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Salongcay RP, Aquino LAC, Alog GP, Locaylocay KB, Saunar AV, Peto T, Silva PS. Accuracy of Integrated Artificial Intelligence Grading Using Handheld Retinal Imaging in a Community Diabetic Eye Screening Program. Ophthalmol Sci 2024; 4:100457. [PMID: 38317871 PMCID: PMC10838904 DOI: 10.1016/j.xops.2023.100457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/08/2023] [Accepted: 12/11/2023] [Indexed: 02/07/2024]
Abstract
Purpose To evaluate mydriatic handheld retinal imaging performance assessed by point-of-care (POC) artificial intelligence (AI) as compared with retinal image graders at a centralized reading center (RC) in identifying diabetic retinopathy (DR) and diabetic macular edema (DME). Design Prospective, comparative study. Subjects Five thousand five hundred eighty-five eyes from 2793 adult patients with diabetes. Methods Point-of-care AI assessment of disc and macular handheld retinal images was compared with RC evaluation of validated 5-field handheld retinal images (disc, macula, superior, inferior, and temporal) in identifying referable DR (refDR; defined as moderate nonproliferative DR [NPDR], or worse, or any level of DME) and vision-threatening DR (vtDR; defined as severe NPDR or worse, or any level of center-involving DME [ciDME]). Reading center evaluation of the 5-field images followed the international DR/DME classification. Sensitivity (SN) and specificity (SP) for ungradable images, refDR, and vtDR were calculated. Main Outcome Measures Agreement for DR and DME; SN and SP for refDR, vtDR, and ungradable images. Results Diabetic retinopathy severity by RC evaluation: no DR, 67.3%; mild NPDR, 9.7%; moderate NPDR, 8.6%; severe NPDR, 4.8%; proliferative DR, 3.8%; and ungradable, 5.8%. Diabetic macular edema severity by RC evaluation was as follows: no DME (80.4%), non-ciDME (7.7%), ciDME (4.4%), and ungradable (7.5%). Referable DR was present in 25.3% and vtDR was present in 17.5% of eyes. Images were ungradable for DR or DME in 7.5% by RC evaluation and 15.4% by AI. There was substantial agreement between AI and RC for refDR (κ = 0.66) and moderate agreement for vtDR (κ = 0.54). The SN/SP of AI grading compared with RC evaluation was 0.86/0.86 for refDR and 0.92/0.80 for vtDR. Conclusions This study demonstrates that POC AI following a defined handheld retinal imaging protocol at the time of imaging has SN and SP for refDR that meets the current United States Food and Drug Administration thresholds of 85% and 82.5%, but not for vtDR. Integrating AI at the POC could substantially reduce centralized RC burden and speed information delivery to the patient, allowing more prompt eye care referral. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
- Recivall P. Salongcay
- Centre for Public Health, Queen’s University Belfast, Belfast, United Kingdom
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Eye and Vision Institute, The Medical City, Metro Manila, Philippines
| | - Lizzie Anne C. Aquino
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | - Glenn P. Alog
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Eye and Vision Institute, The Medical City, Metro Manila, Philippines
| | - Kaye B. Locaylocay
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Eye and Vision Institute, The Medical City, Metro Manila, Philippines
| | - Aileen V. Saunar
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Eye and Vision Institute, The Medical City, Metro Manila, Philippines
| | - Tunde Peto
- Centre for Public Health, Queen’s University Belfast, Belfast, United Kingdom
| | - Paolo S. Silva
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Eye and Vision Institute, The Medical City, Metro Manila, Philippines
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
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Silva PS, Cavallerano JD, Sun JK, Tolson AM, Tolls D, Abrahamson MJ, Aiello LM, Aiello LP. Disparities Between Teleretinal Imaging Findings and Patient-Reported Diabetic Retinopathy Status and Follow-Up Eye Care Interval: A 10-Year Prospective Study. Diabetes Care 2024:dc232282. [PMID: 38457639 DOI: 10.2337/dc23-2282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/13/2024] [Indexed: 03/10/2024]
Abstract
OBJECTIVE To assess self-reported awareness of diabetic retinopathy (DR) and concordance of eye examination follow-up compared with findings from concurrent retinal images. RESEARCH DESIGN AND METHODS We conducted a prospective observational 10-year study of 26,876 consecutive patients with diabetes who underwent retinal imaging during an endocrinology visit. Awareness and concordance were evaluated using questionnaires and retinal imaging. RESULTS Awareness information and gradable images were available in 25,360 patients (94.3%). Severity of DR by imaging was as follows: no DR (n = 14,317; 56.5%), mild DR (n = 6,805; 26.8%), or vision-threatening DR (vtDR; n = 4,238; 16.7%). In the no, mild, and vtDR groups, 96.7%, 88.5%, and 54.9% of patients, respectively, reported being unaware of any prior DR. When DR was present, reporting no prior DR was associated with shorter diabetes duration, milder DR, last eye examination >1 year before, no dilation, no scheduled appointment, and less specialized provider (all P < 0.001). Among patients with vtDR, 41.2%, 58.1%, and 64.2% did not report being aware of any DR and follow-up was concordant with current DR severity in 66.7%, 41.3%, and 25.4% (P < 0.001) of patients when prior examination was performed by a retinal specialist, nonretinal ophthalmologist, or optometrist (P < 0.001), respectively. CONCLUSIONS Substantial discrepancies exist between DR presence, patient awareness, and concordance of follow-up across all DR severity levels. These discrepancies are present across all eye care provider types, with the magnitude influenced by provider type. Therefore, patient self-report should not be relied upon to reflect DR status. Modification of medical care and education models may be necessary to enhance retention of ophthalmic knowledge in patients with diabetes and ensure accurate communication between all health care providers.
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Affiliation(s)
- Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA
- Department of Ophthalmology, Harvard Medical School, Boston, MA
| | - Jerry D Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA
- Department of Ophthalmology, Harvard Medical School, Boston, MA
| | - Jennifer K Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA
- Department of Ophthalmology, Harvard Medical School, Boston, MA
| | - Ann M Tolson
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA
| | - Dorothy Tolls
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA
| | - Martin J Abrahamson
- Adult Diabetes, Joslin Diabetes Center, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Lloyd M Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA
- Department of Ophthalmology, Harvard Medical School, Boston, MA
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA
- Department of Ophthalmology, Harvard Medical School, Boston, MA
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Gulkas S, Salongcay RP, Jacoba CMP, Gomez EDD, Glipo PER, Ashraf M, Cavallerano JD, Silva PS. Peripheral and Vitreous Pathology in Ultrawidefield Cameras in Diabetic Eyes. Ophthalmol Retina 2024:S2468-6530(24)00090-3. [PMID: 38447920 DOI: 10.1016/j.oret.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Samet Gulkas
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
| | | | | | | | | | - Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Jerry D Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.
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Silva PS, Zhang D, Jacoba CMP, Fickweiler W, Lewis D, Leitmeyer J, Curran K, Salongcay RP, Doan D, Ashraf M, Cavallerano JD, Sun JK, Peto T, Aiello LP. Automated Machine Learning for Predicting Diabetic Retinopathy Progression From Ultra-Widefield Retinal Images. JAMA Ophthalmol 2024; 142:171-177. [PMID: 38329765 PMCID: PMC10853872 DOI: 10.1001/jamaophthalmol.2023.6318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 11/24/2023] [Indexed: 02/09/2024]
Abstract
Importance Machine learning (ML) algorithms have the potential to identify eyes with early diabetic retinopathy (DR) at increased risk for disease progression. Objective To create and validate automated ML models (autoML) for DR progression from ultra-widefield (UWF) retinal images. Design, Setting and Participants Deidentified UWF images with mild or moderate nonproliferative DR (NPDR) with 3 years of longitudinal follow-up retinal imaging or evidence of progression within 3 years were used to develop automated ML models for predicting DR progression in UWF images. All images were collected from a tertiary diabetes-specific medical center retinal image dataset. Data were collected from July to September 2022. Exposure Automated ML models were generated from baseline on-axis 200° UWF retinal images. Baseline retinal images were labeled for progression based on centralized reading center evaluation of baseline and follow-up images according to the clinical Early Treatment Diabetic Retinopathy Study severity scale. Images for model development were split 8-1-1 for training, optimization, and testing to detect 1 or more steps of DR progression. Validation was performed using a 328-image set from the same patient population not used in model development. Main Outcomes and Measures Area under the precision-recall curve (AUPRC), sensitivity, specificity, and accuracy. Results A total of 1179 deidentified UWF images with mild (380 [32.2%]) or moderate (799 [67.8%]) NPDR were included. DR progression was present in half of the training set (590 of 1179 [50.0%]). The model's AUPRC was 0.717 for baseline mild NPDR and 0.863 for moderate NPDR. On the validation set for eyes with mild NPDR, sensitivity was 0.72 (95% CI, 0.57-0.83), specificity was 0.63 (95% CI, 0.57-0.69), prevalence was 0.15 (95% CI, 0.12-0.20), and accuracy was 64.3%; for eyes with moderate NPDR, sensitivity was 0.80 (95% CI, 0.70-0.87), specificity was 0.72 (95% CI, 0.66-0.76), prevalence was 0.22 (95% CI, 0.19-0.27), and accuracy was 73.8%. In the validation set, 6 of 9 eyes (75%) with mild NPDR and 35 of 41 eyes (85%) with moderate NPDR progressed 2 steps or more were identified. All 4 eyes with mild NPDR that progressed within 6 months and 1 year were identified, and 8 of 9 (89%) and 17 of 20 (85%) with moderate NPDR that progressed within 6 months and 1 year, respectively, were identified. Conclusions and Relevance This study demonstrates the accuracy and feasibility of automated ML models for identifying DR progression developed using UWF images, especially for prediction of 2-step or greater DR progression within 1 year. Potentially, the use of ML algorithms may refine the risk of disease progression and identify those at highest short-term risk, thus reducing costs and improving vision-related outcomes.
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Affiliation(s)
- Paolo S. Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Dean Zhang
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
| | - Cris Martin P. Jacoba
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Ward Fickweiler
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Drew Lewis
- Estenda Solutions, Conshohocken, Pennsylvania
| | | | - Katie Curran
- Centre for Public Health, Queen’s University Belfast, Belfast, United Kingdom
| | | | - Duy Doan
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
| | - Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Jerry D. Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Jennifer K. Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Tunde Peto
- Centre for Public Health, Queen’s University Belfast, Belfast, United Kingdom
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
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Vujosevic S, Fantaguzzi F, Silva PS, Salongcay R, Brambilla M, Torti E, Nucci P, Peto T. Macula vs periphery in diabetic retinopathy: OCT-angiography and ultrawide field fluorescein angiography imaging of retinal non perfusion. Eye (Lond) 2024:10.1038/s41433-024-02989-3. [PMID: 38402286 DOI: 10.1038/s41433-024-02989-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 01/28/2024] [Accepted: 02/08/2024] [Indexed: 02/26/2024] Open
Abstract
OBJECTIVES To investigate the association between peripheral non-perfusion index (NPI) on ultrawide-field fluorescein angiography (UWF-FA) and quantitative OCT-Angiography (OCT-A) metrics in the macula. METHODS In total, 48 eyes with UWF-colour fundus photos (CFP), UWF-FA (California, Optos) and OCT-A (Spectralis, Heidelberg) were included. OCT-A (3 × 3 mm) was used to determine foveal avascular zone (FAZ) parameters and vessel density (VD), perfusion density (PD), fractal dimension (FD) on superficial capillary plexus (SCP). NPI's extent and distribution was determined on UWF-FA within fovea centred concentric rings corresponding to posterior pole (<10 mm), mid-periphery (10-15 mm), and far-periphery (>15 mm) and within the total retinal area, the central macular field (6×6 mm), ETDRS fields and within each extended ETDRS field (P3-P7). RESULTS Macular PD was correlated to NPI in total area of retina (Spearman ρ = 0.69, p < 0.05), posterior pole (ρ = 0.48, p < 0.05), mid-periphery (ρ = 0.65, p < 0.05), far-periphery (ρ = 0.59, p < 0.05), P3-P7 (ρ = 0,55 at least, p < 0.05 for each), central macula (ρ = 0.47, p < 0.05), total area in ETDRS (ρ = 0.55, p < 0.05). Macular VD and FD were correlated to NPI of total area of the retina (ρ = 0.60 and 0.61, p < 0.05), the mid-periphery (ρ = 0.56, p < 0.05) and far-periphery (ρ = 0.60 and ρ = 0.61, p < 0.05), and in P3-P7 (p < 0.05). FAZ perimeter was significantly corelated to NPI at posterior pole and central macular area (ρ = 0.37 and 0.36, p < 0.05), and FAZ area to NPI in central macular area (ρ = 0.36, p < 0.05). CONCLUSIONS Perfusion macular metrics on OCT-A correlated with UWF-FA's non-perfusion (NP), particularly in the retina's mid and far periphery, suggesting that OCT-A might be a useful non-invasive method to estimate peripheral retinal NP.
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Affiliation(s)
- Stela Vujosevic
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
- Eye Clinic, IRCCS MultiMedica, Milan, Italy.
| | | | - Paolo S Silva
- Harvard Department of Ophthalmology, Joslin Diabetes Center, Beetham Eye Institute, Boston, MA, USA
| | | | - Marco Brambilla
- Department of Medical Physics, University Hospital Maggiore della Carità, Novara, Italy
| | - Emanuele Torti
- Department of Electrical, Computer and Biomedical Engineering, University of Pavia, Pavia, Italy
| | - Paolo Nucci
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, UK
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ElSayed NA, Aleppo G, Bannuru RR, Beverly EA, Bruemmer D, Collins BS, Cusi K, Darville A, Das SR, Ekhlaspour L, Fleming TK, Gaglia JL, Galindo RJ, Gibbons CH, Giurini JM, Hassanein M, Hilliard ME, Johnson EL, Khunti K, Kosiborod MN, Kushner RF, Lingvay I, Matfin G, McCoy RG, Murdock L, Napoli N, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Selvin E, Silva PS, Stanton RC, Verduzco-Gutierrez M, Woodward CC, Younossi ZM, Gabbay RA. Introduction and Methodology: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S1-S4. [PMID: 38078587 PMCID: PMC10725799 DOI: 10.2337/dc24-sint] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
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ElSayed NA, Aleppo G, Bannuru RR, Beverly EA, Bruemmer D, Collins BS, Cusi K, Darville A, Das SR, Ekhlaspour L, Fleming TK, Gaglia JL, Galindo RJ, Gibbons CH, Giurini JM, Hassanein M, Hilliard ME, Johnson EL, Khunti K, Kosiborod MN, Kushner RF, Lingvay I, Matfin G, McCoy RG, Murdock L, Napoli N, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Selvin E, Silva PS, Stanton RC, Verduzco-Gutierrez M, Woodward CC, Younossi ZM, Gabbay RA. Summary of Revisions: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S5-S10. [PMID: 38078579 PMCID: PMC10725800 DOI: 10.2337/dc24-srev] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
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8
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Gibbons CH, Giurini JM, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Silva PS, Stanton RC, Gabbay RA. 12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S231-S243. [PMID: 38078577 PMCID: PMC10725803 DOI: 10.2337/dc24-s012] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Aiello LP, Jacoba CMP, Ashraf M, Cavallerano JD, Tolson AM, Tolls D, Sun JK, Silva PS. INTEGRATING MACULAR OPTICAL COHERENCE TOMOGRAPHY WITH ULTRAWIDE-FIELD IMAGING IN A DIABETIC RETINOPATHY TELEMEDICINE PROGRAM USING A SINGLE DEVICE. Retina 2023; 43:1928-1935. [PMID: 37871272 DOI: 10.1097/iae.0000000000003883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
Abstract
PURPOSE To determine the effect of combined macular spectral-domain optical coherence tomography (SD-OCT) and ultrawide field retinal imaging (UWFI) within a telemedicine program. METHODS Comparative cohort study of consecutive patients with both UWFI and SD-OCT. Ultrawide field retinal imaging and SD-OOCT were independently evaluated for diabetic macular edema (DME) and nondiabetic macular abnormality. Sensitivity and specificity were calculated with SD-OCT as the gold standard. RESULTS Four hundred twenty-two eyes from 211 diabetic patients were evaluated. Diabetic macular edema severity by UWFI was as follows: no DME 93.4%, noncenter involved DME (nonciDME) 5.1%, ciDME 0.7%, ungradable DME 0.7%. SD-OCT was ungradable in 0.5%. Macular abnormality was identified in 34 (8.1%) eyes by UWFI and in 44 (10.4%) eyes by SD-OCT. Diabetic macular edema represented only 38.6% of referable macular abnormality identified by SD-OCT imaging. Sensitivity/specificity of UWFI compared with SD-OCT was 59%/96% for DME and 33%/99% for ciDME. Sensitivity/specificity of UWFI compared with SDOCT was 3%/98% for epiretinal membrane. CONCLUSION Addition of SD-OCT increased the identification of macular abnormality by 29.4%. More than 58.3% of the eyes believed to have any DME on UWF imaging alone were false-positives by SD-OCT. The integration of SD-OCT with UWFI markedly increased detection and reduced false-positive assessments of DME and macular abnormality in a teleophthalmology program.
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Affiliation(s)
- Lloyd Paul Aiello
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts; and
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | | | - Mohamed Ashraf
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts; and
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Jerry D Cavallerano
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts; and
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Ann M Tolson
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts; and
| | - Dorothy Tolls
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts; and
| | - Jennifer K Sun
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts; and
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Paolo S Silva
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts; and
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
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Jacoba CMP, Cavallerano JD, Tolston AM, Silva PS. Effect of Accessible Nonmydriatic Retinal Imaging on Diabetic Retinopathy Surveillance Rates. Telemed J E Health 2023; 29:1667-1672. [PMID: 36912812 DOI: 10.1089/tmj.2022.0313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
Purpose: To evaluate the impact on surveillance rates for diabetic retinopathy (DR) by providing nonmydriatic retinal imaging as part of comprehensive diabetes care at no cost to patients or insurers. Methods: A retrospective comparative cohort study was designed. Patients were imaged from April 1, 2016 to March 31, 2017 at a tertiary diabetes-specific academic medical center. Retinal imaging was provided without additional cost beginning October 16, 2016. Images were evaluated for DR and diabetic macular edema using standard protocol at a centralized reading center. Diabetes surveillance rates before and after no-cost imaging were compared. Results: A total of 759 and 2,080 patients respectively were imaged before and after offering no-cost retinal imaging. The difference represents a 274% increase in the number of patients screened. Furthermore, there was a 292% and 261% increase in the number of eyes with mild DR and referable DR, respectively. In the comparative 6-month period, 92 additional cases of proliferative DR were identified, estimated to prevent 6.7 cases of severe visual loss with annual cost savings of $180,230 (estimated yearly cost of severe vision loss per person: $26,900). In patients with referable DR, self-awareness was low, with no significant difference in the before and after groups (39.4% vs. 43.8%, p = 0.3725). Conclusions: Providing retinal imaging as part of comprehensive diabetes care substantially increased the number of patients identified by nearly threefold. The data suggest that the removal of out-of-pocket costs substantially increased patient surveillance rates, which may translate to improved long-term patient outcomes.
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Affiliation(s)
- Cris Martin P Jacoba
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Jerry D Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Ann M Tolston
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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Nakayama LF, Zago Ribeiro L, Novaes F, Miyawaki IA, Miyawaki AE, de Oliveira JAE, Oliveira T, Malerbi FK, Regatieri CVS, Celi LA, Silva PS. Artificial intelligence for telemedicine diabetic retinopathy screening: a review. Ann Med 2023; 55:2258149. [PMID: 37734417 PMCID: PMC10515659 DOI: 10.1080/07853890.2023.2258149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 08/31/2023] [Indexed: 09/23/2023] Open
Abstract
PURPOSE This study aims to compare artificial intelligence (AI) systems applied in diabetic retinopathy (DR) teleophthalmology screening, currently deployed systems, fairness initiatives and the challenges for implementation. METHODS The review included articles retrieved from PubMed/Medline/EMBASE literature search strategy regarding telemedicine, DR and AI. The screening criteria included human articles in English, Portuguese or Spanish and related to telemedicine and AI for DR screening. The author's affiliations and the study's population income group were classified according to the World Bank Country and Lending Groups. RESULTS The literature search yielded a total of 132 articles, and nine were included after full-text assessment. The selected articles were published between 2004 and 2020 and were grouped as telemedicine systems, algorithms, economic analysis and image quality assessment. Four telemedicine systems that perform a quality assessment, image preprocessing and pathological screening were reviewed. A data and post-deployment bias assessment are not performed in any of the algorithms, and none of the studies evaluate the social impact implementations. There is a lack of representativeness in the reviewed articles, with most authors and target populations from high-income countries and no low-income country representation. CONCLUSIONS Telemedicine and AI hold great promise for augmenting decision-making in medical care, expanding patient access and enhancing cost-effectiveness. Economic studies and social science analysis are crucial to support the implementation of AI in teleophthalmology screening programs. Promoting fairness and generalizability in automated systems combined with telemedicine screening programs is not straightforward. Improving data representativeness, reducing biases and promoting equity in deployment and post-deployment studies are all critical steps in model development.
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Affiliation(s)
- Luis Filipe Nakayama
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Ophthalmology, São Paulo Federal University, Sao Paulo, Brazil
| | - Lucas Zago Ribeiro
- Department of Ophthalmology, São Paulo Federal University, Sao Paulo, Brazil
| | - Frederico Novaes
- Department of Ophthalmology, São Paulo Federal University, Sao Paulo, Brazil
| | | | | | | | - Talita Oliveira
- Department of Ophthalmology, São Paulo Federal University, Sao Paulo, Brazil
| | | | | | - Leo Anthony Celi
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Department of Biostatistics, Harvard TH Chan School of Public Health, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Paolo S. Silva
- Beetham Eye Institute, Joslin Diabetes Centre, Harvard Medical School, Boston, MA, USA
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
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Jacoba CMP, Salongcay RP, Aquino LAC, Salva CMG, Saunar AV, Alog GP, Peto T, Silva PS. Comparisons of handheld retinal imaging devices with ultrawide field images for determining diabetic retinopathy severity. Acta Ophthalmol 2023; 101:670-678. [PMID: 36847205 DOI: 10.1111/aos.15651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/20/2023] [Accepted: 02/09/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE To compare diabetic retinopathy (DR) severity identified on handheld retinal imaging with ultrawide field (UWF) images. METHODS Mydriatic images of 225 eyes of 118 diabetic patients were prospectively imaged with the Aurora (AU) handheld retinal camera [5-field protocol (macula-centred, disc-centred, temporal, superior, inferior)] and compared with UWF images. Images were classified based on the international classification for DR. Sensitivity, specificity, kappa statistics (K/Kw) were calculated on an eye and person-level. RESULTS Distribution of DR severity by AU/UWF images (%) by eye was no DR 41.3/36.0, mild non-proliferative DR (NPDR) 18.7/17.8, moderate 10.2/10.7, severe 16.4/15.1, proliferative DR (PDR) 13.3/20.4. Agreement between UWF and AU was exact in 64.4%, within 1-step 90.7%, k = 0.55 (95% CI:0.45-0.65), and kw = 0.79 (95% CI:0.73-0.85) by eye, and exact in 68%, within 1-step 92.9%, k = 0.58 (95% CI:0.50-0.66), and kw = 0.76 (95% CI:0.70-0.81) by person. Sensitivity/specificity for any DR, refDR, vtDR and PDR were as follows: 0.90/0.83, 0.90/0.97, 0.82/0.95 and 0.69/1.00 by person and 0.86/0.90, 0.84/0.98, 0.75/0.95 and 0.63/0.99 by eye. Handheld imaging missed 37% (17/46) eyes and 30.8% (8/26) persons with PDR. Only 3.9% (1/26) persons or 6.5% (3/46) eyes with PDR were missed if a referral threshold of moderate NPDR was used. CONCLUSIONS Data from this study show that comparing UWF and handheld images, when PDR was the referral threshold for handheld devices, 37.0% of eyes or 30.8% of patients with PDR were missed. Due to the identification of neovascular lesions outside of the handheld fields, lower referral thresholds are needed if handheld devices are used.
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Affiliation(s)
- Cris Martin P Jacoba
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Recivall P Salongcay
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- Eye and Vision Institute, The Medical City, Metro Manila, Philippines
| | - Lizzie Anne C Aquino
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | | | - Aileen V Saunar
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Eye and Vision Institute, The Medical City, Metro Manila, Philippines
| | - Glenn P Alog
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Eye and Vision Institute, The Medical City, Metro Manila, Philippines
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- Eye and Vision Institute, The Medical City, Metro Manila, Philippines
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Ferkowicz MJ, Verma A, Barwinska D, Melo Ferreira R, Henderson JM, Kirkpatrick M, Silva PS, Steenkamp DW, Phillips CL, Waikar SS, Sutton TA. Molecular Signatures of Glomerular Neovascularization in a Patient with Diabetic Kidney Disease. Clin J Am Soc Nephrol 2023; 19:01277230-990000000-00211. [PMID: 37533147 PMCID: PMC10861111 DOI: 10.2215/cjn.0000000000000276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023]
Abstract
The Kidney Precision Medicine Project (KPMP) aims to create a kidney tissue atlas, define disease subgroups, and identify critical cells, pathways, and targets for novel therapies through molecular investigation of human kidney biopsies obtained from participants with acute kidney injury (AKI) or chronic kidney disease (CKD). We present the case of a 66-year-old woman with diabetic kidney disease who underwent a protocol KPMP kidney biopsy. Her clinical history included diabetes mellitus complicated by neuropathy and eye disease, increased insulin resistance, hypertension, albuminuria, and relatively preserved glomerular filtration rate (early CKD stage 3a). The patient's histopathology was consistent with diabetic nephropathy and arterial and arteriolar sclerosis. Three-dimensional, immunofluorescence imaging of the kidney biopsy specimen revealed extensive peri-glomerular neovascularization that was underestimated by standard histopathologic approaches. Spatial transcriptomics was performed to obtain gene expression signatures at discrete areas of the kidney biopsy. Gene expression in the areas of glomerular neovascularization revealed increased expression of genes involved in angiogenic signaling, proliferation and survival of endothelial cells, as well as new vessel maturation and stability. This molecular correlation provides additional insights into the development of kidney disease in patients with diabetes and spotlights how novel molecular techniques employed by the KPMP can supplement and enrich the histopathologic diagnosis obtained from a kidney biopsy.
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Affiliation(s)
- Michael J. Ferkowicz
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ashish Verma
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Daria Barwinska
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ricardo Melo Ferreira
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Joel M. Henderson
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Mary Kirkpatrick
- Section of Endocrinology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Paolo S. Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Devin W. Steenkamp
- Section of Endocrinology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Carrie L. Phillips
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Sushrut S. Waikar
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Timothy A. Sutton
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Jacoba CMP, Doan D, Salongcay RP, Aquino LAC, Silva JPY, Salva CMG, Zhang D, Alog GP, Zhang K, Locaylocay KLRB, Saunar AV, Ashraf M, Sun JK, Peto T, Aiello LP, Silva PS. Performance of Automated Machine Learning for Diabetic Retinopathy Image Classification from Multi-field Handheld Retinal Images. Ophthalmol Retina 2023; 7:703-712. [PMID: 36924893 DOI: 10.1016/j.oret.2023.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 02/07/2023] [Accepted: 03/01/2023] [Indexed: 03/17/2023]
Abstract
PURPOSE To create and validate code-free automated deep learning models (AutoML) for diabetic retinopathy (DR) classification from handheld retinal images. DESIGN Prospective development and validation of AutoML models for DR image classification. PARTICIPANTS A total of 17 829 deidentified retinal images from 3566 eyes with diabetes, acquired using handheld retinal cameras in a community-based DR screening program. METHODS AutoML models were generated based on previously acquired 5-field (macula-centered, disc-centered, superior, inferior, and temporal macula) handheld retinal images. Each individual image was labeled using the International DR and diabetic macular edema (DME) Classification Scale by 4 certified graders at a centralized reading center under oversight by a senior retina specialist. Images for model development were split 8-1-1 for training, optimization, and testing to detect referable DR ([refDR], defined as moderate nonproliferative DR or worse or any level of DME). Internal validation was performed using a published image set from the same patient population (N = 450 images from 225 eyes). External validation was performed using a publicly available retinal imaging data set from the Asia Pacific Tele-Ophthalmology Society (N = 3662 images). MAIN OUTCOME MEASURES Area under the precision-recall curve (AUPRC), sensitivity (SN), specificity (SP), positive predictive value (PPV), negative predictive value (NPV), accuracy, and F1 scores. RESULTS Referable DR was present in 17.3%, 39.1%, and 48.0% of the training set, internal validation, and external validation sets, respectively. The model's AUPRC was 0.995 with a precision and recall of 97% using a score threshold of 0.5. Internal validation showed that SN, SP, PPV, NPV, accuracy, and F1 scores were 0.96 (95% confidence interval [CI], 0.884-0.99), 0.98 (95% CI, 0.937-0.995), 0.96 (95% CI, 0.884-0.99), 0.98 (95% CI, 0.937-0.995), 0.97, and 0.96, respectively. External validation showed that SN, SP, PPV, NPV, accuracy, and F1 scores were 0.94 (95% CI, 0.929-0.951), 0.97 (95% CI, 0.957-0.974), 0.96 (95% CI, 0.952-0.971), 0.95 (95% CI, 0.935-0.956), 0.97, and 0.96, respectively. CONCLUSIONS This study demonstrates the accuracy and feasibility of code-free AutoML models for identifying refDR developed using handheld retinal imaging in a community-based screening program. Potentially, the use of AutoML may increase access to machine learning models that may be adapted for specific programs that are guided by the clinical need to rapidly address disparities in health care delivery. FINANCIAL DISCLOSURE(S) Proprietary or commercial disclosure may be found after the references.
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Affiliation(s)
- Cris Martin P Jacoba
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Duy Doan
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
| | - Recivall P Salongcay
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines; Centre for Public Health, Queen's University Belfast, United Kingdom; Eyes and Vision Institute, the Medical City, Pasig City, Philippines
| | - Lizzie Anne C Aquino
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | - Joseph Paolo Y Silva
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | | | - Dean Zhang
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
| | - Glenn P Alog
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines; Eyes and Vision Institute, the Medical City, Pasig City, Philippines
| | - Kexin Zhang
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
| | - Kaye Lani Rea B Locaylocay
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines; Eyes and Vision Institute, the Medical City, Pasig City, Philippines
| | - Aileen V Saunar
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines; Eyes and Vision Institute, the Medical City, Pasig City, Philippines
| | - Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Jennifer K Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, United Kingdom
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts; Philippine Eye Research Institute, University of the Philippines, Manila, Philippines; Eyes and Vision Institute, the Medical City, Pasig City, Philippines.
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Salongcay RP, Aquino LAC, Salva CMG, Peto T, Silva PS. Comparison of Diabetic Retinopathy Lesions Identified Using Ultrawide Field Imaging and Optical Coherence Tomography Angiography. Ophthalmic Res 2023; 66:1053-1062. [PMID: 37379803 PMCID: PMC10614530 DOI: 10.1159/000531723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/11/2023] [Indexed: 06/30/2023]
Abstract
INTRODUCTION Optical coherence tomography (OCT) angiography (OCTA) has the potential to influence the diagnosis and management of diabetic eye disease. This study aims to determine the correlation between diabetic retinopathy (DR) findings on ultrawide field (UWF) color photography (UWF-CP), UWF fluorescein angiography (UWF-FA), and OCTA. METHODS This is a cross-sectional, prospective study. One hundred and fourteen eyes from 57 patients with diabetes underwent mydriatic UWF-CP, UWF-FA, and OCTA. DR severity was assessed. Ischemic areas were identified on UWF-FA using ImageJ and the nonperfusion index (NPI) was calculated. Diabetic macular edema (DME) was assessed using OCT. Superficial capillary plexus vessel density (VD), vessel perfusion (VP), and foveal avascular zone (FAZ) area were automatically measured on OCTA. Pearson correlation coefficient between the imaging modalities was determined. RESULTS Forty-five eyes were excluded due to non-DR findings or prior laser photocoagulation; 69 eyes were analyzed. DR severity was associated with larger NPI (r = 0.55944, p < 0.0001) even after distinguishing between cones (Cone Nonperfusion Index [CPI]: r = 0.55617, p < 0.0001) and rods (Rod Nonperfusion Index [RPI]: r = 0.55285, p < 0.0001). In eyes with nonproliferative DR (NPDR), NPI is correlated with DME (r = 0.51156, p = 0.0017) and central subfield thickness (CST) (r = 0.67496, p < 0.0001). UWF-FA macular nonperfusion correlated with NPI (r = 0.42899, p = 0.0101), CPI (r = 0.50028, p = 0.0022), and RPI (r = 0.49027, p = 0.0028). Central VD and VP correlated with the DME presence (r = 0.52456, p < 0.0001; r = 0.51952, p < 0.0001) and CST (r = 0.50133, p < 0.0001; r = 0.48731, p < 0.0001). Central VD and VP were correlated with macular nonperfusion (r = 0.44503, p = 0.0065; r = 0.44239, p = 0.0069) in eyes with NPDR. Larger FAZ was correlated with decreased central VD (r = -0.60089, p = 0.0001) and decreased central VP (r = -0.59224, p = 0.0001). CONCLUSION UWF-CP, UWF-FA, and OCTA findings provide relevant clinical information on diabetic eyes. Nonperfusion on UWF-FA is correlated with DR severity and DME. OCTA metrics of the superficial capillary plexus correlate with the incidence of DME and macular ischemia.
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Affiliation(s)
- Recivall P. Salongcay
- Centre for Public Health, Queen’s University Belfast, Belfast, UK
- Eye and Vision Institute, The Medical City, Pasig, Metro Manila, Philippines
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | - Lizzie Anne C. Aquino
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | | | - Tunde Peto
- Centre for Public Health, Queen’s University Belfast, Belfast, UK
| | - Paolo S. Silva
- Eye and Vision Institute, The Medical City, Pasig, Metro Manila, Philippines
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Aquino LAC, Salongcay RP, Alog GP, Locaylocay KB, Saunar AV, Peto T, Silva PS. Comparison of 2-Field and 5-Field Mydriatic Handheld Retinal Imaging in a Community-Based Diabetic Retinopathy Screening Program. Ophthalmologica 2023; 246:203-208. [PMID: 37231995 DOI: 10.1159/000530903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 04/25/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION The purpose of this study was to compare 2-field (2F) and 5-field (5F) mydriatic handheld retinal imaging for the assessment of diabetic retinopathy (DR) severity in a community-based DR screening program (DRSP). METHODS This was a prospective, cross-sectional diagnostic study, evaluating images of 805 eyes from 407 consecutive patients with diabetes acquired from a community-based DRSP. Mydriatic standardized 5F imaging (macula, disc, superior, inferior, temporal) with handheld retinal camera was performed. 2F (disc, macula), and 5F images were independently assessed using the International DR classification at a centralized reading center. Simple (K) and weighted (Kw) kappa statistics were calculated for DR. Sensitivity and specificity for referable DR ([refDR] moderate nonproliferative DR [NPDR] or worse) and vision-threatening DR ([vtDR] severe NPDR or worse) for 2F compared to 5F imaging were calculated. RESULTS Distribution of DR severity by 2F/5F images (%): no DR 66.0/61.7, mild NPDR 10.7/14.4, moderate NPDR 7.9/8.1, severe NPDR 3.3/5.6, proliferative DR 5.6/4.6, ungradable 6.5/5.6. Exact agreement of DR grading between 2F and 5F was 81.7%, within 1-step 97.1% (K = 0.64, Kw = 0.78). Sensitivity/specificity for 2F compared 5F was refDR 0.80/0.97, vtDR 0.73/0.98. The ungradable images rate with 2F was 16.1% higher than with 5F (6.5 vs. 5.6%, p < 0.001). CONCLUSIONS Mydriatic 2F and 5F handheld imaging have substantial agreement in assessing severity of DR. However, the use of mydriatic 2F handheld imaging only meets the minimum standards for sensitivity and specificity for refDR but not for vtDR. When using handheld cameras, the addition of peripheral fields in 5F imaging further refines the referral approach by decreasing ungradable rate and increasing sensitivity for vtDR.
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Affiliation(s)
- Lizzie Anne C Aquino
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | - Recivall P Salongcay
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- Eye and Vision Institute, The Medical City, Pasig, Philippines
| | - Glenn P Alog
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Eye and Vision Institute, The Medical City, Pasig, Philippines
| | - Kaye B Locaylocay
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Eye and Vision Institute, The Medical City, Pasig, Philippines
| | - Aileen V Saunar
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Eye and Vision Institute, The Medical City, Pasig, Philippines
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Paolo S Silva
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Eye and Vision Institute, The Medical City, Pasig, Philippines
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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Salongcay RP, Jacoba CMP, Salva CMG, Rageh A, Aquino LAC, Saunar AV, Alog GP, Ashraf M, Peto T, Silva PS. One-field, two-field and five-field handheld retinal imaging compared with standard seven-field Early Treatment Diabetic Retinopathy Study photography for diabetic retinopathy screening. Br J Ophthalmol 2023:bjo-2022-321849. [PMID: 37094836 DOI: 10.1136/bjo-2022-321849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 03/28/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND/AIMS To determine agreement of one-field (1F, macula-centred), two-field (2F, disc-macula) and five-field (5F, macula, disc, superior, inferior and nasal) mydriatic handheld retinal imaging protocols for the assessment of diabetic retinopathy (DR) as compared with standard seven-field Early Treatment Diabetic Retinopathy Study (ETDRS) photography. METHODS Prospective, comparative instrument validation study. Mydriatic retinal images were taken using three handheld retinal cameras: Aurora (AU; 50° field of view (FOV), 5F), Smartscope (SS; 40° FOV, 5F), and RetinaVue (RV; 60° FOV, 2F) followed by ETDRS photography. Images were evaluated at a centralised reading centre using the international DR classification. Each field protocol (1F, 2F and 5F) was graded independently by masked graders. Weighted kappa (Kw) statistics assessed agreement for DR. Sensitivity (SN) and specificity (SP) for referable diabetic retinopathy (refDR; moderate non-proliferative diabetic retinopathy (NPDR) or worse, or ungradable images) were calculated. RESULTS Images from 225 eyes of 116 patients with diabetes were evaluated. Severity by ETDRS photography: no DR, 33.3%; mild NPDR, 20.4%; moderate, 14.2%; severe, 11.6%; proliferative, 20.4%. Ungradable rate for DR: ETDRS, 0%; AU: 1F 2.23%, 2F 1.79%, 5F 0%; SS: 1F 7.6%, 2F 4.0%, 5F 3.6%; RV: 1F 6.7%, 2F 5.8%. Agreement rates of DR grading between handheld retinal imaging and ETDRS photography were (Kw, SN/SP refDR) AU: 1F 0.54, 0.72/0.92; 2F 0.59, 0.74/0.92; 5F 0.75, 0.86/0.97; SS: 1F 0.51, 0.72/0.92; 2F 0.60, 0.75/0.92; 5F 0.73, 0.88/0.92; RV: 1F 0.77, 0.91/0.95; 2F 0.75, 0.87/0.95. CONCLUSION When using handheld devices, the addition of peripheral fields decreased the ungradable rate and increased SN and SP for refDR. These data suggest the benefit of additional peripheral fields in DR screening programmes that use handheld retinal imaging.
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Affiliation(s)
- Recivall P Salongcay
- Centre for Public Health, Queen's University Belfast, Belfast, UK
- Philippine Eye Research Institute, University of the Philippines Manila, Manila, Philippines
- Eye and Vision Institute, The Medical City, Pasig City, Philippines
| | - Cris Martin P Jacoba
- Joslin Diabetes Center, Beetham Eye Institute, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Claude Michael G Salva
- Philippine Eye Research Institute, University of the Philippines Manila, Manila, Philippines
| | - Abdulrahman Rageh
- Joslin Diabetes Center, Beetham Eye Institute, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Lizzie Anne C Aquino
- Philippine Eye Research Institute, University of the Philippines Manila, Manila, Philippines
| | - Aileen V Saunar
- Philippine Eye Research Institute, University of the Philippines Manila, Manila, Philippines
- Eye and Vision Institute, The Medical City, Pasig City, Philippines
| | - Glenn P Alog
- Philippine Eye Research Institute, University of the Philippines Manila, Manila, Philippines
- Eye and Vision Institute, The Medical City, Pasig City, Philippines
| | - Mohamed Ashraf
- Joslin Diabetes Center, Beetham Eye Institute, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, UK
| | - Paolo S Silva
- Philippine Eye Research Institute, University of the Philippines Manila, Manila, Philippines
- Eye and Vision Institute, The Medical City, Pasig City, Philippines
- Joslin Diabetes Center, Beetham Eye Institute, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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Jacoba CMP, Salongcay RP, Rageh AK, Aquino LAC, Alog GP, Saunar AV, Peto T, Silva PS. Comparisons of Handheld Retinal Imaging with Optical Coherence Tomography for the Identification of Macular Pathology in Patients with Diabetes. Ophthalmic Res 2023; 66:903-912. [PMID: 37080187 DOI: 10.1159/000530720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 04/11/2023] [Indexed: 04/22/2023]
Abstract
INTRODUCTION Handheld retinal imaging cameras are relatively inexpensive and highly portable devices that have the potential to significantly expand diabetic retinopathy (DR) screening, allowing a much broader population to be evaluated. However, it is essential to evaluate if these devices can accurately identify vision-threatening macular diseases if DR screening programs will rely on these instruments. Thus, the purpose of this study was to evaluate the detection of diabetic macular pathology using monoscopic macula-centered images using mydriatic handheld retinal imaging compared with spectral domain optical coherence tomography (SDOCT). METHODS Mydriatic 40°-60° macula-centered images taken with 3 handheld retinal imaging devices (Aurora [AU], SmartScope [SS], RetinaVue 700 [RV]) were compared with the Cirrus 6000 SDOCT taken during the same visit. Images were evaluated for the presence of diabetic macular edema (DME) on monoscopic fundus photographs adapted from Early Treatment Diabetic Retinopathy Study (ETDRS) definitions (no DME, noncenter-involved DME [non-ciDME], and center-involved DME [ciDME]). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each device with SDOCT as gold standard. RESULTS Severity by ETDRS photos: no DR 33.3%, mild NPDR 20.4%, moderate 14.2%, severe 11.6%, proliferative 20.4%, and ungradable for DR 0%; no DME 83.1%, non-ciDME 4.9%, ciDME 12.0%, and ungradable for DME 0%. Gradable images by SDOCT (N = 217, 96.4%) showed no DME in 75.6%, non-ciDME in 9.8%, and ciDME in 11.1%. The ungradable rate for images (poor visualization in >50% of the macula) was AU: 0.9%, SS: 4.4%, and RV: 6.2%. For DME, sensitivity and specificity were similar across devices (0.5-0.64, 0.93-0.97). For nondiabetic macular pathology (ERM, pigment epithelial detachment, traction retinal detachment) across all devices, sensitivity was low to moderate (0.2-0.5) but highly specific (0.93-1.00). CONCLUSIONS Compared to SDOCT, handheld macular imaging attained high specificity but low sensitivity in identifying macular pathology. This suggests the importance of SDOCT evaluation for patients suspected to have DME on fundus photography, leading to more appropriate referral refinement.
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Affiliation(s)
- Cris Martin P Jacoba
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Recivall P Salongcay
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Centre for Public Health, Queen's University, Belfast, UK
- Eyes and Vision Institute, The Medical City, Pasig City, Philippines
| | - Abdulrahman K Rageh
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Lizzie Anne C Aquino
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | - Glenn P Alog
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Eyes and Vision Institute, The Medical City, Pasig City, Philippines
| | - Aileen V Saunar
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Eyes and Vision Institute, The Medical City, Pasig City, Philippines
| | - Tunde Peto
- Centre for Public Health, Queen's University, Belfast, UK
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
- Eyes and Vision Institute, The Medical City, Pasig City, Philippines
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19
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Ashraf M, AbdelAl O, Shokrollahi S, Pitoc CM, Aiello LP, Silva PS. Evaluation of diabetic retinopathy severity on ultrawide field colour images compared with ultrawide fluorescein angiograms. Br J Ophthalmol 2023; 107:534-539. [PMID: 36669774 DOI: 10.1136/bjo-2022-322163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 12/22/2022] [Indexed: 01/21/2023]
Abstract
PURPOSE To compare Early Treatment Diabetic Retinopathy Study (ETDRS) diabetic retinopathy (DR) severity on ultrawide field (UWF) colour imaging (CI) and UWF fluorescein angiography (FA). DESIGN Cross-sectional retrospective review. SUBJECTS Patients with diabetes mellitus and at least mild non-proliferative DR on UWF-CI. METHODS UWF-CI and UWF-FA images acquired within 1 month of each other were evaluated independently using ETDRS DR Severity Scale (DRSS) for colour photography adapted for UWF-CI and UWF-FA. Extent of non-perfusion (NP, mm2) was determined from UWF-FA images. MAIN OUTCOME MEASURES Agreement rate between DRSS on UWF-CI and UWF-FA. RESULTS Images from 218 eyes of 137 patients with diabetes were evaluated. Agreement rate for DRSS between UWF-CI and UWF-FA was moderate to substantial (K=0.46, Kw=0.65). Over-all, DRSS was worse in 73 (33.5%) eyes on UWF-FA and in 16 (7.3%) on UWF-CI. Compared to UWF-CI, UWF-FA identified more severe DRSS in 26.5% (1 step) and 7.34% (≥2 steps) of eyes. DRSS was worse than UWF-FA in 56 (51.4%) in early DR (ETDRS levels 20-47, N=109) and 17 (15.6%) in eyes with severe DR (53 and higher, N=109). In this cohort, the extent of NP significantly increased as eyes approach moderate non-proliferative DR (levels 43-47, p=0.0065). CONCLUSION When evaluating UWF-FA images using the ETDRS colour severity scale, DRSS is graded as more severe in a substantial number of eyes than when evaluating UWF-CI. It is uncertain how the DRSS levels using UWF-FA translate to clinical outcomes, but the additional lesions detected might provide added prognostic value. These and other recent data emphasise the need of obtaining outcome data based on UWF-FA and the potential need to develop DRSS specifically tailored for UWF-FA images.
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Affiliation(s)
- Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Ophthlamology Department, Harvard Medical School, Boston, MA, USA
- Ophthalmology Department, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Omar AbdelAl
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
| | | | - Cloyd M Pitoc
- University of the Philippines Manila, Manila, Philippines
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Ophthlamology Department, Harvard Medical School, Boston, MA, USA
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Ophthlamology Department, Harvard Medical School, Boston, MA, USA
- University of the Philippines Manila, Manila, Philippines
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20
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Cunha M, Silva PS, Vaz R, Pereira P. Answer to the Letter to the Editor of V. Raj, et al. concerning: ''Long-term outcome of redo discectomy for recurrent lumbar disc herniations'' by Cunha M. et al. (Eur Spine J [2023]. https://doi.org/10.1007/s00586-022- 07493-4). Eur Spine J 2023; 32:1858. [PMID: 36933019 DOI: 10.1007/s00586-023-07644-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/05/2023] [Indexed: 03/19/2023]
Affiliation(s)
- Marisa Cunha
- Neurosurgery Department, Centro Hospitalar Universitário São João, Porto, Portugal. .,Faculdade de Medicina da Universidade do Porto, Porto, Portugal.
| | - P S Silva
- Neurosurgery Department, Centro Hospitalar Universitário São João, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - R Vaz
- Neurosurgery Department, Centro Hospitalar Universitário São João, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - P Pereira
- Neurosurgery Department, Centro Hospitalar Universitário São João, Porto, Portugal.,Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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21
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Ashraf M, Sun JK, Silva PS, Aiello LP. Using Ultrawide Field-Directed Optical Coherence Tomography for Differentiating Nonproliferative and Proliferative Diabetic Retinopathy. Transl Vis Sci Technol 2023; 12:7. [PMID: 36745439 PMCID: PMC9910382 DOI: 10.1167/tvst.12.2.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 11/25/2022] [Indexed: 02/07/2023] Open
Abstract
Purpose To evaluate the ability of ultrawide field (UWF)-directed optical coherence tomography (OCT) to detect retinal neovascularization in eyes thought to have severe nonproliferative diabetic retinopathy (NPDR). Methods Retrospective study of 20 consecutive patients diagnosed with severe NPDR by clinical examination. All patients underwent UWF color imaging (UWF-CI) and UWF-directed OCT following a prespecified imaging protocol to assess the mid periphery, 15/32 (46.9%) eyes underwent UWF-fluorescein angiography (FA). On OCT, new vessels elsewhere (NVE) were defined when vessels breached the internal limiting membrane. Results A total of 32 eyes of 20 patients were evaluated. Of the 45 suspected areas of intraretinal microvascular abnormalities (IRMA) on UWF-CI, 38 (84.4%) were imaged by UWF-directed OCT, and 9/38 IRMA (23.7%) were NVE by OCT. Furthermore, UWF-directed OCT identified seven additional NVE in three eyes not seen on UWF-CI. This resulted in a change in diabetic retinopathy (DR) severity from severe NPDR to PDR in 8/32 eyes (25.0%). Among the 46.9% of eyes with UWF-FA, UWF-directed OCT agreed with the UWF-FA findings in 80% (12/15 eyes), missing only one peripheral NVE outside the UWF-OCT scanning area. Two eyes had subtle NVD that were not evident on UWF-directed OCT. Conclusions This pilot study suggests that UWF-directed OCT may help differentiate IRMA from NVE and detect unrecognized NVE in eyes with advanced DR in a clinical practice setting. Future prospective studies in larger cohorts could determine whether this rapid and noninvasive method is clinically relevant in determining NVE presence or retinopathy progression and complication risk. Translational Relevance UWF-directed OCT may offer a noninvasive alternative to detect NVE in eyes with DR.
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Affiliation(s)
- Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- Ophthalmology Department, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Jennifer K. Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Paolo S. Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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22
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Cunha M, Basto D, Silva PS, Vaz R, Pereira P. Long-term outcome of redo discectomy for recurrent lumbar disc herniations. Eur Spine J 2023; 32:534-541. [PMID: 36595137 DOI: 10.1007/s00586-022-07493-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/24/2022] [Accepted: 12/08/2022] [Indexed: 01/04/2023]
Abstract
PURPOSE Recurrent lumbar disc herniation (RLDH) is an important cause of morbidity and healthcare costs. The goal of this investigation is to assess surgical outcomes and their predictors in patients who underwent revision discectomy for RLDH, with a minimum follow-up of ten years, to shed light on the best treatment to offer to these patients. METHODS Patients who underwent revision discectomy to treat RLDH between 2004 and 2011 in our Department were enrolled. Demographic, clinical, and surgical data were collected. The need of third intervention for RLDH was the primary outcome. Patient's satisfaction, Core Outcome Measures Index, Oswestry Disability Index, and EuroQoL-5D scores were also evaluated. RESULTS This study includes 55 patients, with a mean follow-up time of 144 months [112-199]. In this period, a third intervention was needed in 30.9% (n = 17) of patients. Most recurrences took place in the first 2 years after the second surgery (58.8%, n = 10) and the risk of needing a third surgery decreased over time. After 5 years, the probability of not having surgery for recurrence was 71% [CI 95%: 60-84%], with a tendency to stabilize after that. An interval between the first discectomy and the surgery for recurrence shorter than 7.6 months was identified as a predictor for a second recurrence. CONCLUSION The risk of needing a third surgery seems to stabilize after five years. Patients with an early recurrence after the first discectomy seem to have a higher risk of a new recurrence, so an arthrodesis might be worth considering.
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Affiliation(s)
- M Cunha
- Neurosurgery Department, Centro Hospitalar Universitário São João, Porto, Portugal. .,Faculdade de Medicina da Universidade Do Porto, Porto, Portugal.
| | - D Basto
- Faculdade de Medicina da Universidade Do Porto, Porto, Portugal
| | - P S Silva
- Neurosurgery Department, Centro Hospitalar Universitário São João, Porto, Portugal.,Faculdade de Medicina da Universidade Do Porto, Porto, Portugal
| | - R Vaz
- Neurosurgery Department, Centro Hospitalar Universitário São João, Porto, Portugal.,Faculdade de Medicina da Universidade Do Porto, Porto, Portugal
| | - P Pereira
- Neurosurgery Department, Centro Hospitalar Universitário São João, Porto, Portugal.,Faculdade de Medicina da Universidade Do Porto, Porto, Portugal
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23
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Jacoba CMP, Celi LA, Lorch AC, Fickweiler W, Sobrin L, Gichoya JW, Aiello LP, Silva PS. Bias and Non-Diversity of Big Data in Artificial Intelligence: Focus on Retinal Diseases. Semin Ophthalmol 2023:1-9. [PMID: 36651834 DOI: 10.1080/08820538.2023.2168486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Artificial intelligence (AI) applications in healthcare will have a potentially far-reaching impact on patient care, however issues regarding algorithmic bias and fairness have recently surfaced. There is a recognized lack of diversity in the available ophthalmic datasets, with 45% of the global population having no readily accessible representative images, leading to potential misrepresentations of their unique anatomic features and ocular pathology. AI applications in retinal disease may show less accuracy with underrepresented populations that may further widen the gap of health inequality if left unaddressed. Beyond disease symptomatology, social determinants of health must be integrated into our current paradigms of disease understanding, with the goal of more personalized care. AI has the potential to decrease global healthcare inequality, but it will need to be based on a more diverse, transparent and responsible use of healthcare data.
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Affiliation(s)
- Cris Martin P Jacoba
- Ophthalmology Department, Beetham Eye Institute, Joslin Diabetes Centre, Boston, MA, USA.,Massachusetts Eye and Ear Infirmary Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Leo Anthony Celi
- Division of Pulmonary, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard-MIT Health Sciences and Technology Division, Laboratory for Computational Physiology, Cambridge, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Alice C Lorch
- Massachusetts Eye and Ear Infirmary Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Ward Fickweiler
- Ophthalmology Department, Beetham Eye Institute, Joslin Diabetes Centre, Boston, MA, USA.,Massachusetts Eye and Ear Infirmary Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Lucia Sobrin
- Massachusetts Eye and Ear Infirmary Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Judy Wawira Gichoya
- Department of Radiology & Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Lloyd P Aiello
- Ophthalmology Department, Beetham Eye Institute, Joslin Diabetes Centre, Boston, MA, USA.,Massachusetts Eye and Ear Infirmary Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Paolo S Silva
- Ophthalmology Department, Beetham Eye Institute, Joslin Diabetes Centre, Boston, MA, USA.,Massachusetts Eye and Ear Infirmary Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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24
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Figueroa AE, Roy N, Millan-Ferro A, Silva PS, Rosas SE. Association of Diabetic Retinopathy with Chronic Kidney Disease Progression in Latinos with Type 2 Diabetes. Ethn Dis 2023. [DOI: 10.18865/1683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023] Open
Abstract
Aims
Diabetes remains a leading cause of blindness and kidney failure in the United States. Latinos are at increased risk for type 2 diabetes, and microvascular complications such as diabetic retinopathy (DR) and chronic kidney disease (CKD). We evaluated the association of DR with decline in kidney function in Latinos with type 2 diabetes with or without CKD in a multispecialty clinic.
Methods
This is a retrospective cohort study of 351 self-identified Latino individuals with type 2 diabetes enrolled in the Latino Diabetes Initiative at Joslin Diabetes Center. Baseline demographic factors including age, sex, comorbidities, and laboratory values such as A1c and albuminuria were evaluated as predictors of kidney outcomes. The annualized change in estimated glomerular filtration rate (eGFR) was evaluated with a linear regression model. We used logistic regression to evaluate whether DR was associated with development of rapid progressors (>3 mL/min/y eGFR loss) and 30% change in eGFR per year.
Results
DR was present in 39.2% of the cohort with mild nonproliferative DR (NPDR) in 57.1%, moderate to severe NPDR in 27.8%, and proliferative DR in 15.0%. Those with DR had a longer duration of type 2 diabetes (P<.001), higher albuminuria (P=.003), and lower baseline eGFR (P=.001). We found that individuals with moderate to severe NPDR and proliferative DR had a significant decline in GFR (coefficient −6.32; 95% CI, −11.40 to −1.23) and −7.82 (−14.99 to −0.65), compared with individuals without DR.
Conclusions
The presence of DR is a marker for increased eGFR loss, emphasizing the need for routine retinal examinations as part of comprehensive diabetes care. Individuals with DR should be considered at high risk for GFR loss.
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Affiliation(s)
| | - Neil Roy
- 1 Kidney and Hypertension Unit, Joslin Diabetes Center, Boston, MA
| | | | - Paolo S. Silva
- 3 Beetham Eye Institute, Joslin Diabetes Center, Boston, MA
- 4 Harvard Medical School, Boston, MA
| | - Sylvia E. Rosas
- 1 Kidney and Hypertension Unit, Joslin Diabetes Center, Boston, MA
- 2 Latino Diabetes Initiative, Joslin Diabetes Center, Boston, MA
- 4 Harvard Medical School, Boston, MA
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25
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Fonda SJ, Bursell SE, Lewis DG, Clary D, Shahon D, Silva PS. Prevalence of Diabetic Eye Diseases in American Indians and Alaska Natives (AI/AN) as Identified by the Indian Health Service's National Teleophthalmology Program Using Ultrawide Field Imaging (UWFI). Ophthalmic Epidemiol 2022; 29:672-680. [PMID: 34726132 DOI: 10.1080/09286586.2021.1996611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 09/16/2021] [Accepted: 10/15/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Estimates of diabetic eye disease in American Indian and Alaska Natives (AI/AN) vary over time, region, and methods. This article reports recent prevalence of diabetic retinopathy (DR) and diabetic macular edema (DME) in AI/AN served by the Indian Health Services' (IHS) teleophthalmology program, as identified using ultrawide field imaging (UWFI). METHODS This was a retrospective analysis of 2016-2019 clinical data (n = 53,900). UWF images were acquired by certified imagers using a validated protocol, and graded by licensed, certified optometrists supervised by an ophthalmologist. Graders evaluated the extent/severity of retinal lesions in comparison to standard photographs. DR lesions predominantly in any peripheral field were considered "predominantly peripheral lesions" (PPL). The analyses calculated prevalence of any DR, any DME, DR and DME severity, sight-threatening disease, and PPL. RESULTS Patients averaged 56 years of age with a 68 mmol/mol A1c and 55% had had diabetes for 5+ years. Prevalence of any DR, any DME, and sight-threatening disease was 28.6%, 3.0%, and 3.0%. In patients with mild nonproliferative DR, PPL was seen in 25.3%. PPL suggested a more severe level of DR in 8.7% of patients. DR increased with age. DME decreased with age. Males and patients in the Nashville IHS area had more diabetic eye disease. CONCLUSION AI/AN have a high burden of diabetes and its complications. The IHS is resource-constrained, making accurate disease estimates necessary for resource allocation and budget justifications to Congress. These data update the estimates of diabetic eye disease in Indian Country and suggest that UWFI identifies early DR.
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Affiliation(s)
| | - Sven-Erik Bursell
- Telehealth Research Institute, John A. Burns School of Medicine, University of Hawaii, Honolulu, USA
| | | | - Dawn Clary
- Indian Health Service-Joslin Vision Network, Phoenix Indian Medical Center, Phoenix, AZ, USA
| | - Dara Shahon
- Indian Health Service-Joslin Vision Network, Phoenix Indian Medical Center, Phoenix, AZ, USA
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Marcus DM, Silva PS, Liu D, Aiello LP, Antoszyk A, Elman M, Friedman S, Glassman AR, Googe JM, Jampol LM, Martin DF, Melia M, Preston CM, Wykoff CC, Sun JK. Association of Predominantly Peripheral Lesions on Ultra-Widefield Imaging and the Risk of Diabetic Retinopathy Worsening Over Time. JAMA Ophthalmol 2022; 140:946-954. [PMID: 35980608 PMCID: PMC9389433 DOI: 10.1001/jamaophthalmol.2022.3131] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/26/2022] [Indexed: 02/03/2023]
Abstract
Importance Ultra-widefield (UWF) imaging improves the ability to identify peripheral diabetic retinopathy (DR) lesions compared with standard imaging. Whether detection of predominantly peripheral lesions (PPLs) better predicts rates of disease worsening over time is unknown. Objective To determine whether PPLs identified on UWF imaging are associated with increased disease worsening beyond the risk associated with baseline Early Treatment Diabetic Retinopathy Study (ETDRS) Diabetic Retinopathy Severity Scale (DRSS) score. Design, Setting, and Participants This cohort study was a prospective, multicenter, longitudinal observational study conducted at 37 US and Canadian sites with 388 participants enrolled between February and December 2015. At baseline and annually through 4 years, 200° UWF-color images were obtained and graded for DRSS at a reading center. Baseline UWF-color and UWF-fluorescein angiography (FA) images were evaluated for the presence of PPL. Data were analyzed from May 2020 to June 2022. Interventions Treatment of DR or diabetic macular edema was at investigator discretion. Main Outcomes and Measures Predominantly peripheral lesions were defined as DR lesions with a greater extent outside vs inside the 7 standard ETDRS fields. Primary outcome was disease worsening defined as worsening 2 steps or more on the DRSS or receipt of DR treatment. Analyses were adjusted for baseline DRSS score and correlation between 2 study eyes of the same participant. Results Data for 544 study eyes with nonproliferative DR (NPDR) were analyzed (182 [50%] female participants; median age, 62 years; 68% White). The 4-year disease worsening rates were 45% for eyes with baseline mild NPDR, 40% for moderate NPDR, 26% for moderately severe NPDR, and 43% for severe NPDR. Disease worsening was not associated with color PPL at baseline (present vs absent: 38% vs 43%; HR, 0.78; 95% CI, 0.57-1.08; P = .13) but was associated with FA PPL at baseline (present vs absent: 50% vs 31%; HR, 1.72; 95% CI, 1.25-2.36; P < .001). Conclusions and Relevance Although no association was identified with color PPL, presence of FA PPL was associated with greater risk of disease worsening over 4 years, independent of baseline DRSS score. These results suggest that use of UWF-FA to evaluate retinas peripheral to standard ETDRS fields may improve the ability to predict disease worsening in NPDR eyes. These findings support use of UWF-FA for future DR staging systems and clinical care to more accurately determine prognosis in NPDR eyes.
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Affiliation(s)
- Dennis M. Marcus
- Southeast Retina Center, Augusta, Georgia
- Medical College of Georgia, Augusta University, Augusta
| | - Paolo S. Silva
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts
- Harvard Department of Ophthalmology, Boston, Massachusetts
| | - Danni Liu
- Jaeb Center for Health Research, Tampa, Florida
| | - Lloyd Paul Aiello
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts
- Harvard Department of Ophthalmology, Boston, Massachusetts
| | - Andrew Antoszyk
- Charlotte Eye Ear Nose and Throat Associates, Charlotte, North Carolina
| | | | | | | | | | | | | | | | | | | | - Jennifer K. Sun
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts
- Harvard Department of Ophthalmology, Boston, Massachusetts
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Silva PS, Marcus DM, Liu D, Aiello LP, Antoszyk A, Elman M, Friedman S, Glassman AR, Googe JM, Jampol LM, Martin DF, Melia M, Preston CM, Wykoff CC, Sun JK. Association of Ultra-Widefield Fluorescein Angiography-Identified Retinal Nonperfusion and the Risk of Diabetic Retinopathy Worsening Over Time. JAMA Ophthalmol 2022; 140:936-945. [PMID: 35980610 PMCID: PMC9389436 DOI: 10.1001/jamaophthalmol.2022.3130] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 06/26/2022] [Indexed: 02/03/2023]
Abstract
Importance Presence of predominantly peripheral diabetic retinopathy (DR) lesions on ultra-widefield fluorescein angiography (UWF-FA) was associated with greater risk of DR worsening or treatment over 4 years. Whether baseline retinal nonperfusion assessment is additionally predictive of DR disease worsening is unclear. Objective To assess whether the extent and location of retinal nonperfusion identified on UWF-FA are associated with worsening in Diabetic Retinopathy Severity Scale (DRSS) score or DR treatment over time. Design, Setting, and Participants This cohort study was a prospective, multicenter, longitudinal observational study with data for 508 eyes with nonproliferative DR and gradable nonperfusion on UWF-FA at baseline. All images were graded at a centralized reading center; 200° ultra-widefield (UWF) color images were graded for DR at baseline and annually for 4 years. Baseline 200° UWF-FA images were graded for nonperfused area, nonperfusion index (NPI), and presence of predominantly peripheral lesions on UWF-FA (FA PPL). Interventions Treatment of DR or diabetic macular edema was at investigator discretion. Main Outcomes and Measures Association of baseline UWF-FA nonperfusion extent with disease worsening, defined as either 2 or more steps of DRSS worsening within Early Treatment Diabetic Retinopathy Study fields on UWF-color images or receipt of DR treatment. Results After adjusting for baseline DRSS, the risk of disease worsening over 4 years was higher in eyes with greater overall NPI (hazard ratio [HR] for 0.1-unit increase, 1.11; 95% CI, 1.02-1.21; P = .02) and NPI within the posterior pole (HR for 0.1-unit increase, 1.35; 95% CI, 1.17-1.56; P < .001) and midperiphery (HR for 0.1-unit increase, 1.08; 95% CI, 1.00-1.16; P = .04). In a multivariable analysis adjusting for baseline DRSS score and baseline systemic risk factors, greater NPI (HR, 1.11; 95% CI, 1.02-1.22; P = .02) and presence of FA PPL (HR, 1.89; 95% CI, 1.35-2.65; P < .001) remained associated with disease worsening. Conclusions and Relevance This 4-year longitudinal study has demonstrated that both greater baseline retinal nonperfusion and FA PPL on UWF-FA are associated with higher risk of disease worsening, even after adjusting for baseline DRSS score and known systemic risk. These associations between disease worsening and retinal nonperfusion and FA PPL support the increased use of UWF-FA to complement color fundus photography in future efforts for DR prognosis, clinical care, and research.
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Affiliation(s)
- Paolo S. Silva
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts
- Harvard Department of Ophthalmology, Boston, Massachusetts
| | - Dennis M. Marcus
- Southeast Retina Center, Augusta, Georgia
- Medical College of Georgia, Augusta University, Augusta
| | - Danni Liu
- Jaeb Center for Health Research, Tampa, Florida
| | - Lloyd Paul Aiello
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts
- Harvard Department of Ophthalmology, Boston, Massachusetts
| | - Andrew Antoszyk
- Charlotte Eye Ear Nose and Throat Associates, Charlotte, North Carolina
| | | | | | | | | | | | | | | | | | | | - Jennifer K. Sun
- Joslin Diabetes Center, Beetham Eye Institute, Boston, Massachusetts
- Harvard Department of Ophthalmology, Boston, Massachusetts
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Salongcay RP, Aquino LAC, Salva CMG, Saunar AV, Alog GP, Sun JK, Peto T, Silva PS. Comparison of Handheld Retinal Imaging with ETDRS 7-Standard Field Photography for Diabetic Retinopathy and Diabetic Macular Edema. Ophthalmol Retina 2022; 6:548-556. [PMID: 35278726 DOI: 10.1016/j.oret.2022.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE To compare nonmydriatic (NM) and mydriatic (MD) handheld retinal imaging with standard ETDRS 7-field color fundus photography (ETDRS photographs) for the assessment of diabetic retinopathy (DR) and diabetic macular edema (DME). DESIGN Prospective, comparative, instrument validation study. SUBJECTS A total of 225 eyes from 116 patients with diabetes mellitus. METHODS Following a standardized protocol, NM and MD images were acquired using handheld retinal cameras (NM images: Aurora, Smartscope, and RetinaVue-700; MD images: Aurora, Smartscope, RetinaVue-700, and iNview) and dilated ETDRS photographs. Grading was performed at a centralized reading center using the International Clinical Classification for DR and DME. Kappa statistics (simple [K], weighted [Kw]) assessed the level of agreement for DR and DME. Sensitivity and specificity were calculated for any DR, referable DR (refDR), and vision-threatening DR (vtDR). MAIN OUTCOME MEASURES Agreement for DR and DME; sensitivity and specificity for any DR, refDR, and vtDR; ungradable rates. RESULTS Severity by ETDRS photographs: no DR, 33.3%; mild nonproliferative DR, 20.4%; moderate DR, 14.2%; severe DR, 11.6%; proliferative DR, 20.4%; no DME, 68.0%; DME, 9.3%; non-center involving clinically significant DME, 4.9%; center-involving clinically significant DME, 12.4%; and ungradable, 5.3%. For NM handheld retinal imaging, Kw was 0.70 to 0.73 for DR and 0.76 to 0.83 for DME. For MD handheld retinal imaging, Kw was 0.68 to 0.75 for DR and 0.77 to 0.91 for DME. Thresholds for sensitivity (0.80) and specificity (0.95) were met by NM images acquired using Smartscope and MD images acquired using Aurora and RetinaVue-700 cameras for any DR and by MD images acquired using Aurora and RetinaVue-700 cameras for refDR. Thresholds for sensitivity and specificity were met by MD images acquired using Aurora and RetinaVue-700 for DME. Nonmydriatic and MD ungradable rates for DR were 15.1% to 38.3% and 0% to 33.8%, respectively. CONCLUSIONS Following standardized protocols, NM and MD handheld retinal imaging devices have substantial agreement levels for DR and DME. With mydriasis, not all handheld retinal imaging devices meet standards for sensitivity and specificity in identifying any DR and refDR. None of the handheld devices met the established 95% specificity for vtDR, suggesting that lower referral thresholds should be used if handheld devices must be utilized. When using handheld devices, the ungradable rate is significantly reduced with mydriasis and DME sensitivity thresholds are only achieved following dilation.
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Affiliation(s)
- Recivall P Salongcay
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines; Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom; Eye and Vision Institute, The Medical City, Metro Manila, Philippines
| | - Lizzie Anne C Aquino
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | | | - Aileen V Saunar
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines; Eye and Vision Institute, The Medical City, Metro Manila, Philippines
| | - Glenn P Alog
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines; Eye and Vision Institute, The Medical City, Metro Manila, Philippines
| | - Jennifer K Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Tunde Peto
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom
| | - Paolo S Silva
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines; Eye and Vision Institute, The Medical City, Metro Manila, Philippines; Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.
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Ashraf M, Hock KM, Cavallerano JD, Wang FL, Silva PS. Comparison of Widefield Laser Ophthalmoscopy and ETDRS Retinal Area for Diabetic Retinopathy. Ophthalmol Sci 2022; 2:100190. [PMID: 36531579 PMCID: PMC9754965 DOI: 10.1016/j.xops.2022.100190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/19/2022] [Accepted: 06/22/2022] [Indexed: 02/02/2023]
Abstract
Purpose To evaluate agreement of nonmydriatic confocal scanning laser ophthalmoscopy (SLO; EIDON [CenterVue]) and the 7-standard field ETDRS area on ultrawide-field (UWF) SLO imaging for identification of diabetic retinopathy (DR) severity. Design Single-site, prospective, comparative, instrument validation study. Participants One hundred ten eyes of 55 patients with diabetes mellitus were evaluated. Methods Each patient underwent nonmydriatic, nonsimultaneous stereoscopic imaging using the EIDON camera and 4 fields of 60° × 55° were acquired (macula centered, disc centered, temporal macula, superotemporal). Mydriatic UWF retinal images were acquired using a nonsimultaneous stereographic protocol with UWF imaging (California; Optos plc). Before grading, a standardized ETDRS 7-field image mask was applied to all UWF retinal images. Images from each device were graded independently by 2 masked graders using the ETDRS clinical DR classification. Any discrepancy in DR grading between the devices was adjudicated by a third grader. Main Outcome Measures κ Levels of agreement, sensitivity, and specificity for DR thresholds. Results Severity by ETDRS grading was as follows: no DR, 10.9%; mild nonproliferative DR (NPDR), 45.5%; moderate NPDR, 16.5%; severe NPDR, 11.8%; proliferative DR, 12.7%; high-risk proliferative DR, 2.7%; and ungradable, 0%. After adjudication, the level of DR identified on EIDON images agreed exactly with that of UWF ETDRS imaging in 87% of eyes (n = 96) and was within 1 step in 99.1% of eyes (n = 109) with a simple κ value of 0.8244 ± 0.0439 (95% confidence interval [CI], 0.7385-0.9104) and weighted (linear) κ value of 0.9041 ± 0.0257 (95% CI, 0.8537-0.9545). Sensitivity and specificity compared with ETDRS field grading for any DR were 0.96 and 0.75, for moderate NPDR or worse were 0.96 and 0.97, and for severe NPDR or worse were 0.91 and 1.00, respectively. Conclusions Nonmydriatic 4-field stereoscopic widefield imaging using the EIDON device was comparable with the DR severity identified within the ETDRS 7-standard field area of UWF images. Future studies will need to evaluate the applicability of this device as a clinical and research tool and the impact of different widefield coverage areas.
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Affiliation(s)
- Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
| | - Kristen M. Hock
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
| | - Jerry D. Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Frank L. Wang
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
| | - Paolo S. Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts,Correspondence: Paolo S. Silva, MD, Beetham Eye Institute, Joslin Diabetes Center, 1 Joslin Place, Boston, MA 02215.
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Jacoba CMP, Ashraf M, Cavallerano JD, Tolson AM, Tolls D, Pellegrini E, Fleming A, Sun JK, Aiello LP, Silva PS. Association of Maximizing Visible Retinal Area by Manual Eyelid Lifting With Grading of Diabetic Retinopathy Severity and Detection of Predominantly Peripheral Lesions When Using Ultra-Widefield Imaging. JAMA Ophthalmol 2022; 140:421-425. [PMID: 35201258 PMCID: PMC8874906 DOI: 10.1001/jamaophthalmol.2021.6363] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE Methods that increase visible retinal area (VRA; measured in millimeters squared) may improve identification of diabetic retinopathy (DR) lesions. OBJECTIVE To evaluate the association of dilation and manual eyelid lifting (MLL) with VRA on ultra-widefield imaging (UWFI) and the association of VRA with grading of DR severity and detection of predominantly peripheral lesions (PPLs). DESIGN, SETTING, AND PARTICIPANTS Retrospective, comparative case-control study at the Joslin Diabetes Center, Boston, Massachusetts. Nonmydriatic UWFI with MLL was acquired from a DR teleophthalmology program (Joslin Vision Network [JVN]). A second cohort of mydriatic UWFI was acquired at an academic retina practice (Beetham Eye Institute [BEI]) from November 6, 2017, to November 6, 2018, and with MLL thereafter until November 6, 2019. Fully automated algorithms determined VRA and hemorrhage and/or microaneurysm (HMA) counts. Predominantly peripheral lesions and HMAs were defined as present when at least 1 field had greater HMA number in the peripheral retina than within the corresponding Early Treatment Diabetic Retinopathy Study field. Participants included 3014 consecutive patients (5919 eyes) undergoing retinal imaging at JVN and BEI. EXPOSURES Dilation and MLL performed at the time of UWFI. MAIN OUTCOMES AND MEASURES Visible retinal area, DR severity, and presence of PPLs. RESULTS Of the 3014 participants, mean (SD) age was 56.1 (14.5) years, 1302 (43.2%) were female, 2450 (81.3%) were White, and mean (SD) diabetes duration was 15.9 (11.4) years. All images from 5919 eyes with UWFI were analyzed. Mean (SD) VRA was 665.1 (167.6) mm2 for all eyes (theoretical maximal VRA, 923.9 mm2), 550.8 (240.7) mm2 for nonmydriatic JVN with MLL (1418 eyes [24.0%]), 688.1 (119.9) mm2 for mydriatic BEI images (3650 eyes [61.7%]), and 757.0 (69.7) mm2 for mydriatic and MLL BEI images (851 eyes [14.4%]). Dilation increased VRA by 25% (P < .001) and MLL increased VRA an additional 10% (P < .001). Nonmydriatic MLL increased VRA by 11.0%. With MLL, HMA counts in UWFI fields increased by 41.7% (from 4.8 to 6.8; P < .001). Visible retinal area was moderately associated with increasing PPL-HMA overall and in each cohort (all, r = 0.33; BEI, r = 0.29; JVN, r = 0.36; P < .001). In JVN images, increasing VRA was associated with more PPL-HMA (quartile 1 [Q1], 23.7%; Q2, 45.8%; Q3, 60.6%; and Q4, 69.2%; P < .001). CONCLUSIONS AND RELEVANCE Using fully automated VRA and HMA detection algorithms, pupillary dilation and eyelid lifting were shown to substantially increase VRA and PLL-HMA detection. Given the importance of HMA and PPL for determining risk of DR progression, these findings emphasize the importance of maximizing VRA for optimal risk assessment in clinical trials and teleophthalmology programs.
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Affiliation(s)
- Cris Martin P. Jacoba
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Jerry D. Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Ann M. Tolson
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Dorothy Tolls
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | | | | | - Jennifer K. Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Paolo S. Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
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Salongcay R, Anne Aquino L, Michael Salva C, Peto T, Silva PS. Comparison of diabetic retinopathy lesions identified using ultrawide field color photography, ultrawide field fluorescein angiography and optical coherence tomography angiography. Acta Ophthalmol 2022. [DOI: 10.1111/j.1755-3768.2022.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Recivall Salongcay
- Centre for Public Health Queen's University Belfast Belfast UK
- Philippine Eye Research Institute University of the Philippines Manila Philippines
- Eye and Vision Institute The Medical City Metro Manila Philippines
| | - Lizzie Anne Aquino
- Philippine Eye Research Institute University of the Philippines Manila Philippines
| | - Claude Michael Salva
- Philippine Eye Research Institute University of the Philippines Manila Philippines
| | - Tunde Peto
- Centre for Public Health Queen's University Belfast Belfast UK
| | - Paolo S. Silva
- Philippine Eye Research Institute University of the Philippines Manila Philippines
- Eye and Vision Institute The Medical City Metro Manila Philippines
- Beetham Eye Institute Joslin Diabetes Center Boston MA USA
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Ashraf M, Cavallerano JD, Sun JK, Silva PS, Aiello LP. Ultrawide Field Imaging in Diabetic Retinopathy: Exploring the Role of Quantitative Metrics. J Clin Med 2021; 10:jcm10153300. [PMID: 34362084 PMCID: PMC8347462 DOI: 10.3390/jcm10153300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/15/2021] [Accepted: 07/22/2021] [Indexed: 11/25/2022] Open
Abstract
Ultrawide field imaging (UWF) has allowed the visualization of a significantly greater area of the retina than previous standard approaches. In diabetic retinopathy (DR), significantly more lesions are seen on UWF imaging compared to the seven-standard ETDRS fields. In addition, some eyes have lesions that are located predominantly in the peripheral retina that are associated with an increased risk of DR progression. The current DR severity scales are still largely based on clinically visible retinal microvascular lesions and do not incorporate retinal periphery, neuroretinal, or pathophysiologic changes. Thus, current scales are not well suited for documenting progression or regression in eyes with very early or advanced DR, nor in the setting of vascular endothelial growth factor inhibitors (antiVEGF). In addition, the categorical system is highly subjective, and grading is variable between different graders based on experience level and training background. Recently, there have been efforts to quantify DR lesions on UWF imaging in an attempt to generate objective metrics for classification, disease prognostication and prediction of treatment response. The purpose of this review is to examine current quantitative metrics derived from UWF fluorescein angiograms and UWF color imaging to determine their feasibility in any potential future DR classification.
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Affiliation(s)
- Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA 02215, USA; (J.D.C.); (J.K.S.); (P.S.S.); (L.P.A.)
- Ophthalmology Department, Alexandria Faculty of Medicine, Alexandria Governorate 21500, Egypt
- Ophthalmology, Harvard Medical School, Boston, MA 02215, USA
- Correspondence: ; Tel.: +1-(617)-309-2554
| | - Jerry D. Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA 02215, USA; (J.D.C.); (J.K.S.); (P.S.S.); (L.P.A.)
- Ophthalmology, Harvard Medical School, Boston, MA 02215, USA
| | - Jennifer K. Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA 02215, USA; (J.D.C.); (J.K.S.); (P.S.S.); (L.P.A.)
- Ophthalmology, Harvard Medical School, Boston, MA 02215, USA
| | - Paolo S. Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA 02215, USA; (J.D.C.); (J.K.S.); (P.S.S.); (L.P.A.)
- Ophthalmology, Harvard Medical School, Boston, MA 02215, USA
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA 02215, USA; (J.D.C.); (J.K.S.); (P.S.S.); (L.P.A.)
- Ophthalmology, Harvard Medical School, Boston, MA 02215, USA
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Ashraf M, Rageh A, Gilbert M, Tolls D, Fleming A, Souka A, El-Baha S, Cavallerano JD, Sun JK, Aiello LP, Silva PS. Factors Affecting Predominantly Peripheral Lesion Identification and Grading. Transl Vis Sci Technol 2021; 10:6. [PMID: 34100926 PMCID: PMC8196424 DOI: 10.1167/tvst.10.7.6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Purpose The purpose of this study was to determine factors affecting predominantly peripheral lesion (PPL) grading, such as qualitative versus quantitative assessment, device type, and severity of diabetic retinopathy (DR) in ultrawide field color images (UWF-CIs). Methods Patients with DR had UWF-CI qualitatively graded for PPL using standardized techniques and had hemorrhages/microaneurysms (H/Mas) individually annotated for quantitative PPL grading on two different ultrawide field devices. Results Among 791 eyes of 481 patients, 38.2% had mild nonproliferative DR (NPDR), 34.7% had moderate NPDR, and 27.1% had severe NPDR to proliferative DR (PDR). The overall agreement between qualitative and quantitative PPL grading was moderate (ĸ = 0.423, P < 0.001). Agreement rates were fair in eyes with mild NPDR (ĸ = 0.336, P < 0.001) but moderate in eyes with moderate NPDR (ĸ = 0.525, P < 0.001) and severe NPDR-PDR (ĸ = 0.409, P < 0.001). Increasing thresholds for quantitative PPL determination improved agreement rates, with peak agreements at H/Ma count differences of six for mild NPDR, five for moderate NPDR, and nine for severe NPDR-PDR. Based on ultrawide field device type (California = 412 eyes vs. 200Tx = 379 eyes), agreement between qualitative and quantitative PPL grading was moderate for all DR severities in both devices (ĸ = 0.369−0.526, P < 0.001) except for mild NPDR on the 200Tx, which had poor agreement (ĸ = 0.055, P = 0.478). Conclusions Determination of PPL varies between standard qualitative and quantitative grading and is dependent on NPDR severity, device type, and magnitude of lesion differences used for quantitative assessment. Translational Relevance Prior UWF studies have not accounted for imaging and grading factors that affect PPL, such factors need to be reviewed when assessing thresholds for DR progression rates.
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Affiliation(s)
- Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA.,Ophthalmology Department, Alexandria Faculty of Medicine, Egypt
| | - Abdulrahman Rageh
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Michael Gilbert
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Dorothy Tolls
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
| | | | - Ahmed Souka
- Ophthalmology Department, Alexandria Faculty of Medicine, Egypt
| | - Samir El-Baha
- Ophthalmology Department, Alexandria Faculty of Medicine, Egypt
| | - Jerry D Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer K Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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Silva PS, Royo VA, Valerio HM, Fernandes EG, Queiroz MV, Fagundes M. Filtrates from cultures of endophytic fungi isolated from leaves of Copaifera oblongifolia (Fabaceae) affect germination and seedling development differently. BRAZ J BIOL 2021; 83:e242070. [PMID: 34161452 DOI: 10.1590/1519-6984.242070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 01/28/2021] [Indexed: 11/22/2022] Open
Abstract
Interactions between endophytic fungi (EFs) and their host plants range from positive to neutral to negative. The results of such interactions can vary depending on the organ of the infected host plant. EFs isolated from the leaves of some species of plants have potential for use as agents to inhibit seed germination and control invasive plants. The objectives of this study were to identify EFs present in the leaves of Copaifera oblongifolia and to evaluate the role of these fungi in seed germination and seedling development. A total of 11 species of EFs were isolated, which were identified using the internal transcribed spacers (ITS) sequence of the nuclear ribosomal DNA. The isolated species of EFs are generalists and probably are transmitted horizontally. Laboratory tests revealed that filtrates of these fungal isolates differently affect seed germination and seedling development of C. oblongifolia. The species Curvularia intermedia, Neofusicoccum parvum, Pseudofusicoccum stromaticum and Phomopsis sp. negatively affected seed germination, with N. parvum standing out for its negative effects, inhibiting seedling germination and survival in 89 and 222%, respectively. In addition, Cochliobolus intermedius negatively affected seedling development. Thus, the combined use of N. parvum and C. intermedius, or products from the metabolism of these microorganisms, in the control of invasive plants deserves attention from future studies.
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Affiliation(s)
- P S Silva
- Universidade Estadual de Montes Claros - Unimontes, Departamento de Biologia Geral, Programa de Pós-graduação em Biodiversidade e Uso dos Recursos Naturais, Montes Claros, MG, Brasil
| | - V A Royo
- Universidade Estadual de Montes Claros - Unimontes, Departamento de Biologia Geral, Programa de Pós-graduação em Biodiversidade e Uso dos Recursos Naturais, Montes Claros, MG, Brasil
| | - H M Valerio
- Universidade Estadual de Montes Claros - Unimontes, Departamento de Biologia Geral, Programa de Pós-graduação em Biodiversidade e Uso dos Recursos Naturais, Montes Claros, MG, Brasil
| | - E G Fernandes
- Universidade Estadual de Montes Claros - Unimontes, Departamento de Biologia Geral, Programa de Pós-graduação em Biodiversidade e Uso dos Recursos Naturais, Montes Claros, MG, Brasil
| | - M V Queiroz
- Universidade Federal de Viçosa - UFV, Instituto de Biotecnologia Aplicada à Agropecuária - BIOAGRO, Departamento de Microbiologia, Laboratório de Genética Molecular de Fungos, Viçosa, MG, Brasil
| | - M Fagundes
- Universidade Estadual de Montes Claros - Unimontes, Departamento de Biologia Geral, Programa de Pós-graduação em Biodiversidade e Uso dos Recursos Naturais, Montes Claros, MG, Brasil
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Abstract
Diabetes mellitus has profound effects on multiple organ systems; however, the loss of vision caused by diabetic retinopathy might be one of the most impactful in a patient's life. The retina is a highly metabolically active tissue that requires a complex interaction of cells, spanning light sensing photoreceptors to neurons that transfer the electrochemical signal to the brain with support by glia and vascular tissue. Neuronal function depends on a complex inter-dependency of retinal cells that includes the formation of a blood-retinal barrier. This dynamic system is negatively affected by diabetes mellitus, which alters normal cell-cell interactions and leads to profound vascular abnormalities, loss of the blood-retinal barrier and impaired neuronal function. Understanding the normal cell signalling interactions and how they are altered by diabetes mellitus has already led to novel therapies that have improved visual outcomes in many patients. Research highlighted in this Review has led to a new understanding of retinal pathophysiology during diabetes mellitus and has uncovered potential new therapeutic avenues to treat this debilitating disease.
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Affiliation(s)
- David A Antonetti
- Department of Ophthalmology and Visual Sciences, Department of Molecular and Integrative Physiology, Kellogg Eye Center, University of Michigan, Ann Arbor, MI, USA.
| | - Paolo S Silva
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
| | - Alan W Stitt
- Centre for Experimental Medicine, Queen's University, Belfast, UK
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Rageh A, Ashraf M, Fleming A, Silva PS. Automated Microaneurysm Counts on Ultrawide Field Color and Fluorescein Angiography Images. Semin Ophthalmol 2021; 36:315-321. [PMID: 33779483 DOI: 10.1080/08820538.2021.1897852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The severity and extent of microaneurysms (MAs) have been used to determine diabetic retinopathy (DR) severity and estimate the risk of DR progression over time. The recent introduction of ultrawide field (UWF) imaging has allowed ophthalmologists to readily image nearly the entire retina. Manual counting of MAs, especially on UWF images, is laborious and time-consuming, limiting its potential use in clinical settings. Automated MA counting techniques are potentially more accurate and reproducible compared to manual methods. METHOD Review of available literature on current techniques of automated MA counting techniques on both ultrawide field (UWF) color images (CI) and fluorescein angiography (FA) images. RESULTS Automated MA counting techniques on UWF images are still in the early phases of development with UWF-FA counts being further along. Early studies have demonstrated that these techniques are accurate and reproducible. CONCLUSION Automated techniques may be an appropriate option for detecting and quantifying MAs on UWF images, especially in eyes with earlier DR severity. Larger studies are needed to appropriately validate these techniques and determine if they add substantially to clinical practice compared to standard DR grading.
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Affiliation(s)
| | - Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Centre, Boston, MA, USA.,Ophthalmology Department, Alexandria Faculty of Medicine, Alexandria, Egypt
| | | | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Centre, Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Jacoba CMP, Celi LA, Silva PS. Biomarkers for Progression in Diabetic Retinopathy: Expanding Personalized Medicine through Integration of AI with Electronic Health Records. Semin Ophthalmol 2021; 36:250-257. [PMID: 33734908 DOI: 10.1080/08820538.2021.1893351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The goal of personalized diabetes eye care is to accurately predict in real-time the risk of diabetic retinopathy (DR) progression and visual loss. The use of electronic health records (EHR) provides a platform for artificial intelligence (AI) algorithms that predict DR progression to be incorporated into clinical decision-making. By implementing an algorithm on data points from each patient, their risk for retinopathy progression and visual loss can be modeled, allowing them to receive timely treatment. Data can guide algorithms to create models for disease and treatment that may pave the way for more personalized care. Currently, there exist numerous challenges that need to be addressed before reliably building and deploying AI algorithms, including issues with data quality, privacy, intellectual property, and informed consent.
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Affiliation(s)
- Cris Martin P Jacoba
- Joslin Diabetes Centre, Beetham Eye Institute, Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Leo Anthony Celi
- Division of Pulmonary, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Laboratory for Computational Physiology, Harvard-MIT Health Sciences and Technology Division, Cambridge, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Paolo S Silva
- Joslin Diabetes Centre, Beetham Eye Institute, Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Ashraf M, Sampani K, Rageh A, Silva PS, Aiello LP, Sun JK. Interaction Between the Distribution of Diabetic Retinopathy Lesions and the Association of Optical Coherence Tomography Angiography Scans With Diabetic Retinopathy Severity. JAMA Ophthalmol 2021; 138:1291-1297. [PMID: 33119083 DOI: 10.1001/jamaophthalmol.2020.4516] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Importance Studies have not yet determined whether the distribution of lesions in the retinal periphery alters the association between the severity of diabetic retinopathy (DR) and macular vessel density. Objective To evaluate the association of DR lesion distribution with optical coherence tomography angiography (OCTA) metrics and DR severity. Design, Setting, and Participants This cross-sectional observational study was conducted at a tertiary care center for diabetic eye disease among 225 patients with type 1 or 2 diabetes who had undergone imaging between February 15, 2016, and December 31, 2019. Exposures Optical coherence tomography angiography 3 × 3-mm macular scans and ultra-widefield color imaging. Main Outcomes and Measures Optical coherence tomography angiography vessel density in the superficial capillary plexus, intermediate capillary plexus, and deep capillary plexus and choriocapillaris flow density. The severity of DR and the predominantly peripheral lesions (PPL) were evaluated from ultra-widefield color imaging. Results The study evaluated 352 eyes (225 patients; 125 men [55.6%]; mean [SD] age, 52.1 [15.1] years), of which 183 eyes (52.0%) had mild nonproliferative diabetic retinopathy (NPDR), 71 eyes (20.2%) had moderate NPDR, and 98 eyes (27.8%) had severe NPDR or proliferative diabetic retinopathy (PDR). In eyes with no PPL (209 [59.4%]), the mean (SD) vessel density in the superficial capillary plexus (mild NPDR, 38.1% [4.7%]; moderate NPDR, 36.4% [4.6%]; severe NPDR or PDR, 34.1% [4.1%]; P < .001) and the deep capillary plexus (mild NPDR, 45.8% [3.0%]; moderate NPDR, 45.8% [2.2%]; severe NPDR or PDR, 44.5% [1.9%]; P = .002), as well as the mean (SD) choriocapillaris flow density (mild NPDR, 69.7% [6.2%]; moderate NPDR, 67.6% [5.6%]; severe NPDR or PDR, 67.1% [5.6%]; P = .01), decreased with increasing DR severity. These associations remained statistically significant even after correcting for age, signal strength index, spherical equivalent, duration of diabetes, type of diabetes, and correlation between eyes of the same patient. In eyes with PPL (143 [40.6%]), mean (SD) vessel density in the superficial capillary plexus (mild NPDR, 34.1% [4.1%]; moderate NPDR, 35.2% [4.1%]; severe NPDR or PDR, 36.0% [4.3%]; P = .42) and the deep capillary plexus (mild NPDR, 44.5% [1.7%]; moderate NPDR, 45.4% [1.4%]; severe NPDR or PDR, 44.9% [1.5%]; P = .81), as well as the mean (SD) choriocapillaris flow density (mild NPDR, 67.1% [5.6%]; moderate NPDR, 69.3% [4.6%]; severe NPDR or PDR, 68.3% [5.6%]; P = .49), did not appear to change with increasing DR severity. Conclusions and Relevance These results suggest that central retinal vessel density is associated with DR severity in eyes without, but not with, PPL. These findings suggest a potential need to stratify future optical coherence tomography angiography studies of eyes with DR by the presence or absence of PPL. If DR onset and worsening are associated with the location of retinal nonperfusion, assessment of global retinal nonperfusion using widefield angiography may improve the ability to evaluate DR severity and risk of DR worsening over time.
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Affiliation(s)
- Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts.,Ophthalmology Department, Alexandria Faculty of Medicine, Alexandria, Egypt
| | - Konstantina Sampani
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts.,Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Abdulrahman Rageh
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Jennifer K Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
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Silva PS, Hooper HB, Manica E, Merighe GKF, Oliveira SA, Traldi AS, Negrão JA. Heat stress affects the expression of key genes in the placenta, placental characteristics, and efficiency of Saanen goats and the survival and growth of their kids. J Dairy Sci 2021; 104:4970-4979. [PMID: 33551154 DOI: 10.3168/jds.2020-18301] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 11/09/2020] [Indexed: 01/18/2023]
Abstract
Heat stress is detrimental during gestation; however, the effects of heat stress on goat placental characteristics and kid survival remain unclear. The objective of this study was to evaluate the effects of heat stress at final gestation on cortisol concentration, placenta characteristics, and the expression of genes related to placenta. Forty-six primiparous and multiparous Saanen goats were subjected to control (CT; under a thermoneutral environment: air temperature between 12°C and 25°C and the relative humidity from 45 to 73%, n = 23) or heat stress (HS; under a climatic chamber: air temperature at 37°C and the relative humidity at 60 to 70% from 0800 to 1600 h, n = 23) from the last 60 d of pregnancy until the first colostrum suckling. The heat challenge imposed on HS goats during the prepartum period increased their rectal temperature, respiratory frequency, and cortisol levels in plasma and amniotic fluid versus CT goats. In the placenta, HS treatment also increased the expression of the HSPA1A gene. Heat-stressed goats also showed significantly lower expression of HSD11B2 and greater expression of MC2R and NR3C1 than CT goats, suggesting that heat stress decreased the effectiveness by which the HSD11B2 enzyme converts cortisol to cortisone and increased placental responsiveness to cortisol. The HS goats took longer to release the placenta with lighter placental cotyledons, and HS goats had a lower ratio between the kid's weight at birth and placenta weight than CT goats. There was no treatment effect on the kids' survival or weights at birth, but the kids from goats subjected to HS presented lesser cortisol concentration and greater mortality rates at weaning than kids from CT goats. Finally, the overexpression of HSPA1A by HS goats suggests a protective response of placenta. However, the heat stress negatively affected the placenta's expulsion length, placental cotyledons number, weight and area, the ratio between kid's weight and placenta weight, and cortisol signaling. Indeed, the upregulation of MC2R and NR3C1 and downregulation of HSD11B2 on placenta caused by heat stress were associated with greater cortisol concentrations in the amniotic fluid of HS goats. Although HS and CT kids had adequate weights and survival rate during the first weeks of life, the heat stress increased the mortality at weaning of HS kids versus CT kids, suggesting that the heat stress effect persists and can change the ability of kids to respond to weaning challenge.
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Affiliation(s)
- P S Silva
- Department of Basic Sciences, Faculty of Animal Science and Food Engineering, University of São Paulo, Pirassununga, São Paulo, 13635-900, Brazil
| | - H B Hooper
- Department of Basic Sciences, Faculty of Animal Science and Food Engineering, University of São Paulo, Pirassununga, São Paulo, 13635-900, Brazil
| | - E Manica
- Department of Basic Sciences, Faculty of Animal Science and Food Engineering, University of São Paulo, Pirassununga, São Paulo, 13635-900, Brazil
| | - G K F Merighe
- Department of Basic Sciences, Faculty of Animal Science and Food Engineering, University of São Paulo, Pirassununga, São Paulo, 13635-900, Brazil
| | - S A Oliveira
- Department of Basic Sciences, Faculty of Animal Science and Food Engineering, University of São Paulo, Pirassununga, São Paulo, 13635-900, Brazil
| | - A S Traldi
- Department of Animal Reproduction, Faculty of Veterinary Medicine and Animal Science, University of São Paulo, Pirassununga, São Paulo, 13635-900, Brazil
| | - J A Negrão
- Department of Basic Sciences, Faculty of Animal Science and Food Engineering, University of São Paulo, Pirassununga, São Paulo, 13635-900, Brazil.
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Ashraf M, Sampani K, Clermont A, Abu-Qamar O, Rhee J, Silva PS, Aiello LP, Sun JK. Vascular Density of Deep, Intermediate and Superficial Vascular Plexuses Are Differentially Affected by Diabetic Retinopathy Severity. Invest Ophthalmol Vis Sci 2021; 61:53. [PMID: 32866267 PMCID: PMC7463180 DOI: 10.1167/iovs.61.10.53] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose The purpose of this study was to evaluate differences in optical coherence tomography angiography (OCTA) metrics in the superficial (SCP), intermediate (ICP), and deep (DCP) vascular plexuses across diabetic retinopathy (DR) severity levels. Methods This was a cross sectional observational retrospective chart review study. Eligible patients with diabetes who underwent same day RTVue XR Avanti OCTA, spectral-domain optical coherence tomography (SD-OCT), and 200-degree Optos ultrawide field color imaging. SCP, ICP, and DCP vessel density (VD) and vessel length density (VLD) were assessed using 3-D projection artifact removal software (PAROCTA) software. Results Of 396 eyes (237 patients), 16.1% had no DR, 26.9% mild nonproliferative DR (NPDR), 21.1% moderate NPDR, 12.1% severe NPDR, 10.1% proliferative DR (PDR) without panretinal photocoagulation (PRP), and 13.4% PDR with PRP. When comparing mild NPDR to no DR eyes, ICP and DCP VD and VLD were significantly lower, but there was no difference for SCP metrics. In eyes with more severe DR, there were significant differences in SCP VD and VLD between DR severity levels (mild versus moderate NPDR: VD 35.45 ± 3.31 vs. 34.14 ± 3.38, P = 0.008 and VLD 17.59 ± 1.83 vs. 16.80 ± 1.83, P = 0.003; moderate versus severe NPDR: VLD 16.80 ± 1.83 vs. 15.79 ± 1.84, P = 0.019), but no significant differences in ICP or DCP. Conclusions Although VD of each of the three individual layers decreases with increasing DR severity, DR severity has a substantially different effect on OCTA parameters within each layer. Vascular changes in eyes with no to early DR were present primarily in the deeper vascular layers, whereas in eyes with advanced DR the opposite was observed. This study highlights the effects of ICP and the importance of assessing SCP and DCP changes independently across each DR severity level.
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Affiliation(s)
- Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, United States
| | - Konstantina Sampani
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, United States.,Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Allen Clermont
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, United States
| | - Omar Abu-Qamar
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, United States
| | - Jae Rhee
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, United States
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, United States.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, United States.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States
| | - Jennifer K Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, United States.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States
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Ashraf M, Shokrollahi S, Pisig AU, Sampani K, Abdelal O, Cavallerano JD, Robertson G, Fleming A, van Hemert J, Pitoc CM, Sun JK, Aiello LP, Silva PS. Retinal Vascular Caliber Association with Nonperfusion and Diabetic Retinopathy Severity Depends on Vascular Caliber Measurement Location. Ophthalmol Retina 2020; 5:571-579. [PMID: 32927151 DOI: 10.1016/j.oret.2020.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/25/2020] [Accepted: 09/03/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To evaluate the association of retinal nonperfusion and diabetic retinopathy (DR) severity with location of vascular caliber measurement using ultrawide field (UWF) imaging. DESIGN Retrospective image review. PARTICIPANTS Adults with diabetes mellitus. METHODS All images from subjects with same-day UWF fluorescein angiography (FA) and color imaging were evaluated. Predominantly peripheral lesions (PPL) and DR severity were graded from UWF color images. Nonperfusion was quantified using UWF-FA in defined retinal regions [posterior pole (PP), mid-periphery (MP), far-periphery (FP)]. Retinal vessel calibers were measured at an optic disc centered inner and outer zone. MAIN OUTCOME MEASURES Nonperfusion index (NPI) in the PP, MP and FP. Mean arteriole and venule diameter in the inner and outer zones. RESULTS Two hundred eighty-five eyes of 193 patients (24.9% mild nonproliferative DR [NPDR], 22.8% moderate NPDR, 37.5% severe NPDR and 14.7% proliferative DR [PDR]) were reviewed. No significant associations between inner zone arteriolar diameter and retinal NPI overall or in any retinal region. In the outer zone, eyes with thinnest arteriolar calibers (quartile 1) were associated with a 1.7- to 2.4-fold nonperfusion increase across all retinal regions compared to the remaining eyes (P = 0.002 [PP] to 0.048 [FP]). In the outer zone, the percentage of eyes in the thinnest quartile of retinal arteriolar diameter increased with worsening DR severity (mild NPDR: 10% vs PDR: 31%, P = 0.007). This association was not observed when measured within the inner zone (P = 0.129). All venular caliber associations were not statistically significant when corrected for potentially confounding factors. Thinner outer zone retinal arteriolar caliber (quartile 1) was more common in eyes with PPL compared to eyes without PPL (34.1% vs 20.8%, P = 0.017) as were thicker outer venular calibers (quartile 4) (33% vs 21.3%, P = 0.036). Presence of PPL was associated with thinner outer zone arteriolar caliber (109.7 ± 26.5μm vs 123.0 ± 29.5μm, P = 0.001). CONCLUSIONS The association of vascular caliber with nonperfusion and DR severity differs based upon the retinal location at which vascular caliber is measured. Peripheral arterial narrowing is associated with increasing nonperfusion, worsening DR severity and presence of PPL. In contrast, inner zone retinal arteriolar caliber is not associated with these findings.
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Affiliation(s)
- Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Alexandria Faculty of Medicine, Alexandria, Egypt
| | | | - Alex U Pisig
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
| | - Konstantina Sampani
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Omar Abdelal
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts
| | - Jerry D Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Cloyd M Pitoc
- Teleophthalmology and Image Reading Center, Philippine Eye Research Institute, National Institutes of Health, University of the Philippines, Manila, Philippines
| | - Jennifer K Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts; Teleophthalmology and Image Reading Center, Philippine Eye Research Institute, National Institutes of Health, University of the Philippines, Manila, Philippines.
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Sampani K, Abdulaal M, Peiris T, Lin MM, Pitoc C, Ledesma M, Lammer J, Silva PS, Aiello LP, Sun JK. Comparison of SDOCT Scan Types for Grading Disorganization of Retinal Inner Layers and Other Morphologic Features of Diabetic Macular Edema. Transl Vis Sci Technol 2020; 9:45. [PMID: 32855891 PMCID: PMC7422902 DOI: 10.1167/tvst.9.8.45] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/24/2020] [Indexed: 11/28/2022] Open
Abstract
Purpose To assess grading reproducibility of disorganization of the retinal inner layers (DRIL) and other morphologic features of diabetic macular edema (DME) across spectral domain optical coherence tomography (SDOCT) instruments and scan types. Methods A cross-sectional study enrolled participants with current or recent center-involved DME. In group A (27 eyes), we obtained two Cirrus scans (512 × 128 macular cube [Cube] and high-definition five-line raster [HD 5-Line]) and two Spectralis scans (high-resolution [HR] and high-speed [HS]). In group B, 26 eyes underwent HR scans and Optovue AngioVue (OP) 3 × 3-mm scans. All scans were graded for type and extent of DRIL, intraretinal cysts, cone outer segment tip visibility, and subretinal fluid (SRF). Results In the total cohort, mean central subfield thickness was 342.9 ± 83.4 µm. Intraclass correlations were high for DRIL extent across the four different imaging settings (HR vs. HS, r = 0.93; HR vs. Cube, r = 0.84, HR vs. HD 5-Line, r = 0.76, HR vs. OP, r = 0.87) and ranged from good to excellent for intraretinal cyst and SRF area. There were significantly smaller mean normalized differences between HR/HS scans versus HR and all other scan modalities (HR/HS vs. HR/Cube, P = 0.02; HR/HD 5-Line, P = 0.0005; HR/OP, P < 0.0001). Conclusions Our data suggest that the reproducibility for SDOCT parameters of DRIL and intraretinal cysts was high across all five SDOCT scan types; thus, evaluation of DRIL is feasible using multiple SDOCT models in eyes with DME. Translational Relevance DME morphological changes can be evaluated on multiple SDOCT devices with good reproducibility, allowing clinicians and researchers flexibility in DME assessment for clinical care and research.
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Affiliation(s)
- Konstantina Sampani
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Marwan Abdulaal
- Department of Ophthalmology, Case Western Reserve University, Cleveland, OH, USA
| | - Timothy Peiris
- Department of Ophthalmology, Zucker School of Medicine at Hofstra/Northwell, East Garden City, NY, USA
| | - Michael M Lin
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA.,Massachusetts Eye and Ear, Boston, MA, USA
| | - Cloyd Pitoc
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | - Migil Ledesma
- Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | - Jan Lammer
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School, Boston, MA, USA.,Philippine Eye Research Institute, University of the Philippines, Manila, Philippines
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Jennifer K Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA.,Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Ashraf M, Sampani K, Abu-Qamar O, Cavallerano J, Silva PS, Aiello LP, Sun JK. Optical Coherence Tomography Angiography Projection Artifact Removal: Impact on Capillary Density and Interaction with Diabetic Retinopathy Severity. Transl Vis Sci Technol 2020; 9:10. [PMID: 32832217 PMCID: PMC7414622 DOI: 10.1167/tvst.9.7.10] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/29/2020] [Indexed: 12/17/2022] Open
Abstract
Purpose The purpose of this study was to assess how projection artifact removal (PAR) alters optical coherence tomography angiography (OCTA) assessment of superficial capillary plexus (SCP) and deep capillary plexus (DCP) in eyes of patients with diabetes. Methods We acquired 3 × 3 mm scans with RTVue-XR Avanti (Optovue, Inc., Fremont, CA), which were analyzed with PAR software (PAROCTA) and without (non-PAROCTA). SCP, DCP, and full thickness retina vascular density (VD) and vessel linear density (VLD) were manually calculated using ImageJ (version 1.51). Adjusted flow index (AFI) was manually assessed for full thickness images. Results Among 323 eyes of 194 patients (no diabetic retinopathy [DR]: 28 eyes; mild nonproliferative DR (NPDR): 96 eyes; moderate: 82 eyes; severe: 32 eyes; and proliferative DR [PDR]: 81 eyes), SCP VD and VLD were lower with PAROCTA than with non-PAROCTA only in eyes with moderate (VD: P = 0.017; VLD: P = 0.046), severe (P = 0.016; P = 0.009), and PDR (P < 0.001; P = 0.002). DCP VD and VLD were higher with PAROCTA as compared to non-PAROCTA only in eyes with no DR (VD and VLD: P < 0.001), mild (VD and VLD: P < 0.001), moderate (VD: P = 0.005; and VLD: P < 0.001), and severe (VD: P = 0.009; VLD: P < 0.001). Full thickness PAROCTA and non-PAROCTA VD and VLD differed only in eyes with no DR where PAROCTA estimates were higher (VD: P = 0.009; VLD: P = 0.02). PAROCTA AFI was lower than non-PAROCTA AFI for all DR severity levels (P < 0.001) except no DR. Conclusions Although differential effects of PAROCTA software are expected on SCP versus DCP measurements, these findings also suggest an interaction between PAROCTA and DR severity on assessment of VD. Conclusions from previous studies that have not corrected VD with PAR software should be carefully reviewed with regard to the role of specific vascular layers in DR. Translational Relevance Previous OCTA studies that have not corrected VD with PAR software should be carefully reviewed with regard to the role of individual vascular layers in differing severity levels of DR.
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Affiliation(s)
- Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Konstantina Sampani
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA.,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Omar Abu-Qamar
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
| | - Jerry Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer K Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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Affiliation(s)
- Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
| | | | | | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Paolo S. Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, The Medical City, Metro Manila, Philippines
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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Ashraf M, Sampani K, AbdelAl O, Fleming A, Cavallerano J, Souka A, El Baha SM, Silva PS, Sun J, Aiello LP. Disparity of microaneurysm count between ultrawide field colour imaging and ultrawide field fluorescein angiography in eyes with diabetic retinopathy. Br J Ophthalmol 2020; 104:1762-1767. [PMID: 32111607 DOI: 10.1136/bjophthalmol-2019-315807] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/03/2020] [Accepted: 02/10/2020] [Indexed: 01/20/2023]
Abstract
AIMS To compare microaneurysm (MA) counts using ultrawide field colour images (UWF-CI) and ultrawide field fluorescein angiography (UWF-FA). METHODS Retrospective study including patients with type 1 or 2 diabetes mellitus receiving UWF-FA and UWF-CI within 2 weeks. MAs were manually counted in individual Early Treatment Diabetic Retinopathy Study (ETDRS) and extended UWF zones. Fields with MAs ≥20 determined diabetic retinopathy (DR) severity (0 fields=mild, 1-3=moderate, ≥4=severe). UWF-FA and UWF-CI agreement was determined and UWF-CI DR severity sensitivity analysis adjusting for UWF-FA MA counts performed. RESULTS In 193 patients (288 eyes), 2.4% had no DR, 29.9% mild non-proliferative DR (NPDR), 32.6% moderate (NPDR), 22.9% severe NPDR and 12.2% proliferative DR. UWF-FA MA counts were 3.5-fold higher (p<0.001) than UWF-CI counts overall, 3.2x-fold higher in ETDRS fields (p<0.001) and 5.3-fold higher in extended ETDRS fields (p<0.001) and higher in type 1 versus type 2 diabetes (p<0.001). In eyes with NPDR on UWF-CI (n=246), UWF-FA images had 1.6x-3.5x more fields with ≥20 MAs (p<0.001). Fair agreement existed between imaging modalities (k=0.221-0.416). In ETDRS fields, DR severity agreement increased from k=0.346 to 0.600 when dividing UWF-FA counts by a factor of 3, followed by rapid decline in agreement thereafter. Total UWF area agreement increased from k=0.317 to 0.565 with an adjustment factor of either 4 or 5. CONCLUSIONS UWF-FA detects threefold to fivefold more MAs than UWF-CI and identifies 1.6-3.5-fold more fields affecting DR severity. Differences exist at all DR severity levels, thus limiting direct comparison between the modalities. However, correcting UWF-FA MA counts substantially improves DR severity agreement between the modalities.
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Affiliation(s)
- Mohamed Ashraf
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA.,Ophthalmology, Alexandria Faculty of Medicine, Alexandria, Egypt
| | | | - Omar AbdelAl
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA
| | | | - Jerry Cavallerano
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Ahmed Souka
- Ophthalmology, Alexandria Faculty of Medicine, Alexandria, Egypt
| | | | - Paolo S Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, USA .,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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Aiello LP, Odia I, Glassman AR, Melia M, Jampol LM, Bressler NM, Kiss S, Silva PS, Wykoff CC, Sun JK. Comparison of Early Treatment Diabetic Retinopathy Study Standard 7-Field Imaging With Ultrawide-Field Imaging for Determining Severity of Diabetic Retinopathy. JAMA Ophthalmol 2019; 137:65-73. [PMID: 30347105 DOI: 10.1001/jamaophthalmol.2018.4982] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Moderate to substantial agreement between Early Treatment Diabetic Retinopathy Study (ETDRS) 7-field imaging and ultrawide-field (UWF) imaging has been suggested in single-center studies. Comparing images obtained by multiple centers could increase confidence that UWF images can be used reliably in place of ETDRS imaging in future clinical trials. Objective To compare diabetic retinopathy (DR) severity from modified ETDRS 7-field imaging and UWF imaging. Design, Setting, and Participants This preplanned, cross-sectional analysis included modified ETDRS 7-field images obtained using the Diabetic Retinopathy Clinical Research Network acquisition protocol and UWF images obtained captured with the Optos 200Tx system (Optos, PLC) from adult participants (≥18 years old) with type 1 or type 2 diabetes. Both image types were evaluated by trained graders masked to clinical data. Data collection occurred from February 2015 to December 2015, and data analysis from June 2016 to December 2017. Main Outcomes and Measures Agreement between UWF images, UWF images masked to include only the ETDRS 7-field area, and ETDRS 7-field images were calculated using κ statistics. Results A total of 764 eyes from 385 participants were included; participants had a median (IQR) age of 62.2 (53.6-69.2) years, 194 (50.4%) were women, and 256 (66.5%) were white. Of 742 eyes with both ETDRS 7-field images and UWF masked images graded, 359 (48.4% [95% CI, 44.4%-52.4%]) eyes had exact agreement, and 653 eyes (88.0% [95% CI, 85.2%-90.3%]) agreed within 1 step (weighted κ, 0.51 [95% CI, 0.44-0.58]). After open adjudication by an independent senior grader of all images with more than a 2-step discrepancy, perfect agreement was found in 435 eyes (59.0% [95% CI, 55.1%-62.8%]) and agreement within 1 step in 714 eyes (96.9% [95% CI, 95.1%-98.0%]; κ, 0.77 [95% CI, 0.73-0.82]). Ability of the imaging modalities to detect retinopathy severity in an individual eye was considered similar in 59 eyes (50.9% [95% CI, 41.3%-60.4%]), better for ETDRS 7-field imaging in 22 eyes (19.0% [95% CI, 12.5%-27.7%]), and better for UWF-masked images in 31 eyes (26.7% [95% CI 18.8%-36.5%]). Comparing UWF masked and unmasked images, 94 of 751 eyes (12.5%) had DR graded as at least 1 step more severe on UWF unmasked images vs UWF masked images. Predominantly peripheral DR lesions were present in 308 of 751 eyes (41.0%); this suggested increased DR severity by 2 or more steps in 34 eyes (11.0%). Conclusions and Relevance Imaging by the ETDRS 7-field and UWF imaging systems have moderate to substantial agreement when determining the severity of DR within the 7 standard fields. Disparities in an individual eye are equivalently distributed between imaging modalities and can be better or worse on 1 or the other. Longitudinal follow-up will evaluate the primary outcome of this study to determine if peripheral retinal findings are associated with future retinopathy outcomes.
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Affiliation(s)
- Lloyd Paul Aiello
- Joslin Diabetes Center, Beetham Eye Institute, Harvard Department of Ophthalmology Boston, Massachusetts
| | - Isoken Odia
- Jaeb Center for Health Research, Tampa, Florida
| | | | | | - Lee M Jampol
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Neil M Bressler
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Editor
| | - Szilard Kiss
- Department of Ophthalmology, Weill Cornell Medical College, New York, New York
| | - Paolo S Silva
- Joslin Diabetes Center, Beetham Eye Institute, Harvard Department of Ophthalmology Boston, Massachusetts
| | - Charles C Wykoff
- Retina Consultants of Houston, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas
| | - Jennifer K Sun
- Joslin Diabetes Center, Beetham Eye Institute, Harvard Department of Ophthalmology Boston, Massachusetts.,CME Editor
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Lammer J, Karst SG, Lin MM, Cheney M, Silva PS, Burns SA, Aiello LP, Sun JK. Association of Microaneurysms on Adaptive Optics Scanning Laser Ophthalmoscopy With Surrounding Neuroretinal Pathology and Visual Function in Diabetes. Invest Ophthalmol Vis Sci 2018; 59:5633-5640. [PMID: 30481280 PMCID: PMC6262647 DOI: 10.1167/iovs.18-24386] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 09/13/2018] [Indexed: 12/16/2022] Open
Abstract
Purpose We evaluate diabetic microaneurysm (MA) features on high-resolution adaptive optics scanning laser ophthalmoscopy (AOSLO) and their correlations with visual acuity (VA) and local retinal pathology on spectral domain optical coherence tomography (SDOCT). Methods Diabetic participants underwent VA testing and AOSLO and SDOCT imaging of MAs. AOSLO images were graded for MA dimension, wall hyperreflectivity (WH), intraluminal hyperreflectivity (IH), and perfusion pattern. SDOCTs centered on each MA were graded for disorganization of the retinal inner layers (DRIL) and other neuroretinal pathology. Results We imaged 109 MAs (30 eyes). Multivariate modeling, including statistically significant covariates from bivariate analyses, associated WH with greater MA size (P = 0.001) and DRIL (P = 0.04). IH was associated with perfusion (P = 0.003) and MA visibility on photographs (P = 0.0001), and larger MA size with partial perfusion (P = 0.03), MA ring signs (P = 0.0002), and photographic visibility (P = 0.01). Multivariate modeling revealed an association of WH and VA with DRIL. Conclusions AOSLO imaging demonstrates associations of hyperreflective MA walls with MA size and adjacent DRIL, as well as the presence of DRIL with lower VA. This study identifies a correlation between vascular and neural pathology associated with VA decline. Further studies of MA structure and neuroretinal disorganization may enable novel approaches to assess anatomic and functional outcomes in the diabetic eye.
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Affiliation(s)
- Jan Lammer
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, United States
- Department of Ophthalmology and Optometry, Medical University Vienna, Vienna, Austria
| | - Sonja G. Karst
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, United States
- Department of Ophthalmology and Optometry, Medical University Vienna, Vienna, Austria
| | - Michael M. Lin
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, United States
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States
| | - Michael Cheney
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, United States
| | - Paolo S. Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, United States
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States
| | - Stephen A. Burns
- School of Optometry, Indiana University, Bloomington, Indiana, United States
| | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, United States
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States
| | - Jennifer K. Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, Massachusetts, United States
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, United States
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Silva PS, Gupta A, Ajlan RS, Schlossman DK, Tolson AM, Cavallerano JD, Aiello LP. Ultrawide field scanning laser ophthalmoscopy imaging of lipemia retinalis. Acta Ophthalmol 2018; 96:e643-e646. [PMID: 28772065 DOI: 10.1111/aos.13525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 06/05/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To describe the characteristic retinal features of lipemia retinalis when using ultrawide field scanning laser ophthalmoscopy. MAIN POINTS We report a case series of three subjects with ultrawide field retinal images showing cream discoloration of the fundus, light salmon-coloured posterior retinal vessels and greyish pink peripheral vasculature. On green-only imaging, many of the vessels appear light rather than typically dark. CONCLUSION Lipemia retinalis is readily apparent on ultrawide field imaging and illustrates the alterations that systemic diseases may induce in the posterior and peripheral retinal vasculature. Ultrawide field imaging highlights the disparate vascular appearance of the posterior pole and retinal periphery in this condition.
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Affiliation(s)
- Paolo S. Silva
- Beetham Eye Institute; Joslin Diabetes Center; Boston MA USA
- Department of Ophthalmology; Harvard Medical School; Boston MA USA
- Teleophthalmology and Image Reading Center; Philippine Eye Research Institute; National Institutes of Health; University of the Philippines; Manila Philippines
| | - Aditi Gupta
- Beetham Eye Institute; Joslin Diabetes Center; Boston MA USA
| | - Radwan S. Ajlan
- Beetham Eye Institute; Joslin Diabetes Center; Boston MA USA
| | - Deborah K. Schlossman
- Beetham Eye Institute; Joslin Diabetes Center; Boston MA USA
- Department of Ophthalmology; Harvard Medical School; Boston MA USA
| | - Ann M. Tolson
- Beetham Eye Institute; Joslin Diabetes Center; Boston MA USA
| | - Jerry D. Cavallerano
- Beetham Eye Institute; Joslin Diabetes Center; Boston MA USA
- Department of Ophthalmology; Harvard Medical School; Boston MA USA
| | - Lloyd Paul Aiello
- Beetham Eye Institute; Joslin Diabetes Center; Boston MA USA
- Department of Ophthalmology; Harvard Medical School; Boston MA USA
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Abstract
Intravitreous injections are presently the second most frequently performed ophthalmic procedure and the most common vitreoretinal procedure. In diabetic patients, intravitreous injections are frequently performed for the treatment of center-involved diabetic macular edema, proliferative diabetic retinopathy, or other co-existing retinal vascular disease. Diabetic patients may be at higher risk of adverse events compared to non-diabetic individuals, given frequent systemic comorbidities, such as cardiovascular and renal disease and increased susceptibility to infection. This review highlights the potential complications and safety considerations in intravitreous injections in patients with diabetes.
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Affiliation(s)
- Aditi Gupta
- a Beetham Eye Institute, Joslin Diabetes Center , Boston , MA , USA
| | - Jennifer K Sun
- a Beetham Eye Institute, Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
| | - Paolo S Silva
- a Beetham Eye Institute, Joslin Diabetes Center , Boston , MA , USA.,b Department of Ophthalmology , Harvard Medical School , Boston , MA , USA
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Karst SG, Lammer J, Radwan SH, Kwak H, Silva PS, Burns SA, Aiello LP, Sun JK. Characterization of In Vivo Retinal Lesions of Diabetic Retinopathy Using Adaptive Optics Scanning Laser Ophthalmoscopy. Int J Endocrinol 2018; 2018:7492946. [PMID: 29853882 PMCID: PMC5954931 DOI: 10.1155/2018/7492946] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 01/16/2018] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To characterize hallmark diabetic retinopathy (DR) lesions utilizing adaptive optics scanning laser ophthalmoscopy (AOSLO) and to compare AOSLO findings with those on standard imaging techniques. METHODS Cross-sectional study including 35 eyes of 34 study participants. AOSLO confocal and multiply scattered light (MSL) imaging were performed in eyes with DR. Color fundus photographs (CF), infrared images of the macula (Spectralis, Heidelberg), and Spectralis spectral domain optical coherence tomography SDOCT B-scans of each lesion were obtained and registered to corresponding AOSLO images. MAIN OUTCOME MEASURES Individual lesion characterization by AOSLO imaging. AOSLO appearance was compared with CF and SDOCT imaging. RESULTS Characterized lesions encompassed 52 microaneurysms (MA), 20 intraretinal microvascular abnormalities (IRMA), 7 neovascularization (NV), 11 hard exudates (HE), 5 dot/blot hemorrhages (HEM), 4 cotton wool spots (CWS), and 14 intraretinal cysts. AOSLO allowed assessment of perfusion in vascular lesions and enabled the identification of vascular lesions that could not be visualized on CF or SDOCT. CONCLUSIONS AOSLO imaging provides detailed, noninvasive in vivo visualization of DR lesions enhancing the assessment of morphological characteristics. These unique AOSLO attributes may enable new insights into the pathological changes of DR in response to disease onset, development, regression, and response to therapy.
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Affiliation(s)
- Sonja G. Karst
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Jan Lammer
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology and Optometry, Medical University of Vienna, Vienna, Austria
| | - Salma H. Radwan
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Cairo University, Cairo, Egypt
| | - Hanna Kwak
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
| | - Paolo S. Silva
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | | | - Lloyd Paul Aiello
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Jennifer K. Sun
- Beetham Eye Institute, Joslin Diabetes Center, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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