetic peripheral neuropathy, multiple sclerosis, Parkinson's disease, Alzheimer's disease, migraine, systemic sclerosis, cystic fibrosis, thyroid disorders and cancer.
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Affiliation(s)
- Sultan Alotaibi
- Department of Optometry & Vision Science, University of New South Wales, Sydney, Australia.,King Saud University, Riyadh, Saudi Arabia
| | - Maria Markoulli
- Department of Optometry & Vision Science, University of New South Wales, Sydney, Australia
| | - Jerome Ozkan
- Department of Optometry & Vision Science, University of New South Wales, Sydney, Australia
| | - Eric Papas
- Department of Optometry & Vision Science, University of New South Wales, Sydney, Australia
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28
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Perkins BA, Lovblom LE, Lewis EJH, Bril V, Ferdousi M, Orszag A, Edwards K, Pritchard N, Russell A, Dehghani C, Pacaud D, Romanchuk K, Mah JK, Jeziorska M, Marshall A, Shtein RM, Pop-Busui R, Lentz SI, Tavakoli M, Boulton AJM, Efron N, Malik RA. Corneal Confocal Microscopy Predicts the Development of Diabetic Neuropathy: A Longitudinal Diagnostic Multinational Consortium Study. Diabetes Care 2021; 44:2107-2114. [PMID: 34210657 PMCID: PMC8740920 DOI: 10.2337/dc21-0476] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/28/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Corneal nerve fiber length (CNFL) has been shown in research studies to identify diabetic peripheral neuropathy (DPN). In this longitudinal diagnostic study, we assessed the ability of CNFL to predict the development of DPN. RESEARCH DESIGN AND METHODS From a multinational cohort of 998 participants with type 1 and type 2 diabetes, we studied the subset of 261 participants who were free of DPN at baseline and completed at least 4 years of follow-up for incident DPN. The predictive validity of CNFL for the development of DPN was determined using time-dependent receiver operating characteristic (ROC) curves. RESULTS A total of 203 participants had type 1 and 58 had type 2 diabetes. Mean follow-up time was 5.8 years (interquartile range 4.2-7.0). New-onset DPN occurred in 60 participants (23%; 4.29 events per 100 person-years). Participants who developed DPN were older and had a higher prevalence of type 2 diabetes, higher BMI, and longer duration of diabetes. The baseline electrophysiology and corneal confocal microscopy parameters were in the normal range but were all significantly lower in participants who developed DPN. The time-dependent area under the ROC curve for CNFL ranged between 0.61 and 0.69 for years 1-5 and was 0.80 at year 6. The optimal diagnostic threshold for a baseline CNFL of 14.1 mm/mm2 was associated with 67% sensitivity, 71% specificity, and a hazard ratio of 2.95 (95% CI 1.70-5.11; P < 0.001) for new-onset DPN. CONCLUSIONS CNFL showed good predictive validity for identifying patients at higher risk of developing DPN ∼6 years in the future.
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Affiliation(s)
- Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada .,Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Leif Erik Lovblom
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Evan J H Lewis
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Vera Bril
- The Ellen and Martin Prosserman Centre for Neuromuscular Diseases, Krembil Neuroscience Centre, Division of Neurology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Andrej Orszag
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Katie Edwards
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Nicola Pritchard
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Anthony Russell
- University of Queensland, Woolloongabba, Queensland, Australia
| | - Cirous Dehghani
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Danièle Pacaud
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Kenneth Romanchuk
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Jean K Mah
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | | | - Andrew Marshall
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | | | | | | | - Mitra Tavakoli
- University of Manchester, Manchester, U.K.,Diabetes and Vascular Research Centre, NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, U.K
| | | | - Nathan Efron
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Rayaz A Malik
- University of Manchester, Manchester, U.K.,Weill Cornell Medicine-Qatar, Doha, Qatar
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29
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Salahouddin T, Petropoulos IN, Ferdousi M, Ponirakis G, Asghar O, Alam U, Kamran S, Mahfoud ZR, Efron N, Malik RA, Qidwai UA. Artificial Intelligence-Based Classification of Diabetic Peripheral Neuropathy From Corneal Confocal Microscopy Images. Diabetes Care 2021; 44:e151-e153. [PMID: 34083322 PMCID: PMC8323170 DOI: 10.2337/dc20-2012] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 04/25/2021] [Indexed: 02/03/2023]
Affiliation(s)
| | | | - Maryam Ferdousi
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, U.K
| | | | - Omar Asghar
- Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, U.K
| | - Uazman Alam
- Pain Research Institute and Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, U.K.,Department of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, U.K.,Liverpool University Hospital NHS Foundation Trust, Liverpool, U.K
| | - Saadat Kamran
- Neuroscience Institute, Hamad Medical Corporation, Doha, Qatar
| | - Ziyad R Mahfoud
- Division of Medical Education, Weill Cornell Medicine, Doha, Qatar.,Division of Epidemiology, Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Nathan Efron
- School of Optometry and Vision Science, Queensland University of Technology, Brisbane, Australia
| | - Rayaz A Malik
- Division of Research, Weill Cornell Medicine, Doha, Qatar .,Faculty of Biology, Medicine and Health, University of Manchester, Cardiovascular Trials Unit, Manchester University NHS Foundation Trust, Manchester, U.K
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30
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Quinn N, Jenkins A, Ryan C, Januszewski A, Peto T, Brazionis L. Imaging the eye and its relevance to diabetes care. J Diabetes Investig 2021; 12:897-908. [PMID: 33190401 PMCID: PMC8169343 DOI: 10.1111/jdi.13462] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/08/2020] [Accepted: 11/10/2020] [Indexed: 11/28/2022] Open
Abstract
Diabetes is a major cause of vision loss globally, yet this devastating complication is largely preventable. Early detection and treatment of diabetic retinopathy necessitates screening. Ocular imaging is widely used clinically, both for the screening and management of diabetic retinopathy. Common eye conditions, such as glaucoma, cataracts and retinal vessel thrombosis, and signs of systemic conditions, such as hypertension, are frequently revealed. As well as imaging by a skilled clinician during an eye examination, non-ophthalmic clinicians, such as general practitioners, endocrinologists, nurses and trained health workers, can also can carry out diabetic eye screening. This process usually comprises local imaging with remote grading, mostly human grading. However, grading incorporating artificial intelligence is emerging. In a clinical research context, retinal vasculature analyses using semi-automated software in many populations have identified associations between retinal vessel geometry, such as vessel caliber, and the risk of diabetic retinopathy and other chronic complications of type 1 and type 2 diabetes. Similarly, evaluation of corneal nerves by corneal confocal microscopy is revealing diabetes-related abnormalities, and associations with and predictive power for other chronic diabetes complications. As yet, the value of retinal vessel geometry and corneal confocal microscopy measures at an individual level is uncertain. In this article, targeting non-ocular clinicians and researchers, we review existent and emerging ocular imaging and grading tools, including artificial intelligence, and their associations between ocular imaging findings and diabetes and its chronic complications.
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Affiliation(s)
- Nicola Quinn
- National Health and Medical Research Council Clinical Trials CenterThe University of SydneySydneyNew South WalesAustralia
- Center for Public HealthQueen’s University BelfastBelfastUK
| | - Alicia Jenkins
- National Health and Medical Research Council Clinical Trials CenterThe University of SydneySydneyNew South WalesAustralia
- Center for Public HealthQueen’s University BelfastBelfastUK
| | - Chris Ryan
- National Health and Medical Research Council Clinical Trials CenterThe University of SydneySydneyNew South WalesAustralia
- Department of MedicineThe University of MelbourneMelbourneVictoriaAustralia
| | - Andrzej Januszewski
- National Health and Medical Research Council Clinical Trials CenterThe University of SydneySydneyNew South WalesAustralia
- Department of MedicineThe University of MelbourneMelbourneVictoriaAustralia
| | - Tunde Peto
- Center for Public HealthQueen’s University BelfastBelfastUK
| | - Laima Brazionis
- National Health and Medical Research Council Clinical Trials CenterThe University of SydneySydneyNew South WalesAustralia
- Department of MedicineThe University of MelbourneMelbourneVictoriaAustralia
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31
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Chao C, Wang R, Jones M, Karson N, Jussel A, Smith J, Richdale K, Harrison W. The Relationship Between Corneal Nerve Density and Hemoglobin A1c in Patients With Prediabetes and Type 2 Diabetes. Invest Ophthalmol Vis Sci 2021; 61:26. [PMID: 33112943 PMCID: PMC7594598 DOI: 10.1167/iovs.61.12.26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Purpose Decreased corneal nerve fiber density and higher corneal epithelial dendritic cells have been reported in established patients with type 2 diabetes; however, alterations in the subbasal nerve plexus in prediabetes with healthy subjects or subjects with diabetes is limited. The study aimed to determine corneal nerve fiber density and morphology and dendritic cell density between healthy subjects and those with prediabetes or type 2 diabetes. Methods Fifty-two subjects (aged 30–70 years) were recruited. Blood samples and body metrics were taken. Subjects were grouped as: healthy controls (hemoglobin A1c [HbA1c] < 5.7%), prediabetes (5.7–6.4%), and type 2 diabetes (> 6.4% or physician diagnosis). Central corneal subbasal nerve plexus was imaged using in vivo confocal microscopy. Corneal nerve fiber density and morphology, including interconnections and tortuosity, and dendritic cell density were assessed. Kruskal-Wallis tests were carried out to compare differences in the examined variables between groups. Spearman correlations were carried out to examine the associations between body metrics with HbA1c and corneal findings. Results Seventeen healthy controls, 20 subjects with prediabetes, and 15 subjects with type 2 diabetes completed this study. Central corneal nerve fiber density was significantly lower in type 2 diabetes compared to prediabetes (P = 0.045) and healthy controls (P = 0.001). No differences were found in central corneal nerve fiber interconnections, tortuosity, or dendritic cell density between groups. There was a significant association between HbA1c and corneal nerve fiber density (rho = −0.45, P = 0.001) and body mass index (BMI; rho = −0.30, P = 0.04). Conclusions Increased HbA1c values are associated with decreased corneal nerve fiber density across the spectrum of type 2 diabetes.
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Affiliation(s)
- Cecilia Chao
- University of Houston, College of Optometry, Houston, Texas, United States.,School of Optometry and Vision Science, University of New South Wales, Sydney, Australia
| | - Rachel Wang
- University of Houston, College of Optometry, Houston, Texas, United States
| | - Morgan Jones
- University of Houston, College of Optometry, Houston, Texas, United States
| | - Nicole Karson
- University of Houston, College of Optometry, Houston, Texas, United States
| | - Allison Jussel
- University of Houston, College of Optometry, Houston, Texas, United States
| | - Jennyffer Smith
- University of Houston, College of Optometry, Houston, Texas, United States
| | - Kathryn Richdale
- University of Houston, College of Optometry, Houston, Texas, United States
| | - Wendy Harrison
- University of Houston, College of Optometry, Houston, Texas, United States
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32
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Gad H, Al-Jarrah B, Saraswathi S, Mohamed S, Kalteniece A, Petropoulos IN, Khan A, Ponirakis G, Singh P, Khodor SA, Elawad M, Almasri W, Hendaus MA, Akobeng AK, Hussain K, Malik RA. Corneal confocal microscopy identifies a reduction in corneal keratocyte density and sub-basal nerves in children with type 1 diabetes mellitus. Br J Ophthalmol 2021; 106:1368-1372. [PMID: 33931390 DOI: 10.1136/bjophthalmol-2021-319057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/10/2021] [Accepted: 04/20/2021] [Indexed: 11/08/2022]
Abstract
PURPOSE To assess whether alterations in stromal keratocyte density are related to loss of corneal nerve fibres in children with type 1 diabetes mellitus (T1DM). METHODS Twenty participants with T1DM and 20 age-matched healthy controls underwent corneal confocal microscopy. Corneal sub-basal nerve morphology and corneal keratocyte density (KD) were quantified. RESULTS Corneal nerve fibre density (CNFD) (p<0.001), corneal nerve branch density (p<0.001), corneal nerve fibre length (CNFL) (p<0.001) and inferior whorl length (IWL) (p<0.001) were lower in children with T1DM compared with healthy controls. Anterior (p<0.03) and mid (p=0.03) stromal KDs were lower with no difference in posterior KD (PKD) in children with T1DM compared with controls. Age, duration of diabetes, height, weight and body mass index did not correlate with anterior (AKD), mid (MKD) or PKD. Inverse correlations were found between glycated haemoglobin and PKD (r=-0.539, p=0.026), bilirubin with MKD (r=-0.540, p=0.025) and PKD (r=-0.531, p=0.028) and 25-hydroxycholecalciferol with MKD (r=-0.583, p=0.018). CNFD, CNFL and IWL did not correlate with AKD, MKD or PKD. CONCLUSION This study demonstrates a reduction in corneal nerves and anterior and mid stromal KD in children with T1DM, but no correlation between corneal nerve and keratocyte cell loss.
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Affiliation(s)
- Hoda Gad
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
| | | | | | - Sara Mohamed
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Alise Kalteniece
- Cardiovascular Medicine, University of Manchester, Manchester, UK
| | | | - Adnan Khan
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
| | | | | | | | | | | | | | | | | | - Rayaz A Malik
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar .,Cardiovascular Medicine, University of Manchester, Manchester, UK
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33
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Fleischer M, Lee I, Erdlenbruch F, Hinrichs L, Petropoulos IN, Malik RA, Hartung HP, Kieseier BC, Kleinschnitz C, Stettner M. Corneal confocal microscopy differentiates inflammatory from diabetic neuropathy. J Neuroinflammation 2021; 18:89. [PMID: 33832507 PMCID: PMC8033689 DOI: 10.1186/s12974-021-02130-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 03/15/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Immune-mediated neuropathies, such as chronic inflammatory demyelinating polyneuropathy (CIDP) are treatable neuropathies. Among individuals with diabetic neuropathy, it remains a challenge to identify those individuals who develop CIDP. Corneal confocal microscopy (CCM) has been shown to detect corneal nerve fiber loss and cellular infiltrates in the sub-basal layer of the cornea. The objective of the study was to determine whether CCM can distinguish diabetic neuropathy from CIDP and whether CCM can detect CIDP in persons with coexisting diabetes. METHODS In this multicenter, case-control study, participants with CIDP (n = 55) with (n = 10) and without (n = 45) diabetes; participants with diabetes (n = 58) with (n = 28) and without (n = 30) diabetic neuropathy, and healthy controls (n = 58) underwent CCM. Corneal nerve fiber density (CNFD), corneal nerve fiber length (CNFL), corneal nerve branch density (CNBD), and dendritic and non-dendritic cell density, with or without nerve fiber contact were quantified. RESULTS Dendritic cell density in proximity to corneal nerve fibers was significantly higher in participants with CIDP with and without diabetes compared to participants with diabetic neuropathy and controls. CNFD, CNFL, and CNBD were equally reduced in participants with CIDP, diabetic neuropathy, and CIDP with diabetes. CONCLUSIONS An increase in dendritic cell density identifies persons with CIDP. CCM may, therefore, be useful to differentiate inflammatory from non-inflammatory diabetic neuropathy.
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Affiliation(s)
- Michael Fleischer
- Department of Neurology and Center for Translational and Behavioral Neurosciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Inn Lee
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Friedrich Erdlenbruch
- Department of Neurology and Center for Translational and Behavioral Neurosciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Lena Hinrichs
- Department of Cardiology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Ioannis N Petropoulos
- Institute of Cardiovascular Science, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK.,Weill Cornell Medicine-Qatar, Educator City, Doha, Qatar
| | - Rayaz A Malik
- Institute of Cardiovascular Science, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK.,Weill Cornell Medicine-Qatar, Educator City, Doha, Qatar
| | - Hans-Peter Hartung
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany.,Brain and Mind Centre, University of Sydney, Sydney, Australia.,Medical University Vienna, Vienna, Austria.,Department of Neurology, Palacky University, Olomouc, Czech Republic
| | - Bernd C Kieseier
- Department of Neurology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Christoph Kleinschnitz
- Department of Neurology and Center for Translational and Behavioral Neurosciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Mark Stettner
- Department of Neurology and Center for Translational and Behavioral Neurosciences (C-TNBS), University Hospital Essen, University Duisburg-Essen, Essen, Germany.
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Early Detection of Diabetic Peripheral Neuropathy: A Focus on Small Nerve Fibres. Diagnostics (Basel) 2021; 11:diagnostics11020165. [PMID: 33498918 PMCID: PMC7911433 DOI: 10.3390/diagnostics11020165] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/14/2021] [Accepted: 01/20/2021] [Indexed: 02/07/2023] Open
Abstract
Diabetic peripheral neuropathy (DPN) is the most common complication of both type 1 and 2 diabetes. As a result, neuropathic pain, diabetic foot ulcers and lower-limb amputations impact drastically on quality of life, contributing to the individual, societal, financial and healthcare burden of diabetes. DPN is diagnosed at a late, often pre-ulcerative stage due to a lack of early systematic screening and the endorsement of monofilament testing which identifies advanced neuropathy only. Compared to the success of the diabetic eye and kidney screening programmes there is clearly an unmet need for an objective reliable biomarker for the detection of early DPN. This article critically appraises research and clinical methods for the diagnosis or screening of early DPN. In brief, functional measures are subjective and are difficult to implement due to technical complexity. Moreover, skin biopsy is invasive, expensive and lacks diagnostic laboratory capacity. Indeed, point-of-care nerve conduction tests are convenient and easy to implement however questions are raised regarding their suitability for use in screening due to the lack of small nerve fibre evaluation. Corneal confocal microscopy (CCM) is a rapid, non-invasive, and reproducible technique to quantify small nerve fibre damage and repair which can be conducted alongside retinopathy screening. CCM identifies early sub-clinical DPN, predicts the development and allows staging of DPN severity. Automated quantification of CCM with AI has enabled enhanced unbiased quantification of small nerve fibres and potentially early diagnosis of DPN. Improved screening tools will prevent and reduce the burden of foot ulceration and amputations with the primary aim of reducing the prevalence of this common microvascular complication.
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35
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Dhage S, Ferdousi M, Adam S, Ho JH, Kalteniece A, Azmi S, Alam U, Ponirakis G, Petropoulos I, Atkinson AJ, Marshall A, Jeziorska M, Soran H, Malik RA. Corneal confocal microscopy identifies small fibre damage and progression of diabetic neuropathy. Sci Rep 2021; 11:1859. [PMID: 33479291 PMCID: PMC7820596 DOI: 10.1038/s41598-021-81302-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 01/05/2021] [Indexed: 01/25/2023] Open
Abstract
Accurately quantifying the progression of diabetic peripheral neuropathy is key to identify individuals who will progress to foot ulceration and to power clinical intervention trials. We have undertaken detailed neuropathy phenotyping to assess the longitudinal utility of different measures of neuropathy in patients with diabetes. Nineteen patients with diabetes (age 52.5 ± 14.7 years, duration of diabetes 26.0 ± 13.8 years) and 19 healthy controls underwent assessment of symptoms and signs of neuropathy, quantitative sensory testing, autonomic nerve function, neurophysiology, intra-epidermal nerve fibre density (IENFD) and corneal confocal microscopy (CCM) to quantify corneal nerve fibre density (CNFD), branch density (CNBD) and fibre length (CNFL). Mean follow-up was 6.5 years. Glycated haemoglobin (p = 0.04), low-density lipoprotein-cholesterol (LDL-C) (p = 0.0009) and urinary albumin creatinine ratio (p < 0.0001) improved. Neuropathy symptom profile (p = 0.03), neuropathy disability score (p = 0.04), vibration perception threshold (p = 0.02), cold perception threshold (p = 0.006), CNFD (p = 0.03), CNBD (p < 0.0001), CNFL (p < 0.0001), IENFD (p = 0.04), sural (p = 0.02) and peroneal motor nerve conduction velocity (p = 0.03) deteriorated significantly. Change (∆) in CNFL correlated with ∆CPT (p = 0.006) and ∆Expiration/Inspiration ratio (p = 0.002) and ∆IENFD correlated with ∆CNFD (p = 0.005), ∆CNBD (p = 0.02) and ∆CNFL (p = 0.01). This study shows worsening of diabetic neuropathy across a range of neuropathy measures, especially CCM, despite an improvement in HbA1c and LDL-C. It further supports the utility of CCM as a rapid, non-invasive surrogate measure of diabetic neuropathy.
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Affiliation(s)
- Shaishav Dhage
- Department of Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Cardiovascular Research Group, University of Manchester, Manchester, UK
- The Christie NHS Foundation Trust, Manchester, UK
| | - Maryam Ferdousi
- Cardiovascular Research Group, University of Manchester, Manchester, UK
| | - Safwaan Adam
- Department of Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Cardiovascular Research Group, University of Manchester, Manchester, UK
- The Christie NHS Foundation Trust, Manchester, UK
| | - Jan Hoong Ho
- Department of Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Cardiovascular Research Group, University of Manchester, Manchester, UK
- The Christie NHS Foundation Trust, Manchester, UK
| | - Alise Kalteniece
- Cardiovascular Research Group, University of Manchester, Manchester, UK
| | - Shazli Azmi
- Department of Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Cardiovascular Research Group, University of Manchester, Manchester, UK
| | - Uazman Alam
- Institute of Cardiovascular and Metabolic Medicine and The Pain Research Institute, University of Liverpool & Liverpool University NHS Hospital Trust, Liverpool, UK
| | - Georgios Ponirakis
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Ioannis Petropoulos
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Andrew J Atkinson
- Cardiovascular Research Group, University of Manchester, Manchester, UK
| | - Andrew Marshall
- Institute of Life Course and Medical Sciences and The Pain Research Institute, University of Liverpool & Liverpool University NHS Hospital Trust, Liverpool, UK
| | - Maria Jeziorska
- Cardiovascular Research Group, University of Manchester, Manchester, UK
| | - Handrean Soran
- Department of Medicine, Manchester University NHS Foundation Trust, Manchester, UK
- Cardiovascular Research Group, University of Manchester, Manchester, UK
| | - Rayaz A Malik
- Department of Medicine, Manchester University NHS Foundation Trust, Manchester, UK.
- Cardiovascular Research Group, University of Manchester, Manchester, UK.
- Department of Medicine, Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha, Qatar.
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36
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Liu YC, Lin MTY, Mehta JS. Analysis of corneal nerve plexus in corneal confocal microscopy images. Neural Regen Res 2021; 16:690-691. [PMID: 33063728 PMCID: PMC8067927 DOI: 10.4103/1673-5374.289435] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Yu-Chi Liu
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute; Department of Cornea and External Eye Disease, Singapore National Eye Centre; Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
| | - Molly Tzu-Yu Lin
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute, Singapore
| | - Jodhbir S Mehta
- Tissue Engineering and Cell Therapy Group, Singapore Eye Research Institute; Department of Cornea and External Eye Disease, Singapore National Eye Centre; Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
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37
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Ferdousi M, Kalteniece A, Azmi S, Petropoulos IN, Ponirakis G, Alam U, Asghar O, Marshall A, Fullwood C, Jeziorska M, Abbott C, Lauria G, Faber CG, Soran H, Efron N, Boulton AJM, Malik RA. Diagnosis of Neuropathy and Risk Factors for Corneal Nerve Loss in Type 1 and Type 2 Diabetes: A Corneal Confocal Microscopy Study. Diabetes Care 2021; 44:150-156. [PMID: 33144353 PMCID: PMC7783929 DOI: 10.2337/dc20-1482] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/23/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the diagnostic utility of corneal confocal microscopy (CCM) for diabetic peripheral neuropathy (DPN) and the risk factors for corneal nerve loss. RESEARCH DESIGN AND METHODS A total of 490 participants, including 72 healthy control subjects, 149 with type 1 diabetes, and 269 with type 2 diabetes, underwent detailed assessment of peripheral neuropathy and CCM in relation to risk factors. RESULTS Corneal nerve fiber density (CNFD) (P < 0.0001 and P < 0.0001), corneal nerve fiber branch density (CNBD) (P < 0.0001 and P < 0.0001), and corneal nerve fiber length (CNFL) (P < 0.0001 and P = 0.02) were significantly lower in patients with type 1 and type 2 diabetes compared with control subjects. CNFD (P < 0.0001), CNBD (P < 0.0001), and CNFL (P < 0.0001) were lower in type 1 diabetes compared with type 2 diabetes. Receiver operating characteristic curve analysis for the diagnosis of DPN demonstrated a good area under the curve for CNFD of 0.81, CNBD of 0.74, and CNFL of 0.73. Multivariable regression analysis showed a significant association among reduced CNFL with age (β = -0.27, P = 0.007), HbA1c (β = -1.1; P = 0.01), and weight (β = -0.14; P = 0.03) in patients with type 2 diabetes and with duration of diabetes (β = -0.13; P = 0.02), LDL cholesterol (β = 1.8, P = 0.04), and triglycerides (β = -2.87; P = 0.009) in patients with type 1 diabetes. CONCLUSIONS CCM identifies more severe corneal nerve loss in patients with type 1 diabetes compared with type 2 diabetes and shows good diagnostic accuracy for DPN. Furthermore, the risk factors for a reduction in corneal nerve fiber length differ between type 1 and type 2 diabetes.
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Affiliation(s)
- Maryam Ferdousi
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, The University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Alise Kalteniece
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, The University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Shazli Azmi
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, The University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Ioannis N Petropoulos
- Research Division, Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Georgios Ponirakis
- Research Division, Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, U.K
| | - Omar Asghar
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, The University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Andrew Marshall
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, The University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Catherine Fullwood
- Centre for Biostatistics, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K.,Research and Innovation, Manchester University NHS Foundation Trust, Manchester, U.K.,Manchester Academic Health Science Centre, Manchester, U.K
| | - Maria Jeziorska
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, The University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Caroline Abbott
- Research Centre for Musculoskeletal Science and Sports Medicine, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, U.K
| | - Giuseppe Lauria
- IRCCS Foundation "Carlo Besta" Neurological Institute, Milan, Italy
| | - Catharina G Faber
- Department of Neurology, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Handrean Soran
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, The University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Nathan Efron
- Queensland University of Technology, School of Optometry and Vision Science, Brisbane, Queensland, Australia
| | - Andrew J M Boulton
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, The University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, U.K
| | - Rayaz A Malik
- Institute of Cardiovascular Sciences, Cardiac Centre, Faculty of Medical and Human Sciences, The University of Manchester and NIHR/Wellcome Trust Clinical Research Facility, Manchester, U.K. .,Research Division, Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha, Qatar
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Carmichael J, Fadavi H, Ishibashi F, Shore AC, Tavakoli M. Advances in Screening, Early Diagnosis and Accurate Staging of Diabetic Neuropathy. Front Endocrinol (Lausanne) 2021; 12:671257. [PMID: 34122344 PMCID: PMC8188984 DOI: 10.3389/fendo.2021.671257] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/17/2021] [Indexed: 12/14/2022] Open
Abstract
The incidence of both type 1 and type 2 diabetes is increasing worldwide. Diabetic peripheral neuropathy (DPN) is among the most distressing and costly of all the chronic complications of diabetes and is a cause of significant disability and poor quality of life. This incurs a significant burden on health care costs and society, especially as these young people enter their peak working and earning capacity at the time when diabetes-related complications most often first occur. DPN is often asymptomatic during the early stages; however, once symptoms and overt deficits have developed, it cannot be reversed. Therefore, early diagnosis and timely intervention are essential to prevent the development and progression of diabetic neuropathy. The diagnosis of DPN, the determination of the global prevalence, and incidence rates of DPN remain challenging. The opinions vary about the effectiveness of the expansion of screenings to enable early diagnosis and treatment initiation before disease onset and progression. Although research has evolved over the years, DPN still represents an enormous burden for clinicians and health systems worldwide due to its difficult diagnosis, high costs related to treatment, and the multidisciplinary approach required for effective management. Therefore, there is an unmet need for reliable surrogate biomarkers to monitor the onset and progression of early neuropathic changes in DPN and facilitate drug discovery. In this review paper, the aim was to assess the currently available tests for DPN's sensitivity and performance.
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Affiliation(s)
- Josie Carmichael
- Diabetes and Vascular Research Centre, National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, United Kingdom
| | - Hassan Fadavi
- Peripheral Neuropathy Group, Imperial College, London, United Kingdom
| | - Fukashi Ishibashi
- Internal Medicine, Ishibashi Medical and Diabetes Centre, Hiroshima, Japan
| | - Angela C Shore
- Diabetes and Vascular Research Centre, National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, United Kingdom
| | - Mitra Tavakoli
- Diabetes and Vascular Research Centre, National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, United Kingdom
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Ferdousi M, Kalteniece A, Azmi S, Petropoulos IN, Worthington A, D'Onofrio L, Dhage S, Ponirakis G, Alam U, Marshall A, Faber CG, Lauria G, Soran H, Malik RA. Corneal confocal microscopy compared with quantitative sensory testing and nerve conduction for diagnosing and stratifying the severity of diabetic peripheral neuropathy. BMJ Open Diabetes Res Care 2020; 8:8/2/e001801. [PMID: 33355206 PMCID: PMC7754626 DOI: 10.1136/bmjdrc-2020-001801] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/28/2020] [Accepted: 11/21/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Diabetic neuropathy can be diagnosed and assessed using a number of techniques including corneal confocal microscopy (CCM). RESEARCH DESIGN AND METHODS We have undertaken quantitative sensory testing, nerve conduction studies and CCM in 143 patients with type 1 and type 2 diabetes without neuropathy (n=51), mild neuropathy (n=47) and moderate to severe neuropathy (n=45) and age-matched controls (n=30). RESULTS Vibration perception threshold (p<0.0001), warm perception threshold (WPT) (p<0.001), sural nerve conduction velocity (SNCV) (p<0.001), corneal nerve fiber density (CNFD) (p<0.0001), corneal nerve branch density (CNBD) (p<0.0001), corneal nerve fiber length (CNFL) (p=0.002), inferior whorl length (IWL) (p=0.0001) and average nerve fiber length (ANFL) (p=0.0001) showed a progressive abnormality with increasing severity of diabetic neuropathy. Receiver operating characteristic curve analysis for the diagnosis of diabetic neuropathy showed comparable performance in relation to the area under the curve (AUC) but differing sensitivities and specificities for vibration perception threshold (AUC 0.79, sensitivity 55%, specificity 90%), WPT (AUC 0.67, sensitivity 50%, specificity 76%), cold perception threshold (AUC 0.64, sensitivity 80%, specificity 47%), SNCV (AUC 0.70, sensitivity 76%, specificity 54%), CNFD (AUC 0.71, sensitivity 58%, specificity 83%), CNBD (AUC 0.70, sensitivity 69%, specificity 65%), CNFL (AUC 0.68, sensitivity 64%, specificity 67%), IWL (AUC 0.72, sensitivity 70%, specificity 65%) and ANFL (AUC 0.72, sensitivity 71%, specificity 66%). CONCLUSION This study shows that CCM identifies early and progressive corneal nerve loss at the inferior whorl and central cornea and has comparable utility with quantitative sensory testing and nerve conduction in the diagnosis of diabetic neuropathy.
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Affiliation(s)
- Maryam Ferdousi
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Alise Kalteniece
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Shazli Azmi
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | | | - Anne Worthington
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Luca D'Onofrio
- Department of Experimental Medicine, University of Rome La Sapienza, Roma, Lazio, Italy
| | - Shaishav Dhage
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | | | - Uazman Alam
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Andrew Marshall
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Catharina G Faber
- Department of Neurology, Maastricht University, Maastricht, Limburg, The Netherlands
| | - Giuseppe Lauria
- Department of Clinical Neurosciences, Università di Milano - Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Milan, Italy
| | - Handrean Soran
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- University Department of Medicine, Central Manchester University Hospitals NHS Foundation Trust, Manchester, Greater Manchester, UK
| | - Rayaz A Malik
- Division of Cardiovascular Sciences, Cardiac Centre, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Research Division, Weill Cornell Medical College in Qatar, Doha, Qatar
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40
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Gao M, Yun X, Zhang T. VSA-3000: A Quantitative Vibration Sensation Testing Device for Patients With Central Nervous System Injury. Front Neurol 2020; 11:936. [PMID: 33013633 PMCID: PMC7505990 DOI: 10.3389/fneur.2020.00936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 07/20/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: To investigate the effect of using Vibration Sensory Analyzer-3000 (VSA-3000) in patients with impaired vibration sensation caused by central nervous system injury. Design: Prospective observational study. Setting: A university hospital for the research and clinical practice of rehabilitation. Subjects: Sixty patients (30 stroke and 30 spinal cord injury) were recruited, aged between 20 and 71 years old, under stable medication. Interventions: Not applicable. Main Measure: VSA-3000 threshold test, tuning fork test and somatosensory evoked potential (SSEP) measurement. Results: Test-retest reliability was determined based on data collected from 60 subjects, and the intraclass correlation coefficient (ICC) for vibration perception thresholds (VPTs) was in the “substantial” range. The kappa value between VSA-3000 and SSEP was 0.877, which was higher than that of tuning fork (κ = 0.732). VSA-3000 had good diagnostic accuracy with a sensitivity of 94.8%, specificity of 92.9%, and positive-predictive value of 93.8% and negative-predictive value of 94.0%, each value was higher than that of tuning fork. The area under the receiver operating characteristic curve (AUC) of VSA-3000 was 0.95 (95% CI: 0.91 to 0.98) and that of tuning fork was 0.89 (95% CI: 0.85 to 0.95), and there was a significant difference between the two values (P = 0.0216). The types of injury and age were the independent correlates of the VPTs. Conclusion: The present study provides preliminary evidence that VSA-3000 is a non-invasive and convenient quantitative testing instrument with good diagnostic accuracy, and it may be useful as a screening tool for assessing impaired vibration sensation caused by central nerve injury.
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Affiliation(s)
- Mingming Gao
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China.,Department of Rehabilitation Evaluation, China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Xiaoping Yun
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China.,Department of Rehabilitation Evaluation, China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
| | - Tong Zhang
- School of Rehabilitation Medicine, Capital Medical University, Beijing, China.,Neurorehabilitation Center, China Rehabilitation Research Center, Beijing Bo'ai Hospital, Beijing, China
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Zhao Y, Zhang J, Pereira E, Zheng Y, Su P, Xie J, Zhao Y, Shi Y, Qi H, Liu J, Liu Y. Automated Tortuosity Analysis of Nerve Fibers in Corneal Confocal Microscopy. IEEE TRANSACTIONS ON MEDICAL IMAGING 2020; 39:2725-2737. [PMID: 32078542 DOI: 10.1109/tmi.2020.2974499] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Precise characterization and analysis of corneal nerve fiber tortuosity are of great importance in facilitating examination and diagnosis of many eye-related diseases. In this paper we propose a fully automated method for image-level tortuosity estimation, comprising image enhancement, exponential curvature estimation, and tortuosity level classification. The image enhancement component is based on an extended Retinex model, which not only corrects imbalanced illumination and improves image contrast in an image, but also models noise explicitly to aid removal of imaging noise. Afterwards, we take advantage of exponential curvature estimation in the 3D space of positions and orientations to directly measure curvature based on the enhanced images, rather than relying on the explicit segmentation and skeletonization steps in a conventional pipeline usually with accumulated pre-processing errors. The proposed method has been applied over two corneal nerve microscopy datasets for the estimation of a tortuosity level for each image. The experimental results show that it performs better than several selected state-of-the-art methods. Furthermore, we have performed manual gradings at tortuosity level of four hundred and three corneal nerve microscopic images, and this dataset has been released for public access to facilitate other researchers in the community in carrying out further research on the same and related topics.
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Petropoulos IN, Al-Mohammedi A, Chen X, Ferdousi M, Ponirakis G, Kemp H, Chopra R, Hau S, Schargus M, Vollert J, Sturm D, Bharani T, Kleinschnitz C, Stettner M, Peto T, Maier C, Rice ASC, Malik RA. The Utility of Corneal Nerve Fractal Dimension Analysis in Peripheral Neuropathies of Different Etiology. Transl Vis Sci Technol 2020; 9:43. [PMID: 32934893 PMCID: PMC7463182 DOI: 10.1167/tvst.9.9.43] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 08/10/2020] [Indexed: 02/07/2023] Open
Abstract
Purpose Quantification of corneal confocal microscopy (CCM) images has shown a significant reduction in corneal nerve fiber length (CNFL) in a range of peripheral neuropathies. We assessed whether corneal nerve fractal dimension (CNFrD) analysis, a novel metric to quantify the topological complexity of corneal subbasal nerves, can differentiate peripheral neuropathies of different etiology. Methods Ninety patients with peripheral neuropathy, including 29 with diabetic peripheral neuropathy (DPN), 34 with chronic inflammatory demyelinating polyneuropathy (CIDP), 13 with chemotherapy-induced peripheral neuropathy (CIPN), 14 with human immunodeficiency virus-associated sensory neuropathy (HIV-SN), and 20 healthy controls (HCs), underwent CCM for estimation of corneal nerve fiber density (CNFD), CNFL, corneal nerve branch density (CNBD), CNFrD, and CNFrD adjusted for CNFL (ACNFrD). Results In patients with DPN, CIDP, CIPN, or HIV-SN compared to HCs, CNFD (P = 0.004-0.0001) and CNFL (P = 0.05-0.0001) were significantly lower, with a further significant reduction among subgroups. CNFrD was significantly lower in patients with CIDP compared to HCs and patients with HIV-SN (P = 0.02-0.0009) and in patients with DPN compared to HCs and patients with HIV-SN, CIPN, or CIDP (P = 0.001-0.0001). ACNFrD was lower in patients with CIPN, CIDP, or DPN compared to HCs (P = 0.03-0.0001) and in patients with DPN compared to those with HIV-SN, CIPN, or CIDP (P = 0.01-0.005). Conclusions CNFrD can detect a distinct pattern of corneal nerve loss in patients with DPN or CIDP compared to those with CIPN or HIV-SN and controls. Translational Relevance Various peripheral neuropathies are characterized by a comparable degree of corneal nerve loss. Assessment of corneal nerve topology by CNFrD could be useful in differentiating neuropathies based on the pattern of loss.
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Affiliation(s)
| | | | - Xin Chen
- School of Computer Science, University of Nottingham, Nottingham, UK
| | - Maryam Ferdousi
- Institute of Cardiovascular Science, University of Manchester, Manchester, UK
| | | | - Harriet Kemp
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Reena Chopra
- NIHR Moorfields Clinical Research Facility, Moorfields Eye Hospital, London, UK
| | - Scott Hau
- NIHR Moorfields Clinical Research Facility, Moorfields Eye Hospital, London, UK
| | - Marc Schargus
- Department of Ophthalmology, University Eye Hospital, Dusseldorf, Germany
| | - Jan Vollert
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.,Division of Neurophysiology, Center of Biomedicine and Medical Technology Mannheim (CBTM), Medical Faculty Mannheim, Ruprecht-Karls University, Heidelberg, Germany
| | - Dietrich Sturm
- BG Universitätsklinikum Bergmannsheil GmbH, Department of Neurology, Ruhr University, Bochum, Germany
| | - Tina Bharani
- Division of Research, Weill Cornell Medicine-Qatar, Doha, Qatar
| | | | - Mark Stettner
- Department of Neurology, Essen University Hospital, Essen, Germany
| | - Tunde Peto
- Queen's University Belfast, Belfast, Northern Ireland
| | - Christoph Maier
- BG Universitätsklinikum Bergmannsheil GmbH, Department of Pain Medicine, Ruhr University, Bochum, Germany
| | - Andrew S C Rice
- Pain Research, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Rayaz A Malik
- Division of Research, Weill Cornell Medicine-Qatar, Doha, Qatar
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De Clerck EE, Schouten JS, Berendschot TT, Koolschijn RS, Nuijts RM, Schram MT, Schaper NC, Henry RM, Dagnelie PC, Ruggeri A, Guimarães P, Stehouwer CD, Webers CA. Reduced corneal nerve fibre length in prediabetes and type 2 diabetes: The Maastricht Study. Acta Ophthalmol 2020; 98:485-491. [PMID: 32017403 PMCID: PMC7496813 DOI: 10.1111/aos.14359] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 01/04/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE In individuals with diabetes, injury to the corneal nerve fibres predisposes to delayed corneal epithelial healing, reduced corneal sensitivity and corneal erosion. We investigated to what extent a reduction in corneal nerve fibre length (CNFL) is present in individuals with prediabetes or type 2 diabetes (DM2) compared with individuals with normal glucose metabolism (NGM). METHODS Using composite images acquired by corneal confocal microscopy, we assessed total CNFL per mm2 in the subbasal nerve plexus of the cornea in 134 participants (mean age 59 ± 8 years, 49% men, 87 NGM, 20 prediabetes, 27 DM2). Multivariable linear regression was used to assess the association between CNFL and glucose metabolism status, adjusted for age and sex. RESULTS In individuals with type 2 diabetes, the mean CNFL was significantly reduced [β = -1.86 mm/mm2 (95% CI -3.64 to -0.08), p = 0.04], as compared with individuals with normal glucose metabolism after adjustment for age and sex. Part of the reduction was present in individuals with prediabetes [β = -0.96 mm/mm2 (95% CI -2.91 to 0.99), p = 0.34], with a linear trend of corneal nerve fibre reduction with severity of glucose metabolism status (p trend = 0.04). CONCLUSIONS A significant reduction in CNFL was found in individuals with DM2 compared with individuals with NGM. A trend of reduction in CNFL was observed between individuals with NGM and prediabetes. The reduction in corneal nerve fibre length could contribute to a delayed corneal healing and an increased risk for corneal complications after surgery.
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Affiliation(s)
- Eline E.B. De Clerck
- University Eye Clinic MaastrichtMaastricht University Medical Center +Maastrichtthe Netherlands
| | - Jan S.A.G. Schouten
- University Eye Clinic MaastrichtMaastricht University Medical Center +Maastrichtthe Netherlands
| | - Tos T.J.M. Berendschot
- University Eye Clinic MaastrichtMaastricht University Medical Center +Maastrichtthe Netherlands
| | - Renée S. Koolschijn
- University Eye Clinic MaastrichtMaastricht University Medical Center +Maastrichtthe Netherlands
| | - Rudy M.M.A. Nuijts
- University Eye Clinic MaastrichtMaastricht University Medical Center +Maastrichtthe Netherlands
| | - Miranda T. Schram
- Department of Internal MedicineMaastricht University Medical Center +Maastrichtthe Netherlands,CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtthe Netherlands
| | - Nicolaas C. Schaper
- Department of Internal MedicineMaastricht University Medical Center +Maastrichtthe Netherlands,CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtthe Netherlands,CAPHRI School for Public Health and Primary CareMaastricht UniversityMaastrichtthe Netherlands
| | - Ronald M.A. Henry
- Department of Internal MedicineMaastricht University Medical Center +Maastrichtthe Netherlands,CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtthe Netherlands
| | - Pieter C. Dagnelie
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtthe Netherlands,CAPHRI School for Public Health and Primary CareMaastricht UniversityMaastrichtthe Netherlands,Department of EpidemiologyMaastricht UniversityMaastrichtthe Netherlands
| | - Alfredo Ruggeri
- Department of Information EngineeringUniversity of PaduaPaduaItaly
| | - Pedro Guimarães
- Department of Information EngineeringUniversity of PaduaPaduaItaly
| | - Coen D.A. Stehouwer
- Department of Internal MedicineMaastricht University Medical Center +Maastrichtthe Netherlands,CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtthe Netherlands
| | - Carroll A.B. Webers
- University Eye Clinic MaastrichtMaastricht University Medical Center +Maastrichtthe Netherlands
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Gad H, Al-Jarrah B, Saraswathi S, Petropoulos IN, Ponirakis G, Khan A, Singh P, Al Khodor S, Elawad M, Almasri W, Abdelrahman H, Elawwa A, Khalifa A, Shamekh A, Al-Khalaf F, Petrovski G, Al Zyoud M, Al Maadheed M, Hendaus MA, Hussain K, Akobeng AK, Malik RA. Corneal nerve loss in children with type 1 diabetes mellitus without retinopathy or microalbuminuria. J Diabetes Investig 2020; 11:1594-1601. [PMID: 32491258 PMCID: PMC7610109 DOI: 10.1111/jdi.13313] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/18/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022] Open
Abstract
Aims/Introduction Corneal confocal microscopy is a rapid, non‐invasive ophthalmic technique to identify subclinical neuropathy. The aim of this study was to quantify corneal nerve morphology in children with type 1 diabetes mellitus compared with age‐matched healthy controls using corneal confocal microscopy. Materials and Methods A total of 20 participants with type 1 diabetes mellitus (age 14 ± 2 years, diabetes duration 4.08 ± 2.91 years, glycated hemoglobin 9.3 ± 2.1%) without retinopathy or microalbuminuria and 20 healthy controls were recruited from outpatient clinics. Corneal confocal microscopy was undertaken, and corneal nerve fiber density (n/mm2), corneal nerve branch density (n/mm2), corneal nerve fiber length (mm/mm2), corneal nerve fiber tortuosity and inferior whorl length (mm/mm2) were quantified manually. Results Corneal nerve fiber density (22.73 ± 8.84 vs 32.92 ± 8.59; P < 0.001), corneal nerve branch density (26.19 ± 14.64 vs 47.34 ± 20.01; P < 0.001), corneal nerve fiber length (13.26 ± 4.06 vs 19.52 ± 4.54; P < 0.001) and inferior whorl length (15.50 ± 5.48 vs 23.42 ± 3.94; P < 0.0001) were significantly lower, whereas corneal nerve fiber tortuosity (14.88 ± 5.28 vs 13.52 ± 3.01; P = 0.323) did not differ between children with type 1 diabetes mellitus and controls. Glycated hemoglobin correlated with corneal nerve fiber tortuosity (P < 0.006) and aspartate aminotransferase correlated with corneal nerve fiber density (P = 0.039), corneal nerve branch density (P = 0.003) and corneal nerve fiber length (P = 0.037). Conclusion Corneal confocal microscopy identifies significant subclinical corneal nerve loss, especially in the inferior whorl of children with type 1 diabetes mellitus without retinopathy or microalbuminuria.
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Affiliation(s)
- Hoda Gad
- Medicine Department, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Bara Al-Jarrah
- Gastroenterology Department, Sidra Medicine, Doha, Qatar
| | | | | | | | - Adnan Khan
- Medicine Department, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Parul Singh
- Research Department, Sidra Medicine, Doha, Qatar
| | | | - Mamoun Elawad
- Gastroenterology Department, Sidra Medicine, Doha, Qatar
| | - Wesam Almasri
- Gastroenterology Department, Sidra Medicine, Doha, Qatar
| | | | - Ahmed Elawwa
- Endocrinology Department, Sidra Medicine, Doha, Qatar
| | - Amel Khalifa
- Endocrinology Department, Sidra Medicine, Doha, Qatar
| | - Ahmed Shamekh
- Endocrinology Department, Sidra Medicine, Doha, Qatar
| | | | | | | | | | | | | | | | - Rayaz A Malik
- Medicine Department, Weill Cornell Medicine-Qatar, Doha, Qatar.,Institute of Cardiovascular Medicine, University of Manchester, Manchester, UK
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Ponirakis G, Abdul-Ghani MA, Jayyousi A, Almuhannadi H, Petropoulos IN, Khan A, Gad H, Migahid O, Megahed A, DeFronzo R, Mahfoud Z, Hassan M, Al Hamad H, Ramadan M, Alam U, Malik RA. Effect of treatment with exenatide and pioglitazone or basal-bolus insulin on diabetic neuropathy: a substudy of the Qatar Study. BMJ Open Diabetes Res Care 2020; 8:8/1/e001420. [PMID: 32576561 PMCID: PMC7312325 DOI: 10.1136/bmjdrc-2020-001420] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 04/28/2020] [Accepted: 05/13/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION To assess the effect of exenatide and pioglitazone or basal-bolus insulin on diabetic peripheral neuropathy (DPN) in patients with poorly controlled type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS This is a substudy of the Qatar Study, an open-label, randomized controlled trial. 38 subjects with poorly controlled T2D were studied at baseline and 1-year follow-up and 18 control subjects were assessed at baseline only. A combination of exenatide (2 mg/week) and pioglitazone (30 mg/day) or glargine with aspart insulin were randomly assigned to patients to achieve an HbA1c <53 mmol/mol (<7%). DPN was assessed with corneal confocal microscopy (CCM), DN4, vibration perception and sudomotor function. RESULTS Subjects with T2D had reduced corneal nerves, but other DPN measures were comparable with the control group. In the combination treatment arm (n=21), HbA1c decreased by 35.2 mmol/mol (3.8 %) (p<0.0001), body weight increased by 5.6 kg (p<0.0001), corneal nerve branch density increased (p<0.05), vibration perception worsened (p<0.05), and DN4 and sudomotor function showed no change. In the insulin treatment arm, HbA1c decreased by 28.7 mmol/mol (2.7 %) (p<0.0001), body weight increased by 4.6 kg (p<0.01), corneal nerve branch density and fiber length increased (p≤0.01), vibration perception improved (p<0.01), and DN4 and sudomotor function showed no change. There was no association between the change in CCM measures with change in HbA1c, weight or lipids. CONCLUSIONS Treatment with exenatide and pioglitazone or basal-bolus insulin results in corneal nerve regeneration, but no change in neuropathic symptoms or sudomotor function over 1 year.
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Affiliation(s)
- Georgios Ponirakis
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
- Manchester Metropolitan University, Manchester, Greater Manchester, UK
| | | | - Amin Jayyousi
- Department of Diabetes and Endocrinology, Hamad Medical Corporation, Doha, Ad Dawhah, Qatar
| | | | | | - Adnan Khan
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Hoda Gad
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Osama Migahid
- Department of Diabetes and Endocrinology, Hamad Medical Corporation, Doha, Ad Dawhah, Qatar
| | - Ayman Megahed
- Department of Diabetes and Endocrinology, Hamad Medical Corporation, Doha, Ad Dawhah, Qatar
| | - Ralph DeFronzo
- University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ziyad Mahfoud
- Department of Medicine, Weill Cornell Medicine, Doha, Qatar
| | - Mona Hassan
- Department of Diabetes and Endocrinology, Hamad Medical Corporation, Doha, Ad Dawhah, Qatar
| | - Hanadi Al Hamad
- Department of Geriatrics and Long Term Care, Qatar Rehabilitation Institute, Doha, Qatar
| | - Marwan Ramadan
- Department of Geriatrics and Long Term Care, Qatar Rehabilitation Institute, Doha, Qatar
| | - Uazman Alam
- Aintree University Hospitals NHS Foundation Trust, Liverpool, Liverpool, UK
| | - Rayaz A Malik
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
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46
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Elhardt C, Wertheimer CM, Wartak A, Zhao J, Leung HM, Kassumeh SA, Yin B, Tearney GJ, Birngruber R. Stromal Nerve Imaging and Tracking Using Micro-Optical Coherence Tomography. Transl Vis Sci Technol 2020; 9:6. [PMID: 32821478 PMCID: PMC7401960 DOI: 10.1167/tvst.9.5.6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 01/12/2020] [Indexed: 12/26/2022] Open
Abstract
Purpose To image, track and map the nerve fiber distribution in excised rabbit corneas over the entire stromal thickness using micro-optical coherence tomography (µOCT) to develop a screening tool for early peripheral neuropathy. Methods Excised rabbit corneas were consecutively imaged by a custom-designed µOCT prototype and a commercial laser scanning fluorescence confocal microscope. The µOCT images with a field of view of approximately 1 × 1 mm were recorded with axial and transverse resolutions of approximately 1 µm and approximately 4 µm, respectively. In the volumetric µOCT image data, network maps of hyper-reflective, branched structures traversing different stromal compartments were segmented using semiautomatic image processing algorithms. Furthermore, the same corneas received βIII-tubulin antibody immunostaining before digital confocal microscopy, and a comparison between µOCT image data and immunohistochemistry analysis was performed to validate the nerval origin of the tracked network structures. Results Semiautomatic tracing of the nerves with a high range of different thicknesses was possible through the whole corneal volumes, creating a skeleton of the traced nerves. There was a good conformity between the hyper-reflective structures in the µOCT data and the stained nerval structures in the immunohistochemistry data. Conclusions This article demonstrates nerval imaging and tracking as well as a spatial correlation between µOCT and a fluorescence corneal nerve standard for larger nerves throughout the full thickness of the cornea ex vivo. Translational Relevance Owing to its advantageous properties, µOCT may become useful as a noncontact method for assessing nerval structures in humans to screen for early peripheral neuropathy.
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Affiliation(s)
- Carolin Elhardt
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Ophthalmology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Christian M Wertheimer
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Ophthalmology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Andreas Wartak
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Jie Zhao
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Hui Min Leung
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Stefan A Kassumeh
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.,Department of Ophthalmology, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Biwei Yin
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Guillermo J Tearney
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard-MIT Division of Health Sciences and Technology, Cambridge, MA, USA.,Department of Pathology, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Reginald Birngruber
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.,Institute of Biomedical Optics, University of Lübeck, Lübeck, Germany
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47
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Ramm L, Spoerl E, Pillunat LE, Terai N. Is the Corneal Thickness Profile Altered in Diabetes Mellitus? Curr Eye Res 2020; 45:1228-1234. [PMID: 32180465 DOI: 10.1080/02713683.2020.1741009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Purpose: To investigate the influence of chronic hyperglycemia in diabetes mellitus (DM) on spatial corneal thickness distribution and to analyze the influence of disease-specific factors. Methods: DM patients and healthy subjects were matched according to age and intraocular pressure (IOP). In diabetics, disease duration, DM type, and HbA1c value were assessed. Spatially resolved corneal thickness was measured by Pentacam HR. Thinnest corneal thickness (TCT) and peripheral pachymetry of concentric circles around TCT were determined. The Dynamic Scheimpflug Analyzer Corvis ST (CST) was used to measure the parameter pachy slope, which is an indicator of the change of corneal thickness from the apex to the periphery. Results: 59 DM patients and 57 healthy subjects were included. Age (P = .486) and IOP (P = .154) were not different between the groups. In DM, pachy slope was significantly higher than in healthy subjects (41.1 ± 9.87 vs. 35.18 ± 10.64 μm, P = .004). Also, the differences between TCT and the average of peripheral corneal thickness of concentric circles with a diameter of 2 mm (10.3 ± 1.7 vs. 9.3 ± 3.8 μm, P < .001) to 6 mm (82.2 ± 12.4 vs. 76.8 ± 12.6 μm, P = .011) were increased in patients. Changes in thickness profile were associated with HbA1c value and presence of diabetic retinopathy or maculopathy. Conclusion: In DM, a stronger peripheral corneal thickness increase was detectable. This change was shown using the novel CST parameter pachy slope and confirmed by Pentacam readings. These alterations might affect IOP and biomechanical measurements, and influence refractive procedures.
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Affiliation(s)
- Lisa Ramm
- Department of Ophthalmology, University Hospital Dresden , Dresden, Germany
| | - Eberhard Spoerl
- Department of Ophthalmology, University Hospital Dresden , Dresden, Germany
| | - Lutz E Pillunat
- Department of Ophthalmology, University Hospital Dresden , Dresden, Germany
| | - Naim Terai
- Department of Ophthalmology, University Hospital Dresden , Dresden, Germany
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48
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Williams BM, Borroni D, Liu R, Zhao Y, Zhang J, Lim J, Ma B, Romano V, Qi H, Ferdousi M, Petropoulos IN, Ponirakis G, Kaye S, Malik RA, Alam U, Zheng Y. An artificial intelligence-based deep learning algorithm for the diagnosis of diabetic neuropathy using corneal confocal microscopy: a development and validation study. Diabetologia 2020; 63:419-430. [PMID: 31720728 PMCID: PMC6946763 DOI: 10.1007/s00125-019-05023-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/30/2019] [Indexed: 12/31/2022]
Abstract
AIMS/HYPOTHESIS Corneal confocal microscopy is a rapid non-invasive ophthalmic imaging technique that identifies peripheral and central neurodegenerative disease. Quantification of corneal sub-basal nerve plexus morphology, however, requires either time-consuming manual annotation or a less-sensitive automated image analysis approach. We aimed to develop and validate an artificial intelligence-based, deep learning algorithm for the quantification of nerve fibre properties relevant to the diagnosis of diabetic neuropathy and to compare it with a validated automated analysis program, ACCMetrics. METHODS Our deep learning algorithm, which employs a convolutional neural network with data augmentation, was developed for the automated quantification of the corneal sub-basal nerve plexus for the diagnosis of diabetic neuropathy. The algorithm was trained using a high-end graphics processor unit on 1698 corneal confocal microscopy images; for external validation, it was further tested on 2137 images. The algorithm was developed to identify total nerve fibre length, branch points, tail points, number and length of nerve segments, and fractal numbers. Sensitivity analyses were undertaken to determine the AUC for ACCMetrics and our algorithm for the diagnosis of diabetic neuropathy. RESULTS The intraclass correlation coefficients for our algorithm were superior to those for ACCMetrics for total corneal nerve fibre length (0.933 vs 0.825), mean length per segment (0.656 vs 0.325), number of branch points (0.891 vs 0.570), number of tail points (0.623 vs 0.257), number of nerve segments (0.878 vs 0.504) and fractals (0.927 vs 0.758). In addition, our proposed algorithm achieved an AUC of 0.83, specificity of 0.87 and sensitivity of 0.68 for the classification of participants without (n = 90) and with (n = 132) neuropathy (defined by the Toronto criteria). CONCLUSIONS/INTERPRETATION These results demonstrated that our deep learning algorithm provides rapid and excellent localisation performance for the quantification of corneal nerve biomarkers. This model has potential for adoption into clinical screening programmes for diabetic neuropathy. DATA AVAILABILITY The publicly shared cornea nerve dataset (dataset 1) is available at http://bioimlab.dei.unipd.it/Corneal%20Nerve%20Tortuosity%20Data%20Set.htm and http://bioimlab.dei.unipd.it/Corneal%20Nerve%20Data%20Set.htm.
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Affiliation(s)
- Bryan M Williams
- Department of Eye and Vision Science, University of Liverpool, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
- Data Science Institute, Lancaster University, Lancaster, UK
| | - Davide Borroni
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
- Department of Ophthalmology, Riga Stradins University, Riga, Latvia
| | - Rongjun Liu
- Department of Ophthalmology, Peking University Third Hospital, Beijing, China
| | - Yitian Zhao
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
- Cixi Institute of Biomedical Engineering, Ningbo Institute of Industrial Technology, Chinese Academy of Sciences, Ningbo, China
| | - Jiong Zhang
- Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jonathan Lim
- Department of Endocrinology and Diabetes, University Hospital Aintree, Longmoor Lane, Liverpool, UK
| | - Baikai Ma
- Department of Ophthalmology, Peking University Third Hospital, Beijing, China
| | - Vito Romano
- Department of Eye and Vision Science, University of Liverpool, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Hong Qi
- Department of Ophthalmology, Peking University Third Hospital, Beijing, China
| | - Maryam Ferdousi
- Department of Endocrinology and Diabetes, University Hospital Aintree, Longmoor Lane, Liverpool, UK
| | | | | | - Stephen Kaye
- Department of Eye and Vision Science, University of Liverpool, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | | | - Uazman Alam
- Diabetes and Neuropathy Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK.
- Department of Diabetes and Endocrinology, Royal Liverpool and Broadgreen University NHS Hospital Trust, Liverpool, UK.
- Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, UK.
| | - Yalin Zheng
- Department of Eye and Vision Science, University of Liverpool, William Henry Duncan Building, 6 West Derby Street, Liverpool, L7 8TX, UK.
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK.
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49
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Yang H, Sloan G, Ye Y, Wang S, Duan B, Tesfaye S, Gao L. New Perspective in Diabetic Neuropathy: From the Periphery to the Brain, a Call for Early Detection, and Precision Medicine. Front Endocrinol (Lausanne) 2020; 10:929. [PMID: 32010062 PMCID: PMC6978915 DOI: 10.3389/fendo.2019.00929] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 12/19/2019] [Indexed: 12/12/2022] Open
Abstract
Diabetic peripheral neuropathy (DPN) is a common chronic complication of diabetes mellitus. It leads to distressing and expensive clinical sequelae such as foot ulceration, leg amputation, and neuropathic pain (painful-DPN). Unfortunately, DPN is often diagnosed late when irreversible nerve injury has occurred and its first presentation may be with a diabetic foot ulcer. Several novel diagnostic techniques are available which may supplement clinical assessment and aid the early detection of DPN. Moreover, treatments for DPN and painful-DPN are limited. Only tight glucose control in type 1 diabetes has robust evidence in reducing the risk of developing DPN. However, neither glucose control nor pathogenetic treatments are effective in painful-DPN and symptomatic treatments are often inadequate. It has recently been hypothesized that using various patient characteristics it may be possible to stratify individuals and assign them targeted therapies to produce better pain relief. We review the diagnostic techniques which may aid the early detection of DPN in the clinical and research environment, and recent advances in precision medicine techniques for the treatment of painful-DPN.
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Affiliation(s)
- Heng Yang
- Endocrinology Department, Renmin Hospital of Wuhan University, Wuhan, China
| | - Gordon Sloan
- Diabetes Research Unit, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Yingchun Ye
- Endocrinology Department, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shuo Wang
- Endocrinology Department, Renmin Hospital of Wuhan University, Wuhan, China
| | - Bihan Duan
- Endocrinology Department, Renmin Hospital of Wuhan University, Wuhan, China
| | - Solomon Tesfaye
- Diabetes Research Unit, Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Ling Gao
- Endocrinology Department, Renmin Hospital of Wuhan University, Wuhan, China
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50
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Avetisov SE, Chernenkova NA, Surnina ZV, Akhmedzhanova LT, Fokina AS, Strokov IA. [Early diagnosis of diabetic polyneuropathy based on the results of corneal nerve fibers examination]. Vestn Oftalmol 2020; 136:155-162. [PMID: 33063958 DOI: 10.17116/oftalma2020136052155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
UNLABELLED Laser corneal confocal microscopy (CCM) is a method of objective visualization of thin corneal nerve fibers (CNF), the structure of which changes in patients with diabetes mellitus (DM). PURPOSE To conduct comparative analysis of the results of CNF assessment using CCM and other known neurological instrumental techniques as well as evaluate their applicability to the early diagnosis of diabetic polyneuropathy (DPN). MATERIAL AND METHODS We examined a total of 46 patients (85 eyes) with type 1 DM and either subclinical (24 patients), or clinical-stage DPN (22 patients) and 50 patients (87 eyes) with type 2 DM (subclinical DPN in 27 patients and clinical-stage DPN in 23 patients). The control group consisted of 34 healthy volunteers (68 eyes). All patients underwent standard ophthalmological examination, CCM with nerve tortuosity assessment (including calculation of coefficients of CNF orientation anisotropy, KΔL, and symmetry, Ksym) and interocular asymmetry, electroneuromyography (ENMG), and quantitative sensory testing (QST). RESULTS Analysis of the CCM results revealed a reliable decrease in the average KΔL values in patients with type 1 and type 2 DM compared with the control group. In the group of patients with type 1 DM and subclinical DPN, correlations were revealed between the CNF tortuosity coefficients and a number of ENMG parameters, such as the M-response amplitude of the peroneal nerve (r=0.73, p≤0.02), M-response amplitude of the tibial nerve (r=0.58, p≤0.01), residual latency (r= -0.62, p≤0.05), and peroneal nerve conduction velocity (r=0.57, p≤0.01). Ksym values correlated with the warm sensitivity threshold (r=0.6, p≤0.008). Among patients with type 2 DM and subclinical DPN, the KΔL coefficient correlated with the peroneal nerve conduction velocity (r=0.46, p≤0.02), M-response amplitude of the tibial nerve (r=0.6, p≤0.04), and residual latency of the peroneal nerve (r=-0.56, p≤0.05). CONCLUSION The state of thin corneal nerves correlates with functional changes in the peripheral nerves. Pathological changes in CNF in patients with DM can be detected at an early (subclinical) stage of DPN using laser CCM and a program for corneal nerve tortuosity analysis.
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Affiliation(s)
- S E Avetisov
- Research Institute of Eye Diseases, Moscow, Russia
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - N A Chernenkova
- Research Institute of Eye Diseases, Moscow, Russia
- Research Center of Neurology, Moscow, Russia
| | - Z V Surnina
- Research Institute of Eye Diseases, Moscow, Russia
| | - L T Akhmedzhanova
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - A S Fokina
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - I A Strokov
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
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