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Travé-Huarte S, Wolffsohn JS. Sutureless Dehydrated Amniotic Membrane (Omnigen) Application Using a Specialised Bandage Contact Lens (OmniLenz) for the Treatment of Dry Eye Disease: A 6-Month Randomised Control Trial. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:985. [PMID: 38929602 PMCID: PMC11205730 DOI: 10.3390/medicina60060985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024]
Abstract
Background and Objectives: Dry Eye Disease (DED) is a chronic condition characterised by tear film instability and ocular surface disruption, significantly impacting patients' quality of life. This study aimed to provide top-level clinical evidence for the long-term efficacy of dehydrated amniotic membrane (dAM, Omnigen®) delivered via a specialised bandage contact lens (sBCL, OmniLenz) for managing moderate-to-severe DED. Materials and Methods: This randomised controlled trial (NCT04553432) involved 93 participants with moderate-to-severe DED, randomised to receive a 1-week bilateral treatment of either dAM (17 mm diameter with 6 mm central 'window') applied under a sBCL or sBCL alone. Participants were assessed at baseline and followed up at 1, 3, and 6 months post-treatment. Outcomes included changes in symptomatology, tear film and ocular surface measurements, and in vivo confocal microscopy imaging of corneal nerve parameters and corneal dendritic cell (CDC) counts. Results: The dAM-sBCL group demonstrated a 65% reduction in OSDI scores at 6 months (p < 0.001), with 88% of participants showing improvement at 1 month. Corneal staining was significantly reduced in both groups. dAM-sBCL provided significant improvements in corneal nerve parameters at 1 month, with sustained positive trends at 3 months. Additionally, dAM-sBCL significantly reduced mature CDC counts, suggesting an anti-inflammatory effect. Conclusions: Treatment with dAM-sBCL for just 1 week significantly and rapidly improved dry eye symptoms as well as ocular surface signs for at least 3 months. It also enhanced corneal nerve health while reducing activated/mature corneal inflammatory cell numbers, presenting a safe and promising new treatment for moderate-to-severe DED.
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Affiliation(s)
- Sònia Travé-Huarte
- College of Health and Life Sciences, Aston University, Birmingham B4 7ET, UK;
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Chin JY, Liu C, Lee IXY, Lin MTY, Cheng CY, Wong JHF, Teo CL, Mehta JS, Liu YC. Impact of Age on the Characteristics of Corneal Nerves and Corneal Epithelial Cells in Healthy Adults. Cornea 2024; 43:409-418. [PMID: 37643477 PMCID: PMC10906190 DOI: 10.1097/ico.0000000000003363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/26/2023] [Accepted: 07/02/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE The aim of this study was to investigate age-related changes in corneal nerves and corneal epithelial cell parameters and to establish age-adjusted reference values. METHODS A total of 7025 corneal nerve images and 4215 corneal epithelial images obtained using in vivo confocal microscopy from 281 eyes of 143 healthy participants were included. Seven corneal nerve parameters and 3 corneal epithelial cell parameters were quantified using 2 automatic analytic software and analyzed across 6 age groups ranging from 21 to 80 years. RESULTS There was a declining trend in all 7 nerve parameters with advancing age. In particular, corneal nerve fiber length and corneal nerve fiber density demonstrated a significant decrease in subjects aged 65 years or older compared with subjects younger than 65 years (10.8 ± 2.6 mm/mm 2 vs. 9.9 ± 2.0 mm/mm 2 , P = 0.011 in corneal nerve fiber length; 15.8 ± 5.2 fibers/mm 2 vs. 14.4 ± 4.3 fibers/mm 2 , P = 0.046 in corneal nerve fiber density), whereas corneal nerve fractal dimension demonstrated a borderline significant decrease ( P = 0.057). Similarly, there was a general declining trend in all epithelial cell parameters with advancing age. Corneal epithelial cell circularity was significantly lower in subjects aged 65 years and older as compared to subjects younger than 65 years (0.722 ± 0.021 μm 2 vs. 0.714 ± 0.021 μm 2 ; P = 0.011). CONCLUSIONS Advancing age results in reduced corneal nerve metrics and alteration of corneal cell morphology. Aging effects should be considered when evaluating patients with corneal neuropathy.
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Affiliation(s)
- Jia Ying Chin
- Tissue Engineering and Stem Cell Group, Singapore Eye Research Institute, Singapore
| | - Chang Liu
- Tissue Engineering and Stem Cell Group, Singapore Eye Research Institute, Singapore
| | - Isabelle Xin Yu Lee
- Tissue Engineering and Stem Cell Group, Singapore Eye Research Institute, Singapore
| | - Molly Tzu Yu Lin
- Tissue Engineering and Stem Cell Group, Singapore Eye Research Institute, Singapore
| | - Ching-Yu Cheng
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
- Epidemiology Group, Singapore Eye Research Institute, Singapore
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
| | - Jipson Hon Fai Wong
- Tissue Engineering and Stem Cell Group, Singapore Eye Research Institute, Singapore
| | - Cong Ling Teo
- Epidemiology Group, Singapore Eye Research Institute, Singapore
| | - Jodhbir S. Mehta
- Tissue Engineering and Stem Cell Group, Singapore Eye Research Institute, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
- Department of Cornea and External Eye Disease, Singapore National Eye Centre, Singapore; and
| | - Yu-Chi Liu
- Tissue Engineering and Stem Cell Group, Singapore Eye Research Institute, Singapore
- Ophthalmology and Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
- Department of Cornea and External Eye Disease, Singapore National Eye Centre, Singapore; and
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
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Niu X, Yin P, Guan C, Shao Q, Cui G, Zan K, Xu C. Corneal confocal microscopy may help to distinguish Multiple System Atrophy from Parkinson's disease. NPJ Parkinsons Dis 2024; 10:63. [PMID: 38493181 PMCID: PMC10944503 DOI: 10.1038/s41531-024-00680-8] [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: 11/06/2023] [Accepted: 03/07/2024] [Indexed: 03/18/2024] Open
Abstract
Multiple system atrophy (MSA) and Parkinson's disease (PD) have clinical overlapping symptoms, which makes differential diagnosis difficult. Our research aimed to distinguish MSA from PD using corneal confocal microscopy (CCM), a noninvasive and objective test. The study included 63 PD patients, 30 MSA patients, and 31 healthy controls (HC). When recruiting PD and MSA, questionnaires were conducted on motor and non-motor functions, such as autonomic and cognitive functions. Participants underwent CCM to quantify the corneal nerve fibers. Corneal nerve fiber density (CNFD) and corneal nerve fiber length (CNFL) values in MSA are lower than PD (MSA vs. PD: CNFD, 20.68 ± 6.70 vs. 24.64 ± 6.43 no./mm2, p < 0.05; CNFL, 12.01 ± 3.25 vs. 14.17 ± 3.52 no./mm2, p < 0.05). In MSA + PD (combined), there is a negative correlation between CNFD and the Orthostatic Grading Scale (OGS) (r = -0.284, p = 0.007). Similarly, CNFD in the only MSA group was negatively correlated with the Unified Multiple System Atrophy Rating Scale I and II (r = -0.391, p = 0.044; r = -0.382, p = 0.049). CNFD and CNFL were inversely associated with MSA (CNFD: β = -0.071; OR, 0.932; 95% CI, 0.872 ~ 0.996; p = 0.038; CNFL: β = -0.135; OR, 0.874; 95% CI, 0.768-0.994; p = 0.040). Furthermore, we found the area under the receiver operating characteristic curve (ROC) of CNFL was the largest, 72.01%. The CCM could be an objective and sensitive biomarker to distinguish MSA from PD. It visually reflects a more severe degeneration in MSA compared to PD.
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Affiliation(s)
- Xuebin Niu
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
- Department of Neurology, The First Clinical College, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Peixiao Yin
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
- Department of Neurology, The First Clinical College, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Chenyang Guan
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
- Department of Neurology, The First Clinical College, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Qiuyue Shao
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
- Department of Neurology, The First Clinical College, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Guiyun Cui
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
- Department of Neurology, The First Clinical College, Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Kun Zan
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China.
- Department of Neurology, The First Clinical College, Xuzhou Medical University, Xuzhou, Jiangsu, China.
| | - Chuanying Xu
- Department of Neurology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China.
- Department of Neurology, The First Clinical College, Xuzhou Medical University, Xuzhou, Jiangsu, China.
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Katz M, Mork H, Baghdasaryan N, Hesse L, Wille K, Treichel J, Motte J, Klimas R, Sturm D, Schellinger PD, Hettlich HJ, Philipps J. High-resolution nerve ultrasound and corneal confocal microscopy in taxane-induced polyneuropathy. Eur J Neurol 2024; 31:e16141. [PMID: 37969021 DOI: 10.1111/ene.16141] [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: 08/29/2023] [Revised: 10/18/2023] [Accepted: 10/25/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND AND PURPOSE The role of high-resolution nerve ultrasound (HRUS) and corneal confocal microscopy (CCM) in the early detection of taxane-induced polyneuropathy (TIPN) is unclear. The present prospective longitudinal controlled observational pilot study estimates the role of HRUS and CCM in the early diagnosis of TIPN in breast cancer patients. METHODS Fifteen breast cancer patients receiving paclitaxel and 15 healthy age matched controls were included. Visits before and 3 weeks, 8 weeks and 6 months after treatment included clinical examination, the total neuropathy score, nerve conduction studies (NCS), monocular CCM including corneal nerve fibre length, density and branching and HRUS of bilateral median, ulnar, radial, tibial, peroneal and sural nerves. Patients were compared between different visits and to healthy controls. RESULTS Total neuropathy score increased from 2.2 at baseline to 5.8 (p < 0.001) at week 8. NCS showed a decreased sensory amplitude in the sural, radial, ulnar and median nerve after 6 months (p < 0.001). HRUS revealed a significant increase of cross-sectional area in the sural nerve (p = 0.004), the median nerve (p = 0.003) at the carpal tunnel and the ulnar nerve in the forearm (p = 0.006) after 6 months. CCM showed no changes at different visits. CONCLUSIONS Corneal confocal microscopy and HRUS do not detect early signs of TIPN during the paclitaxel treatment period. HRUS and NCS might detect congruent signs of an axonal, predominantly sensory polyneuropathy after 6 months. The clinical examination remains the most sensitive tool in the early detection of TIPN in breast cancer patients.
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Affiliation(s)
- Maria Katz
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Hannah Mork
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Nazik Baghdasaryan
- Clinic for Ophthalmology, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Lukas Hesse
- Clinic for Ophthalmology, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Kai Wille
- University Clinic for Haematology, Oncology, Haemostaseology and Palliative Care, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Jasmin Treichel
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Jeremias Motte
- Department of Neurology, St Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Rafael Klimas
- Department of Neurology, St Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Dietrich Sturm
- Department of Neurology, Agaplesion Bethesda Krankenhaus, Wuppertal, Germany
| | - Peter Dieter Schellinger
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Hans-Joachim Hettlich
- Clinic for Ophthalmology, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
| | - Jörg Philipps
- Department of Neurology and Neurogeriatrics, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany
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Raasing LRM, Vogels OJM, Datema M, Tannemaat MR, Veltkamp M, Grutters JC. Fully Automatic, Semiautomatic, and Manual Corneal Nerve Fiber Analysis in Patients With Sarcoidosis. Transl Vis Sci Technol 2023; 12:3. [PMID: 38047722 PMCID: PMC10702781 DOI: 10.1167/tvst.12.12.3] [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: 04/11/2023] [Accepted: 11/03/2023] [Indexed: 12/05/2023] Open
Abstract
Purpose No guidelines are available on the preferred method for analyzing corneal confocal microscopy (CCM) data. Manual, semiautomatic, and automatic analyzes are all currently in use. The purpose of the present study was threefold. First, we aimed to investigate the different methods for CCM analysis in patients with and without small fiber neuropathy (SFN). Second, to determine the correlation of different methods for measuring corneal nerve fiber length (CNFL) and nerve fiber area (NFA). Finally, we investigated the added value of automatic NFA analysis. Methods We included 20 healthy controls and 80 patients with sarcoidosis, 31 with established SFN and 49 without SFN. The CNFL was measured using CCMetrics, ACCMetrics, and NeuronJ. NFA was measured with NFA FIJI and ACCMetrics NFA. Results CNFL and NFA could not distinguish sarcoidosis with and without SFN or healthy controls. CCMetrics, NeuronJ, and ACCMetrics CNFL highly correlated. Also, NFA FIJI and ACCMetrics NFA highly correlated. Reproducing a nonlinear formula between CNFL and NFA confirmed the quadratic relation between NFA FIJI and ACCMetrics CNFL. CCMetrics and NeuronJ instead showed a square root relationship and seem to be less comparable owing to differences between automatic and manual techniques. Conclusions ACCMetrics can be used for fully automatic analysis of CCM images to optimize efficiency. However, CNFL and NFA do not seem to have a discriminatory value for SFN in sarcoidosis. Further research is needed to determine the added value and normative values of NFA in CCM analysis. Translational Relevance Our study improves the knowledge about CCM software and pathophysiology of SFN.
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Affiliation(s)
- Lisette R. M. Raasing
- ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Oscar J. M. Vogels
- ILD Center of Excellence, Department of Neurology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Mirjam Datema
- Department of Clinical Neurophysiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Martijn R. Tannemaat
- Department of Clinical Neurophysiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marcel Veltkamp
- ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jan C. Grutters
- ILD Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Division of Heart and Lungs, University Medical Center Utrecht, Utrecht, the Netherlands
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Bjørnkaer A, Gaist LM, Holbech JV, Gaist D, Wirenfeldt M, Sindrup SH, Krøigård T. Corneal confocal microscopy in small and mixed fiber neuropathy-Comparison with skin biopsy and cold detection in a large prospective cohort. J Peripher Nerv Syst 2023; 28:664-676. [PMID: 37651181 DOI: 10.1111/jns.12595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND AND AIMS The diagnosis of small fiber neuropathy (SFN) is supported by reduced intraepidermal nerve fiber density (IENFD). The noninvasive method corneal confocal microscopy (CCM) has the potential to be a practical alternative. We aimed to estimate the diagnostic accuracy of CCM compared with IENFD and cold detection thresholds (CDT) in SFN and mixed fiber neuropathy (MFN). METHODS CCM was performed in an unselected prospective cohort of patients with a clinical suspicion of polyneuropathy. Predefined criteria were used to classify SFN and MFN. Neuropathy scores, including the Utah early neuropathy scale (UENS), were used to describe severity. Patients with established other diagnoses were used for diagnostic specificity calculations. RESULTS Data were taken from 680 patients, of which 244 had SFN or MFN. There was no significant difference in sensitivities [95%CI] of CCM (0.44 [0.38-0.51]), IEFND (0.43 [0.36-0.49]), and CDT (0.34 [0.29-0.41]). CCM specificity (0.75 [0.69-0.81]) was lower (p = .044) than for IENFD (0.99 [0.96-1.00]) but not than for CDT (0.81 [0.75-0.86]). The AUCs of the ROC curves of 0.63, 0.63 and 0.74 respectively, was lower for corneal nerve fiber density (p = .0012) and corneal nerve fiber length (p = .0015) compared with IENFD. While UENS correlated significantly with IENFD (p = .0016; R2 = .041) and CDT (p = .0002; R2 = .056), it did not correlate with CCM measures. INTERPRETATION The diagnostic utility of CCM in SNF and MFN is limited by the low specificity compared with skin biopsy. Further, CCM is less suitable than skin biopsy and CDT as a marker for neuropathy severity.
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Affiliation(s)
- Asger Bjørnkaer
- Neurology Research Unit, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
| | - Laura M Gaist
- Neurology Research Unit, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
| | - Jakob V Holbech
- Neurology Research Unit, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
| | - David Gaist
- Neurology Research Unit, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
| | - Martin Wirenfeldt
- University of Southern Denmark, Odense, Denmark
- Pathology Research Unit, Odense University Hospital, Odense, Denmark
| | - Søren H Sindrup
- Neurology Research Unit, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
- Odense Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Thomas Krøigård
- Neurology Research Unit, Odense University Hospital, Odense, Denmark
- University of Southern Denmark, Odense, Denmark
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Zhang C, Zhu L, Liang X, Li Y, Sun G, Hu J, Zhang H. Corneal characteristics of Mongolian population with type 2 diabetic peripheral neuropathy in inner Mongolia, China: an assessment using corneal confocal microscopy. BMC Ophthalmol 2023; 23:460. [PMID: 37968622 PMCID: PMC10652475 DOI: 10.1186/s12886-023-03181-z] [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: 03/02/2023] [Accepted: 10/20/2023] [Indexed: 11/17/2023] Open
Abstract
OBJECTIVE To quantify corneal nerve fiber parameters in a Mongolian population with diabetic peripheral neuropathy (DPN) by corneal confocal microscopy. METHODS This study conducted a comprehensive evaluation of 114 participants from Hulunbuir between January 2020 and December 2021. The participants included healthy controls, Mongolian and Han patients with type 2 diabetes mellitus. Demographic, medical, and laboratory data were collected, and neuropathy was evaluated by confocal corneal microscopy. And compare various parameters between Han and Mongolian were performed using SPSS software. RESULTS The average waist circumference of Mongolian diabetic patients was larger than that of Han diabetic patients (P < 0.05). The mean HbA1c of Mongolian was 9.30 (8.15, 10.30) %, and that of Han was 8.30 (7.20, 9.40) % (P = 0.023). The average values of Corneal Nerve Fiber Density (CNFD), Corneal Nerve Fiber Length (CNFL) and corneal nerve branch density (CNBD) in Mongolian diabetic patients were significantly lower than those in Han diabetic patients (P < 0.05). The correlation coefficient between CNFL and age was - 0.368. ROC results show that CNBD has a certain diagnostic value for DPN in Mongolian patients with type 2 diabetes and the optimal cut-off point value is 24.99(no./mm2), the sensitivity is 80.0%, and the specificity is 77.8%. CONCLUSION The corneal confocal microscopy could possibly represent a promising adjuvant technique for the early diagnosis and assessment of PDN in Mongolian T2DM patients.
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Affiliation(s)
- Chi Zhang
- Department of Endocrinology, The Second Affiliated Hospital of Soochow University, 1055 San-Xiang Road, Suzhou, 215000, China
- Department of Endocrinology, Hulunbeir People's Hospital, Hulunbuir, China
| | - Lei Zhu
- Department of Orthopedics, Hulunbeir People's Hospital, Hulunbuir, China
| | - Xiuwen Liang
- Department of Cardiology, Hulunbuir Zhong Meng Hospital, Hulunbuir, China
| | - Yue Li
- Department of Ophthalmology, Hulunbeir People's Hospital, Hulunbuir, China
| | - Guotong Sun
- Department of Cardiology, Shouguang Hospital of T.C.M, Weifang, China
| | - Ji Hu
- Department of Endocrinology, The Second Affiliated Hospital of Soochow University, 1055 San-Xiang Road, Suzhou, 215000, China.
| | - Honghong Zhang
- Department of Endocrinology, The Second Affiliated Hospital of Soochow University, 1055 San-Xiang Road, Suzhou, 215000, China.
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Nortey J, Tsang A, Lopez S, Gebreegziabher E, Keenan JD, Lietman T, Gonzales JA. Central Corneal Subbasal Nerve Plexus Abnormalities in Sjögren Disease: A Pilot Study. Cornea 2023; 42:1432-1438. [PMID: 36747319 PMCID: PMC10404635 DOI: 10.1097/ico.0000000000003248] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 01/03/2023] [Indexed: 02/08/2023]
Abstract
PURPOSE Small-fiber neuropathy (SFN) is known to be associated with Sjögren disease (SjD), and in vivo corneal confocal microscopy can identify features compatible with SFN. Here, we performed a descriptive study to identify features of SFN of the corneal subbasal nerve plexus using in vivo confocal microscopy. METHODS We recruited 10 participants from the Sjögren's International Collaborative Clinical Alliance (SICCA), 1 new participant (in an effort to expand the SICCA cohort), and 22 healthy controls. All participants underwent slit-lamp examination and in vivo confocal microscopy of the central corneal subbasal nerve plexus centered about the central whorl to create a 30-image montage. Each image was analyzed with automated software (ACCmetrics, Manchester, United Kingdom) to produce 7 nerve metrics. We performed t-tests and age-adjusted regressions to make comparisons of nerve metrics between participants with SjD and healthy controls. RESULTS Most nerve metrics were significantly lower in participants with SjD compared with healthy controls. The mean corneal nerve fiber density was found to be 3.5 mm/mm 2 in participants with SjD compared with 10.6 mm/mm 2 in healthy controls (95% confidence interval, -8.4 to -0.93; P = 0.02). Within the 11 participants with SjD, 22 eyes were analyzed on confocal microscopy, and 16 of those eyes (from 9 individuals) did not have an identifiable central whorl. Within the 22 healthy controls, 22 eyes (right eye alone) were analyzed on confocal microscopy, and 21 of those eyes had an identifiable central whorl. CONCLUSIONS SjD exhibits lower corneal nerve metrics compared with healthy controls. These findings suggest that features compatible with SFN can distinguish SjD from healthy controls and may serve as a potential novel biomarker in identifying SjD.
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Affiliation(s)
- Jeremy Nortey
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA
- University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC; and
| | - Adrian Tsang
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA
| | - Sarah Lopez
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA
| | | | - Jeremy D Keenan
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA
| | - Tom Lietman
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA
| | - John A Gonzales
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA
- Department of Ophthalmology, University of California, San Francisco, San Francisco, CA
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Nosch DS, Käser E, Bracher T, Joos RE. Age-Related Changes in Corneal Sensitivity. Cornea 2023; 42:1257-1262. [PMID: 36730377 DOI: 10.1097/ico.0000000000003183] [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: 06/06/2022] [Accepted: 09/12/2022] [Indexed: 02/04/2023]
Abstract
PURPOSE The aim of this prospective cross-sectional cohort study was to clinically test whether corneal sensation decreases with age, based on subject feedback (psychophysical method), and whether it correlates with general pain perception. METHODS Subjects were recruited from 2 equally large age groups: group A (18-30 years) and group B (50-70 years; n = 45 per group). The inclusion criteria were healthy eyes, Ocular Surface Disease Index ≤13, and no contact lens wear. Corneal sensitivity threshold (CST) measurements were performed twice during each of the 2 visits, with the aid of the new Swiss liquid jet esthesiometer for corneal sensitivity (SLACS) and Cochet-Bonnet (CB) esthesiometer. A general pain sensitivity score was obtained from all participants. RESULTS Ninety subjects completed the study (n = 45 per age group, average age in group A: 24.2 ± 2.94 years, group B: 58.5 ± 5.71 years). Statistically higher CSTs for age group B were only observed for SLACS (mean difference: 1.58 dB, P < 0.001). No correlation was observed between the pain score and the CSTs obtained with either esthesiometry method (r = 0.11, P = 0.25 for liquid jet and r=-0.076, P = 0.61 CB). CONCLUSIONS A statistically significant decrease in corneal sensitivity was observed for the older age group with SLACS in this study, with CB however only a trend in the same direction was noted. General pain perception was not found to correlate with ocular surface sensation.
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Affiliation(s)
- Daniela S Nosch
- Institute of Optometry, School of Engineering, University of Applied Sciences and Arts Northwestern Switzerland (FHNW), Olten, Switzerland
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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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11
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Su D, Zhang J, Wu Y, Wang W, Wang W, Shao C, Li J. Evaluation of Corneal Nerve Regeneration After Minimally Invasive Corneal Neurotization. Asia Pac J Ophthalmol (Phila) 2023; 12:427-436. [PMID: 37527446 DOI: 10.1097/apo.0000000000000626] [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: 01/20/2023] [Accepted: 05/31/2023] [Indexed: 08/03/2023] Open
Abstract
PURPOSE To evaluate the corneal nerve regeneration after minimally invasive corneal neurotization (MICN) and to further clarify the recovery patterns of sensory and trophic functions of the corneal nerves. DESIGN A retrospective cohort study based in the Shanghai Ninth People's Hospital. METHODS Eighteen patients (18 eyes) who underwent MICN for neurotrophic keratopathy due to intracranial surgery was conducted to analyze their follow-up data at 6, 12, 18, and 24 months after surgery. RESULTS At 12 months postoperatively, the growth of the central and peripheral corneal nerve fiber density (CNFD) was 11.47±8.56 and 14.73±8.08 n/mm 2 with subsequent improvement slowing down, and the patient's corneal epithelium defect was healed ahead of the accomplishment of corneal nerve regeneration. The number of dendritic cells also reached its peak. At 18 months postoperatively, the recovery of central and peripheral corneal sensation was 37.22±23.06 mm and 39.38±18.08 mm with no subsequent improvement, and the growth of the central and peripheral corneal nerve branch density (CNBD) was 29.69±11.05 and 43.75±1.41 n/mm 2 , with a positive and significant correlation between corneal sensation and CNBD (at central r =0.632, P <0.005; at peripheral r =0.645, P <0.005). At 24 months postoperatively, mean CNFD, CNBD, and corneal sensation recovered significantly compared with preoperative, but a few patients' corneal sensation recovered insignificantly with good CNFD recovery and poor CNBD recovery. CONCLUSIONS After MICN, the trophic function of the corneal nerve recovers before the sensory function, and in particular, the recovery of sensation is based on the coexistence of the corneal nerve trunk and branches.
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Affiliation(s)
- Dai Su
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Jiaying Zhang
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Yue Wu
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Wenjin Wang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Wang
- Department of Plastic and Reconstructive Surgery, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chunyi Shao
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
| | - Jin Li
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Ophthalmology, Shanghai Key Laboratory of Orbital Diseases and Ocular Oncology, Shanghai, China
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12
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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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13
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Guldiken YC, Petropoulos IN, Malik A, Malik RA, Yüksel R, Budak F, Selekler HM. Corneal confocal microscopy identifies corneal nerve fiber loss in patients with migraine. Cephalalgia 2023; 43:3331024231170810. [PMID: 37177828 DOI: 10.1177/03331024231170810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND/HYPOTHESIS Migraine affects >1 billion people but its pathophysiology remains poorly understood. Alterations in the trigeminovascular system play an important role. We have compared corneal nerve morphology in patients with migraine to healthy controls. METHODS Sixty patients with episodic (n = 32) or chronic (n = 28) migraine and 20 age-matched healthy control subjects were studied cross-sectionally. Their migraine characteristics and signs and symptoms of dry eyes were assessed. Manual and automated quantification of corneal nerves was undertaken by corneal confocal microscopy. RESULTS In patients with migraine compared to controls, manual corneal nerve fiber density (P < 0.001), branch density (P = 0.015) and length (P < 0.001); and automated corneal nerve fiber density (P < 0.001), branch density (P < 0.001), length (P < 0.001), total branch density (P < 0.001), nerve fiber area (P < 0.001), nerve fiber width (P = 0.045) and fractal dimension (P < 0.001) were lower. Automated corneal nerve fiber density was higher in patients with episodic migraine and aura (P = 0.010); and fractal dimension (P = 0.029) was lower in patients with more headache days in the last three months. Automated corneal nerve fiber density predicted a significant amount of the observed variance in pain intensity (adjusted r2 = 0.14, partial r = -0.37, P = 0.004) in patients with migraine. CONCLUSIONS Corneal confocal microscopy reveals corneal nerve loss in patients with migraine. It may serve as an objective imaging biomarker of neurodegeneration in migraine.
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Affiliation(s)
- Yigit Can Guldiken
- Department of Neurology, Kocaeli University Research and Application Hospital, İzmit/Kocaeli, Turkey
| | | | - Ayesha Malik
- Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Rayaz A Malik
- Weill Cornell Medicine-Qatar, Qatar Foundation, Education City, Doha, Qatar
| | - Refref Yüksel
- Department of Ophthalmology, Kocaeli University Research and Application Hospital, İzmit/Kocaeli, Turkey
| | - Faik Budak
- Department of Neurology, Kocaeli University Research and Application Hospital, İzmit/Kocaeli, Turkey
| | - Hamit Macit Selekler
- Department of Neurology, Kocaeli University Research and Application Hospital, İzmit/Kocaeli, Turkey
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Small Fiber Neuropathy: A Clinical and Practical Approach. J Nurse Pract 2023. [DOI: 10.1016/j.nurpra.2023.104547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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15
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Kv R, Prasad K, Peralam Yegneswaran P. Segmentation and Classification Approaches of Clinically Relevant Curvilinear Structures: A Review. J Med Syst 2023; 47:40. [PMID: 36971852 PMCID: PMC10042761 DOI: 10.1007/s10916-023-01927-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/25/2023] [Indexed: 03/29/2023]
Abstract
Detection of curvilinear structures from microscopic images, which help the clinicians to make an unambiguous diagnosis is assuming paramount importance in recent clinical practice. Appearance and size of dermatophytic hyphae, keratitic fungi, corneal and retinal vessels vary widely making their automated detection cumbersome. Automated deep learning methods, endowed with superior self-learning capacity, have superseded the traditional machine learning methods, especially in complex images with challenging background. Automatic feature learning ability using large input data with better generalization and recognition capability, but devoid of human interference and excessive pre-processing, is highly beneficial in the above context. Varied attempts have been made by researchers to overcome challenges such as thin vessels, bifurcations and obstructive lesions in retinal vessel detection as revealed through several publications reviewed here. Revelations of diabetic neuropathic complications such as tortuosity, changes in the density and angles of the corneal fibers have been successfully sorted in many publications reviewed here. Since artifacts complicate the images and affect the quality of analysis, methods addressing these challenges have been described. Traditional and deep learning methods, that have been adapted and published between 2015 and 2021 covering retinal vessels, corneal nerves and filamentous fungi have been summarized in this review. We find several novel and meritorious ideas and techniques being put to use in the case of retinal vessel segmentation and classification, which by way of cross-domain adaptation can be utilized in the case of corneal and filamentous fungi also, making suitable adaptations to the challenges to be addressed.
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Affiliation(s)
- Rajitha Kv
- Department of Biomedical Engineering, Manipal Institute of Technology, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
| | - Keerthana Prasad
- Manipal School of Information Sciences, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India.
| | - Prakash Peralam Yegneswaran
- Department of Microbiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India
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Røikjer J, Croosu SS, Sejergaard BF, Hansen TM, Frøkjær JB, Søndergaard CB, Petropoulos IN, Malik RA, Nielsen E, Mørch CD, Ejskjaer N. Diagnostic Accuracy of Perception Threshold Tracking in the Detection of Small Fiber Damage in Type 1 Diabetes. J Diabetes Sci Technol 2023:19322968231157431. [PMID: 36825610 DOI: 10.1177/19322968231157431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
AIM An objective assessment of small nerve fibers is key to the early detection of diabetic peripheral neuropathy (DPN). This study investigates the diagnostic accuracy of a novel perception threshold tracking technique in detecting small nerve fiber damage. METHODS Participants with type 1 diabetes (T1DM) without DPN (n = 20), with DPN (n = 20), with painful DPN (n = 20) and 20 healthy controls (HCs) underwent perception threshold tracking on the foot and corneal confocal microscopy. Diagnostic accuracy of perception threshold tracking compared to corneal confocal microscopy was analyzed using logistic regression. RESULTS The rheobase, corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), and corneal nerve fiber length (CNFL) (all P < .001) differed between groups. The diagnostic accuracy of perception threshold tracking (rheobase) was excellent for identifying small nerve fiber damage, especially for CNFL with a sensitivity of 94%, specificity 94%, positive predictive value 97%, and negative predictive value 89%. There was a significant correlation between rheobase with CNFD, CNBD, CNFL, and Michigan Neuropathy Screening Instrument (all P < .001). CONCLUSION Perception threshold tracking had a very high diagnostic agreement with corneal confocal microscopy for detecting small nerve fiber loss and may have clinical utility for assessing small nerve fiber damage and hence early DPN. CLINICAL TRIALS NCT04078516.
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Affiliation(s)
- Johan Røikjer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Suganthiya Santhiapillai Croosu
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Tine Maria Hansen
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jens Brøndum Frøkjær
- Department of Radiology, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | | | | | - Esben Nielsen
- Department of Ophthalmology, Aarhus University Hospital, Aarhus, Denmark
| | - Carsten Dahl Mørch
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
- Center for Neuroplasticity and Pain, Center for Sensory-Motor Interaction, Aalborg, Denmark
| | - Niels Ejskjaer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Clinical Medicine and Endocrinology, Aalborg University Hospital, Aalborg, Denmark
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17
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Marshall A, Kalteniece A, Ferdousi M, Azmi S, Jude EB, Adamson C, D’Onofrio L, Dhage S, Soran H, Campbell J, Lee-Kubli CA, Hamdy S, Malik RA, Calcutt NA, Marshall AG. Spinal disinhibition: evidence for a hyperpathia phenotype in painful diabetic neuropathy. Brain Commun 2023; 5:fcad051. [PMID: 36938521 PMCID: PMC10016414 DOI: 10.1093/braincomms/fcad051] [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: 05/10/2022] [Revised: 01/09/2023] [Accepted: 02/27/2023] [Indexed: 03/05/2023] Open
Abstract
The dominant sensory phenotype in patients with diabetic polyneuropathy and neuropathic pain is a loss of function. This raises questions as to which mechanisms underlie pain generation in the face of potentially reduced afferent input. One potential mechanism is spinal disinhibition, whereby a loss of spinal inhibition leads to increased ascending nociceptive drive due to amplification of, or a failure to suppress, incoming signals from the periphery. We aimed to explore whether a putative biomarker of spinal disinhibition, impaired rate-dependent depression of the Hoffmann reflex, is associated with a mechanistically appropriate and distinct pain phenotype in patients with painful diabetic neuropathy. In this cross-sectional study, 93 patients with diabetic neuropathy underwent testing of Hoffmann reflex rate-dependent depression and detailed clinical and sensory phenotyping, including quantitative sensory testing. Compared to neuropathic patients without pain, patients with painful diabetic neuropathy had impaired Hoffmann reflex rate-dependent depression at 1, 2 and 3 Hz (P ≤ 0.001). Patients with painful diabetic neuropathy exhibited an overall loss of function profile on quantitative sensory testing. However, within the painful diabetic neuropathy group, cluster analysis showed evidence of greater spinal disinhibition associated with greater mechanical pain sensitivity, relative heat hyperalgesia and higher ratings of spontaneous burning pain. These findings support spinal disinhibition as an important centrally mediated pain amplification mechanism in painful diabetic neuropathy. Furthermore, our analysis indicates an association between spinal disinhibition and a distinct phenotype, arguably akin to hyperpathia, with combined loss and relative gain of function leading to increasing nociceptive drive.
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Affiliation(s)
- Anne Marshall
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
- Institute of Life course and Medical Sciences, University of Liverpool, Liverpool L69 3BX, UK
| | - Alise Kalteniece
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Maryam Ferdousi
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Shazli Azmi
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
- Diabetes Centre, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK
| | - Edward B Jude
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
- Department of Diabetes and Endocrinology, Tameside and Glossop Integrated Care NHS Foundation Trust, Manchester OL6 9RW, UK
| | - Clare Adamson
- Diabetes Centre, Manchester University NHS Foundation Trust, Manchester M13 9WL, UK
| | - Luca D’Onofrio
- Department of Experimental Medicine, Sapienza University, Rome 00185, Italy
| | - Shaishav Dhage
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Handrean Soran
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Jackie Campbell
- Faculty of Health, Education and Society, University of Northampton, Northampton NN1 5PH, UK
| | - Corinne A Lee-Kubli
- Molecular Neurobiology Laboratory, The Salk Institute for Biological Studies, La Jolla, CA 92037, USA
| | - Shaheen Hamdy
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
| | - Rayaz A Malik
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK
- Weill Cornell Medicine-Qatar, Research Division, Qatar Foundation, Doha 24144, Qatar
| | - Nigel A Calcutt
- Department of Pathology, University of California, La Jolla, CA 92093, USA
| | - Andrew G Marshall
- Correspondence to: Andrew G. Marshall The Pain Research Institute, Aintree University Hospital 2nd Floor Clinical Science Centre, Lower Lane, Liverpool L9 7AL, UK E-mail:
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Andreeva IG, Gvozdeva A, Pimenova V, Ryabkova V, Lukashenko M, Kamaeva E, Shapkina V, Soprun L, Gavrilova N, Fedotkina TV, Churilov LP, Shoenfeld Y. Assessment of Hearing and Vestibular Functions in a Post-COVID-19 Patient: A Clinical Case Study. Diagnostics (Basel) 2022; 13:diagnostics13010122. [PMID: 36611414 PMCID: PMC9819003 DOI: 10.3390/diagnostics13010122] [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: 10/03/2022] [Revised: 12/19/2022] [Accepted: 12/21/2022] [Indexed: 12/31/2022] Open
Abstract
SARS-CoV-2 infection may cause such complications as post-COVID-19 syndrome, which includes chronic fatigue, myalgia, arthralgia, as well as a variety of neurological manifestations, e.g., neuropathy of small fibers, hearing and vestibular dysfunction, and cognitive impairment. This clinical case describes a 41-year-old patient suffering from post-COVID-19 syndrome and chronic fatigue syndrome. A detailed examination was performed, including an in-depth study of peripheral and central hearing and vestibular functions, as well as small nerve fibers length and density in the skin and cornea of the eye. Contrary to expectations, no peripheral nervous system dysfunction was detected, despite the presence of dizziness and gait instability in the patient. Hearing tests (gap detection test and dichotic test) showed central auditory processing disorders. The evaluated lesion in the processing of temporal and verbal auditory information can be a significant factor contributing to additional overload of the neural activity and leading to chronic fatigue when performing daily activities in patients with CFS and post-COVID-19 complications.
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Affiliation(s)
- Irina Germanovna Andreeva
- Sechenov Institute of Evolutionary Physiology and Biochemistry of the Russian Academy of Sciences (IEPhB RAS), Laboratory of Comparative Sensory Physiology, 194223 St. Petersburg, Russia
| | - Alisa Gvozdeva
- Sechenov Institute of Evolutionary Physiology and Biochemistry of the Russian Academy of Sciences (IEPhB RAS), Laboratory of Comparative Sensory Physiology, 194223 St. Petersburg, Russia
| | - Vera Pimenova
- Sechenov Institute of Evolutionary Physiology and Biochemistry of the Russian Academy of Sciences (IEPhB RAS), Laboratory of Comparative Sensory Physiology, 194223 St. Petersburg, Russia
| | - Varvara Ryabkova
- Department of Therapy, Pavlov First St. Petersburg State Medical University, 197022 St. Petersburg, Russia
- Laboratory of the Mosaic of Autoimmunity, Saint-Petersburg State University, 199034 St. Petersburg, Russia
| | - Maria Lukashenko
- Laboratory of the Mosaic of Autoimmunity, Saint-Petersburg State University, 199034 St. Petersburg, Russia
| | - Evelina Kamaeva
- Laboratory of the Mosaic of Autoimmunity, Saint-Petersburg State University, 199034 St. Petersburg, Russia
| | - Valeria Shapkina
- Department of Hospital Surgery, Saint-Petersburg State University, 199034 St. Petersburg, Russia
| | - Lidia Soprun
- Department of Healthcare and Medical law, Saint-Petersburg State University, 199034 St. Petersburg, Russia
- Outpatient Clinic No. 1, Saint-Petersburg State University Clinic, 190103 St. Petersburg, Russia
| | - Natalia Gavrilova
- Outpatient Clinic No. 1, Saint-Petersburg State University Clinic, 190103 St. Petersburg, Russia
- Department of Faculty Therapy, Saint-Petersburg State University, 199034 St. Petersburg, Russia
- St. Petersburg Research Institute of Phthisiopulmonology of the Ministry of Health of the Russian Federation, 191036 St. Petersburg, Russia
- Correspondence:
| | - Tamara Viktorovna Fedotkina
- Sechenov Institute of Evolutionary Physiology and Biochemistry of the Russian Academy of Sciences (IEPhB RAS), Laboratory of Comparative Sensory Physiology, 194223 St. Petersburg, Russia
- Laboratory of the Mosaic of Autoimmunity, Saint-Petersburg State University, 199034 St. Petersburg, Russia
| | - Leonid Pavlovich Churilov
- St. Petersburg Research Institute of Phthisiopulmonology of the Ministry of Health of the Russian Federation, 191036 St. Petersburg, Russia
- Department of Pathology, Saint-Petersburg State University, 199034 St. Petersburg, Russia
| | - Yehuda Shoenfeld
- Laboratory of the Mosaic of Autoimmunity, Saint-Petersburg State University, 199034 St. Petersburg, Russia
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel HaShomer 5265601, Israel
- Sackler Faculty of Medicine, Ariel University, Ariel 40700, Israel
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Zhang Z, Lu S, Jiang Y, Sun S. Assessing the corneal sub-basal nerve plexus by in vivo confocal microscopy in patients with blepharoptosis. Ann Med 2022; 54:227-234. [PMID: 35014936 PMCID: PMC8757600 DOI: 10.1080/07853890.2021.2024246] [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] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND To assess in vivo confocal microscopy features of corneal sub-basal nerve plexus in patients with congenital or aponeurogenic blepharoptosis using a fully automated software (ACCMetrics). PATIENTS AND METHODS This prospective study included 33 patients with blepharoptosis and 17 normal controls. The corneal sub-basal nerve plexus was assessed using in vivo confocal microscopy, and the ocular surface status was evaluated by tear break-up times. RESULTS The mean age of 33 patients with blepharoptosis and 17 normal controls were 38.77 ± 22.81 years and 48.35 ± 17.15 years, respectively. The mean duration of blepharoptosis was 16.42 ± 15.60 years. In 13 patients with unilateral blepharoptosis, there was no significant difference between affected eyes and contralateral eyes (all ps > .05), except for wider corneal nerve fibre width (CNFW) in affected eyes (0.024 ± 0.001 versus 0.023 ± 0.001 mm/mm2, p = .021). In 20 patients with bilateral blepharoptosis, there was no significant difference between the eyes. No significant difference was detected between 19 cases with congenital blepharoptosis and 14 cases with aponeurogenic blepharoptosis. When compared with normal controls, eyes with both unilateral and bilateral blepharoptosis had significantly wider CNFW. But from the point of aetiology, only eyes with congenital blepharoptosis presented with wider CNFW (p = .001), rather than the eyes with aponeurogenic blepharoptosis (p = .093). Besides, four young patients with congenital blepharoptosis revealed very sparse sub-basal nerve plexus. CONCLUSIONS These data suggested that corneal confocal microscopy demonstrated no significant changes in patients with blepharoptosis as compared with normal controls, except for relatively wider CNFW in congenital affected eyes. However, in some children and young adults with congenital blepharoptosis, the density of corneal sub-basal nerve plexus was evidently decreased, which needs to be cautioned when ones with congenital blepharoptosis want to take corneal surgeries or wear contact lens.Key messagesWhen compared with normal controls, no significant effect was found in the influence of blepharoptosis on the most of corneal nerve parameters, except for corneal nerve fibre width (CNFW) in the group of congenital blepharoptosis.The age of onset of blepharoptosis may influence corneal nerve fibres, so timely surgical treatment of congenital blepharoptosis is not only conducive to the development of normal vision, but also beneficial to the reduction of corneal nerve lesions to some extent.We noted that some young blepharoptosis patients revealed sparse corneal nerve, which should be taken precaution when ones with congenital blepharoptosis who want to take corneal surgeries or wear contact lens.
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Affiliation(s)
- Zhengwei Zhang
- Department of Ophthalmology, Affiliated Wuxi Clinical College of Nantong University, Wuxi, People's Republic of China.,Department of Ophthalmology, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, People's Republic of China
| | - Shui Lu
- Department of Ophthalmology, Affiliated Wuxi Clinical College of Nantong University, Wuxi, People's Republic of China.,Department of Ophthalmology, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, People's Republic of China
| | - Yunjia Jiang
- Department of Ophthalmology, Affiliated Wuxi Clinical College of Nantong University, Wuxi, People's Republic of China.,Department of Ophthalmology, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, People's Republic of China
| | - Song Sun
- Department of Ophthalmology, Affiliated Wuxi Clinical College of Nantong University, Wuxi, People's Republic of China.,Department of Ophthalmology, The Affiliated Wuxi No. 2 People's Hospital of Nanjing Medical University, Wuxi, People's Republic of China
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20
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So WZ, Qi Wong NS, Tan HC, Yu Lin MT, Yu Lee IX, Mehta JS, Liu YC. Diabetic corneal neuropathy as a surrogate marker for diabetic peripheral neuropathy. Neural Regen Res 2022; 17:2172-2178. [PMID: 35259825 PMCID: PMC9083173 DOI: 10.4103/1673-5374.327364] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Diabetic neuropathy is a prevalent microvascular complication of diabetes mellitus, affecting nerves in all parts of the body including corneal nerves and peripheral nervous system, leading to diabetic corneal neuropathy and diabetic peripheral neuropathy, respectively. Diabetic peripheral neuropathy is diagnosed in clinical practice using electrophysiological nerve conduction studies, clinical scoring, and skin biopsies. However, these diagnostic methods have limited sensitivity in detecting small-fiber disease, hence they do not accurately reflect the status of diabetic neuropathy. More recently, analysis of alterations in the corneal nerves has emerged as a promising surrogate marker for diabetic peripheral neuropathy. In this review, we will discuss the relationship between diabetic corneal neuropathy and diabetic peripheral neuropathy, elaborating on the foundational aspects of each: pathogenesis, clinical presentation, evaluation, and management. We will further discuss the relevance of diabetic corneal neuropathy in detecting the presence of diabetic peripheral neuropathy, particularly early diabetic peripheral neuropathy; the correlation between the severity of diabetic corneal neuropathy and that of diabetic peripheral neuropathy; and the role of diabetic corneal neuropathy in the stratification of complications of diabetic peripheral neuropathy.
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Affiliation(s)
- Wei Zheng So
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Singapore Eye Research Institute, Singapore, Singapore
| | - Natalie Shi Qi Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Singapore Eye Research Institute, Singapore, Singapore
| | - Hong Chang Tan
- Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | | | | | - Jodhbir S Mehta
- 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, Singapore
| | - Yu-Chi Liu
- 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, Singapore
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21
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Che NN, Chen S, Jiang QH, Chen SY, Zhao ZX, Li X, Malik RA, Ma JJ, Yang HQ. Corneal confocal microscopy differentiates patients with Parkinson’s disease with and without autonomic involvement. NPJ Parkinsons Dis 2022; 8:114. [PMID: 36085290 PMCID: PMC9463159 DOI: 10.1038/s41531-022-00387-8] [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: 03/22/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022] Open
Abstract
Autonomic dysregulation in Parkinson’s disease (PD) can precede motor deficits and is associated with reduced quality of life, disease progression, and increased mortality. Objective markers of autonomic involvement in PD are limited. Corneal confocal microscopy (CCM) is a rapid ophthalmic technique that can quantify small nerve damage in a range of peripheral and autonomic neuropathies. Here we investigated whether CCM can be used to assess autonomic symptoms in PD. Based on the scale for outcomes in Parkinson’s disease for autonomic symptoms (SCOPA-AUT), patients with PD were classified into those without autonomic symptoms (AutD-N), with single (AutD-S), and multiple (AutD-M) domain autonomic dysfunction. Corneal nerve fiber pathology was quantified using CCM, and the relationship with autonomic symptoms was explored. The study enrolled 71 PD patients and 30 control subjects. Corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), corneal nerve fiber length (CNFL), and CNBD/CNFD ratio were lower in PD patients with autonomic symptoms compared to those without autonomic symptoms. Autonomic symptoms correlated positively with CNFD (r = −0.350, p = 0.004), and were not related to Levodopa equivalent daily dose (r = 0.042, p = 0.733) after adjusting for age, disease severity, disease duration or cognitive function. CCM parameters had high sensitivity and specificity in distinguishing patients with PD with and without autonomic symptoms. PD patients with autonomic symptoms have corneal nerve loss, and CCM could serve as an objective ophthalmic imaging technique to identify patients with PD and autonomic symptoms.
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22
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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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23
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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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24
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Seeliger T, Gehlhaar MA, Oluwatoba-Popoola I, Konen FF, Haar M, Donicova E, Wachsmann M, Pielen A, Gingele S, Prenzler NK, Ernst D, Witte T, Framme C, Bajor A, Skripuletz T. Trigeminal Nerve Affection in Patients with Neuro-Sjögren Detected by Corneal Confocal Microscopy. J Clin Med 2022; 11:jcm11154484. [PMID: 35956101 PMCID: PMC9369441 DOI: 10.3390/jcm11154484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 07/28/2022] [Accepted: 07/30/2022] [Indexed: 01/29/2023] Open
Abstract
Background: Patients with Sjögren’s syndrome and polyneuropathy more frequently develop cranial nerve affection when compared to patients with chronic inflammatory demyelinating polyneuropathy (CIDP). We therefore aimed to analyze trigeminal corneal nerve fibre characteristics in both patient groups. Methods: A total of 26 patients with Sjögren’s syndrome associated neuropathy and 29 patients with CIDP were recruited at our university hospital and compared to 6 healthy controls. Dry eye symptoms and signs were assessed via clinical examination and the Ocular Disease Surface Index questionnaire. Trigeminal corneal nerve fibres were analyzed via corneal confocal microscopy (CCM) as a non-invasive in vivo microscopy. Results: CCM revealed significantly reduced corneal nerve fibre density and corneal nerve fibre main branch density in the Neuro-Sjögren group when compared with healthy controls. There were no significant group differences between the Neuro-Sjögren and the CIDP group for any of the microscopic parameters. Dry eye assessment showed similarly reduced scores for both patient groups, while healthy controls showed better results for objective dry eye signs. There was no correlation between microscopic parameters of the corneal confocal microscopy and parameters of dry eye assessment. Conclusions: Our data revealed trigeminal corneal nerve affection in patients with neuropathy associated with Sjögren’s syndrome and patients with CIDP detected by CCM. No difference was found between both neuropathy groups indicating that CCM is not able to distinguish between both entities.
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Affiliation(s)
- Tabea Seeliger
- Department of Neurology, Hannover Medical School, 30625 Hannover, Germany; (T.S.); (F.F.K.); (S.G.)
| | - Marten A. Gehlhaar
- Department of Ophthalmology, Hannover Medical School, 30625 Hannover, Germany; (M.A.G.); (I.O.-P.); (M.H.); (E.D.); (M.W.); (A.P.); (C.F.); (A.B.)
| | - Irene Oluwatoba-Popoola
- Department of Ophthalmology, Hannover Medical School, 30625 Hannover, Germany; (M.A.G.); (I.O.-P.); (M.H.); (E.D.); (M.W.); (A.P.); (C.F.); (A.B.)
| | - Franz F. Konen
- Department of Neurology, Hannover Medical School, 30625 Hannover, Germany; (T.S.); (F.F.K.); (S.G.)
| | - Melanie Haar
- Department of Ophthalmology, Hannover Medical School, 30625 Hannover, Germany; (M.A.G.); (I.O.-P.); (M.H.); (E.D.); (M.W.); (A.P.); (C.F.); (A.B.)
| | - Emilia Donicova
- Department of Ophthalmology, Hannover Medical School, 30625 Hannover, Germany; (M.A.G.); (I.O.-P.); (M.H.); (E.D.); (M.W.); (A.P.); (C.F.); (A.B.)
| | - Marija Wachsmann
- Department of Ophthalmology, Hannover Medical School, 30625 Hannover, Germany; (M.A.G.); (I.O.-P.); (M.H.); (E.D.); (M.W.); (A.P.); (C.F.); (A.B.)
| | - Amelie Pielen
- Department of Ophthalmology, Hannover Medical School, 30625 Hannover, Germany; (M.A.G.); (I.O.-P.); (M.H.); (E.D.); (M.W.); (A.P.); (C.F.); (A.B.)
| | - Stefan Gingele
- Department of Neurology, Hannover Medical School, 30625 Hannover, Germany; (T.S.); (F.F.K.); (S.G.)
| | - Nils K. Prenzler
- Department of Otolaryngology, Hannover Medical School, 30625 Hannover, Germany;
| | - Diana Ernst
- Department of Rheumatology & Immunology, Hannover Medical School, 30625 Hannover, Germany; (D.E.); (T.W.)
| | - Torsten Witte
- Department of Rheumatology & Immunology, Hannover Medical School, 30625 Hannover, Germany; (D.E.); (T.W.)
| | - Carsten Framme
- Department of Ophthalmology, Hannover Medical School, 30625 Hannover, Germany; (M.A.G.); (I.O.-P.); (M.H.); (E.D.); (M.W.); (A.P.); (C.F.); (A.B.)
| | - Anna Bajor
- Department of Ophthalmology, Hannover Medical School, 30625 Hannover, Germany; (M.A.G.); (I.O.-P.); (M.H.); (E.D.); (M.W.); (A.P.); (C.F.); (A.B.)
| | - Thomas Skripuletz
- Department of Neurology, Hannover Medical School, 30625 Hannover, Germany; (T.S.); (F.F.K.); (S.G.)
- Correspondence: ; Tel.: +49-511-532-3816
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25
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Malik RA. Corneal confocal microscopy for the assessment of diabetic neuropathy and beyond in Brazil. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:767-769. [PMID: 36252583 PMCID: PMC9703882 DOI: 10.1055/s-0042-1756169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Rayaz A. Malik
- Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, Doha, Qatar
- University of Manchester, Division of Cardiovascular Sciences, Manchester, United Kingdom
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26
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Recombinant Human Nerve Growth Factor for Pediatric Neurotrophic Keratopathy. Eye Contact Lens 2022; 48:303-305. [PMID: 35726907 DOI: 10.1097/icl.0000000000000912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2022] [Indexed: 11/25/2022]
Abstract
ABSTRACT A 4-year-old boy presented with right neurotrophic corneal ulcer, lagophthalmos, and facial palsy 8 months after neurosurgery for synchronous brain tumors. Initial treatment with topical antibiotics, topical corticosteroids, lubrication, and lateral tarsorrhaphy successfully treated the corneal epithelial defect; however, the cornea continued to demonstrate diffuse epitheliopathy and a dense stromal opacity and remained insensate on Cochet-Bonnet esthesiometry. After a course of topical cenegermin, central corneal sensation normalized, and the corneal epitheliopathy was markedly improved. Two years after the completion of cenegermin, corneal sensation was maintained; there were no recurrences of epithelial defects, and the stromal opacity had markedly improved. In vivo confocal microscopy (IVCM) demonstrated the presence of subbasal corneal innervation. This report highlights the safety and prolonged effects of cenegermin for the treatment of pediatric iatrogenic neurotrophic keratopathy, as evidenced by the clinical course and IVCM.
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27
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Corneal toxicity associated with belantamab mafodotin is not restricted to the epithelium: neuropathy studied with confocal microscopy. Am J Ophthalmol 2022; 242:116-124. [PMID: 35752319 DOI: 10.1016/j.ajo.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/12/2022] [Accepted: 06/13/2022] [Indexed: 11/20/2022]
Abstract
PURPOSE The purpose of this study was to investigate epithelial and neuronal changes in patients with refractory/relapsed multiple myeloma (RRMM) before/during belantamab mafodotin (belamaf) treatment using confocal microscopy. DESIGN Retrospective case series. METHODS RRMM patients underwent best corrected visual acuity (BCVA) testing and slit-lamp examination/photography, followed by corneal confocal microscopy (CCM) to evaluate the epithelium and subbasal nerve plexus (SNP) to measure corneal nerve fiber density (CNFD), -branch density (CNBD), and -fiber length (CNFL) before and during belamaf treatment. RESULTS In 14 eyes of 7 patients (4 female, 68±10 years) with complete follow-up (4±2 months), the median BCVA dropped from 20/25 (20/25-20/20) to 20/40 (20/200-20/32) in the worse eye at the end of follow-up. Microcystic epithelial changes and ocular surface disease were demonstrated biomicroscopically. CCM showed "grape-like" hyperreflective spots in the central basal epithelium that changed to polymorphous-structured cysts in the superficial epithelium, with no pathology detected at the(peri-)limbal structures. The baseline, normal SNP morphology with a mean CNFD, CNBD, and CNFL of 20.25±7.06/mm2, 19.49±12.34/mm2, and 11.8±3.74mm/mm2 respectively, showed severe fiber fragmentation during follow-up, and an observed complete loss of the SNP at the end of follow-up in all eyes. CONCLUSIONS This study is the first to illustrate neurotoxic effects of belamaf on the human cornea.
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28
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Enax-Krumova EK, Dahlhaus I, Görlach J, Claeys KG, Montagnese F, Schneider L, Sturm D, Fangerau T, Schlierbach H, Roth A, Wanschitz JV, Löscher WN, Güttsches AK, Vielhaber S, Hasseli R, Zunk L, Krämer HH, Hahn A, Schoser B, Rosenbohm A, Schänzer A. Small fiber involvement is independent from clinical pain in late-onset Pompe disease. Orphanet J Rare Dis 2022; 17:177. [PMID: 35477515 PMCID: PMC9044713 DOI: 10.1186/s13023-022-02327-4] [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: 02/10/2022] [Accepted: 04/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain occurs in the majority of patients with late onset Pompe disease (LOPD) and is associated with a reduced quality of life. The aim of this study was to analyse the pain characteristics and its relation to a small nerve fiber involvement in LOPD patients. METHODS In 35 patients with LOPD under enzyme replacement therapy without clinical signs of polyneuropathy (19 females; 51 ± 15 years), pain characteristics as well as depressive and anxiety symptoms were assessed using the PainDetect questionnaire (PDQ) and the hospital anxiety and depression scale (HADS), respectively. Distal skin biopsies were analysed for intraepidermal nerve fiber density (IENFD) and compared to age- and gender-matched reference data. Skin biopsies from 20 healthy subjects served as controls to assure validity of the morphometric analysis. RESULTS Pain was reported in 69% of the patients with an average intensity of 4.1 ± 1.1 on the numeric rating scale (NRS; anchors: 0-10). According to PDQ, neuropathic pain was likely in one patient, possible in 29%, and unlikely in 67%. Relevant depression and anxiety symptoms occurred in 31% and 23%, respectively, and correlated with pain intensity. Distal IENFD (3.98 ± 1.95 fibers/mm) was reduced in 57% of the patients. The degree of IENFD reduction did not correlate with the durations of symptoms to ERT or duration of ERT to biopsy. CONCLUSIONS Pain is a frequent symptom in treated LOPD on ERT, though a screening questionnaire seldom indicated neuropathic pain. The high frequency of small nerve fiber pathology in a treated LOPD cohort was found regardless of the presence of pain or comorbid risk factors for SFN and needs further exploration in terms of clinical context, exact mechanisms and when developing novel therapeutic options for LOPD.
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Affiliation(s)
- Elena K Enax-Krumova
- Department of Neurology, BG University Hospital Bergmannsheil, Ruhr-University, Bochum, Germany.,Heimer-Institute for Muscle Research, BG University Hospital Bergmannsheil, Ruhr-University, Bochum, Germany
| | - Iris Dahlhaus
- Institute of Medical Informatics, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jonas Görlach
- Institute of Neuropathology, Justus Liebig University Giessen, Arndstr.16, 35392, Giessen, Germany
| | - Kristl G Claeys
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium.,Laboratory for Muscle Diseases and Neuropathies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Federica Montagnese
- Friedrich-Baur-Institute, Department of Neurology, LMU University Munich, Munich, Germany
| | - Llka Schneider
- Department of Neurology, Martin Luther University Halle-Wittenberg, Halle, Germany.,Department of Neurology, St Georg Hospital, Leipzig, Germany
| | - Dietrich Sturm
- Department of Neurology, BG University Hospital Bergmannsheil, Ruhr-University, Bochum, Germany.,Heimer-Institute for Muscle Research, BG University Hospital Bergmannsheil, Ruhr-University, Bochum, Germany
| | - Tanja Fangerau
- Department of Neurology, University of Ulm, Ulm, Germany
| | - Hannah Schlierbach
- Institute of Neuropathology, Justus Liebig University Giessen, Arndstr.16, 35392, Giessen, Germany
| | - Angela Roth
- Institute of Neuropathology, Justus Liebig University Giessen, Arndstr.16, 35392, Giessen, Germany
| | - Julia V Wanschitz
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Wolfgang N Löscher
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Anne-Katrin Güttsches
- Department of Neurology, BG University Hospital Bergmannsheil, Ruhr-University, Bochum, Germany.,Heimer-Institute for Muscle Research, BG University Hospital Bergmannsheil, Ruhr-University, Bochum, Germany
| | - Stefan Vielhaber
- Department of Neurology, Otto-Von-Guericke University, Magdeburg, Germany
| | - Rebecca Hasseli
- Department of Rheumtaology and Clinical Immunology, Campus Kerkhoff, Justus-Liebig University, Giessen, Germany
| | - Lea Zunk
- Institute of Neuropathology, Justus Liebig University Giessen, Arndstr.16, 35392, Giessen, Germany
| | - Heidrun H Krämer
- Department of Neurology, Justus Liebig University, Giessen, Germany
| | - Andreas Hahn
- Department of Child Neurology, Justus Liebig University, Giessen, Germany
| | - Benedikt Schoser
- Friedrich-Baur-Institute, Department of Neurology, LMU University Munich, Munich, Germany
| | | | - Anne Schänzer
- Institute of Neuropathology, Justus Liebig University Giessen, Arndstr.16, 35392, Giessen, Germany.
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29
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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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30
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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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31
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Di Zazzo A, Coassin M, Surico PL, Bonini S. Age-related ocular surface failure: A narrative review. Exp Eye Res 2022; 219:109035. [DOI: 10.1016/j.exer.2022.109035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/28/2022] [Accepted: 03/13/2022] [Indexed: 12/26/2022]
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32
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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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Preston FG, Meng Y, Burgess J, Ferdousi M, Azmi S, Petropoulos IN, Kaye S, Malik RA, Zheng Y, Alam U. Artificial intelligence utilising corneal confocal microscopy for the diagnosis of peripheral neuropathy in diabetes mellitus and prediabetes. Diabetologia 2022; 65:457-466. [PMID: 34806115 PMCID: PMC8803718 DOI: 10.1007/s00125-021-05617-x] [Citation(s) in RCA: 4] [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: 06/03/2021] [Accepted: 10/07/2021] [Indexed: 01/03/2023]
Abstract
AIMS/HYPOTHESIS We aimed to develop an artificial intelligence (AI)-based deep learning algorithm (DLA) applying attribution methods without image segmentation to corneal confocal microscopy images and to accurately classify peripheral neuropathy (or lack of). METHODS The AI-based DLA utilised convolutional neural networks with data augmentation to increase the algorithm's generalisability. The algorithm was trained using a high-end graphics processor for 300 epochs on 329 corneal nerve images and tested on 40 images (1 image/participant). Participants consisted of healthy volunteer (HV) participants (n = 90) and participants with type 1 diabetes (n = 88), type 2 diabetes (n = 141) and prediabetes (n = 50) (defined as impaired fasting glucose, impaired glucose tolerance or a combination of both), and were classified into HV, those without neuropathy (PN-) (n = 149) and those with neuropathy (PN+) (n = 130). For the AI-based DLA, a modified residual neural network called ResNet-50 was developed and used to extract features from images and perform classification. The algorithm was tested on 40 participants (15 HV, 13 PN-, 12 PN+). Attribution methods gradient-weighted class activation mapping (Grad-CAM), Guided Grad-CAM and occlusion sensitivity displayed the areas within the image that had the greatest impact on the decision of the algorithm. RESULTS The results were as follows: HV: recall of 1.0 (95% CI 1.0, 1.0), precision of 0.83 (95% CI 0.65, 1.0), F1-score of 0.91 (95% CI 0.79, 1.0); PN-: recall of 0.85 (95% CI 0.62, 1.0), precision of 0.92 (95% CI 0.73, 1.0), F1-score of 0.88 (95% CI 0.71, 1.0); PN+: recall of 0.83 (95% CI 0.58, 1.0), precision of 1.0 (95% CI 1.0, 1.0), F1-score of 0.91 (95% CI 0.74, 1.0). The features displayed by the attribution methods demonstrated more corneal nerves in HV, a reduction in corneal nerves for PN- and an absence of corneal nerves for PN+ images. CONCLUSIONS/INTERPRETATION We demonstrate promising results in the rapid classification of peripheral neuropathy using a single corneal image. A large-scale multicentre validation study is required to assess the utility of AI-based DLA in screening and diagnostic programmes for diabetic neuropathy.
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Affiliation(s)
- Frank G Preston
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Yanda Meng
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - 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, UK
| | - Maryam Ferdousi
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
| | - Shazli Azmi
- Institute of Cardiovascular Science, University of Manchester and Manchester Diabetes Centre, Manchester Foundation Trust, Manchester, UK
| | | | - Stephen Kaye
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | | | - Yalin Zheng
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, 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, UK.
- Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, UK.
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Pedrotti E, Bonacci E, Chierego C, De Gregorio A, Cozzini T, Brighenti T, Caldarella G, Pastore G, Fasolo A, Marchini G. Eight months follow-up of corneal nerves and sensitivity after treatment with cenegermin for neurotrophic keratopathy. Orphanet J Rare Dis 2022; 17:63. [PMID: 35189948 PMCID: PMC8862484 DOI: 10.1186/s13023-022-02237-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Accepted: 02/06/2022] [Indexed: 11/10/2022] Open
Abstract
Backgroud Cenegermin (Oxervate, Dompè Farmaceutici, Milan, IT), a recombinant human NGF, is a potentially healing new drug for neurotrophic keratopathy (NK), a rare but challenging disease affecting the cornea. To date, studies that evaluate its mid-term effect on corneal nerves and sensitivity are lacking. Objective To evaluate the recovery and morphology of subbasal corneal nerves in patients treated with Cenegermin for NK and assess their correlation with corneal sensitivity. Methods This prospective, observational case series study was carried out between May 2018 and August 2020 at the Ophthalmic Clinic of the University of Verona. Clinical evaluation, sensitivity, and in vivo confocal microscopy (IVCM) were performed in the central and all four corneal sectors at baseline, the end of therapy (8 weeks), and 2, 4, and 8 months after therapy. Consecutive patients with NK (stage 2–3), treated with Cenegermin (1 drop 6 times daily for 8 weeks), were enrolled. During each visit, Corneal nerve fiber length (CNFL), corneal nerve fiber total branch density (CTBD), corneal nerve fiber fractal dimension (CNFraD) and Cochet-Bonnet esthesiometry (CBE) were measured. Results We enrolled 18 patients. Complete NK healing was noted in 14/18(78%) patients after 8 weeks of treatment; then in 14(78%), 15(83%), and 13(72%) patients at 2-, 4-, and 8-months, respectively. Starting at 8 weeks through 4-month follow-up there was progressive improvement in CBE in all corneal sectors (p ≤ 0.01), which continued thereafter. There was significant corneal nerve regrowth especially in the peripheral cornea: centripetal progression starting at 8 weeks (CNFL and CNFrad) and significant branching starting at 2 months (CTBD), which continued through to the end of follow up. Sector-coupled IVCM and CBE findings correlated at all evaluations (all r ≥ 0.62 starting at 2 months, with highest values in the peripheral sectors). Conclusions After Cenegermin we observed a subbasal corneal nerve regeneration, a recovery of sensitivity and a lasting epithelial healing, suggesting that the effect of its action persists several months after discontinuation in patients with NK.
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Zhang Y, Wu Y, Li W, Huang X. Semiautomated and Automated Quantitative Analysis of Corneal Sub-Basal Nerves in Patients With DED With Ocular Pain Using IVCM. Front Med (Lausanne) 2022; 9:831307. [PMID: 35223926 PMCID: PMC8873156 DOI: 10.3389/fmed.2022.831307] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 01/12/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose Investigate the correlation and agreement between the results of semiautomated and fully automated quantitative analysis of the corneal sub-basal nerve plexus (SNP) in patients with dry eye disease (DED) with ocular pain using in vivo confocal microscopy (IVCM). Method A total of 50 voluntary participants were enrolled in this study, i.e., 25 DED patients with ocular pain and 25 healthy controls. Each patient underwent an evaluation of ocular symptoms that utilized: the Ocular Surface Disease Index (OSDI), the Ocular Pain Assessment Survey (OPAS), the tear film breakup time (TBUT) test, the Schirmer test, corneal staining, and IVCM. Five SNP images of the cornea of each eye were selected and analyzed using a semiautomated analysis software (NeuronJ) and a fully automated method (ACCMetrics) to quantify corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), and corneal nerve fiber length (CNFL). Results The intraclass correlation coefficient (ICC) of the CNFD (0.460 [0.382–0.532], p < 0.001), CNBD (0.608 [0.545–0.665], p < 0.001), and CNFL (0.851 [0.822–0.875], p < 0.001) represents the repeatability and consistency of measurements by the NeuronJ and ACCMetrics software. The CNFL values (r = 0.881, p < 0.001) obtained using the two methods have extremely high correlation, and similarly, the CNFD values (r = 0.669, p < 0.001) and CNBD values (r = 0.703, p < 0.001) are highly correlated. The CNFL had the biggest area under the curve (AUC; 0.747 [0.700–0.793], p < 0.001) when using ACCMetrics. In DED patients with ocular pain, the mean CNFD values for semiautomated and fully automated quantization were 23.5 ± 8.1 and 23.8 ± 8.6 n/mm2; the mean CNBD values were 46.0 ± 21.3, 35.7 ± 23.3 n/mm2; and the mean CNFL values were 19.3 ± 4.3 and 15.2 ± 3.8 mm/mm2, which were significantly lower than healthy subjects (p < 0.001). Conclusion There is a significant correlation between the measurements obtained via ACCMetrics and NeuronJ, especially for CNFL, which can be considered as the primary indicator in the diagnosis of DED with ocular pain. The SNP of the disease was significantly lower than that of healthy subjects.
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Carmichael J, Fadavi H, Tavakoli M. Neurodegeneration of the cornea and retina in patients with type 1 diabetes without clinical evidence of diabetic retinopathy. Front Endocrinol (Lausanne) 2022; 13:790255. [PMID: 36277683 PMCID: PMC9581164 DOI: 10.3389/fendo.2022.790255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
AIM Diabetic retinopathy (DR) is widely considered the earliest and most common microvascular complication of diabetes. However, recent studies have shown that retinal nerve fiber layer and corneal nerve abnormalities may be present in diabetic patients without retinopathy. This preliminary study aimed to establish if structural and functional changes in the nerve fiber layer of the retina and cornea occur in patients with type 1 diabetes (T1DM) without retinopathy. METHODS Twenty patients with T1DM, without clinical evidence of retinopathy (Age: 47.0 ± 2.5 years; Duration diabetes: 27.0 ± 3 years) and 15 age-matched healthy control subjects underwent detailed medical neurological examinations. Ophthalmic examinations using Spectral Domain Optical coherence tomography (SD-OCT), Standard Automated Perimetry (SAP), Flicker Defined Form High Edge Perimetry (FDF), Corneal Confocal Microscopy (CCM) and Non-contact corneal Aesthesiometry (NCCA) were performed to quantify the structure and function of the nerves in the retina and cornea, respectively. RESULTS At the structural level, retinal nerve fiber layer thickness (RNFL) was significantly reduced in the superior nasal (p=0.001) and inferior temporal (p=0.004) sectors, in diabetic patients. Retinal ganglion layer function was reduced in the patient group when assessed using Flicker Defined Form Perimetry (FDF), but this was not significant. The function of the cornea assessed by corneal sensitivity, using a non-contact corneal aesthesiometer (NCCA), was significantly reduced (p=0.001). Structural assessment of corneal nerves using corneal confocal microscopy (CCM) showed reduction at corneal nerve fiber density (CNFD) (p=0.01), branch density (CNBD) (p=0.006) and length (CNFL) (p=0.01) in patients with diabetes. Compared to control subjects, the percentage of abnormality in patients with T1DM for RNFL was 32% while the FDF was abnormal in 61% of patients. Corneal abnormality was observed in 47% for NCCA, 28% for CNFD, and 17% for CNFL. There was no correlation between neuronal damage in the retina and cornea. CONCLUSIONS Neuronal abnormalities were observed in both the retina and cornea of diabetic patients without evidence of retinopathy. The prevalence of structural and functional changes was higher in the retina compared to the cornea. This preliminary study suggests that structural neuronal changes may occur in parallel and correlate with functional changes. The assessment of corneal and retinal nerve structure may be clinically useful for detecting and monitoring the earliest stages of diabetic microvascular abnormalities.
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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, University of Exeter Medical School, Exeter, United Kingdom
| | - Hassan Fadavi
- Peripheral Neuropathy Group, Imperial College, London, United Kingdom
| | - Mitra Tavakoli
- Exeter Centre of Excellence for Diabetes Research, National Institute for Health and Care Research (NIHR) Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, United Kingdom
- *Correspondence: Mitra Tavakoli,
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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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Bönhof GJ, Herder C, Ziegler D. Diagnostic Tools, Biomarkers, and Treatments in Diabetic polyneuropathy and Cardiovascular Autonomic Neuropathy. Curr Diabetes Rev 2022; 18:e120421192781. [PMID: 33845748 DOI: 10.2174/1573399817666210412123740] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/24/2021] [Accepted: 03/02/2021] [Indexed: 11/22/2022]
Abstract
The various manifestations of diabetic neuropathy, including distal symmetric sensorimotor polyneuropathy (DSPN) and cardiovascular autonomic neuropathy (CAN), are among the most prevalent chronic complications of diabetes. Major clinical complications of diabetic neuropathies, such as neuropathic pain, chronic foot ulcers, and orthostatic hypotension, are associated with considerable morbidity, increased mortality, and diminished quality of life. Despite the substantial individual and socioeconomic burden, the strategies to diagnose and treat diabetic neuropathies remain insufficient. This review provides an overview of the current clinical aspects and recent advances in exploring local and systemic biomarkers of both DSPN and CAN assessed in human studies (such as biomarkers of inflammation and oxidative stress) for better understanding of the underlying pathophysiology and for improving early detection. Current therapeutic options for DSPN are (I) causal treatment, including lifestyle modification, optimal glycemic control, and multifactorial risk intervention, (II) pharmacotherapy derived from pathogenetic concepts, and (III) analgesic treatment against neuropathic pain. Recent advances in each category are discussed, including non-pharmacological approaches, such as electrical stimulation. Finally, the current therapeutic options for cardiovascular autonomic complications are provided. These insights should contribute to a broader understanding of the various manifestations of diabetic neuropathies from both the research and clinical perspectives.
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Affiliation(s)
- Gidon J Bönhof
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
| | - Christian Herder
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
| | - Dan Ziegler
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Endocrinology, Medical Faculty and University Hospital, Heinrich Heine University, Düsseldorf, Germany
- German Center for Diabetes Research, Partner Düsseldorf, München-Neuherberg, Germany
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Cao J, Qu J, Odilov B, Lu B, Zhang Y, Li L, Zhang Y, Xiong Q, Hong Y, Li J, Shen Y, Hou X. Corneal Nerve Parameter Reference Values for Chinese Adults Assessed by Corneal Confocal Microscopy. J Diabetes Res 2022; 2022:4913031. [PMID: 35265718 PMCID: PMC8898861 DOI: 10.1155/2022/4913031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 02/09/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Confocal corneal microscopy is an excellent new noninvasive tool for assessing diabetic peripheral neuropathy. We aimed to investigate the clinical variables associated with corneal nerve parameters and establish reference values for clinical use in healthy Chinese adults. METHODS The study enlisted 257 healthy volunteers (137 females and 120 males) from two clinical academic centers in China. Two experts captured and selected images of the central corneal subbasal nerve plexus at each center using the same corneal confocal microscopy instrument according to a commonly adopted protocol. Corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), and corneal nerve fiber length (CNFL) were measured using fully automated software (ACCMetrics). The correlation between clinical indicators and confocal corneal microscopy measures was determined using partial correlation. Quantile regression was used to calculate reference values and estimate the effects of clinical factors on the normative values of confocal corneal microscopy measures. RESULTS Females had significantly higher CNFD, CNBD, and CNFL than males. There was no correlation between age, glycated hemoglobin (HbA1c), height, weight, body mass index (BMI), and any corneal nerve fiber parameter in both sexes. In either sex, age, weight, height, BMI, and HbA1c did not affect the 0.05th quantile values of any corneal nerve parameter. CONCLUSIONS This study establishes sex-adjusted reference values for corneal confocal microscopy measures in Chinese adults and provides a reference for clinical practice and research with this technique.
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Affiliation(s)
- Juan Cao
- Department of Endocrinology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
- Department of Health Management Center, Qilu Hospital of Shandong University, 107 Wenhua W Road, Jinan, Shandong 250012, China
| | - Jingru Qu
- Department of Endocrinology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
- Institute of Endocrine and Metabolic Diseases of Shandong University, 107 Wenhua W Road, Jinan, Shandong 250012, China
- Key Laboratory of Endocrine and Metabolic Diseases, Shandong Province Medicine & Health, 107 Wenhua W Road, Jinan, Shandong 250012, China
- Jinan Clinical Research Center for Endocrine and Metabolic Diseases, Shandong Province Medicine & Health, 107 Wenhua W Road, Jinan, Shandong 250012, China
| | - Bekzod Odilov
- Department of Endocrinology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
| | - Bin Lu
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai 200040, China
| | - Yuanpin Zhang
- Department of Endocrinology and Metabolism, Huashan Hospital, Fudan University, 12 Wulumuqi Middle Road, Shanghai 200040, China
| | - Lili Li
- Department of Endocrinology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
- Department of Ultrasound, Qilu Hospital of Shandong University, 758 Hefei Road, Qingdao, Shandong 266000, China
| | - Yuan Zhang
- Clinical Epidemiology Unit, Qilu Hospital of Shandong University, 107 Wenhua W Road, Jinan, Shandong 250012, China
- Clinical Research Center of Shandong University, 107 Wenhua W Road, Jinan, Shandong 250012, China
| | - Qian Xiong
- Department of Endocrinology and Metabolism, Gonghui Hospital, 315 Shimen No. 1 Road, Shanghai 200040, China
| | - Yu Hong
- Department of Endocrinology and Metabolism, Gonghui Hospital, 315 Shimen No. 1 Road, Shanghai 200040, China
| | - Jianqiao Li
- Department of Ophthalmology, Qilu Hospital of Shandong University, 107 Wenhua W Road, Jinan, Shandong 250012, China
| | - Yunfeng Shen
- Department of Endocrinology and Metabolism, Institute for the Study of Endocrinology and Metabolism in Jiangxi Province, The Second Affiliated Hospital of Nanchang University, 1 Minde Road, Nanchang, Jiangxi 330006, China
| | - Xinguo Hou
- Department of Endocrinology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong 250012, China
- Institute of Endocrine and Metabolic Diseases of Shandong University, 107 Wenhua W Road, Jinan, Shandong 250012, China
- Key Laboratory of Endocrine and Metabolic Diseases, Shandong Province Medicine & Health, 107 Wenhua W Road, Jinan, Shandong 250012, China
- Jinan Clinical Research Center for Endocrine and Metabolic Diseases, Shandong Province Medicine & Health, 107 Wenhua W Road, Jinan, Shandong 250012, China
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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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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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Corneal Confocal Microscopy in the Diagnosis of Small Fiber Neuropathy: Faster, Easier, and More Efficient Than Skin Biopsy? PATHOPHYSIOLOGY 2021; 29:1-8. [PMID: 35366285 PMCID: PMC8954271 DOI: 10.3390/pathophysiology29010001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic pain may affect 30–50% of the world’s population and an important cause is small fiber neuropathy (SFN). Recent research suggests that autoimmune diseases may be one of the most common causes of small nerve fiber damage. There is low awareness of SFN among patients and clinicians and it is difficult to diagnose as routine electrophysiological methods only detect large fiber abnormalities, and specialized small fiber tests, like skin biopsy and quantitative sensory testing, are not routinely available. Corneal confocal microscopy (CCM) is a rapid, non-invasive, reproducible method for quantifying small nerve fiber degeneration and regeneration, and could be an important tool for diagnosing SFN. This review considers the advantages and disadvantages of CCM and highlights the evolution of this technique from a research tool to a diagnostic test for small fiber damage, which can be a valuable contribution to the study and management of autoimmune disease.
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Cell Morphology as an In Vivo Parameter for the Diagnosis of Limbal Stem Cell Deficiency. Cornea 2021; 41:995-1001. [PMID: 34935665 PMCID: PMC9218010 DOI: 10.1097/ico.0000000000002955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 10/25/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The aim of this study was to investigate basal epithelial cell morphology (CM) in the central cornea and limbal areas of eyes with limbal stem cell deficiency (LSCD). METHODS This was a prospective, cross-sectional comparative study. We developed a CM scoring system based on basal epithelial cell phenotypes graded from 0 (normal) to 3 (severe morphologic alterations); this system was evaluated by 2 independent masked observers. The CM score was compared with the LSCD clinical score, mean best-corrected visual acuity, and in vivo laser scanning confocal microscopy parameters used to stage LSCD (ie, basal epithelial cell density, basal epithelial thickness, and subbasal corneal nerve fiber length density). RESULTS One hundred sixty-eight eyes with LSCD and 63 normal eyes were included. Compared with the control group, the LSCD group had significantly higher mean (±SD) CM scores in the central cornea (1.8 ± 0.7 vs. 0.5 ± 0.4, respectively; P = 0.01) and limbal areas (1.6 ± 0.2 vs. 1.3 ± 0.0, respectively; P < 0.05). The mean CM score in the central cornea was positively correlated with the clinical score (P < 0.01, r = 0.66) and negatively correlated with the best-corrected visual acuity (P < 0.01, r = 0.42). The CM scores were positively correlated with all other in vivo laser scanning confocal microscopy parameters in the central cornea and limbal areas (all P < 0.001). CONCLUSIONS Basal epithelial CM is altered in the central cornea and limbus of eyes with LSCD and thus can be used to stage the clinical severity of the disease.
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Ramírez M, Guerra-Juárez A, Miyake DY, Sebastian-Arellano C, Estrada-Mata AG, González-Moyotl NJ, Rodríguez-Aguayo AM, Martínez-Lavin M, Martínez-Martínez LA. Correlation Between Corneal Nerve Density and Symptoms of Small Fiber Neuropathy in Patients With Fibromyalgia: The Confounding Role of Severe Anxiety or Depression. J Clin Rheumatol 2021; 27:e606-e608. [PMID: 33044388 DOI: 10.1097/rhu.0000000000001592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE A consistent line of investigation proposes fibromyalgia as a dysautonomia-associated neuropathic pain syndrome. Comorbid anxiety or depression amplifies fibromyalgia symptoms. The recent recognition of small fiber neuropathy in fibromyalgia patients supports the neuropathic nature of the illness. Corneal confocal microscopy accurately identifies small nerve fiber pathology. The newly developed Small-Fiber Symptom Survey captures the spectrum of small fiber neuropathy symptoms. We aimed to correlate corneal nerve density with different fibromyalgia disease severity questionnaires including the Small-Fiber Symptom Survey. We defined the possible confounding role of comorbid anxiety or depression severity in the clinical-pathological association. METHODS This is a case series of 28 women with fibromyalgia. A single ophthalmologist quantified corneal subbasal plexus nerve density. Corneal innervation was correlated (Spearman ρ) with the following clinical questionnaires scores: Small-Fiber Symptom Survey, Revised Fibromyalgia Impact Questionnaire, and COMPASS-31 (Composite Autonomic Symptom Survey 31-Item Score). Validated inquiry forms assessed the comorbid anxiety and/or depression severity. RESULTS There were no clinical-pathological correlations in the group as a whole. In the subgroup of fibromyalgia women without severe anxiety or depression (n = 13), there was a strong negative correlation between corneal nerve density with the Small-Fiber Symptom Survey score (ρ = -0.771, p = 0.002) and COMPASS-31 score (ρ = -0.648, p = 0.017). Patients with profound anxiety or depression (n = 15) had more intense symptoms but had not clinical-pathological correlations. CONCLUSIONS Small fiber neuropathy and dysautonomia symptoms correlate with corneal denervation in women with fibromyalgia without severe anxiety or depression. This clinical-pathological association reinforces fibromyalgia as a dysautonomia-related neuropathic pain syndrome. Severe anxiety or depression distorts fibromyalgia symptoms. PRACTICAL POINT Corneal confocal microscopy may become a useful procedure to study fibromyalgia patients.
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Affiliation(s)
- Manuel Ramírez
- From the Servicio de Cornea del Hospital Sánchez Bulnes de la Asociación para Evitar la Ceguera en México
| | - Arturo Guerra-Juárez
- From the Servicio de Cornea del Hospital Sánchez Bulnes de la Asociación para Evitar la Ceguera en México
| | - Daniel-Yoshiro Miyake
- From the Servicio de Cornea del Hospital Sánchez Bulnes de la Asociación para Evitar la Ceguera en México
| | | | | | | | | | - Manuel Martínez-Lavin
- Departamento de Reumatología del Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
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Qureshi AG, Jha SK, Iskander J, Avanthika C, Jhaveri S, Patel VH, Rasagna Potini B, Talha Azam A. Diagnostic Challenges and Management of Fibromyalgia. Cureus 2021; 13:e18692. [PMID: 34786265 PMCID: PMC8580749 DOI: 10.7759/cureus.18692] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 12/13/2022] Open
Abstract
The World Health Organization regards chronic pain to be a public health concern. In clinical medicine, fibromyalgia (FM) is the most prevalent chronic widespread pain disease. In terms of impairment, consumption of health and social resources, and impact on primary and speciality care systems, it has reached worrisome proportions. This disease is frequently managed by primary care providers. Because of its intricacy, fibromyalgia diagnosis and treatment can be difficult. Fibromyalgia is a controversial condition. It might appear ill-defined in comparison to other pain conditions, with no clear knowledge of pathophysiology and hence no particular targeted therapy. This invariably sparks debates and challenges. There is no obvious cut-off point that distinguishes FM from non-FM. The diagnosis of fibromyalgia has been complicated by several factors, including patients' health-seeking behaviour, symptom identification, and physician labelling of the disease. Fibromyalgia is currently considered a centralized pain condition, according to research that has improved our understanding of its etiopathology. A multidisciplinary strategy combining pharmacological and non-pharmacological therapies based on a biopsychosocial paradigm can result in effective therapy. Cultural and psychosocial variables appear to be a recent development in fibromyalgia, and they appear to have a larger influence on physician diagnosis than severe symptom levels in FM patients. Although physicians rely on FM criteria as the only way to classify FM patients in research and clinical settings, some crucial elements of the diagnostic challenge of fibromyalgia remain unsolved - invalidation, psychosocial variables, and diverse illness manifestation are some examples. Beyond the existing constructional scores, physicians' judgment gained in real communicative contexts with patients, appears to be the only dependable route for a more accurate diagnosis for fibromyalgia. We have performed an exhaustive review of the literature using the keywords "Fibromyalgia", "challenges" and "diagnosis" in PubMed and Google Scholar indexes up to September 2021. This article aims to examine the causes, diagnosis, and current treatment protocols of FM, as well as discuss some continuing debates and diagnostic challenges which physicians face in accurately diagnosing fibromyalgia.
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Affiliation(s)
- Aniqa G Qureshi
- Medicine and Surgery, Jinggangshan Medical University, Jian, CHN
| | - Saurav K Jha
- Internal Medicine, Kankai Hospital, Birtamode, NPL
| | - John Iskander
- Family Medicine, American University of Antigua, St. John's, ATG
| | - Chaithanya Avanthika
- Medicine and Surgery, Karnataka Institute of Medical Sciences, Hubli, IND
- Pediatrics, Karnataka Institute of Medical Sciences, Hubli, IND
| | - Sharan Jhaveri
- Medicine, Smt Nathiba Hargovandas Lakhmichand Municipal Medical College (NHLMMC), Ahmedabad, IND
| | - Vithi Hitendra Patel
- Family Medicine, GMERS Medical College and Hospital, Valsad, IND
- Internal Medicine, Gujarat Cancer Society Medical College and Research Center, Ahmedabad, IND
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Wu PY, Wu JH, Hsieh YT, Chen LCC, Cheng T, Wu PY, Hsieh BJ, Huang WL, Huang SL, Chen WL. Comparing the results of manual and automated quantitative corneal neuroanalysing modules for beginners. Sci Rep 2021; 11:18208. [PMID: 34521890 PMCID: PMC8440557 DOI: 10.1038/s41598-021-97567-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/24/2021] [Indexed: 11/11/2022] Open
Abstract
This study aimed to evaluate the reliability of in vivo confocal microscopic neuroanalysis by beginners using manual and automated modules. Images of sub-basal corneal nerve plexus (SCNP) from 108 images of 18 healthy participants were analyzed by 7 beginner observers using manual (CCMetrics, [CCM]) and automated (ACCMetrics, [ACCM]) module. SCNP parameters analyzed included corneal nerve fiber density (NFD), corneal nerve branch density (NBD), corneal nerve fiber length (NFL), and tortuosity coefficient (TC). The intra-observer repeatability, inter-observer reliability, inter-module agreement, and left–right eye symmetry level of SCNP parameters were examined. All observers showed good intra-observer repeatability using CCM (intraclass correlation coefficient [ICC] > 0.60 for all), except when measuring TC. Two observers demonstrated especially excellent repeatability in analyzing NFD, NBD, and NFL using manual mode, indicating the quality of interpretation may still be observer-dependent. Among all SCNP parameters, NFL had the best inter-observer reliability (Spearman’s rank-sum correlation coefficient [SpCC] and ICC > 0.85 for the 3 original observers) and left–right symmetry level (SpCC and ICC > 0.60). In the additional analysis of inter-observer reliability using results by all 7 observers, only NFL showed good inter-observer reliability (ICC = 0.79). Compared with CCM measurements, values of ACCM measurements were significantly lower, implying a poor inter-module agreement. Our result suggested that performance of quantitative corneal neuroanalysis by beginners maybe acceptable, with NFL being the most reliable parameter, and automated method cannot fully replace manual work.
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Affiliation(s)
- Po-Ying Wu
- Department of General Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jo-Hsuan Wu
- Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California, San Diego, USA
| | - Yi-Ting Hsieh
- Department of Ophthalmology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Lin Chih-Chieh Chen
- Graduate Institute of Photonics and Optoelectronics, National Taiwan University, Taipei, Taiwan.,Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan
| | - Ting Cheng
- Department of Ophthalmology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Po-Yi Wu
- Department of Ophthalmology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Bing-Jun Hsieh
- Department of Ophthalmology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Wei-Lun Huang
- Department of Ophthalmology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan
| | - Sheng-Lung Huang
- Graduate Institute of Photonics and Optoelectronics, National Taiwan University, Taipei, Taiwan.,Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan
| | - Wei-Li Chen
- Department of Ophthalmology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei, Taiwan. .,Advanced Ocular Surface and Corneal Nerve Regeneration Center, National Taiwan University Hospital, Taipei, Taiwan. .,Department of Ophthalmology, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Majeed A, Marwick B, Yu H, Fadavi H, Tavakoli M. Ophthalmic Biomarkers for Alzheimer's Disease: A Review. Front Aging Neurosci 2021; 13:720167. [PMID: 34566623 PMCID: PMC8461312 DOI: 10.3389/fnagi.2021.720167] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 08/11/2021] [Indexed: 11/13/2022] Open
Abstract
Alzheimer's disease (AD) is a progressive neurodegenerative disease characterized by neuronal loss, extracellular amyloid-β (Aβ) plaques, and intracellular neurofibrillary tau tangles. A diagnosis is currently made from the presenting symptoms, and the only definitive diagnosis can be done post-mortem. Over recent years, significant advances have been made in using ocular biomarkers to diagnose various neurodegenerative diseases, including AD. As the eye is an extension of the central nervous system (CNS), reviewing changes in the eye's biology could lead to developing a series of non-invasive, differential diagnostic tests for AD that could be further applied to other diseases. Significant changes have been identified in the retinal nerve fiber layer (RNFL), cornea, ocular vasculature, and retina. In the present paper, we review current research and assess some ocular biomarkers' accuracy and reliability that could potentially be used for diagnostic purposes. Additionally, we review the various imaging techniques used in the measurement of these biomarkers.
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Affiliation(s)
- Ayesha Majeed
- Medical School, University of Exeter, Exeter, United Kingdom
| | - Ben Marwick
- Medical School, University of Exeter, Exeter, United Kingdom
| | - Haoqing Yu
- Medical School, University of Exeter, Exeter, United Kingdom
| | | | - Mitra Tavakoli
- Medical School, University of Exeter, Exeter, United Kingdom
- Exeter Centre of Excellence for Diabetes Research, University of Exeter, Exeter, United Kingdom
- National Institute for Health Research, Exeter Clinical Research Facility, Exeter, United Kingdom
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Chirapapaisan C, Thongsuwan S, Chirapapaisan N, Chonpimai P, Veeraburinon A. Characteristics of Corneal Subbasal Nerves in Different Age Groups: An in vivo Confocal Microscopic Analysis. Clin Ophthalmol 2021; 15:3563-3572. [PMID: 34465977 PMCID: PMC8403225 DOI: 10.2147/opth.s324169] [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: 06/10/2021] [Accepted: 08/11/2021] [Indexed: 01/03/2023] Open
Abstract
Purpose To determine the normative characteristics of corneal subbasal nerves in different age groups using laser scanning in vivo confocal microscopy (IVCM). Patients and Methods This descriptive observational study recruited healthy subjects (aged 20–60 years) from Siriraj Health-Screening Center. Excluded were individuals who had abnormal ocular symptoms, previous ocular surgery, a history of any diseases related to systemic and/or corneal neuropathy, or abnormal corneal sensitivity. Corneal IVCM (HRT3/Rostock Corneal Module) was performed at the central cornea to analyze the subbasal nerve plexus. The corneal nerve characteristics, comprising the number and density of nerves (main nerve trunks, branches, and total nerves) were analyzed using the NeuronJ program, and the corneal nerve tortuosity was graded. The correlations between the subbasal nerve density, tortuosity and age were then analyzed. Results Eighty subjects were enrolled, with twenty in each of four age groups (20–30, >30–40, >40–50, and >50–60 years). Overall, the mean number and density of main nerve trunks were 27.93±0.81/mm2 and 11.22±0.30 mm/mm2, respectively. As of the nerve branches, the average number and density were 103.56±2.37/mm2 and 9.15±0.30 mm/mm2, respectively. The total nerve density was 20.37±0.39 mm/mm2. There were no significant differences between subbasal nerve parameters of the four age groups. It is noteworthy that 65% of the subjects aged over 40 years revealed high-grade nerve tortuosity. Conclusion The corneal subbasal nerve numbers and densities were not significantly different among a healthy population aged 20–60 years. However, there was a trend towards high tortuosity of the corneal nerve in people aged over 40 years.
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Affiliation(s)
- Chareenun Chirapapaisan
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sittiphong Thongsuwan
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Niphon Chirapapaisan
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pratuangsri Chonpimai
- Department of Ophthalmology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Anupong Veeraburinon
- Research Division, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailanda
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In vivo corneal confocal microscopy and optical coherence tomography on eyes of participants with type 2 diabetes mellitus and obese participants without diabetes. Graefes Arch Clin Exp Ophthalmol 2021; 259:3339-3350. [PMID: 34283292 PMCID: PMC8523500 DOI: 10.1007/s00417-021-05251-8] [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: 01/28/2021] [Revised: 05/07/2021] [Accepted: 05/19/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSES To examine corneal nerve and retinal nerve characteristics of participants with type 2 diabetes mellitus (T2DM) compared with obese participants without diabetes to discover potential nerve vulnerabilities. METHODS All participants underwent a complete medical examination including a physical examination and blood sample tests. The ophthalmologic examination included best-corrected visual acuity, intraocular pressure, Schirmer test, tear film breakup time, slit-lamp examination, dilated fundus photography, in vivo corneal confocal microscopy (IVCCM), and optical coherence tomography (OCT). RESULTS The study cohort consisted of 83 eyes of 83 individuals: a group of 44 participants with T2DM, and a control group of 39 obese participants with no history of diabetes. Comparing measurements on the two groups, participants with T2DM had lower values with statistical significance for retinal nerve fiber layer (RNFL) nasal superior thickness (p = 0.010) and three corneal nerve (CN) parameters: fiber length (p = 0.025), total branch density (p = 0.013), and fiber area (p = 0.009). There was a borderline significant difference in CN fiber width (p = 0.051) and RNFL nasal inferior thickness (p = 0.056). No other significant differences were observed in the IVCCM and OCT parameters. No statistically significant correlation was found between CN and RNFL parameters. CONCLUSIONS Progression from a pre-diabetic obese state to a T2DM condition might entail a loss or diminishment of certain corneal nerve fibers or retinal nerve fibers, but not necessarily a loss of both corneal and retinal nerve fibers simultaneously. Using IVCCM and OCT together enables monitoring of both corneal and retinal health of the eye.
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Chiang JCB, Goldstein D, Park SB, Krishnan AV, Markoulli M. Corneal nerve changes following treatment with neurotoxic anticancer drugs. Ocul Surf 2021; 21:221-237. [PMID: 34144206 DOI: 10.1016/j.jtos.2021.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/20/2021] [Accepted: 06/09/2021] [Indexed: 12/13/2022]
Abstract
Survival rates of cancer has improved with the development of anticancer drugs including systemic chemotherapeutic agents. However, long-lasting side effects could impact treated patients. Neurotoxic anticancer drugs are specific agents which cause chemotherapy-induced peripheral neuropathy (CIPN), a debilitating condition that severely deteriorates quality of life of cancer patients and survivors. The ocular surface is also prone to neurotoxicity but investigation into the effects of neurotoxic chemotherapy on the ocular surface has been more limited compared to other systemic etiologies such as diabetes. There is also no standardized protocol for CIPN diagnosis with an absence of a reliable, objective method of observing nerve damage structurally. As the cornea is the most densely innervated region of the body, researchers have started to focus on corneal neuropathic changes that are associated with neurotoxic chemotherapy treatment. In-vivo corneal confocal microscopy enables rapid and objective structural imaging of ocular surface microscopic structures such as corneal nerves, while esthesiometers provide means of functional assessment by examining corneal sensitivity. The current article explores the current guidelines and gaps in our knowledge of CIPN diagnosis and the potential role of in-vivo corneal confocal microscopy as a diagnostic or prognostic tool. Corneal neuropathic changes with neurotoxic anticancer drugs from animal research progressing through to human clinical studies are also discussed, with a focus on how these data inform our understanding of CIPN.
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Affiliation(s)
- Jeremy Chung Bo Chiang
- School of Optometry & Vision Science, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia.
| | - David Goldstein
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia; Department of Medical Oncology, Prince of Wales Hospital, Sydney, Australia
| | - Susanna B Park
- Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Arun V Krishnan
- Prince of Wales Clinical School, University of New South Wales, Sydney, Australia
| | - Maria Markoulli
- School of Optometry & Vision Science, Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
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