Aqueous humor endothelin-1 and total retinal blood flow in patients with non-proliferative diabetic retinopathy.

PurposeThe purpose of this study was to determine the association between aqueous ET-1 levels and total retinal blood flow (TRBF) in patients with non-insulin-dependent type 2 diabetes mellitus (T2DM) and early non-proliferative diabetic retinopathy (NPDR).Patients and methodsA total of 15 age-matched controls and 15 T2DM patients with NPDR were recruited into the study. Aqueous humor (~80-120 µl) was collected before cataract surgery to measure the levels of ET-1 using suspension multiplex array technology. Four weeks post surgery, six images were acquired to assess TRBF using the prototype RTVue Doppler FD-OCT (Optovue, Inc., Fremont, CA, USA) with a double circular scan protocol. At the same visit, forearm blood was collected to determine plasma glycosylated hemoglobin (A1c) levels.ResultsAqueous ET-1 was significantly elevated in the NPDR group compared with the control group (3.5±1.8 vs 2.2±0.8, P=0.02). TRBF was found to be significantly reduced in the NPDR group compared with the control group (34.5±9.1 vs 44.1±4.6 µl/min, P=0.002). TRBF and aqueous ET-1 were not correlated within the NPDR group (r=-0.24, P=0.22). In a multivariate analysis, high A1c was associated with reduced TRBF and aqueous ET-1 levels across control and NPDR groups (P<0.01).ConclusionAqueous ET-1 levels were increased while TRBF was reduced in patients with NPDR compared with the control group. Although not directly associated, the vasoconstrictory effects of ET-1 are consistent with a reduced TRBF observed in early DR. ET-1 dysregulation may contribute to a reduction in retinal blood flow during early DR.

The effect of hypercapnia on the sensitivity to flicker defined stimuli.

BACKGROUND/AIMS: To investigate the effect of increased CO2 levels on flicker defined stimuli. METHODS: The sensitivity of two flicker defined tasks was measured in nine healthy, trained observers using the Flicker Defined Form (FDF) stimulus of the Heidelberg Edge Perimeter (HEP; Heidelberg Engineering) and Frequency Doubling Technology (FDT) stimulus of the Matrix perimeter (Carl Zeiss Meditec) during normoxia and 15% hypercapnia (end-tidal CO2 increased by 15% relative to baseline). HEP-FDF and Matrix-FDT sensitivities were analysed for the global field, superior and inferior hemifields and at specific matched eccentricities, using repeated measures analysis of variance. The main effect of hypercapnia on flicker sensitivity was analysed using regression models. RESULTS: Higher flicker sensitivity outcomes with increasing CO2 values were found for HEP-FDF and Matrix-FDT with a statistically significant main effect for HEP-FDF global, superior and inferior hemifields (p<0.01 for all) as well as 6°, 18°, 12° and 24° eccentricities (p=0.03, 0.04, 0.01, 0.05, respectively). When comparing mean sensitivity values between normocapnia and hypercapnia conditions, no statistically significantly different results were found for HEP-FDF and Matrix-FDT (p>0.05). CONCLUSIONS: As CO2 levels were increased in healthy young individuals, there was an associated increase in visual sensitivity that was only significant for HEP-FDF stimuli, highlighting the different mechanisms involved in processing each of HEP-FDF and Matrix-FDT stimuli. Mean visual sensitivity outcomes were found to be similar for normocapnia and hypercapnia suggesting that a capability to compensate for a mild and stable increase in systemic CO2 levels may exist.

Application of Elliptic Fourier analysis to describe the lamina cribrosa shape with age and intraocular pressure.

The lamina cribrosa (LC) plays an important biomechanical role in the optic nerve head (ONH). We developed a statistical shape model of the LC and tested if the shape varies with age or IOP. The ONHs of 18 donor eyes (47-91 years, mean 76 years) fixed at either 5 or 50 mmHg of IOP were sectioned, stained, and imaged under a microscope. A 3D model of each ONH was reconstructed and the outline of the vertical sagittal section closest to the geometric center of the LC extracted. The outline shape was described using Elliptic Fourier analysis, and principal components analysis (PCA) employed to identify the primary modes of LC shape variation. Linear mixed effect models were used to determine if the shape measurements were associated with age or IOP. The analysis revealed several modes of shape variation: thickness and depth directly (PC 1), or inversely (PC 2) related, and superior-inferior asymmetry (PC 3). Only PC 3 was associated with IOP, with higher IOP correlating with greater curvature of the LC superiorly compared to inferiorly. Our analysis enabled a concise and complete characterization of LC shape, revealing variations without defining them a priori. No association between LC shape and age was found for the relatively old population studied. Superior-inferior asymmetry of LC shape was associated with IOP, with more asymmetry at higher IOP. Increased IOP was not associated with LC thickness or depth.

Clinical significance of optic disc progression by topographic change analysis maps in glaucoma: an 8-year follow-up study.

Aim. To investigate the ability of Heidelberg Retina Tomograph (HRT3) Topographic Change Analysis (TCA) map to predict the subsequent development of clinical change, in patients with glaucoma. Materials. 61 eyes of 61 patients, which, from a retrospective review were defined as stable on optic nerve head (ONH) stereophotographs and visual field (VF), were enrolled in a prospective study. Eyes were classified as TCA-stable or TCA-progressed based on the TCA map. All patients underwent HRT3, VF, and ONH stereophotography at 9-12 months intervals. Clinical glaucoma progression was determined by masked assessment of ONH stereophotographs and VF Guided Progression Analysis. Results. The median (IQR) total HRT follow-up period was 8.1 (7.3, 9.1) years, which included a median retrospective and prospective follow-up time of 3.9 (3.1, 5.0) and 4.0 (3.5, 4.7) years, respectively. In the TCA-stable eyes, VF and/or photographic progression occurred in 5/13 (38.4%) eyes compared to 11/48 (22.9%) of the TCA-progressed eyes. There was no statistically significant association between TCA progression and clinically relevant (photographic and/or VF) progression (hazard ratio, 1.18; P = 0.762). The observed median time to clinical progression from enrollment was significantly shorter in the TCA-progressed group compared to the TCA-stable group (P = 0.04). Conclusion. Our results indicate that the commercially available TCA progression criteria do not adequately predict subsequent photographic and/or VF progression.

Regional variation in human retinal vessel oxygen saturation.

The purpose of this study was to investigate regional differences in oxygen saturation of blood in first degree retinal vessels using a novel non-flash hyperspectral retinal camera (Photon etc Inc). Nine healthy individuals (mean age 24.4 ± 3.6 yrs, 5 males) were imaged at 548, 569, 586, 600, 605 and 610 nm wavelengths. Optical density values were extracted with the aid of Image-J software for blood oxygen saturation (SO2) determination. Arteriolar and venular SO2 were measured at three locations (ranging 1-3 optic nerve head radii) from the disc margin along the vessels in the superior and inferior temporal quadrants. Retinal SO2 was significantly higher in the superior temporal arteriole and venule as compared to the inferior temporal vessels (p = 0.033 and p = 0.032 for arterioles and venules, respectively). SO2 was not significantly different between the three measurement sites for any of the given vessels imaged (p > 0.05). In conclusion, greater SO2 values were found in the superior temporal first degree retinal arterioles and venules in young healthy individuals than in the equivalent inferior vessels. However, there were no detectable differences in retinal SO2 along each of the major vessels, a finding that is consistent with the concept of these vessels not contributing primarily to gas exchange. Moreover, the SO2 was consistently higher in the arterioles than in the equivalent venules (p < 0.0001).

Impact of simulated light scatter on scanning laser Doppler flowmetry.

AIM: To determine the impact of simulated light scatter on scanning laser Doppler flowmetry (SLDF) assessment of retinal capillary blood flow and retinal image quality. METHODS: One eye of 10 normal subjects (mean (SD) age 24 (1.7) years, range 22-27) was randomly selected. Varying concentrations of polystyrene microspheres were suspended in optically clear cells to simulate light scatter. The microsphere concentrations used were 0.05%, 0.03%, 0.02%, 0.01%, and a cell containing only water. LogMAR visual acuity and contrast sensitivity were measured both with and without cells. Optimal focus and alignment was established by acquiring three SLDF images each of the optic nerve head (ONH) and of the macula using the Heidelberg retina flowmeter (HRF) with no cell in place. SLDF images were subsequently acquired with each of the light scatter cells mounted in front of the HRF. The group mean retinal capillary blood flow was compared using repeated measures analysis of variance (reANOVA) as a function of microsphere concentration. RESULTS: Retinal capillary blood flow increased significantly in the ONH, nasal macula, fovea, and temporal macula with increasing microsphere concentration (p<0.0001). Using Dunnett's post hoc test, retinal capillary blood flow was found to be significantly increased relative to the no cell condition for the 0.03% and 0.05% cell concentrations. CONCLUSIONS: Simulated light scatter produces an artifactual increase in retinal capillary blood flow. The impact of cataract on SLDF measurements has yet to be determined.

Defining the limits of flicker defined form: effect of stimulus size, eccentricity and number of random dots.

We investigated the spatio-temporal limits of flicker defined form (FDF) phase contrast thresholds generated from the phantom contour illusion. Random dots (diameter 0.25 degrees, tapered edge) were used throughout the test field. FDF was generated using circular stimuli (temporal frequency 30 Hz, mean background luminance 50 cdm(-2)), the edges being defined by illusory borders generated from the out-of-phase dots within the display. Thresholds improved with increasing stimulus size and number of random dots at all eccentricities. For a constant threshold, fewer random dots were required with increasing eccentricity. Predictive mathematical relationships between contrast threshold, stimulus size and random dot number are discussed.

Exaggerated relative nasal-temporal asymmetry of macular capillary blood flow in patients with clinically significant diabetic macular oedema.

AIMS: To compare the macular capillary blood flow of patients with clinically significant diabetic macular oedema (DMO) with that of non-diabetic subjects and to determine the relation between blood flow and capillary leakage in patients with DMO. METHODS: The sample comprised 45 non-diabetic subjects (mean age 59 years) and 18 type 2 patients with clinically significant DMO (mean age 60 years). Macular capillary blood flow measurements were acquired using the Heidelberg retina flowmeter (HRF) and a 10 degrees x2.5 degrees scan field centred on the fovea. Fluorescein angiography was undertaken on each of the diabetic patients after the completion of HRF measurements. RESULTS: Temporal macular capillary blood flow was significantly lower for the patients with clinically significant DMO compared with age matched non-diabetic subjects (ANCOVA, p = 0.0011) while relative nasal-temporal asymmetry of macular capillary blood flow was significantly higher (p = 0.0125). Nasal-temporal asymmetry of macular capillary blood flow was significantly higher for the patients with DMO and capillary leakage within the scan area (two tailed t test, p = 0.0071). Macular capillary blood flow was always lower in areas of DMO and capillary leakage. CONCLUSION: Capillary blood flow was reduced in areas of DMO and capillary leakage, suggesting the presence of a localised perturbation of capillary blood flow regulation.

The effect of image alignment on capillary blood flow measurement of the neuroretinal rim using the Heidelberg retina flowmeter.

AIM: To examine the influence of image alignment on the repeatability of blood flow measurements of the optic nerve. METHODS: 10 normal subjects were examined. Heidelberg retina tomograph imaging was performed to establish best location and focus for the temporal neuroretinal rim. Two high quality Heidelberg retina flowmeter (HRF) images were acquired for three methods of alignment: central, nasal, and temporal. A 10 x 10 pixel measurement window was selected and exactly reproduced on all images. The interquartile pixel values were used to calculate capillary flow. ANOVA, intraclass correlation coefficients (ICC) and the coefficient of repeatability (CoR) were used for analysis. RESULTS: There was no difference between methods (p = 0.47) or between visits (p = 0.51). The ICCs were 0.83 for the central, 0.34 for the nasal, and 0.42 for the temporal alignment. The CoR was 31.5 for central (mean effect 235.1), 234.6 for nasal, and 256.7 for temporal alignment. CONCLUSION: Central alignment was the most repeatable method for the measurement of neuroretinal rim capillary blood flow using the HRF.

Monocular and dichoptic masking effects on the frequency doubling illusion.

The purpose of this paper was to investigate the effects of both monocular and dichoptic masking on the frequency doubling (FD) illusion, using both temporal and spatial masks. Monocular spatial tuning effects occurred around the fundamental FD spatial frequency of 0.25 cycles per degree (c/deg), whereas dichoptic spatial frequency tuning effects occurred at the doubled spatial frequency of 0.50 c/deg. Temporal tuning effects were observed at the FD temporal frequency of 25 Hz, in both monocular and dichoptic paradigms. These results suggest that the FD illusion is cortical in origin and is dominated by a flicker component.

Inflammation-mediated retinal edema in the rabbit is inhibited by topical nepafenac.

The purpose of this study was to evaluate the ability of the nonsteroidal anti-inflammatory drug nepafenac to prevent development of mitogen-induced pan-retinal edema following topical ocular application in the rabbit. Anesthetized Dutch Belted rabbits were injected intravitreally (30 microg/20 microL) with the mitogen concanavalin A to induce posterior segment inflammation and thickening (edema) of the retina. The Heidelberg Retina Tomograph was used to generate edema maps using custom software. Blood-retinal barrier breakdown was assessed by determining the protein concentration in vitreous humor, whereas analysis of PGE2 in vitreous humor was performed by radioimmunoassay. Inhibition of concanavalin A-induced retinal edema was assessed 72 h after initiation of topical treatment with nepafenac (0.1-1.0%, w/v), dexamethasone (0.1%), VOLTAREN (0.1%), or ACULAR (0.5%). Concanavalin A elicited marked increases in vitreal protein and PGE2 synthesis at 72 h postinjection. Retinal thickness was also increased by 32%, concomitant with the inflammatory response. Topical application of 0.5% nepafenac produced 65% reduction in retinal edema which was correlated with 62% inhibition of blood-retinal barrier breakdown. In a subsequent study, 0.5% nepafenac significantly inhibited (46%) blood-retinal barrier breakdown concomitant with near total suppression of PGE2 synthesis (96%). Neither Voltaren nor Acular inhibited accumulation of these markers of inflammation in the vitreous when tested in parallel. This study demonstrates that nepafenac exhibits superior pharmacodynamic properties in the posterior segment following topical ocular dosing, suggesting a unique therapeutic potential for a variety of conditions associated with retinal edema.

The effect of simulated obstructive apnoea on intraocular pressure and pulsatile ocular blood flow in healthy young adults.

AIM: To investigate the effect of negative inspiratory effort, as generated by the Mueller manoeuvre, on intraocular pressure (IOP) and pulsatile ocular blood flow (POBF) in healthy young adults. METHODS: Seven volunteers with no history of systemic or ocular disease were recruited (mean age 30.7 years, range 25-40 years, M/F: 4/3). After initial instruction and practice of the Mueller manoeuvre, baseline measurements of IOP and POBF were obtained for both eyes after 10 and 15 minutes of rest, respectively, in the supine position. Thereafter, the Mueller manoeuvre was performed creating a mouthpiece pressure of -20 cm H(2)O, for at least 15 seconds followed by a 5 minute rest. The manoeuvre was repeated with a mouthpiece pressure of -40 cm H(2)O. IOP and POBF were measured 5-15 seconds into the manoeuvre for both -20 cm H(2)O (M2A) and -40 cm H(2)O (M4A) and directly upon recovery (after two respiratory cycles) from each manoeuvre (M2B, M4B). Baseline measurements were compared using paired t test, whereas manoeuvre induced changes in IOP and POBF were analysed individually using repeated measures ANOVA with Student-Newman Keuls post hoc analyses. Linear regression analysis was used to investigate a dose-response effect. RESULTS: No significant differences were found between baseline measurements so they were subsequently pooled. There was a significant decrease in IOP for M2B (-9.2%, p<0.05), M4A (-13.8%, p<0.05), and M4B (-15.6%, p<0.05), relative to baseline. A dose-response relation was found for the effect of mouthpiece pressure on measurements 5-10 seconds into the manoeuvre (M2A and M4A, r = 0.54, p = 0.045). There was a trend of increased POBF relative to baseline for all measurements; however, significance was reached for M4B only (p = 0.039). CONCLUSION: It was shown that forced inspiratory efforts as generated by the Mueller manoeuvre are associated with a dose dependent decrease in IOP and a concomitant increase in pulsatile ocular blood flow.

Correlation of a scanning laser derived oedema index and visual function following grid laser treatment for diabetic macular oedema.

AIM: To correlate change of an oedema index derived by scanning laser tomography with change of visual function in patients undergoing grid laser photocoagulation for clinically significant diabetic macular oedema (DMO). METHODS: The sample comprised 24 diabetic patients with retinal thickening within 500 micro m of the fovea. Inclusion criteria included a logMAR visual acuity of 0.25, or better. Patients were assessed twice before a single session of grid laser treatment and within 1 week of, and at 1, 2, 4, and 12 weeks after, treatment. At each visit, patients underwent logMAR visual acuity, conventional and short wavelength automated perimetry (SWAP), and scanning laser tomography. Each visual function parameter was correlated with the mean oedema index. The mean oedema index represented the z-profile signal width divided by the maximum reflectance intensity (arbitrary units). A Pearson correlation coefficient (Bonferroni corrected) was undertaken on the data set of each patient. RESULTS: 13 patients exhibited significant correlation of the mean oedema index and at least one measure of visual function for the 10 degrees x 10 degrees scan field while 10 patients correlated for the 20 degrees x 20 degrees scan field. Seven patients demonstrated correlation for both scan fields. Laser photocoagulation typically resulted in an immediate loss of perimetric sensitivity whereas the oedema index changed over a period of weeks. Localised oedema did not impact upon visual acuity or letter contrast sensitivity when situated extrafoveally. CONCLUSIONS: Correlation of change of the oedema index and of visual function following grid laser photocoagulation was not found in all patients. An absence of correlation can be explained by the localised distribution of DMO in this sample of patients, as well as by differences in the time course of change of the oedema index and visual function. The study has objectively documented change in the magnitude and distribution of DMO following grid laser treatment and has established the relation of this change to the change in visual function.

Enhanced plasticity of retinothalamic projections in an ephrin-A2/A5 double mutant.

Ascending sensory information reaches primary sensory cortical areas via thalamic relay neurons that are organized into modality-specific compartments or nuclei. Although the sensory relay nuclei of the thalamus show consistent modality-specific segregation of afferents, we now show in a wild-type mouse strain that the visual pathway can be surgically "rewired" so as to induce permanent retinal innervation of auditory thalamic cell groups. Applying the same rewiring paradigm to a transgenic mouse lacking the EphA receptor family ligands ephrin-A2 and ephrin-A5 results in more extensive rewiring than in the wild-type strain. We also show for the first time that ephrin-A2 and ephrin-A5 define a distinct border between visual and auditory thalamus. In the absence of this ephrin-A2/A5 border and after rewiring surgery, retinal afferents are better able to invade and innervate the deafferented auditory thalamus. These data suggest that signals that induce retinal axons to innervate the denervated auditory thalamus may compete with barriers, such as the ephrins, that serve to contain them within the normal target. The present findings thus show that the targeting of retinothalamic projections can be surgically manipulated in the mouse and that such plasticity can be controlled by proteins known to regulate topographic mapping.

Long-term fluctuation in short-wavelength automated perimetry in glaucoma suspects and glaucoma patients.

PURPOSE: To determine the magnitude of the homogeneous, LF(Ho), and the heterogeneous, LF(He), components of the long-term fluctuation (LF) in glaucoma suspects and in stable primary open angle glaucoma (POAG) patients undergoing short-wavelength automated perimetry (SWAP) and to compare the magnitude of the SWAP LF components with those elicited by standard white-on-white (W-W) perimetry. METHODS: The sample comprised 33 glaucoma suspects and 17 patients with early-to-moderate stable POAG who underwent W-W perimetry and SWAP at each of six visits over a mean period of 12.75 months (SD, 2.29). The LF(Ho), LF(He), and error components of the long-term fluctuation were determined between the third and seventh visual field examinations. The intervening visual field examinations and the optic nerve head parameters, derived both by stereo observation and by the Heidelberg Retinal Tomograph, were used to confirm stability over the follow-up period. RESULTS: The LF(Ho) and LF(He) components were larger in the POAG patients than in the glaucoma suspects for both W-W perimetry and SWAP; the magnitude was independent of the depth of defect and of the short-term fluctuation. All three components of long-term fluctuation were greater for SWAP than for W-W perimetry, both in the glaucoma suspects and in the POAG patients. CONCLUSIONS: SWAP exhibits greater long-term fluctuation than white-on-white perimetry. The usefulness of SWAP will be limited if the extent of this variability is not overcome in future statistical procedures developed to detect progressive visual field loss.

Ephrin-B reverse signaling is mediated by a novel PDZ-RGS protein and selectively inhibits G protein-coupled chemoattraction.

Transmembrane B ephrins and their Eph receptors signal bidirectionally. However, neither the cell biological effects nor signal transduction mechanisms of the reverse signal are well understood. We describe a cytoplasmic protein, PDZ-RGS3, which binds B ephrins through a PDZ domain, and has a regulator of heterotrimeric G protein signaling (RGS) domain. PDZ-RGS3 can mediate signaling from the ephrin-B cytoplasmic tail. SDF-1, a chemokine with a G protein-coupled receptor, or BDNF, act as chemoattractants for cerebellar granule cells, with SDF-1 action being selectively inhibited by soluble EphB receptor. This study reveals a pathway that links reverse signaling to cellular guidance, uncovers a novel mode of control for G proteins, and demonstrates a mechanism for selective regulation of responsiveness to neuronal guidance cues.

Intraocular and interocular symmetry in normal retinal capillary perfusion.

PURPOSE: To investigate retinal capillary perfusion in different areas of the posterior pole (intraocular symmetry) and to compare capillary perfusion between the right and left eyes (interocular symmetry). METHODS: The study consisted of 52 clinically healthy patients between the ages of 45 and 74 years. Good quality images were obtained in 30 patients. By using scanning laser Doppler flowmetry with the Heidelberg Retina Flowmeter, three 10 degree scans were obtained from the fovea and superior and inferior retina of the study eye (for intraocular symmetry) and from the fovea of the fellow eye (for interocular comparison). Values of volume, flow, and velocity were recorded from each of these areas. Repeated measures analysis of variance, with Bonferroni correction, was used for groupwise comparison between areas in the study eye. Paired t tests, with Bonferroni correction, were used to compare nonfoveolar perfusion between the right and left eyes for each patient. RESULTS: Capillary volume in the foveola was significantly less than that in areas superior and inferior and 3 degrees nasal and temporal, and it was found to increase with eccentricity in the macular region. Only 2 of 30 patients had significant interocular differences between the extrafoveolar areas. CONCLUSION: Significant differences in retinal capillary perfusion were found across the macular region and corresponded with the increase in capillary beds. The Heidelberg Retina Flowmeter also measured the expected decrease in volume at the foveolar avascular zone. There were no significant interocular differences in perfusion. Eye movements, media opacities, and poor tear film quality had a deleterious effect on image quality.