Regulation of retinal oxygen metabolism in humans during graded hypoxia

Retinal vessel analysis to assess microvascular function in the healthy eye: A systematic review on the response to acute physiological and pathological stressors

The retina allows noninvasive in vivo assessment of the microcirculation. Autoregulation of the retinal microvasculature meets the changing requirements of local metabolic demand and maintains adequate blood flow. Analysis of the retinal vascular reactivity contributes to the understanding of regulatory physiology and its relationship to the systemic microcirculation. We conducted a literature review on the effect of different acute stimuli onto the retinal vasculature was conducted in accordance with the PRISMA guidelines. A literature search between 1-1-2005 and 17-10-2022 was performed in Medline, Embase, Web of Science and the Cochrane Library. We report the retinal vascular behavior of healthy individuals in response to both physiological and pathological stressors in 106 included articles. We provide ables of methodological characteristics for each stressor. Hypoxia, hypercapnia, high altitude, flicker light stimulation, rise of core temperature, blood pressure lowering, and the condition immediately after endurance exercise associate with larger retinal vessels. Hyperoxia, hypocapnia, blood pressure rise (Bayliss effect), and the condition during isometric exercise associate with smaller retinal vessels. The retinal vasculature is highly reactive to physiological and pathological stressors. This autoregulatory capacity is hypothesized to be a source of biomarkers for vascular health. Dynamic and static retinal vessel analysis are noninvasive methods to assess this (micro)vascular function. Exploring its diagnostic potential and application into clinical practice requires the development of standardized assessment methods, for which some recommendations are made.

Difference in Optical Coherence Tomography Angiography Parameters After SARS-CoV-2 Infection During the Alpha and Delta Variant Dominance Periods

The SARS-CoV-2 infection manifests with diverse clinical manifestations, with severity potentially influenced by the viral variant. COVID-19 has also been shown to impact ocular microcirculation in some patients, but whether this effect varies by viral lineage remains unclear. This prospective study compared clinical features and ocular parameters assessed via optical coherence tomography angiography (OCTA) in patients recovering from SARS-CoV-2 infections during the dominance of two distinctive viral lineages, Alpha (B.1.1.7) and Delta (B.1.617.2), and compared them to a control group. The following parameters were measured: vessel density (VD) in the superficial capillary plexus (SCP), deep capillary plexus (DCP), and choriocapillaris (CCP) using OCTA, with a manual assessment of the foveal avascular zones in the SCP (FAZs) and DCP (FAZd). A control group was also included. Among 63 patients in the Alpha group and 41 in the Delta group, no eye-related symptoms were reported during the examination. However, the Delta group showed significantly lower VD in the SCP and DCP across all quadrants (p < 0.001-0.039), while the Alpha group showed reduced VD in the foveal CCP (p = 0.005) and significantly wider FAZs and FAZd (p = 0.002 for both). In conclusion, ocular microcirculatory changes differed between the two variants, with Alpha associated with foveal choroidal VD reduction and larger FAZs and Delta linked to lower SCP and DCP VD across multiple regions. These findings highlight the potential for SARS-CoV-2 variants to differentially impact ocular vasculature, underscoring the need for variant-specific follow-up in COVID-19 patients.

A New Approach to Retinal Oxygen Extraction Measurement Based on Laser Speckle Flowgraphy and Retinal Oximetry

Purpose

Currently, no standard for the measurement of retinal oxygen extraction exists. Here, we present a novel approach for measurement of retinal oxygen extraction based on two commercially available devices, namely laser speckle flowgraphy (LSFG) and retinal oximetry.

Methods

The study was conducted in a randomized, double-masked design. Two study days were scheduled for each healthy participant. On one study day, measurements were performed during breathing of 100% oxygen to induce hyperoxia and on the other study day during breathing of 12% oxygen in nitrogen to induce hypoxia. To obtain data for short- and long-term reproducibility, baseline measurements during breathing of room air were performed twice on both study days. Retinal oxygen extraction was calculated from retinal oxygen saturation measurements using the oxygen module of the dynamic vessel analyzer (Imedos, Jena, Germany) and retinal blood flow measurements using LSFG (Nidek, Tokyo, Japan).

Results

As expected, breathing of 100% oxygen induced a significant decrease in retinal oxygen extraction of 36% ± 17% (P < 0.001). During hypoxia, retinal oxygen extraction did not change from baseline (P = 0.153). For short-term reproducibility, the intraclass correlation coefficient was excellent (0.910) and good (0.879) for long-term reproducibility. Coefficient of variation between measurements was 9.8% ± 7.0% for short-term and 10.4% ± 8.8% for long-term reproducibility.

Conclusions

The data obtained in the present experiments show that the new approach to measure retinal oxygen extraction is valid and reproducible in healthy volunteers.

Translational Relevance

The technique may become a valuable tool in studying retinal hypoxia in a wide variety of ocular and systemic diseases in the future.

Systemic Hypoxia and Interventions on Nitric Oxide Metabolism Affect Retinal Vasomotion in Healthy Subjects

Purpose

Previous in vitro studies on porcine retinal arterioles have shown that the frequency and amplitude of retinal vasomotion can be affected by hypoxia and nitric oxide (NO). However, it is unknown whether these effects can be reproduced in humans in vivo.

Methods

Video recordings of retinal arterioles from 40 healthy subjects were studied before and during breathing of a hypoxic gas mixture consisting of 12.5% oxygen and 87.5% nitrogen. The experiments were repeated before and after the addition of either an NO donor or continuous infusion of an NO synthesis inhibitor. The harmonic content of spontaneous diameter changes in retinal arterioles was extracted by Fourier analysis, and the effects of the interventions were studied on the amplitudes of diameter oscillations in the frequency bands 1: 0.5/min-3.5/min, 2: 4/min-7.5/min, 3: 8/min-17.5/min, and 4: 18/min-30/min.

Results

Hypoxia significantly increased the amplitude of spontaneous diameter oscillations within the low (1) and high (3-4) frequency bands (P < 0.006 for all comparisons), and the effect in frequency band 1 was eliminated by the NO donor. In frequency band 2, hypoxia had no significant effect on the amplitude of diameter oscillations, but the amplitudes were significantly reduced by the NO donor (P < 0.01) and significantly increased by the NO synthesis inhibitor (P = 0.03).

Conclusions

Hypoxia and interventions on NO metabolism can affect spontaneous diameter oscillations in retinal arterioles. Disturbances in vasomotion may play a role in hemodynamic changes in retinal diseases in which hypoxia and changes in NO metabolism are involved in the disease pathogenesis.

Quantitative assessment of retinal vasculature changes in systemic lupus erythematosus using wide-field OCTA and the correlation with disease activity

Purpose

To assess the retinal vasculature changes quantitatively using wide-field optical coherence tomography angiography (OCTA) in systemic lupus erythematosus (SLE), and explore its correlation with systemic clinical features.

Design

Prospective, cross-sectional, observational study.

Participants and controls

Patients with SLE who presented to the Ophthalmology Department of Peking Union Medical College Hospital from November 2022 to April 2023 were collected. The subjects were divided into retinopathy and without retinopathy groups. Age and gender-matched healthy subjects were selected as controls.

Methods

Patients with SLE and control subjects were imaged with 24×20 mm OCTA scans centered on the fovea and 6×6 mm OCTA scans centered on the optic disc. The sub-layers of OCTA images were stratified by the built-in software of the device and then the retinal thickness and vessel density were measured automatically. The characteristics of retinal OCTA parameters of SLE and its correlation with systemic clinical indicators of patients without retinopathy were analyzed.

Main outcome measures

OCTA parameters, visual acuity, intraocular pressure, and systemic clinical indicators of patients such as disease activity index, autoimmune antibodies, and inflammatory marker levels were collected.

Results

A total of 102 SLE patients were included, 24 of which had retinopathy, and 78 had unaffected retina. Wide-field OCTA could effectively detect retinal vascular obstruction, non-perfusion area, and morphological abnormalities in patients with lupus retinopathy. SLE patients without retinopathy had significantly higher retinal superficial vessel density (SVD) in foveal (P=0.02), para-foveal temporal (P=0.01), nasal (P=0.01), peripheral foveal temporal (P=0.02), and inferior areas (P=0.02), as well as subregion temporal (P=0.01) and inferior areas (P=0.03) when compared with healthy controls (n=65 eyes from 65 participants). The area under curve (AUC) value of subregion inferior SVD combined parafoveal temporal SVD was up to 0.70. There was a significantly positive correlation between SVD and disease activity in SLE without retinopathy group. Patients with severe activity had the most significant increase in SVD.

Conclusion

Wide-field OCTA can provide a relatively comprehensive assessment of the retinal vasculature in SLE. In the absence of pathological changes of the retina, the SVD was significantly increased and was positively correlated with the disease activity of SLE.

The accumulated oxygen deficit as an indicator of the ischemic retinal insult

We here attempt to improve quantification of the ischemic retinal insult, that is, what is imposed on the retinal tissue by ischemia, especially in experimental models of ischemia. The ischemic retinal insult initiates the ischemic retinal injury (or outcome). Accordingly, it is reasonable to assume that the better the quantification of the insult, the better the correlation with, and thereby estimation of, the injury. The insult seldom has been quantified in terms of the relevant physiological factors, especially in connection with the rate of oxygen delivery (DO2). We here propose the accumulated oxygen deficit (AO2D) as an indicator of the ischemic retinal insult. We hypothesized that AO2D is correlated with the rate of oxygen metabolism measured 1 h after reperfusion following an episode of ischemia (MO2_1_Hr). Previously, we showed that MO2_1_Hr is related to the electroretinogram amplitude and the retinal thickness when they are measured seven days after reperfusion. We studied 27 rats, as well as 26 rats from our published data on retinal ischemia in which we had measurements of DO2 and duration of ischemia (T) of various levels and durations. We also measured DO2 in 29 rats treated with sham surgery. Ischemia was induced by either ipsilateral or bilateral common carotid artery occlusion or by ophthalmic artery occlusion, which gave a wide range of DO2. DO2 and MO2_1_Hr were evaluated based on three types of images: 1) red-free images to measure vessel diameters, 2) fluorescence images to estimate blood velocities by the displacement of intravascular fluorescent microspheres over time, and 3) phosphorescence images to quantify vascular oxygen tension from the phosphorescence lifetime of an intravascular oxygen sensitive phosphor. Loss of oxygen delivery (DO2L) was calculated as the difference between DO2 under normal/sham condition and DO2 during ischemia. AO2D, a volume of oxygen, was calculated as the product DO2L and T. Including all data, the linear relationship between AO2D and MO2_1_Hr was significant (R2 = 0.261, P = 0.0003). Limiting data to that in which T or DO2L was maximal also yielded significant relationships, and revealed that DO2L at a long duration of ischemia contributed disproportionately more than T to MO2_1_Hr. We discuss the potential of AO2D for quantifying the ischemic retinal insult, predicting the ischemic retinal injury and evaluating the likelihood of infarction.

Characterization of Oxygen Nanobubbles and In Vitro Evaluation of Retinal Cells in Hypoxia

Purpose

Vein or artery occlusion causes a hypoxic environment by preventing oxygen delivery and diffusion to tissues. Diseases such as retinal vein occlusion, central retinal artery occlusion, or diabetic retinopathy create a stroke-type condition that leads to functional blindness in the effected eye. We aim to develop an oxygen delivery system consisting of oxygen nanobubbles (ONBs) that can mitigate retinal ischemia during a severe hypoxic event such as central retinal artery occlusion.

Methods

ONBs were synthesized to encapsulate oxygen saturated molecular medical grade water. Stability, oxygen release, biocompatibility, reactive oxygen species, superoxide, MTT, and terminal uridine nick-end labeling assays were performed. Cell viability was evaluated, and safety experiments were conducted in rabbits.

Results

The ONBs were approximately 220 nm in diameter, with a zeta potential of -58.8 mV. Oxygen release studies indicated that 74.06 µg of O2 is released from the ONBs after 12 hours at 37°C. Cell studies indicated that ONBs are safe and cells are viable. There was no significant increase in reactive oxygen species, superoxide, or double-stranded DNA damage after ONB treatment. ONBs preserve mitochondrial function and viability. Histological sections from rabbit eyes indicated that ONBs were not toxic.

Conclusions

The ONBs proposed have excellent oxygen holding and release properties to mitigate ischemic conditions in the retina. They are sterile, stable, and nontoxic.

Translation Relevance

ONB technology was evaluated for its physical properties, oxygen release, sterility, stability, and safety. Our results indicate that ONBs could be a viable treatment approach to mitigate hypoxia during ischemic conditions in the eye upon timely administration.

Methods to measure blood flow and vascular reactivity in the retina

Disturbances of retinal perfusion are involved in the onset and maintenance of several ocular diseases, including diabetic retinopathy, glaucoma, and retinal vascular occlusion. Hence, knowledge on ocular vascular anatomy and function is highly relevant for basic research studies and for clinical judgment and treatment. The retinal vasculature is composed of the superficial, intermediate, and deep vascular layer. Detection of changes in blood flow and vascular diameter especially in smaller vessels is essential to understand and to analyze vascular diseases. Several methods to evaluate blood flow regulation in the retina have been described so far, but no gold standard has been established. For highly reliable assessment of retinal blood flow, exact determination of vessel diameter is necessary. Several measurement methods have already been reported in humans. But for further analysis of retinal vascular diseases, studies in laboratory animals, including genetically modified mice, are important. As for mice, the small vessel size is challenging requiring devices with high optic resolution. In this review, we recapitulate different methods for retinal blood flow and vessel diameter measurement. Moreover, studies in humans and in experimental animals are described.

Retinal Oxygen Metabolism in Patients With Type 2 Diabetes and Different Stages of Diabetic Retinopathy

The aim of this cross-sectional study was to assess retinal oxygen metabolism in patients with type 2 diabetes and different stages of nonproliferative diabetic retinopathy (DR) (n = 67) compared with healthy control subjects (n = 20). Thirty-four patients had no DR, 15 had mild DR, and 18 had moderate to severe DR. Retinal oxygen saturation in arteries and veins was measured using the oxygen module of a retinal vessel analyzer. Total retinal blood flow (TRBF) was measured using a custom-built Doppler optical coherence tomography system. Retinal oxygen extraction was calculated from retinal oxygen saturation and TRBF. Arteriovenous difference in oxygen saturation was highest in healthy subjects (34.9 ± 7.5%), followed by patients with no DR (32.5 ± 6.3%) and moderate to severe DR (30.3 ± 6.5%). The lowest values were found in patients with mild DR (27.3 ± 8.0%, P = 0.010 vs. healthy subjects). TRBF tended to be higher in patients with no DR (40.1 ± 9.2 μL/min) and mild DR (41.8 ± 15.0 μL/min) than in healthy subjects (37.2 ± 5.7 μL/min) and patients with moderate to severe DR (34.6 ± 10.4 μL/min). Retinal oxygen extraction was the highest in healthy subjects (2.24 ± 0.57 μL O2/min), followed by patients with no DR (2.14 ± 0.6 μL O2/min), mild DR (1.90 ± 0.77 μL O2/min), and moderate to severe DR (1.78 ± 0.57 μL O2/min, P = 0.040 vs. healthy subjects). These results indicate that retinal oxygen metabolism is altered in patients with type 2 diabetes. Furthermore, retinal oxygen extraction decreases with increasing severity of DR.

Retinopathy of prematurity: Metabolic risk factors

At preterm birth, the retina is incompletely vascularized. Retinopathy of prematurity (ROP) is initiated by the postnatal suppression of physiological retinal vascular development that would normally occur in utero. As the neural retina slowly matures, increasing metabolic demand including in the peripheral avascular retina, leads to signals for compensatory but pathological neovascularization. Currently, only late neovascular ROP is treated. ROP could be prevented by promoting normal vascular growth. Early perinatal metabolic dysregulation is a strong but understudied risk factor for ROP and other long-term sequelae of preterm birth. We will discuss the metabolic and oxygen needs of retina, current treatments, and potential interventions to promote normal vessel growth including control of postnatal hyperglycemia, dyslipidemia and hyperoxia-induced retinal metabolic alterations. Early supplementation of missing nutrients and growth factors and control of supplemental oxygen promotes physiological retinal development. We will discuss the current knowledge gap in retinal metabolism after preterm birth.

Retinal Oxygen Extraction in Patients with Primary Open-Angle Glaucoma

Objective: To compare total retinal oxygen extraction between patients with primary open-angle glaucoma (POAG) and healthy control subjects. Design: A prospective, single-center, cross-sectional, case−control study performed at the Medical University of Vienna. Subjects: Forty patients with POAG and 40 age- and sex-matched control subjects. Methods: Total retinal blood flow was measured using Doppler optical coherence tomography (OCT). Retinal arterial and venous oxygen saturation was measured using reflectance spectroscopy. From these parameters, oxygen content in the retinal arterial and venous circulation as well as total retinal oxygen extraction were calculated. Results: Total retinal blood flow was lower in POAG (25.2 ± 6.7 µL/min) as compared to healthy control subjects (35.6 ± 8.3 µL/min, p < 0.001). Retinal arterial oxygen content was not different between the two groups (0.18 ± 0.01 mL(O2)/mL in both groups, p < 0.761), but retinal venous oxygen content was higher in POAG (0.15 ± 0.01 mL(O2)/mL) than in healthy controls (0.14 ± 0.01 mL(O2)/mL p < 0.001). Accordingly, retinal oxygen extraction was reduced in POAG (0.8 ± 0.3 µL(O2)/min as compared to healthy controls: 1.4 ± 0.4 µL(O2)/min, p < 0.001). There was a significant association between total retinal blood flow and total retinal oxygen extraction with measures of structural and functional damage (p < 0.001 each). Conclusions: This study indicates that POAG is associated with a reduction in total retinal oxygen extraction linked to structural and functional damage of the disease. Since the technology is non-invasive, it allows for longitudinal studies investigating to which degree low retinal oxygen extraction is linked to the progression of the disease.

Effect of hyperoxia and hypoxia on retinal vascular parameters assessed with optical coherence tomography angiography

PURPOSE

To investigate the response of the superficial and deep capillary plexuses to hyperoxia and hypoxia using optical coherence tomography angiography (OCT-A) and retinal vessel analyzer.

METHODS

Twenty-four healthy volunteers participated in this randomized, double-masked, cross-over study. For each subject, two study days were scheduled: on one study day, hyperoxia was induced by breathing 100% oxygen whereas on the other study day, hypoxia was induced by breathing a mixture of 88% nitrogen and 12% oxygen. Perfusion density was calculated in the superficial vascular plexus (SVP) and the deep capillary plexus (DCP), using OCT-A before (normal breathing) and during breathing of the gas mixtures. Retinal vessel calibres in major retinal vessels were measured using a dynamic vessel analyzer.

RESULTS

During 100% oxygen breathing, a significant decrease in DCP perfusion density from 41.7 ± 2.4 a.u to 35.6 ± 3.1 a.u. (p < 0.001) was observed, which was accompanied by a significant decrease in vessel diameters in major retinal arteries and veins (p < 0.001 each). No significant change in perfusion density in the SVP occurred (p = 0.33). In contrast, during hypoxia, perfusion density in the SVP significantly increased from 34.4 ± 3.0 a.u. to 37.1 ± 2.2 a.u. (p < 0.001), while it remained stable in the DCP (p = 0.25). A significant increase in retinal vessel diameters was found (p < 0.01). Systemic oxygen saturation correlated negatively with perfusion density in the SVP and the DCP and retinal vessel diameters (p < 0.005 each).

CONCLUSION

Our results show that systemic hyperoxia induces a significant decrease in vessel density in the DCP, while hypoxia leads to increased vessel density limited to the SVP. These results indicate that the retinal circulation shows the ability to adapt its blood flow to metabolic changes with high local resolution dependent on the capillary plexus.

Microvascular changes in the macular and parafoveal areas of multiple sclerosis patients without optic neuritis

Retinal imaging has been proposed as a biomarker for neurological diseases such as multiple sclerosis (MS). Recently, a technique for non-invasive assessment of the retinal microvasculature called optical coherence tomography angiography (OCTA) was introduced. We investigated retinal microvasculature alterations in participants with relapsing–remitting MS (RRMS) without history of optic neuritis (ON) and compared them to a healthy control group. The study was performed in a prospective, case–control design, including 58 participants (n = 100 eyes) with RRMS without ON and 78 age- and sex-matched control participants (n = 136 eyes). OCTA images of the superficial capillary plexus (SCP), deep capillary plexus (DCP) and choriocapillaris (CC) were obtained using a commercial OCTA system (Zeiss Cirrus HD-5000 Spectral-Domain OCT with AngioPlex OCTA, Carl Zeiss Meditec, Dublin, CA). The outcome variables were perfusion density (PD) and foveal avascular zone (FAZ) features (area and circularity) in both the SCP and DCP, and flow deficit in the CC. MS group had on average higher intraocular pressure (IOP) than controls (P < 0.001). After adjusting for confounders, MS participants showed significantly increased PD in SCP (P = 0.003) and decreased PD in DCP (P < 0.001) as compared to controls. A significant difference was still noted when large vessels (LV) in the SCP were removed from the PD calculation (P = 0.004). Deep FAZ was significantly larger (P = 0.005) and less circular (P < 0.001) in the eyes of MS participants compared to the control ones. Neither LV, PD or FAZ features in the SCP, nor flow deficits in the CC showed any statistically significant differences between the MS group and control group (P > 0.186). Our study indicates that there are microvascular changes in the macular parafoveal retina of RRMS patients without ON, showing increased PD in SCP and decreased PD in DCP. Further studies with a larger cohort of MS patients and MRI correlations are necessary to validate retinal microvascular changes as imaging biomarkers for diagnosis and screening of MS.

Lack of predictive value of retinal oxygen saturation for visual outcome after angiostatic treatment of branch retinal vein occlusion

PURPOSE

Previous studies have shown that the retinal oxygen saturation in central retinal vein occlusion treated with anti-VEGF compound has no predictive value for visual outcome after 12 months. It is of interest to evaluate whether this conclusion is similar for patients with branch retinal vein occlusion among whom only some patients are treated.

METHODS

Retinal oxygen saturation, visual acuity and central retinal thickness were studied at the time of referral and after six and 12 months in 111 patients successively referred to the Department of Ophthalmology, Aarhus University Hospital, with a venous occlusion affecting branches peripheral from the central retinal venule. The predictive value of the oxygen saturation at referral was investigated in treated and untreated patients.

RESULTS

Seventy-three patients with visual acuity between 35 and 70 ETDRS letters at referral were treated with intravitreal injection of anti-VEGF compound. Over 12 months, the venous oxygen saturation improved in parallel with central retinal thickness and visual acuity but had no predictive value for visual outcome. In 12 untreated patients with visual acuity >70 ETDRS letters, younger age and high oxygen saturation at the time of referral were positive predictors for the visual outcome after 12 months.

CONCLUSION

Oxygen saturation, visual acuity and central retinal thickness improve in parallel during treatment of branch retinal vein occlusion with intravitreal anti-VEGF medication. Retinal oximetry at referral cannot predict visual acuity after 12 months in treated patients but may perhaps become a tool for predicting the visual prognosis in a subgroup of patients where treatment is omitted because of a too high visual acuity at the time of diagnosis of the disease.

Retinal Oxygen Delivery and Extraction in Ophthalmologically Healthy Subjects With Different Blood Pressure Status

Purpose

To compare retinal oxygen delivery (DO2) and oxygen extraction (VO2) in ophthalmologically healthy subjects with different blood pressure (BP) status.

Methods

In this case-control study, we prospectively included 93 eyes of 93 subjects (aged 50-65 years) from a Dutch cohort (n = 167,000) and allocated them to four groups (low BP, normal BP [controls], treated arterial hypertension [AHT], untreated AHT). We estimated vascular calibers from fundus images and fractal dimension from optical coherence tomography angiography scans. We combined calibers, fractal dimension, BP, and intraocular pressure measurements in a proxy of retinal blood flow (RBF), using a Poiseuille-based model. We measured arterial and venous oxygen saturations (SaO2, SvO2) with a scanning laser ophthalmoscope. We calculated the DO2 and VO2 from the RBF, SaO2, and SvO2. We compared the DO2 and VO2 between groups and investigated the DO2-VO2 association.

Results

DO2 and VO2 were different between groups (P = 0.009, P = 0.036, respectively). In a post hoc analysis, the low BP group had lower DO2 than the untreated AHT group (P = 4.9 × 10-4). The low BP group and the treated AHT group had a lower VO2 than the untreated AHT group (P = 0.021 and P = 0.034, respectively). There was a significant DO2-VO2 correlation (Robs = 0.65, bobs = 0.51, P = 2.4 × 10-12). After correcting for shared measurement error, the slope was not significant.

Conclusions

The DO2 and VO2 were altered in ophthalmologically healthy subjects with different BP status. Future studies could elucidate whether these changes can explain the increased risk of ophthalmic pathologies in those subjects.

Translational Relevance

Understanding the baseline interplay between BP, retinal perfusion, and oxygenation allows for improved evaluation of retinal disease manifestation.

Retinal vessel diameters, flicker-induced retinal vasodilation and retinal oxygen saturation in high- and low-risk pregnancy

Purpose

To compare retinal vascular parameters between high‐risk and low‐risk pregnant women over time during pregnancy.

Methods

In a longitudinal study, we included pregnant women with normal blood pressure and normal body mass index (BMI, group 1), pregnant women with systemic hypertension and/or overweight (group 2) and age‐matched nonpregnant healthy women (group 3). Using the dynamic vessel analyser (DVA) we investigated flicker‐induced vasodilation in retinal arteries (FLA) and veins (FLV), central retinal arterial and vein equivalent (CRAE, CRVE), arterio‐venous ratio (AVR) and retinal arterial and venous oxygen saturation (SartO₂, SveinO₂). Study visits were scheduled 2nd trimester (TP 2), 3rd trimester (TP 3) and postpartum (PP).

Results

Data from 29 women in group 1, 25 women in group 2 and 33 women in group 3 were included for analysis. FLA, FLV, CRAE, CRVE, AVR and SveinO₂ were altered in group 2 (p‐values between < 0.001 and 0.009). At TP 3 the differences between groups were most pronounced. In contrast, there were only minor differences between group 1 and 3. Changes in retinal parameters were independently associated with systemic blood pressure and BMI.

Conclusions

The present analysis indicates that flicker‐induced retinal vasodilation, retinal vessel diameters and retinal oxygen saturation are altered in high‐risk pregnant women. Hence, these parameters are candidate biomarkers for pregnancy complications, a hypothesis that deserves further study.

Retinal oximetry in glaucoma: investigations and findings reviewed

Abnormalities of the retinal blood supply have been widely implicated in primary open-angle glaucoma (POAG). Impaired blood supply to the retina and optic nerve head (ONH) may be a primary pathophysiologic mechanism contributing to POAG ('vascular hypothesis'). However, the decreased metabolic activity of atrophic tissue is itself known to induce both vascular changes and decreased blood flow due to reduced oxygen demand. Therefore, primary nonvascular factors could potentially induce glaucomatous atrophy, with subsequent secondary vascular pathology ('mechanical hypothesis'). Retinal oximetry holds great promise in the investigation of glaucoma pathogenesis, as it can provide useful data on retinal metabolic oxygen demand, especially when combined with measurements of retinal blood flow. This review surveys the research on retinal metabolism in POAG using spectroscopic retinal oximetry. The use of mathematical models in combination with oximetric data to investigate the role of retinal metabolism and oxygen supply in POAG is also discussed.

Optical Coherence Tomography Angiography in Diabetes and Diabetic Retinopathy

Diabetic retinopathy (DR) is a common complication of diabetes mellitus that disrupts the retinal microvasculature and is a leading cause of vision loss globally. Recently, optical coherence tomography angiography (OCTA) has been developed to image the retinal microvasculature, by generating 3-dimensional images based on the motion contrast of circulating blood cells. OCTA offers numerous benefits over traditional fluorescein angiography in visualizing the retinal vasculature in that it is non-invasive and safer; while its depth-resolved ability makes it possible to visualize the finer capillaries of the retinal capillary plexuses and choriocapillaris. High-quality OCTA images have also enabled the visualization of features associated with DR, including microaneurysms and neovascularization and the quantification of alterations in retinal capillary and choriocapillaris, thereby suggesting a promising role for OCTA as an objective technology for accurate DR classification. Of interest is the potential of OCTA to examine the effect of DR on individual retinal layers, and to detect DR even before it is clinically detectable on fundus examination. We will focus the review on the clinical applicability of OCTA derived quantitative metrics that appear to be clinically relevant to the diagnosis, classification, and management of patients with diabetes or DR. Future studies with longitudinal design of multiethnic multicenter populations, as well as the inclusion of pertinent systemic information that may affect vascular changes, will improve our understanding on the benefit of OCTA biomarkers in the detection and progression of DR.

Age-Related Decline of Retinal Oxygen Extraction in Healthy Subjects

Purpose

To investigate the age-dependence of total retinal blood flow and total retinal oxygen extraction in healthy subjects and determine their possible correlations with structural optical coherence tomography (OCT) parameters.

Methods

This observational cross-sectional study consisted of 68 healthy subjects (mean ± SD age, 45.6 ± 16.3 years; 47% female). Total retinal oxygen extraction was calculated based on measurement of total retinal blood flow using bi-directional Doppler OCT and measurement of oxygen saturation using spectroscopic reflectometry. Retinal nerve fiber layer thickness was measured using OCT, and the total number of retinal ganglion cells was estimated based on a previous published model. Correlation of these parameters with age was studied and the association between structural OCT parameters and hemodynamic vascular parameters was calculated.

Results

Both structural and vascular parameters showed a significant decline with increasing age. The correlation coefficients were between r = -0.25 and r = -0.41. Furthermore, structural and vascular parameters were significantly correlated with each other. The strongest association was found between the level of total retinal oxygen extraction and the number of retinal ganglion cells (r = 0.75, P < 0.001).

Conclusions

We showed that there was an age-related decline of retinal oxygen extraction. Levels of retinal oxygen extraction are correlated to retinal nerve fiber layer thickness and number of retinal ganglion cells. Our data partially explain the wide inter-individual variability in retinal blood flow values in healthy subjects. Longitudinal studies are required to study the time course of vascular and neuronal loss in humans.

Alterations in Retinal Oxygen Delivery, Metabolism, and Extraction Fraction During Bilateral Common Carotid Artery Occlusion in Rats

Purpose

The purpose of the current study was to investigate alterations in retinal oxygen delivery, metabolism, and extraction fraction and elucidate their relationships in an experimental model of retinal ischemia.

Methods

We subjected 14 rats to permanent bilateral common carotid artery occlusion using clamp or suture ligation, or they underwent sham procedure. Within 30 minutes of the procedure, phosphorescence lifetime imaging was performed to measure retinal vascular oxygen tension and derive arterial and venous oxygen contents, and arteriovenous oxygen content difference. Fluorescent microsphere and red-free retinal imaging were performed to measure total retinal blood flow. Retinal oxygen delivery rate (DO₂), oxygen metabolism rate (MO₂), and oxygen extraction fraction (OEF) were calculated.

Results

DO₂ and MO₂ were lower in ligation and clamp groups compared to the sham group, and also lower in the ligation group compared to the clamp group (P ≤ 0.05). OEF was higher in the ligation group compared to clamp and sham groups (P ≤ 0.03). The relationships of MO₂ and OEF with DO₂ were mathematically modeled by exponential functions. With moderate DO₂ reductions, OEF increased while MO₂ minimally decreased. Under severe DO₂ reductions, OEF reached a maximum value and subsequently MO₂ decreased with DO₂.

Conclusions

The findings improve knowledge of mechanisms that can maintain MO₂ and may clarify the pathophysiology of retinal ischemic injury.

Retinal Oxygen Delivery, Metabolism and Extraction Fraction and Retinal Thickness Immediately Following an Interval of Ophthalmic Vessel Occlusion in Rats

Limited knowledge is currently available about alterations of retinal blood flow (F), oxygen delivery (DO₂), oxygen metabolism (MO₂), oxygen extraction fraction (OEF), or thickness after the ophthalmic blood vessels have been closed for a substantial interval and then reopened. We ligated the ophthalmic vessels for 120 minutes in one eye of 17 rats, and measured these variables within 20 minutes after release of the ligature in the 10 rats which had immediate reflow. F, DO₂ and MO₂ were 5.2 ± 3.1 μL/min, 428 ± 271 nL O₂/min, and 234 ± 133 nL O₂/min, respectively, that is, to 58%, 46% and 60% of values obtained from normal fellow eyes (P < 0.004). OEF was 0.65 ± 0.23, 148% of normal (P = 0.03). Inner and total retinal thicknesses were 195 ± 24 and 293 ± 20 μm, respectively, 117% and 114% of normal, and inversely related to MO₂ (P ≤ 0.02). These results reflect how much energy is available to the retina immediately after an interval of nonperfusion for 120 minutes. Thus, they elucidate aspects of the pathophysiology of nonperfusion retinal injury and may improve therapy in patients with retinal artery or ophthalmic artery obstructions.

Short- and middle-term high-altitude exposure does not affect visual acuity and contrast sensitivity of healthy young people

OBJECTIVE

Visual acuity and contrast sensitivity are crucial for optimal performance and safe sport activity. From a practical sport-specific perspective, visual performance is obligatory for orientation and movement control in mountainous areas. The purpose of this study was to analyze the effect of hypobaric hypoxic conditions on visual acuity and contrast sensitivity of short-term and middle-term acclimatized healthy young people.

DESIGN

This study used a repeated-measure design with ten eye-healthy and physically active students representing different types of sports.

METHODS

With the help of a computer-based Landolt C and a Sine Wave Contrast test, visual performance was investigated similar before (156 m), during a nine-day high-altitude sojourn (sleeping level: 890-4640 m), and three months later (156 m). All tests were performed under standardized illumination conditions. Additionally, morning blood oxygen saturation, hematocrits, hemoglobin, body mass, and self-reported symptoms of acute mountain sickness criteria were determined.

RESULTS

Whole blood oxygen saturation declined during altitude exposure. The analysis of central visual performance at altitude showed no effect of hypobaric hypoxia.

CONCLUSION

Our data suggest that activity in a hypobaric hypoxia condition at moderate to high altitude levels of up to 4600 m does not affect visual acuity and contrast sensitivity of acclimatized healthy young people. However, in contrast to previous studies that outlined acutely impaired central visual performance with respect to hypoxia, we suggest that acclimatization might induce adaptation of visual perception performance and therefore reduce the risk of accidents resulting from partial loss of visual performance at altitude.

Retinal vessel oxygen saturation and vessel diameter in healthy individuals during high-altitude exposure

PURPOSE

To assess changes of retinal vessel oxygen saturation and vessel diameter in healthy individuals during high-altitude exposure.

METHODS

Retinal oxygen saturation and vessel diameter were obtained at sea level (SL, 40 m) and high altitude (HA, 3681 m) on 17 healthy individuals from Beijing (six males, 28.06 ± 8.06 years) using Oxymap T1 and then compared with 21 residents from Yushu (10 males, 28.63 ± 6.00 years). Systemic and ocular parameters were also measured before and after high-altitude exposure. Data were presented as mean ± SD and analysed using paired and independent Student t-test with significance accepted at p < 0.05.

RESULTS

Short-term high-altitude exposure of Beijing Group significantly affected all the systemic and ocular parameters, as well as retinal oxygen saturation and vessel diameter ranging from overall quadrant to different quadrants, other than retinal venous oxygen saturation and retinal arterial diameter. However, these changes were not evident in those permanently living at HA. Pearson's correlation analysis revealed correlations between retinal oxygen saturation and systemic and ocular parameters (all p < 0.05). The multivariate linear regression analysis indicated that retinal arterial oxygen saturation was significantly associated with arterial peripheral arterial oxygen saturation (SpO₂ ) and subfoveal choroidal thickness.

CONCLUSION

Short-term exposure to HA induces retinal microcirculation disturbance and auto-regulatory response in healthy individuals, which is probably attributed to arterial SpO₂ and endothelial dysfunction under hypoxic conditions.

Retinal oxygen saturation as a non-invasive estimate for mixed venous oxygen saturation and cardiac output

PURPOSE

To investigate the correlation between retinal vessel oxygen saturation and mixed venous oxygen saturation (SvO_2-mixed ) and cardiac output (CO).

METHODS

Retinal arterial (SaO_2-retinal ) and venous (SvO_2-retinal ) oxygen saturation were measured non-invasively with dual-wavelength retinal oximetry in subjects receiving invasive measurements of SvO_2-mixed and CO through right heart catheterization. Correlations were analysed using Spearman's rank correlation coefficients and linear regression models.

RESULTS

Fourteen patients (median age 62.7 years, range: 21-77) were included in the analysis. When adjusted for age, SvO_2-retinal showed a positive correlation with SvO_2-mixed (β = 0.80, p = 0.003). Retinal arteriovenous oxygen saturation difference was significantly correlated with the inverse of CO (Spearman's ρ = 0.59, p = 0.026).

CONCLUSION

This pilot study provides proof of concept for the use of retinal oximetry as a non-invasive tool to assess systemic cardiovascular function.

[Structural endpoints for glaucoma studies]

BACKGROUND

Structural endpoints have been discussed as surrogate endpoints for the approval of neuroprotective drugs in glaucoma.

OBJECTIVE

Is the evidence strong enough to establish structural endpoints as surrogate endpoints?

MATERIAL AND METHODS

Review of current understanding between structure and function in glaucoma.

RESULTS

The introduction of optical coherence tomography has revolutionized imaging in glaucoma patients. Clinically either the nerve fiber layer thickness can be measured along a circle centered in the optic nerve head or the ganglion cell layer thickness can be assessed in the macular region, the latter being quantified in combination with other inner retinal layers. On a microscopic level there is a strong correlation between structural and functional loss but this relation can only partially be described with currently available clinical methods. This is particularly true for longitudinal course of the disease in glaucoma patients. Novel imaging techniques that are not yet used clinically may have the potential to increase our understanding between structure and function in glaucoma but further research in this field is required.

CONCLUSION

The current evidence does not allow the establishment of structural endpoints as surrogate endpoints for phase 3 studies in glaucoma. Neuroprotective drugs have to be approved on the basis of visual field data because this is the patient-relevant endpoint. Structural endpoints can, however, play an important role in phase 2 and proof of concept studies.

Retinal oximetry and systemic arterial oxygen levels

PURPOSE

Continuous peripheral pulse oximetry for monitoring adequacy of oxygenation is probably the most important technological advance for patients' monitoring and safety in the last decades. Pulse oximetry has the disadvantage of measuring the peripheral circulation, and the only mean to measure oxygen content of the central circulation is by invasive technology. Determination of blood oxyhaemoglobin saturation in the retinal vessels of the eye can be achieved noninvasively through spectrophotometric retinal oximetry which provides access to the central nervous system circulation. The aim of the thesis was to determine whether retinal oximetry technique can be applied for estimation of the central nervous system circulation which until now has only been possible invasively. This was achieved by measuring oxyhaemoglobin saturation in three adult subject study groups: in people with central retinal vein occlusion (CRVO) to observe local tissue hypoxia, in patients with severe chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy to observe systemic hypoxaemia and in healthy subjects during hyperoxic breathing to observe systemic hyperoxemia. In addition, the fourth study that is mentioned was performed to test whether retinal oximetry is feasible for neonates.

METHODS

Retinal oximetry in central retinal vein occlusion: Sixteen subjects with central retinal vein occlusion participated in the study. The oxyhaemoglobin saturation of the central retinal vein occlusion affected eye was compared with the fellow unaffected eye. Retinal oximetry in healthy people under hyperoxia: Thirty healthy subjects participated in the study, and the oxyhaemoglobin saturation of retinal arterioles and venules was compared between normoxic and hyperoxic breathing. Retinal oximetry in severe chronic obstructive pulmonary disease: Eleven patients with severe chronic obstructive pulmonary disease participated in the study. Retinal oximetry measurements were made with and without their daily supplemental oxygen therapy. Retinal arteriolar oxyhaemoglobin saturation when inspiring ambient air was compared with blood samples from the radial artery and finger pulse oximetry and healthy controls. The healthy control group was assembled from our database for comparison of oxyhaemoglobin saturation of retinal arterioles and venules during the ambient air breathing. The retinal oximeter is based on a conventional fundus camera and a specialized software. A beam splitter coupled with two high-resolution digital cameras allows for simultaneous acquisition of retinal images at separative wavelengths for calculation of oxyhaemoglobin saturation. In addition, retinal images of 28 full-term healthy neonates were obtained with scanning laser ophthalmoscope combined with modified Oxymap analysis software for calculation of the optical density ratio and vessel diameter RESULTS: Retinal oximetry in central retinal vein occlusion: Mean retinal venous oxyhaemoglobin saturation was 31 ± 12% in CRVO eyes and 52 ± 11% in unaffected fellow eyes (mean ± SD, n = 14, p < 0.0001). The arteriovenous oxygen difference (AV-difference) was 63 ± 11% in CRVO eyes and 43 ± 7% in fellow eyes (p < 0.0001). The variability of retinal venous oxyhaemoglobin saturation was considerable within and between eyes affected by CRVO. There was no difference in oxyhaemoglobin saturation of retinal arterioles between the CRVO eyes and the unaffected eyes (p = 0.49). Retinal oximetry in healthy people under hyperoxia: During hyperoxic breathing, the oxyhaemoglobin saturation in retinal arterioles increased to 94.5 ± 3.8% as compared with 92.0 ± 3.7% at baseline (n = 30, p < 0.0001). In venules, the mean oxyhaemoglobin saturation increased to 76.2 ± 8.0% from 51.3 ± 5.6% (p < 0.0001) at baseline. The AV-difference was markedly lower during hyperoxic breathing as compared with the normoxic breathing (18.3 ± 9.0% versus 40.7 ± 5.7%, p < 0.0001). Retinal oximetry in severe chronic obstructive pulmonary disease: During ambient air breathing, chronic obstructive pulmonary disease subjects had significantly lower oxyhaemoglobin saturation than healthy controls in both retinal arterioles (87.2 ± 4.9% versus 93.4 ± 4.3%, p = 0.02, n = 11) and venules (45.0 ± 10.3% versus 55.2 ± 5.5%, p = 0.01) but the AV-difference was not markedly different (p = 0.17). Administration of their prescribed oxygen therapy significantly increased the oxyhaemoglobin saturation in retinal arterioles (87.2 ± 4.9% to 89.5 ± 6.0%, p = 0.02) but not in venules (45.0 ± 10.3% to 46.7 ± 12.8%, p = 0.3). Retinal oximetry values were slightly lower than finger pulse oximetry (mean percentage points difference = -3.1 ± 5.5) and radial artery blood values (-5.0 ± 5.4). Retinal oximetry study in neonates: The modified version of the retinal oximetry instrument estimated the optical density ratio in retinal arterioles to be 0.256 ± 0.041 that was significantly different from the 0.421 ± 0.089 in venules (n = 28, p < 0.001, paired t-test). The vascular diameter of retinal arterioles was markedly narrower than of venules (14.1 ± 2.7 and 19.7 ± 3.7 pixels, p < 0.001).

CONCLUSION

The results of this thesis indicate that spectrophotometric retinal oximetry is sensitive to both local and systemic changes in oxyhaemoglobin saturation. Retinal oxyhaemoglobin saturation values are slightly lower than radial artery blood sample and finger pulse oximetry values. The discrepancies between the different modalities are expected to derive from countercurrent exchange between central retinal artery and vein within the optic nerve but calibration issues cannot be excluded as contributing to this difference. Despite these differences, the findings indicate the potential of retinal oximetry for noninvasive real-time measurements of oxyhaemoglobin saturation in central nervous system vessels. Following calibration upgrade and technological improvement, verification retinal oximetry may potentially be applied to critically ill and anaesthesia care patients. The study on combined scanning laser ophthalmoscope and retinal oximetry supports the feasibility of the technique for oximetry analysis in newly born babies.

Toward Generating More Diagnostic Features from Photoplethysmogram Waveforms

Photoplethysmogram (PPG) signals collected using a pulse oximeter are increasingly being used for screening and diagnosis purposes. Because of the non-invasive, cost-effective, and easy-to-use nature of the pulse oximeter, clinicians and biomedical engineers are investigating how PPG signals can help in the management of many medical conditions, especially for global health application. The study of PPG signal analysis is relatively new compared to research in electrocardiogram signals, for instance; however, we anticipate that in the near future blood pressure, cardiac output, and other clinical parameters will be measured from wearable devices that collect PPG signals, based on the signal’s vast potential. This article attempts to organize and standardize the names of PPG waveforms to ensure consistent terminologies, thereby helping the rapid developments in this research area, decreasing the disconnect within and among different disciplines, and increasing the number of features generated from PPG waveforms.

Non-invasive assessment of cerebral oxygenation: A comparison of retinal and transcranial oximetry

BACKGROUND

To investigate the correlation between cerebral (SO2-transcranial), retinal arterial (SaO2-retinal) and venous (SvO2-retinal) oxygen saturation as measured by near-infrared spectroscopy (NIRS) and retinal oximetry respectively.

METHODS

Paired retinal and cerebral oxygen saturation measurements were performed in healthy volunteers. Arterial and venous retinal oxygen saturation and diameter were measured using a non-invasive spectrophotometric retinal oximeter. Cerebral oxygen saturation was measured using near-infrared spectroscopy. Correlations between SO2-transcranial and retinal oxygen saturation and diameter measurements were assessed using Pearson correlation coefficients. Lin's concordance correlation coefficient (CCC) and Bland-Altman analysis were performed to evaluate the agreement between SO2-transcranial as measured by NIRS and as estimated using a fixed arterial:venous ratio as 0.3 x SaO2-retinal + 0.7 x SvO2-retinal. The individual relative weight of SaO2-retinal and SvO2-retinal to obtain the measured SO2-transcranial was calculated for all subjects.

RESULTS

Twenty-one healthy individuals aged 26.4 ± 2.2 years were analyzed. SO2-transcranial was positively correlated with both SaO2-retinal and SvO2-retinal (r = 0.44, p = 0.045 and r = 0.43, p = 0.049 respectively) and negatively correlated with retinal venous diameter (r = -0.51, p = 0.017). Estimated SO2-transcranial based on retinal oximetry showed a tolerance interval of (-13.70 to 14.72) and CCC of 0.46 (95% confidence interval: 0.05 to 0.73) with measured SO2-transcranial. The average relative weights of SaO2-retinal and SvO2-retinal to obtain SO2-transcranial were 0.31 ± 0.11 and 0.69 ± 0.11, respectively.

CONCLUSION

This is the first study to show the correlation between retinal and cerebral oxygen saturation, measured by NIRS and retinal oximetry. The average relative weight of arterial and venous retinal oxygen saturation to obtain the measured transcranial oxygen saturation as measured by NIRS, approximates the established arterial:venous ratio of 30:70 closely, but shows substantial inter-individual variation. These findings provide a proof of concept for the role of retinal oximetry in evaluating cerebral oxygenation.

Retinal oxygen extraction in individuals with type 1 diabetes with no or mild diabetic retinopathy

AIMS/HYPOTHESIS

The aim of this study was to compare retinal oxygen extraction in individuals with diabetes with no or mild non-proliferative diabetic retinopathy and healthy age- and sex-matched volunteers.

METHODS

A total of 24 participants with type 1 diabetes and 24 healthy age- and sex-matched volunteers were included in this cross-sectional study. Retinal oxygen extraction was measured by combining total retinal blood flow measurements using a custom-built bi-directional Doppler optical coherence tomography system with measurements of oxygen saturation using spectroscopic reflectometry. Based on previously published mathematical modelling, the oxygen content in retinal vessels and total retinal oxygen extraction were calculated.

RESULTS

Total retinal blood flow was higher in diabetic participants (46.4 ± 7.4 μl/min) than in healthy volunteers (40.4 ± 5.3 μl/min, p = 0.002 between groups). Oxygen content in retinal arteries was comparable between the two groups, but oxygen content in retinal veins was higher in participants with diabetes (0.15 ± 0.02 ml O₂/ml) compared with healthy control participants (0.13 ± 0.02 ml O₂/ml, p < 0.001). As such, the arteriovenous oxygen difference and total retinal oxygen extraction were reduced in participants with diabetes compared with healthy volunteers (total retinal oxygen extraction 1.40 ± 0.44 vs 1.70 ± 0.47 μl O₂/min, respectively, p = 0.03).

CONCLUSIONS/INTERPRETATION

Our data indicate early retinal hypoxia in individuals with type 1 diabetes with no or mild diabetic retinopathy as compared with healthy control individuals. Further studies are required to fully understand the potential of the technique in risk stratification and treatment monitoring.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01843114.

Retinal vascular changes after vitrectomy for idiopathic epiretinal membrane: a pilot study with dynamic vessel analysis

PURPOSE

To investigate, using the Dynamic Vessel Analyzer (DVA), the retinal vascular changes that may occur after vitrectomy for idiopathic epiretinal membrane (ERM).

METHODS

Twenty-six eyes of 13 patients affected by unilateral idiopathic ERM were prospectively analyzed. 13 fellow eyes were used as control. The static (central retinal artery and vein equivalents) and dynamic (after flicker light stimulus) DVA analysis was performed at baseline (1 day before surgery) and 6 months after vitrectomy.

RESULTS

The static DVA analysis did not highlight any significant change between investigational eyes and controls at baseline and 6 months after surgery. The DVA dynamic analysis showed similar arterial flicker response between cases and controls at baseline (p = 0.3396), but disclosed a significant reduction of the arterial flicker response after surgery in the study eyes compared to fellow eyes (p = 0.0024). No significant changes were appreciated in the venous flicker response after surgery between cases and controls, both at baseline (p = 0.3450) and at the follow-up examination (p = 0.4214).

CONCLUSIONS

The physiological flicker-induced vasoconstriction is reduced after vitrectomy in arteries. The oxygen saturation change occurring after vitrectomy might have a role in the vascular tone modification.

Retinal oximetry measures systemic hypoxia in central nervous system vessels in chronic obstructive pulmonary disease

BACKGROUND

Determination of the blood oxyhemoglobin saturation in the retinal vessels of the eye can be achieved through spectrophotometric retinal oximetry which provides access to the state of oxyhemoglobin saturation in the central nervous system circulation. The purpose of this study was to test the capability of the Oxymap T1 oximeter to detect systemic hypoxemia and the effect of supplemental oxygen on retinal vessel oxyhemoglobin saturation.

METHODS

Oxygen saturation of hemoglobin in retinal arterioles and venules was measured in 11 subjects with severe chronic obstructive pulmonary disease (COPD) on long term oxygen therapy. Measurements were made with and without their daily supplemental oxygen. Eleven healthy age and gender matched subjects were measured during ambient air breathing for comparison of oxyhemoglobin saturation in retinal arterioles and venules. Retinal arteriolar oxyhemoglobin saturation in COPD subjects inspiring ambient air was compared with finger pulse oximetry and blood samples from radial artery.

RESULTS

COPD subjects had significantly lower oxyhemoglobin saturation during ambient air breathing than healthy controls in both retinal arterioles (87.2%±4.9% vs. 93.4%±4.3%, p = 0.02; n = 11) and venules (45.0%±10.3% vs. 55.2%±5.5%, p = 0.01). Administration of their prescribed supplemental oxygen increased oxyhemoglobin saturation in retinal arterioles (87.2%±4.9% to 89.5%±6.0%, p = 0.02) but not in venules (45.0%±10.3% to 46.7%±12.8%, p = 0.3). Retinal oximetry values were slightly lower than radial artery blood values (mean percentage points difference = -5.0±5.4, 95% CI: -15.68 to 5.67) and finger pulse oximetry values (-3.1±5.5, 95% CI: -14.05 to 7.84).

CONCLUSIONS

The noninvasive Oxymap T1 retinal oximetry detects hypoxemia in central nervous system vessels in patients with severe COPD compared with healthy controls. The instrument is sensitive to changes in oxygen breathing but displays slightly lower measures than finger pulse oximetry or radial artery measures. With further technological improvement, retinal oximetry may offer noninvasive "on-line" measurement of oxygen levels in central circulation in general anesthesia and critically ill patients.

Retinal oxygen: from animals to humans

This article discusses retinal oxygenation and retinal metabolism by focusing on measurements made with two of the principal methods used to study O₂ in the retina: measurements of PO₂ with oxygen-sensitive microelectrodes in vivo in animals with a retinal circulation similar to that of humans, and oximetry, which can be used non-invasively in both animals and humans to measure O₂ concentration in retinal vessels. Microelectrodes uniquely have high spatial resolution, allowing the mapping of PO₂ in detail, and when combined with mathematical models of diffusion and consumption, they provide information about retinal metabolism. Mathematical models, grounded in experiments, can also be used to simulate situations that are not amenable to experimental study. New methods of oximetry, particularly photoacoustic ophthalmoscopy and visible light optical coherence tomography, provide depth-resolved methods that can separate signals from blood vessels and surrounding tissues, and can be combined with blood flow measures to determine metabolic rate. We discuss the effects on retinal oxygenation of illumination, hypoxia and hyperoxia, and describe retinal oxygenation in diabetes, retinal detachment, arterial occlusion, and macular degeneration. We explain how the metabolic measurements obtained from microelectrodes and imaging are different, and how they need to be brought together in the future. Finally, we argue for revisiting the clinical use of hyperoxia in ophthalmology, particularly in retinal arterial occlusions and retinal detachment, based on animal research and diffusion theory.

The diameter response of retinal arterioles in diabetic maculopathy is reduced during hypoxia and is unaffected by the inhibition of cyclo-oxygenase and nitric oxide synthesis

PURPOSE

Diabetic retinopathy is accompanied with changes in the diameter regulation and oxygenation of retinal vessels. Previous studies have shown that in normal persons and in diabetic patients without retinopathy hypoxia-induced vasodilatation is mediated by cyclo-oxygenase (COX) products and nitric oxide (NO). The purpose of the present study was to study whether these effects can be reproduced in patients with diabetic maculopathy.

METHODS

Eighteen patients with diabetic maculopathy aged 29-57 years were examined using the Dynamic Vessel Analyzer. The resting diameter and the diameter changes of retinal arterioles during isometric exercise and flicker stimulation were studied before and during breathing a hypoxic gas mixture. The examinations were also performed before and during intravenous infusion of the NOS inhibitor L-NMMA, and were repeated on a second day after topical administration of the COX-inhibitor diclofenac.

RESULTS

The diameter of retinal arterioles showed no significant change during hypoxia or L-NMMA infusion, or after topical application of diclofenac (p > 0.25 for all comparisons). The resting diameter of the venules was significantly increased during hypoxia (p = 0.003) and decreased during L-NMMA infusion (p < 0.0001). The diameter of retinal venules during isometric exercise increased significantly during hypoxia (p = 0.01). Flicker stimulation induced significant dilatation of the venules, which was significantly reduced during hypoxia and increased during L-NMMA infusion (p < 0.0001 for all comparisons).

CONCLUSION

Hypoxia-induced dilatation of retinal arterioles is severely reduced in patients with diabetic maculopathy. Future intervention studies aimed at normalizing the diameter regulation of retinal arterioles in diabetic patients should preferentially be conducted in the early stages of the disease where the potential for changing the vessel diameter is preserved. ClinicalTrials.gov identifier: NCT01689090.

Preserved Pressure Autoregulation but Disturbed Cyclo-Oxygenase and Nitric Oxide Effects on Retinal Arterioles during Acute Hypoxia in Diabetic Patients without Retinopathy

BACKGROUND

Acute hypoxia induces retinal vasodilatation, which depends on cyclooxygenase (COX) products and nitric oxide (NO) in vitro. However, it is unknown whether these mechanisms are active in diabetic patients and may contribute to the development of diabetic retinopathy.

METHODS

The Dynamic Vessel Analyzer was used to study the diameter regulation in retinal vessels during hypoxia in type 1 diabetic patients without retinopathy. The influence of NO and COX synthesis inhibition on the diameter of larger retinal vessels was studied during hypoxia, during isometric exercise and during flicker stimulation.

RESULTS

Increased arterial blood pressure during L-NMMA infusion and isometric exercise were paralleled by constriction of the retinal arterioles suggesting normal pressure autoregulation. Hypoxia significantly reduced the diameter responses during isometric exercise and during flicker stimulation as compared to normal persons.

CONCLUSION

The findings support that changes in metabolic autoregulation develop before changes in pressure autoregulation in diabetic patients.

Relation of retinal blood flow and retinal oxygen extraction during stimulation with diffuse luminance flicker

Cerebral and retinal blood flow are dependent on local neuronal activity. Several studies quantified the increase in cerebral blood flow and oxygen consumption during activity. In the present study we investigated the relation between changes in retinal blood flow and oxygen extraction during stimulation with diffuse luminance flicker and the influence of breathing gas mixtures with different fractions of O₂ (FiO₂; 100% 15% and 12%). Twenty-four healthy subjects were included. Retinal blood flow was studied by combining measurement of vessel diameters using the Dynamic Vessel Analyser with measurements of blood velocity using laser Doppler velocimetry. Oxygen saturation was measured using spectroscopic reflectometry and oxygen extraction was calculated. Flicker stimulation increased retinal blood flow (57.7 ± 17.8%) and oxygen extraction (34.6 ± 24.1%; p < 0.001 each). During 100% oxygen breathing the response of retinal blood flow and oxygen extraction was increased (p < 0.01 each). By contrast, breathing gas mixtures with 12% and 15% FiO₂ did not alter flicker–induced retinal haemodynamic changes. The present study indicates that at a comparable increase in blood flow the increase in oxygen extraction in the retina is larger than in the brain. During systemic hyperoxia the blood flow and oxygen extraction responses to neural stimulation are augmented. The underlying mechanism is unknown.

Lack of effect of nitroglycerin on the diameter response of larger retinal arterioles in normal persons during hypoxia

PURPOSE

Retinal hypoxia with consequent changes in blood flow play a role in a number of vision-threatening diseases, such as diabetic retinopathy. Previous studies have shown that the inhibition of nitric oxide synthase (NOS) and cyclooxygenase (COX) products are involved in the diameter regulation of the retinal vessels during hypoxia. Therefore, the aim of the present study was to examine the effects of an NO donor combined with COX inhibition on the diameter regulation of retinal vessels during hypoxia in normal persons.

METHODS

Twenty normal persons aged 21-47 years were examined. The Dynamic Vessel Analyzer (DVA) was used to measure retinal vessel diameters at rest, during isometric exercise, and during flicker stimulation. The measurements were performed during normoxia and hypoxia before and after sublingual administration of the NO donor nitroglycerin, and were repeated on a second study day after topical administration of the COX-inhibitor diclofenac.

RESULTS

The resting diameter of arterioles and venules increased significantly during hypoxia (p < 0.0001). Hypoxia also significantly reduced the arteriolar constriction during isometric exercise, and the dilatation of the arterioles and venules during flicker stimulation (p < 0.0001). Diclofenac further reduced the arteriolar constriction induced by isometric exercise during hypoxia (p = 0.005). However, the NO-donor nitroglycerin had no effect on vascular diameters.

CONCLUSION

Diameter regulation of retinal vessels during hypoxia in normal persons can be influenced by the inhibition of COX products, but not by increasing the NO concentration. The findings suggest that the vasoactive effects of NO on retinal arterioles during hypoxia are saturated in normal persons.

The effect of intravitreal vascular endothelial growth factor on inner retinal oxygen delivery and metabolism in rats

Vascular endothelial growth factor (VEGF) is stimulated by hypoxia and plays an important role in pathologic vascular leakage and neovascularization. Increased VEGF may affect inner retinal oxygen delivery (DO2) and oxygen metabolism (MO2), however, quantitative information is lacking. We tested the hypotheses that VEGF increases DO2, but does not alter MO2. In 10 rats, VEGF was injected intravitreally into one eye, whereas balanced salt solution (BSS) was injected into the fellow eye, 24 h prior to imaging. Vessel diameters and blood velocities were determined by red-free and fluorescent microsphere imaging, respectively. Vascular PO2 values were derived by phosphorescence lifetime imaging of an intravascular oxyphor. Retinal blood flow, vascular oxygen content, DO2 and MO2 were calculated. Retinal arterial and venous diameters were larger in VEGF-injected eyes compared to control eyes (P < 0.03), however no significant difference was observed in blood velocity (P = 0.21). Thus, retinal blood flow was greater in VEGF-injected eyes (P = 0.007). Retinal vascular PO2 and oxygen content were similar between control and VEGF-injected eyes (P > 0.11), while the arteriovenous oxygen content difference was marginally lower in VEGF-injected eyes (P = 0.05). DO2 was 950 ± 340 and 1380 ± 650 nL O2/min in control and VEGF-injected eyes, respectively (P = 0.005). MO2 was 440 ± 150 and 490 ± 190 nL O2/min in control and VEGF-injected eyes, respectively (P = 0.31). Intravitreally administered VEGF did not alter MO2 but increased DO2, suggesting VEGF may play an offsetting role in conditions characterized by retinal hypoxia.

Retinal oxygen extraction in humans

Adequate function of the retina is dependent on proper oxygen supply. In humans, the inner retina is oxygenated via the retinal circulation. We present a method to calculate total retinal oxygen extraction based on measurement of total retinal blood flow using dual-beam bidirectional Doppler optical coherence tomography and measurement of oxygen saturation by spectrophotometry. These measurements were done on 8 healthy subjects while breathing ambient room air and 100% oxygen. Total retinal blood flow was 44.3 ± 9.0 μl/min during baseline and decreased to 18.7 ± 4.2 μl/min during 100% oxygen breathing (P < 0.001) resulting in a pronounced decrease in retinal oxygen extraction from 2.33 ± 0.51 μl(O₂)/min to 0.88 ± 0.14 μl(O₂)/min during breathing of 100% oxygen. The method presented in this paper may have significant potential to study oxygen metabolism in hypoxic retinal diseases such as diabetic retinopathy.

Visible light optical coherence tomography measures retinal oxygen metabolic response to systemic oxygenation

The lack of capability to quantify oxygen metabolism noninvasively impedes both fundamental investigation and clinical diagnosis of a wide spectrum of diseases including all the major blinding diseases such as age-related macular degeneration, diabetic retinopathy, and glaucoma. Using visible light optical coherence tomography (vis-OCT), we demonstrated accurate and robust measurement of retinal oxygen metabolic rate (rMRO₂) noninvasively in rat eyes. We continuously monitored the regulatory response of oxygen consumption to a progressive hypoxic challenge. We found that both oxygen delivery, and rMRO₂ increased from the highly regulated retinal circulation (RC) under hypoxia, by 0.28 ± 0.08 μL min^-1 (p < 0.001), and 0.20 ± 0.04 μL min^-1 (p < 0.001) per 100 mmHg systemic pO₂ reduction, respectively. The increased oxygen extraction compensated for the deficient oxygen supply from the poorly regulated choroidal circulation. Results from an oxygen diffusion model based on previous oxygen electrode measurements corroborated our in vivo observations. We believe that vis-OCT has the potential to reveal the fundamental role of oxygen metabolism in various retinal diseases.