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Pandit AS, China M, Jain R, Jalal AHB, Jelen M, Joshi SB, Skye C, Abdi Z, Aldabbagh Y, Alradhawi M, Banks PDW, Stasiak MK, Tan EBC, Yildirim FC, Ruffle JK, D'Antona L, Asif H, Thorne L, Watkins LD, Nachev P, Toma AK. The utility of MRI radiological biomarkers in determining intracranial pressure. Sci Rep 2024; 14:23238. [PMID: 39369053 PMCID: PMC11455934 DOI: 10.1038/s41598-024-73750-9] [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: 02/05/2024] [Accepted: 09/20/2024] [Indexed: 10/07/2024] Open
Abstract
Intracranial pressure (ICP) is a physiological parameter that conventionally requires invasive monitoring for accurate measurement. Utilising multivariate predictive models, we sought to evaluate the utility of non-invasive, widely accessible MRI biomarkers in predicting ICP and their reversibility following cerebrospinal fluid (CSF) diversion. The retrospective study included 325 adult patients with suspected CSF dynamic disorders who underwent brain MRI scans within three months of elective 24-h ICP monitoring. Five MRI biomarkers were assessed: Yuh sella grade, optic nerve vertical tortuosity (VT), optic nerve sheath distension, posterior globe flattening and optic disc protrusion (ODP). The association between individual biomarkers and 24-h ICP was examined and reversibility of each following CSF diversion was assessed. Multivariate models incorporating these radiological biomarkers were utilised to predict 24-h median intracranial pressure. All five biomarkers were significantly associated with median 24-h ICP (p < 0.0001). Using a pair-wise approach, the presence of each abnormal biomarker was significantly associated with higher median 24-h ICP (p < 0.0001). On multivariate analysis, ICP was significantly and positively associated with Yuh sella grade (p < 0.0001), VT (p < 0.0001) and ODP (p = 0.003), after accounting for age and suspected diagnosis. The Bayesian multiple linear regression model predicted 24-h median ICP with a mean absolute error of 2.71 mmHg. Following CSF diversion, we found pituitary sella grade to show significant pairwise reversibility (p < 0.001). ICP was predicted with clinically useful precision utilising a compact Bayesian model, offering an easily interpretable tool using non-invasive MRI data. Brain MRI biomarkers are anticipated to play a more significant role in the screening, triaging, and referral of patients with suspected CSF dynamic disorders.
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Affiliation(s)
- Anand S Pandit
- High-Dimensional Neurology Group, UCL Queen Square Institute of Neurology, University College London, London, UK.
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK.
| | - Musa China
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
- Division of Medicine, University College London, UCL, London, UK
| | - Raunak Jain
- Division of Medicine, University College London, UCL, London, UK
| | - Arif H B Jalal
- Division of Medicine, University College London, UCL, London, UK
| | - Maria Jelen
- Department of Psychology and Language Sciences, University College London, London, UK
| | - Shivani B Joshi
- Division of Medicine, University College London, UCL, London, UK
| | - Crystallynn Skye
- Division of Medicine, University College London, UCL, London, UK
| | - Zakee Abdi
- School of Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yousif Aldabbagh
- Division of Medicine, University College London, UCL, London, UK
| | | | - Ptolemy D W Banks
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Martyna K Stasiak
- Department of Psychology and Language Sciences, University College London, London, UK
| | - Emily B C Tan
- Division of Medicine, University College London, UCL, London, UK
| | - Fleur C Yildirim
- Department of Psychology and Language Sciences, University College London, London, UK
| | - James K Ruffle
- High-Dimensional Neurology Group, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Linda D'Antona
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Hasan Asif
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Lewis Thorne
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Laurence D Watkins
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Parashkev Nachev
- High-Dimensional Neurology Group, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Ahmed K Toma
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
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D'Antona L, Asif H, Craven CL, McHugh JA, Vassiliou A, Thorne L, Matharu MS, Watkins LD, Bremner F, Toma AK. Brain MRI and Ophthalmic Biomarkers of Intracranial Pressure. Neurology 2021; 96:e2714-e2723. [PMID: 33849988 PMCID: PMC8205470 DOI: 10.1212/wnl.0000000000012023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 03/04/2021] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To evaluate the utility of brain MRI and ophthalmic biomarkers for the prediction of intracranial hypertension, we have studied the association between 6 biomarkers and 24-hour intracranial pressure (ICP) monitoring results in 45 patients. METHODS This single-center observational study includes patients who underwent 24-hour ICP monitoring, brain MRI (within 3 months), and ophthalmic assessment (during ICP monitoring). Six biomarkers were investigated: pituitary gland shape, vertical tortuosity of the optic nerve, distension of the optic nerve sheath, optic disc protrusion (MRI), papilledema (slit lamp biomicroscopy), and spontaneous venous pulsations (SVP, infrared video recordings). RESULTS Forty-five patients (mean age 39 ± 14 years, 38 women) met the inclusion criteria. All 6 biomarkers had a significant association with 24-hour ICP. Concave pituitary gland was observed with moderately elevated median ICP. Protrusion of the optic disc (MRI), papilledema, and absence of SVP were associated with the highest median ICP values. Twenty patients had raised ICP (median 24-hour ICP >5.96 mm Hg, cutoff obtained through Youden index calculation). Patients with all normal biomarkers had normal median ICP in 94% (standard error 6%) of the cases. All patients with ≥3 abnormal biomarkers had intracranial hypertension. The combination of at least 1 abnormal biomarker in MRI and ophthalmic assessments was highly suggestive of intracranial hypertension (area under the curve 0.94, 95% confidence interval 0.93-0.94) CONCLUSIONS: Brain MRI and ophthalmic biomarkers can noninvasively guide the management of patients with suspected CSF dynamics abnormalities. Patients with multiple abnormal biomarkers (≥3) or a combination of abnormal MRI and ophthalmic biomarkers are likely to have intracranial hypertension and should be managed promptly.
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Affiliation(s)
- Linda D'Antona
- From the National Hospital for Neurology and Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., M.S.M., L.D.W., F.B., A.K.); Victor Horsley Department of Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., L.D.W., A.K.); UCL Queen Square Institute of Neurology (L.D., M.S.M., L.D.W., F.B., A.K.); King's College Hospital NHS Foundation Trust (J.A.M.); Department of Ophthalmology (J.A.M., F.B.); and Headache and Facial Pain Group (M.S.M.), London, UK.. linda.d'
| | - Hasan Asif
- From the National Hospital for Neurology and Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., M.S.M., L.D.W., F.B., A.K.); Victor Horsley Department of Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., L.D.W., A.K.); UCL Queen Square Institute of Neurology (L.D., M.S.M., L.D.W., F.B., A.K.); King's College Hospital NHS Foundation Trust (J.A.M.); Department of Ophthalmology (J.A.M., F.B.); and Headache and Facial Pain Group (M.S.M.), London, UK
| | - Claudia Louise Craven
- From the National Hospital for Neurology and Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., M.S.M., L.D.W., F.B., A.K.); Victor Horsley Department of Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., L.D.W., A.K.); UCL Queen Square Institute of Neurology (L.D., M.S.M., L.D.W., F.B., A.K.); King's College Hospital NHS Foundation Trust (J.A.M.); Department of Ophthalmology (J.A.M., F.B.); and Headache and Facial Pain Group (M.S.M.), London, UK
| | - James Alexander McHugh
- From the National Hospital for Neurology and Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., M.S.M., L.D.W., F.B., A.K.); Victor Horsley Department of Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., L.D.W., A.K.); UCL Queen Square Institute of Neurology (L.D., M.S.M., L.D.W., F.B., A.K.); King's College Hospital NHS Foundation Trust (J.A.M.); Department of Ophthalmology (J.A.M., F.B.); and Headache and Facial Pain Group (M.S.M.), London, UK
| | - Anna Vassiliou
- From the National Hospital for Neurology and Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., M.S.M., L.D.W., F.B., A.K.); Victor Horsley Department of Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., L.D.W., A.K.); UCL Queen Square Institute of Neurology (L.D., M.S.M., L.D.W., F.B., A.K.); King's College Hospital NHS Foundation Trust (J.A.M.); Department of Ophthalmology (J.A.M., F.B.); and Headache and Facial Pain Group (M.S.M.), London, UK
| | - Lewis Thorne
- From the National Hospital for Neurology and Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., M.S.M., L.D.W., F.B., A.K.); Victor Horsley Department of Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., L.D.W., A.K.); UCL Queen Square Institute of Neurology (L.D., M.S.M., L.D.W., F.B., A.K.); King's College Hospital NHS Foundation Trust (J.A.M.); Department of Ophthalmology (J.A.M., F.B.); and Headache and Facial Pain Group (M.S.M.), London, UK
| | - Manjit Singh Matharu
- From the National Hospital for Neurology and Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., M.S.M., L.D.W., F.B., A.K.); Victor Horsley Department of Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., L.D.W., A.K.); UCL Queen Square Institute of Neurology (L.D., M.S.M., L.D.W., F.B., A.K.); King's College Hospital NHS Foundation Trust (J.A.M.); Department of Ophthalmology (J.A.M., F.B.); and Headache and Facial Pain Group (M.S.M.), London, UK
| | - Laurence Dale Watkins
- From the National Hospital for Neurology and Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., M.S.M., L.D.W., F.B., A.K.); Victor Horsley Department of Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., L.D.W., A.K.); UCL Queen Square Institute of Neurology (L.D., M.S.M., L.D.W., F.B., A.K.); King's College Hospital NHS Foundation Trust (J.A.M.); Department of Ophthalmology (J.A.M., F.B.); and Headache and Facial Pain Group (M.S.M.), London, UK
| | - Fion Bremner
- From the National Hospital for Neurology and Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., M.S.M., L.D.W., F.B., A.K.); Victor Horsley Department of Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., L.D.W., A.K.); UCL Queen Square Institute of Neurology (L.D., M.S.M., L.D.W., F.B., A.K.); King's College Hospital NHS Foundation Trust (J.A.M.); Department of Ophthalmology (J.A.M., F.B.); and Headache and Facial Pain Group (M.S.M.), London, UK
| | - Ahmed Kassem Toma
- From the National Hospital for Neurology and Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., M.S.M., L.D.W., F.B., A.K.); Victor Horsley Department of Neurosurgery (L.D., H.A., C.L.C., A.V., L.T., L.D.W., A.K.); UCL Queen Square Institute of Neurology (L.D., M.S.M., L.D.W., F.B., A.K.); King's College Hospital NHS Foundation Trust (J.A.M.); Department of Ophthalmology (J.A.M., F.B.); and Headache and Facial Pain Group (M.S.M.), London, UK
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Vasseneix C, Najjar RP, Xu X, Tang Z, Loo JL, Singhal S, Tow S, Milea L, Ting DSW, Liu Y, Wong TY, Newman NJ, Biousse V, Milea D. Accuracy of a Deep Learning System for Classification of Papilledema Severity on Ocular Fundus Photographs. Neurology 2021; 97:e369-e377. [PMID: 34011570 DOI: 10.1212/wnl.0000000000012226] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/19/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the performance of a deep learning system (DLS) in classifying the severity of papilledema associated with increased intracranial pressure on standard retinal fundus photographs. METHODS A DLS was trained to automatically classify papilledema severity in 965 patients (2,103 mydriatic fundus photographs), representing a multiethnic cohort of patients with confirmed elevated intracranial pressure. Training was performed on 1,052 photographs with mild/moderate papilledema (MP) and 1,051 photographs with severe papilledema (SP) classified by a panel of experts. The performance of the DLS and that of 3 independent neuro-ophthalmologists were tested in 111 patients (214 photographs, 92 with MP and 122 with SP) by calculating the area under the receiver operating characteristics curve (AUC), accuracy, sensitivity, and specificity. Kappa agreement scores between the DLS and each of the 3 graders and among the 3 graders were calculated. RESULTS The DLS successfully discriminated between photographs of MP and SP, with an AUC of 0.93 (95% confidence interval [CI] 0.89-0.96) and an accuracy, sensitivity, and specificity of 87.9%, 91.8%, and 86.2%, respectively. This performance was comparable with that of the 3 neuro-ophthalmologists (84.1%, 91.8%, and 73.9%, p = 0.19, p = 1, p = 0.09, respectively). Misclassification by the DLS was mainly observed for moderate papilledema (Frisén grade 3). Agreement scores between the DLS and the neuro-ophthalmologists' evaluation was 0.62 (95% CI 0.57-0.68), whereas the intergrader agreement among the 3 neuro-ophthalmologists was 0.54 (95% CI 0.47-0.62). CONCLUSIONS Our DLS accurately classified the severity of papilledema on an independent set of mydriatic fundus photographs, achieving a comparable performance with that of independent neuro-ophthalmologists. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that a DLS using mydriatic retinal fundus photographs accurately classified the severity of papilledema associated in patients with a diagnosis of increased intracranial pressure.
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Affiliation(s)
- Caroline Vasseneix
- From the Singapore Eye Research Institute (C.V., R.P.N., Z.T., J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); Duke-NUS Medical School (R.P.N., J.L.L., S.S., S.T., T.Y.W., D.M.); Institute of High Performance Computing (X.X., Y.L.), Agency for Science, Technology and Research (A*STAR); Singapore National Eye Centre (J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); University of Berkeley (L.M.), CA; Departments of Ophthalmology and Neurology (N.J.N., V.B.), Emory University School of Medicine, Atlanta, GA; and Copenhagen University Hospital (D.M.), Denmark
| | - Raymond P Najjar
- From the Singapore Eye Research Institute (C.V., R.P.N., Z.T., J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); Duke-NUS Medical School (R.P.N., J.L.L., S.S., S.T., T.Y.W., D.M.); Institute of High Performance Computing (X.X., Y.L.), Agency for Science, Technology and Research (A*STAR); Singapore National Eye Centre (J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); University of Berkeley (L.M.), CA; Departments of Ophthalmology and Neurology (N.J.N., V.B.), Emory University School of Medicine, Atlanta, GA; and Copenhagen University Hospital (D.M.), Denmark
| | - Xinxing Xu
- From the Singapore Eye Research Institute (C.V., R.P.N., Z.T., J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); Duke-NUS Medical School (R.P.N., J.L.L., S.S., S.T., T.Y.W., D.M.); Institute of High Performance Computing (X.X., Y.L.), Agency for Science, Technology and Research (A*STAR); Singapore National Eye Centre (J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); University of Berkeley (L.M.), CA; Departments of Ophthalmology and Neurology (N.J.N., V.B.), Emory University School of Medicine, Atlanta, GA; and Copenhagen University Hospital (D.M.), Denmark
| | - Zhiqun Tang
- From the Singapore Eye Research Institute (C.V., R.P.N., Z.T., J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); Duke-NUS Medical School (R.P.N., J.L.L., S.S., S.T., T.Y.W., D.M.); Institute of High Performance Computing (X.X., Y.L.), Agency for Science, Technology and Research (A*STAR); Singapore National Eye Centre (J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); University of Berkeley (L.M.), CA; Departments of Ophthalmology and Neurology (N.J.N., V.B.), Emory University School of Medicine, Atlanta, GA; and Copenhagen University Hospital (D.M.), Denmark
| | - Jing Liang Loo
- From the Singapore Eye Research Institute (C.V., R.P.N., Z.T., J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); Duke-NUS Medical School (R.P.N., J.L.L., S.S., S.T., T.Y.W., D.M.); Institute of High Performance Computing (X.X., Y.L.), Agency for Science, Technology and Research (A*STAR); Singapore National Eye Centre (J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); University of Berkeley (L.M.), CA; Departments of Ophthalmology and Neurology (N.J.N., V.B.), Emory University School of Medicine, Atlanta, GA; and Copenhagen University Hospital (D.M.), Denmark
| | - Shweta Singhal
- From the Singapore Eye Research Institute (C.V., R.P.N., Z.T., J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); Duke-NUS Medical School (R.P.N., J.L.L., S.S., S.T., T.Y.W., D.M.); Institute of High Performance Computing (X.X., Y.L.), Agency for Science, Technology and Research (A*STAR); Singapore National Eye Centre (J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); University of Berkeley (L.M.), CA; Departments of Ophthalmology and Neurology (N.J.N., V.B.), Emory University School of Medicine, Atlanta, GA; and Copenhagen University Hospital (D.M.), Denmark
| | - Sharon Tow
- From the Singapore Eye Research Institute (C.V., R.P.N., Z.T., J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); Duke-NUS Medical School (R.P.N., J.L.L., S.S., S.T., T.Y.W., D.M.); Institute of High Performance Computing (X.X., Y.L.), Agency for Science, Technology and Research (A*STAR); Singapore National Eye Centre (J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); University of Berkeley (L.M.), CA; Departments of Ophthalmology and Neurology (N.J.N., V.B.), Emory University School of Medicine, Atlanta, GA; and Copenhagen University Hospital (D.M.), Denmark
| | - Leonard Milea
- From the Singapore Eye Research Institute (C.V., R.P.N., Z.T., J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); Duke-NUS Medical School (R.P.N., J.L.L., S.S., S.T., T.Y.W., D.M.); Institute of High Performance Computing (X.X., Y.L.), Agency for Science, Technology and Research (A*STAR); Singapore National Eye Centre (J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); University of Berkeley (L.M.), CA; Departments of Ophthalmology and Neurology (N.J.N., V.B.), Emory University School of Medicine, Atlanta, GA; and Copenhagen University Hospital (D.M.), Denmark.
| | - Daniel Shu Wei Ting
- From the Singapore Eye Research Institute (C.V., R.P.N., Z.T., J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); Duke-NUS Medical School (R.P.N., J.L.L., S.S., S.T., T.Y.W., D.M.); Institute of High Performance Computing (X.X., Y.L.), Agency for Science, Technology and Research (A*STAR); Singapore National Eye Centre (J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); University of Berkeley (L.M.), CA; Departments of Ophthalmology and Neurology (N.J.N., V.B.), Emory University School of Medicine, Atlanta, GA; and Copenhagen University Hospital (D.M.), Denmark
| | - Yong Liu
- From the Singapore Eye Research Institute (C.V., R.P.N., Z.T., J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); Duke-NUS Medical School (R.P.N., J.L.L., S.S., S.T., T.Y.W., D.M.); Institute of High Performance Computing (X.X., Y.L.), Agency for Science, Technology and Research (A*STAR); Singapore National Eye Centre (J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); University of Berkeley (L.M.), CA; Departments of Ophthalmology and Neurology (N.J.N., V.B.), Emory University School of Medicine, Atlanta, GA; and Copenhagen University Hospital (D.M.), Denmark
| | - Tien Y Wong
- From the Singapore Eye Research Institute (C.V., R.P.N., Z.T., J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); Duke-NUS Medical School (R.P.N., J.L.L., S.S., S.T., T.Y.W., D.M.); Institute of High Performance Computing (X.X., Y.L.), Agency for Science, Technology and Research (A*STAR); Singapore National Eye Centre (J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); University of Berkeley (L.M.), CA; Departments of Ophthalmology and Neurology (N.J.N., V.B.), Emory University School of Medicine, Atlanta, GA; and Copenhagen University Hospital (D.M.), Denmark
| | - Nancy J Newman
- From the Singapore Eye Research Institute (C.V., R.P.N., Z.T., J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); Duke-NUS Medical School (R.P.N., J.L.L., S.S., S.T., T.Y.W., D.M.); Institute of High Performance Computing (X.X., Y.L.), Agency for Science, Technology and Research (A*STAR); Singapore National Eye Centre (J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); University of Berkeley (L.M.), CA; Departments of Ophthalmology and Neurology (N.J.N., V.B.), Emory University School of Medicine, Atlanta, GA; and Copenhagen University Hospital (D.M.), Denmark
| | - Valerie Biousse
- From the Singapore Eye Research Institute (C.V., R.P.N., Z.T., J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); Duke-NUS Medical School (R.P.N., J.L.L., S.S., S.T., T.Y.W., D.M.); Institute of High Performance Computing (X.X., Y.L.), Agency for Science, Technology and Research (A*STAR); Singapore National Eye Centre (J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); University of Berkeley (L.M.), CA; Departments of Ophthalmology and Neurology (N.J.N., V.B.), Emory University School of Medicine, Atlanta, GA; and Copenhagen University Hospital (D.M.), Denmark
| | - Dan Milea
- From the Singapore Eye Research Institute (C.V., R.P.N., Z.T., J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); Duke-NUS Medical School (R.P.N., J.L.L., S.S., S.T., T.Y.W., D.M.); Institute of High Performance Computing (X.X., Y.L.), Agency for Science, Technology and Research (A*STAR); Singapore National Eye Centre (J.L.L., S.S., S.T., D.S.W.T., T.Y.W., D.M.); University of Berkeley (L.M.), CA; Departments of Ophthalmology and Neurology (N.J.N., V.B.), Emory University School of Medicine, Atlanta, GA; and Copenhagen University Hospital (D.M.), Denmark.
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