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Abalo-Lojo JM, Arias-Gomez M, Gonzalez F. Circular statistics for analyzing changes in retinal nerve fiber layer. CANADIAN JOURNAL OF OPHTHALMOLOGY 2024:S0008-4182(24)00065-6. [PMID: 38580212 DOI: 10.1016/j.jcjo.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 01/24/2024] [Accepted: 03/08/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE To evaluate the use of circular statistics to analyze retinal nerve fibre layer (RNFL) thickness in eyes with and without a prior history of optic neuritis (ON). DESIGN Single-centre consecutive study. PARTICIPANTS Twenty-two multiple sclerosis patients and 20 healthy control subjects. METHODS Data on 28 eyes with a history of ON of 22 multiple sclerosis patients and 40 eyes of 20 healthy control subjects collected in 2010 and 2015. RNFL thickness was measured separately in 12 sectors around the optic nerve head. We used circular statistics to calculate the mean weighted vector of RNFL thickness for each sector and eye in 2 measurements made 5 years apart (2010 and 2015). Comparisons of weighted mean vectors between groups were made using a paired Mardia-Watson-Wheeler test. RESULTS The directions of the mean weighted vectors for ON eyes were 45.8º in 2010 and 56.0º in 2015, whereas in control eyes the directions were 319.4º in 2010 and 188.9º in 2015. No significant differences were found between 2010 and 2015 in any of the 2 groups. However, significant differences were found between ON and control eyes in 2010 and 2015. CONCLUSIONS This paper provides an example of how to use circular statistics in cases of directional data in ophthalmology and demonstrates that circular statistics are a suitable tool for this purpose.
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Affiliation(s)
- Jose M Abalo-Lojo
- Department of Ophthalmology and Health Research Institute of Santiago de Compostela (IDIS), Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Department of Surgery, University of Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Center for Research in Molecular Medicine and Chronic Diseases (CIMUS), University of Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Manuel Arias-Gomez
- Department of Neurology, Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Francisco Gonzalez
- Department of Ophthalmology and Health Research Institute of Santiago de Compostela (IDIS), Complexo Hospitalario Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Department of Surgery, University of Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Center for Research in Molecular Medicine and Chronic Diseases (CIMUS), University of Santiago de Compostela, Santiago de Compostela, A Coruña, Spain.
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van der Feen FE, de Haan GA, van der Lijn I, Stellingwerf C, Vrijling ACL, Heersema DJ, Meilof JF, Heutink J. The complex relation between visual complaints and decline in visual, visuoperceptual and cognitive functions in people with multiple sclerosis. Neuropsychol Rehabil 2024; 34:220-243. [PMID: 36871257 DOI: 10.1080/09602011.2023.2179075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 02/05/2023] [Indexed: 03/06/2023]
Abstract
People with multiple sclerosis (pwMS) report many different visual complaints, but not all of them are well understood. Decline in visual, visuoperceptual and cognitive functions do occur in pwMS, but it is unclear to what extend those help us understand visual complaints. The purpose of this cross-sectional study was to explore the relation between visual complaints and decline in visual, visuoperceptual and cognitive functions, to optimize care for pwMS. Visual, visuoperceptual and cognitive functions of 68 pwMS with visual complaints and 37 pwMS with no or minimal visual complaints were assessed. The frequency of functional decline was compared between the two groups and correlations were calculated between visual complaints and the assessed functions. Decline in several functions occurred more frequently in pwMS with visual complaints. Visual complaints may be an indication of declined visual or cognitive functioning. However, as most correlations were not significant or weak, we cannot infer that visual complaints are directly related to functions. The relationship may be indirect and more complex. Future research could focus on the overarching cognitive capacity that may contribute to visual complaints. Further research into these and other explanations for visual complaints could help us to provide appropriate care for pwMS.
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Affiliation(s)
- F E van der Feen
- Clinical and Developmental Neuropsychology, University of Groningen, Groningen, Netherlands
- Centre of Expertise for blind and partially sighted people, Royal Dutch Visio, Huizen, Netherlands
| | - G A de Haan
- Clinical and Developmental Neuropsychology, University of Groningen, Groningen, Netherlands
- Centre of Expertise for blind and partially sighted people, Royal Dutch Visio, Huizen, Netherlands
| | - I van der Lijn
- Clinical and Developmental Neuropsychology, University of Groningen, Groningen, Netherlands
- Centre of Expertise for blind and partially sighted people, Royal Dutch Visio, Huizen, Netherlands
| | - C Stellingwerf
- Centre of Expertise for blind and partially sighted people, Royal Dutch Visio, Huizen, Netherlands
| | - A C L Vrijling
- Centre of Expertise for blind and partially sighted people, Royal Dutch Visio, Huizen, Netherlands
| | - D J Heersema
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
- MS Centrum Noord Nederland, Groningen, Netherlands
| | - J F Meilof
- Department of Neurology, Martini Hospital Groningen, Groningen, Netherlands
- MS Centrum Noord Nederland, Groningen, Netherlands
| | - J Heutink
- Clinical and Developmental Neuropsychology, University of Groningen, Groningen, Netherlands
- Centre of Expertise for blind and partially sighted people, Royal Dutch Visio, Huizen, Netherlands
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3
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Satue M, Castro L, Vilades E, Cordon B, Errea JM, Pueyo A, Chueca EP, Garcia-Martin E. Ability of Swept-source OCT and OCT-angiography to detect neuroretinal and vasculature changes in patients with Parkinson disease and essential tremor. Eye (Lond) 2023; 37:1314-1319. [PMID: 35650321 PMCID: PMC10169798 DOI: 10.1038/s41433-022-02112-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/19/2022] [Accepted: 05/13/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND/OBJECTIVES To evaluate the ability of swept-source optical coherence tomography (SS-OCT) implemented with angiography analysis (SS-OCTA) to detect neuro-retinal and vasculature changes in patients with Parkinson's disease (PD) and essential tremor (ET), and to distinguish between both pathologies. SUBJECTS/METHODS A total 42 PD and 26 ET patients and 146 controls underwent retinal evaluation using SS-OCT plus OCT-Angio™. The macular (m) and peripapillary (p) retinal nerve fiber layer (RNFL) and ganglion cell layer (GCL), and macular vasculature were assessed. A Linear discriminant function (LDF) was calculated to evaluate the diagnostic ability of SS-OCTA in both PD and ET. RESULTS PD patients presented a reduction in mRNFL (p < 0.005), mGCL (all sectors, p < 0.05) and pRNFL (p < 0.005) vs healthy controls, and in mRNFL and pRNFL vs ET patients (p < 0.001). ET patients showed a significant reduction in mGCL vs controls (p < 0.001). No differences were observed in the macular vasculature between groups. Predictive diagnostic variables were significant only for PD and a LDF was obtained with an area under the ROC curve of 0.796. CONCLUSIONS Neuro-retinal thinning is present in both diseases, being greater in PD. While SS-OCT could be useful in diagnosing ET and PD, the diagnostic potential for SS-OCTA based on an LDF applies only to PD, not ET.
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Affiliation(s)
- Maria Satue
- Ophthalmology Department, Miguel Servet University Hospital, Zaragoza, Spain.
- Miguel Servet Ophthalmology Research and Innovation Group (GIMSO), Aragon Institute for Health Research (IIS Aragón), Zaragoza University, Zaragoza, Spain.
| | - Luisa Castro
- Ophthalmology Department, Miguel Servet University Hospital, Zaragoza, Spain
- Miguel Servet Ophthalmology Research and Innovation Group (GIMSO), Aragon Institute for Health Research (IIS Aragón), Zaragoza University, Zaragoza, Spain
| | - Elisa Vilades
- Ophthalmology Department, Miguel Servet University Hospital, Zaragoza, Spain
- Miguel Servet Ophthalmology Research and Innovation Group (GIMSO), Aragon Institute for Health Research (IIS Aragón), Zaragoza University, Zaragoza, Spain
| | - Beatriz Cordon
- Ophthalmology Department, Miguel Servet University Hospital, Zaragoza, Spain
- Miguel Servet Ophthalmology Research and Innovation Group (GIMSO), Aragon Institute for Health Research (IIS Aragón), Zaragoza University, Zaragoza, Spain
| | - Jose M Errea
- Neurology Department, Miguel Servet University Hospital, Zaragoza, Spain
| | - Ana Pueyo
- Neurology Department, Miguel Servet University Hospital, Zaragoza, Spain
| | - Eva Pilar Chueca
- Parkinson's Association of Aragon Integral Rehabilitation Center, Zaragoza, Spain
| | - Elena Garcia-Martin
- Ophthalmology Department, Miguel Servet University Hospital, Zaragoza, Spain
- Miguel Servet Ophthalmology Research and Innovation Group (GIMSO), Aragon Institute for Health Research (IIS Aragón), Zaragoza University, Zaragoza, Spain
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Torun IM, Tukenmez Dikmen N, Tellioglu Saka N, Sonmez M. Choroidal Structural Alterations and Choroidal Vascularity Index in Bipolar Disorder Patients. Photodiagnosis Photodyn Ther 2023; 42:103518. [PMID: 36948410 DOI: 10.1016/j.pdpdt.2023.103518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 03/24/2023]
Abstract
PURPOSE The aim of this study was to compare bipolar disorder (BD) patients with age- and sex-matched healthy individuals in order to assess the choroidal structural alterations, retinal nerve fiber layer (RNFL) thickness, and retinal changes in BD patients using encanhed depth imaging optic coherence tomography (EDI-OCT). METHOD For this research, 39 eyes of BD patients and 36 eyes of age-matched healthy volunteers were used. Five locations were used to assess the choroidal thickness (CT): subfoveal, 500 µm nasal and 1500 µm nasal to the fovea, 500 µm temporal and 1500 µm temporal to the fovea. Image-J was used to determine the total choroidal area (TCA), luminal area (LA), and choroidal vascularity index (CVI). The Spectralis-OCT device was used to evaluate the central macular thickness (CMT), retinal nerve fiber layer (RNFL), and ganglion cell layer (GCL). The data were statistically compared. RESULTS BD patients had significantly decreased subfoveal, nasal, and temporal CTs than controls (for all three, p = 0.0001). The results of CMT and GCL were found to be thinner than controls. (for all p=0.0001) In comparison to the controls, the mean TCA and LA were decreased in the BD group. (p=0.0001, p=0.0001 respectively,). Between the RNFL and CVI values in the BD and control groups, there was no statistically significant difference (p>0.05). CONCLUSION The results of this investigation showed that the retina and choroid of patients with BD had considerable anatomical changes.
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Affiliation(s)
- Isil Merve Torun
- Department of Ophthalmology, Medical Health Sciences University, Sultan Abdulhamid Han Training and Research Hospital, İstanbul, Turkey.
| | - Nejla Tukenmez Dikmen
- Department of Ophthalmology, Medical Health Sciences University, Sultan Abdulhamid Han Training and Research Hospital, İstanbul, Turkey.
| | - Nergis Tellioglu Saka
- Department of Psychiatry, Medical Health Sciences University, Sultan Abdulhamid Han Training and Research Hospital, İstanbul, Turkey.
| | - Murat Sonmez
- Department of Ophthalmology, Medical Health Sciences University, Sultan Abdulhamid Han Training and Research Hospital, İstanbul, Turkey.
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Al-Rashdi AA, Sabt BI, Al-Mujaini AS. Effect of fingolimod therapy on quantitative macular changes among patients with relapsing-remitting multiple sclerosis: a four-year follow-up study from Oman. BMC Ophthalmol 2022; 22:470. [PMID: 36471269 PMCID: PMC9720917 DOI: 10.1186/s12886-022-02701-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 11/23/2022] [Indexed: 12/09/2022] Open
Abstract
PURPOSE Fingolimod (FTY-720) is an immunomodulatory oral agent approved for the treatment of relapsing-remitting multiple sclerosis (RRMS); however, several clinical trials have shown that some recipients may develop macular oedema (ME) as an adverse reaction. As there are no studies assessing the long-term (> 1 year) effect of fingolimod on the macula, this study aimed to evaluate the quantitative effect of fingolimod therapy on central macular thickness (CMT) and total macular volume (TMV) over a four-year period. METHODS This retrospective longitudinal cohort study was performed between January 2014 and December 2018. A total of 21 patients with RRMS receiving fingolimod therapy were recruited and followed-up over 4 years to assess CMT and TMV changes measured using spectral domain optical coherence tomography. A paired sample t-test was used to compare mean CMT and TMV values calculated at baseline prior to the initiation of fingolimod therapy with those observed at three, six, 12, 24, 36 and 48 months of treatment. RESULTS None of the patients developed ME over the four-year study period. In addition, there was no significant difference in baseline mean CMT values and those observed at a four-year follow-up. Although mean TMV values remained constant initially, there was a significant decrease towards the end of the study period. CONCLUSIONS Long-term fingolimod therapy did not result in significant CFT changes. While there was a reduction in TMV towards the end of the study, this is likely due to the degenerative effect of the disease itself on the nerve fibres of the retina.
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Affiliation(s)
| | - Buthaina I. Sabt
- grid.412855.f0000 0004 0442 8821Department of Ophthalmology, Sultan Qaboos University Hospital, Muscat, Oman
| | - Abdullah S. Al-Mujaini
- grid.412846.d0000 0001 0726 9430Department of Ophthalmology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Oman
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Paul DA, Rodrigue A, Contento N, Haber S, Hoang R, Rahmani R, Hirad A, Shafiq I, Williams Z, Vates GE. Prolactin at moderately increased levels confers a neuroprotective effect in non-secreting pituitary macroadenomas. PLoS One 2022; 17:e0271690. [PMID: 35921360 PMCID: PMC9348739 DOI: 10.1371/journal.pone.0271690] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 07/05/2022] [Indexed: 11/24/2022] Open
Abstract
Context Prolactin, a hormone synthesized by the anterior pituitary gland demonstrates promise as a neuroprotective agent, however, its role in humans and in vivo during injury is not fully understood. Objective To investigate whether elevated levels of prolactin attenuate injury to the retinal nerve fiber layer (RNFL) following compression of the optic chiasm in patients with a prolactin secreting pituitary macroadenoma (i.e., prolactinoma). Design setting and participants A retrospective cross-sectional study of all pituitary macroadenoma patients treated at a single institution between 2009 and 2019. Main outcome measure(s) Primary outcome measures included RNFL thickness, mean deviation, and prolactin levels for both prolactin-secreting and non-secreting pituitary macroadenoma patients. Results Sixty-six patients met inclusion criteria for this study (14 prolactin-secreting and 52 non-secreting macroadenoma patients). Of 52 non-secreting macroadenoma patients, 12 had moderate elevation of prolactin secondary to stalk effect. Patients with moderate elevation in prolactin demonstrated increased RNFL thickness compared to patients with normal prolactin levels (p < 0.01). Additionally, a significant positive relation between increasing levels of prolactin and RNFL thickness was identified in patients with moderate prolactin elevation (R = 0.51, p-value = 0.035). No significant difference was identified between prolactinoma patients and those with normal prolactin levels. Conclusions Moderately increased serum prolactin is associated with increased RNFL thickness when compared to controls. These associations are lost when serum prolactin is < 30 ng/ml or elevated in prolactinomas. This suggests a neuroprotective effect of prolactin at moderately increased levels in preserving retinal function during optic chiasm compression.
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Affiliation(s)
- David A. Paul
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, United States of America
| | - Alejandra Rodrigue
- University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
- Department of Ophthalmology, University of Rochester Medical Center, Rochester, New York, United States of America
| | - Nicholas Contento
- University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
| | - Sam Haber
- University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
- Department of Brain and Cognitive Sciences, University of Rochester, Rochester, New York, United States of America
| | - Ricky Hoang
- University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, United States of America
| | - Adnan Hirad
- University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
| | - Ismat Shafiq
- Division of Endocrinology and Metabolism, University of Rochester Medical Center, Rochester, New York, United States of America
| | - Zoë Williams
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, United States of America
- Department of Ophthalmology, University of Rochester Medical Center, Rochester, New York, United States of America
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, United States of America
| | - G. Edward Vates
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, United States of America
- * E-mail:
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Hamdy E, Talaat F, Said SM, Ramadan I, Marouf H, Hamdy MM, Sadallah H, Ashmawi GAH, Elsalamawy D. Diagnosing ‘transition’ to secondary progressive multiple sclerosis (SPMS): A step-by-step approach for clinicians. Mult Scler Relat Disord 2022; 60:103718. [DOI: 10.1016/j.msard.2022.103718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 02/13/2022] [Accepted: 02/27/2022] [Indexed: 11/29/2022]
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Macular volume and fovea thickness as OCT-criteria for multiple sclerosis. Preliminary results. ACTA BIOMEDICA SCIENTIFICA 2021. [DOI: 10.29413/abs.2021-6.6-1.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background. The characteristic optical coherence tomography (OCT) changes in the optic nerve head in patients with multiple sclerosis are known and have been described many times, however, the state of the macular area is described in a small number of publications.The aim: to analyze the changes in the macular area of the retina in patients with multiple sclerosis, to identify the OCT signs pathognomonic for this disease and to trace their changes over time as the disease progresses.Material and methods. In addition to the standard ophthalmological examination, 28 patients (55 eyes) diagnosed with multiple sclerosis underwent OCT of the macular zone to determine the thickness of the fovea and the volume of the macula in the 6 mm zone. The follow-up period was 6–12 years. The endpoints were the primary treatment and the most recent inspection.Results. At the initial examination, the visual acuity was 0.96 ± 0.24 (95% CI: 0.9–1.03), fovea thickness – 253.0 μm (Q1–Q3: 233.0–264.0), macular volume – 5.471 mm3 (Q1–Q3: 5.281–5.625). In 37 cases (67.3 %), the macular volume was below normal. The initial fovea thickness was below normal in 9 cases (16.4 %). At the end of the study, visual acuity did not change statistically (p = 0.824) and amounted to 0.96 ± 0.25 (95% CI: 0.90–1.04). The fi nal thickness of the fovea was 247.5 μm (Q1–Q3: 233.0–260.0), changes are statistically significant (p = 0.02). Number of cases with a thickness below normal in the fi nal study was 11 (20 %), change of frequency of cases was not statistically signifi cant (p = 0.5). The fi nal macular volume was 5.393 mm3 (Q1–Q3: 5.197–5.565), the changes are statistically significant (p = 0.023). The final number of cases with a volume below the norm was 42 (76.4 %), the change in the frequency of cases is close to statistically signifi cant (p = 0.063). At all stages of the study, there was no case of an isolated decrease in the thickness of the fovea without a decrease in the volume of the macula.Conclusion. The decrease in the volume of the macula with time while maintaining the thickness of the fovea within the normal range can be attributed to the pathognomonic OCT signs of multiple sclerosis. This criterion can be used for a comprehensive assessment of the course and therapy of this disease.
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Barreiro-González A, Sanz MT, Carratalà-Boscà S, Pérez-Miralles F, Alcalá C, España-Gregori E, Casanova B. Dyschromatopsia in multiple sclerosis reflects diffuse chronic neurodegeneration beyond anatomical landmarks. Acta Neurol Belg 2021; 121:1767-1775. [PMID: 33044738 DOI: 10.1007/s13760-020-01516-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
Abstract
To formulate and validate a dyschromatopsia linear regression model in patients with multiple sclerosis (MS). 64 MS patients (50 to formulate the model and 14 for its validation) underwent neurological (Expanded Disability Status Scale, EDSS), color vision (Farnsworth D15 test), and peripapillary retinal nerve fiber layer (pRNFL) and retinal evaluation with spectral-domain optical coherence tomography (SD-OCT). Neuroradiological examination permitted to obtain brain parenchymal fraction (BPF) and cervical spinal cord volume (SC). Ophthalmic parameters were calculated as the average of both non-optic neuritis (ON) eyes, and in case the patient had previous ON, the value of the fellow non-ON eye was taken. The influence of sex, age, disease duration, and history of disease-modifying treatment (first- or second-line DMT) was tested as covariables that could influence color perception. Color confusion index (log CCI) correlated with pRNFL (r = - 0.322, p = 0.009), ganglion cell layer (GCL, r = - 0.321, p = 0.01), BPF (r = - 0.287, p = 0.021), SC volume (r = - 0.33, p = 0.008), patients' age (r = 0.417, p = 0.001), disease duration (r = 0.371, p = 0.003), and EDSS (r = 0.44, p = 0.001). The following CCI equation was obtained: log (CCI) = 0.316-0.224 BPF - 0.187 SC volume (mm3) + 0.226 age (years) + 0.012 disease duration (years) - 0.372 GCL (µm). CCI correlates with MS clinical and paraclinical established biomarkers suggesting chronic diffuse neurodegeneration in MS operates at brain, SC, and retina linking all three compartments. Color vision outcome can be calculated through the aforementioned variables for clinical and research purposes.
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Affiliation(s)
- Antonio Barreiro-González
- Ophthalmology Department, University and Polytechnic Hospital La Fe, Avenida Fernando Abril Martorell 106, 46026, Valencia, Spain.
| | - Maria T Sanz
- Departamento de Didáctica de La Matemática, Universidad de Valencia, Valencia, Spain
| | - Sara Carratalà-Boscà
- Neurology Department, University and Polytechnic Hospital La Fe, Valencia, Spain
| | | | - Carmen Alcalá
- Neurology Department, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Enrique España-Gregori
- Ophthalmology Department, University and Polytechnic Hospital La Fe, Avenida Fernando Abril Martorell 106, 46026, Valencia, Spain
- Surgery Department, Faculty of Medicine, University of Valencia, Valencia, Spain
| | - Bonaventura Casanova
- Neurology Department, University and Polytechnic Hospital La Fe, Valencia, Spain
- Medicine Department, Faculty of Medicine, University of Valencia, Valencia, Spain
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Evaluation of Retinal Structure and Optic Nerve Function Changes in Multiple Sclerosis: Longitudinal Study with 1-Year Follow-Up. Neurol Res Int 2021; 2021:5573839. [PMID: 34221503 PMCID: PMC8225456 DOI: 10.1155/2021/5573839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/23/2021] [Accepted: 05/31/2021] [Indexed: 11/17/2022] Open
Abstract
Background Multiple sclerosis (MS) is an autoimmune disease characterized by inflammation and demyelination of the central nervous system which often involves the optic nerve even though only 20% of the patients experience optic neuritis (ON). Objective This study aims to compare the retinal structure and optic nerve function between patients with MS and healthy controls (HCs), evaluate optic nerve alterations in MS over 1-year follow-up, and analyze its correlations with disease duration, number of relapses, degree of disability, and different subtypes. Methods This is a prospective cohort study involving 58 eyes of MS patients. Optic nerve function was evaluated with best-corrected visual acuity (BCVA), contrast sensitivity, and P100 latency, while the retinal structure was evaluated from the GCIPL and RNFL thickness measured with optical coherence tomography (OCT) and fundus photography. Results The MS group had lower BCVA (p=0.001), contrast sensitivity (p < 0.001), mean GCIPL thickness (p < 0.001), and mean RNFL thickness (p < 0.001) than HC. At 6 and 12 months of observations, GCIPL and RNFL (nasal quadrant) of MS patients decreased significantly (p=0.007 and p=0.004, respectively). Disease duration and the number of relapses correlated with delayed P100 latency (r = −0.61, p < 0.001 and r = −0.46, p=0.02). GCIPL and RNFL in the SPMS subtype were thinner than in RRMS. Conclusions The retinal structure and optic nerve function of MS patients are worse than those of normal individuals. GCIPL and RNFL thinning occurs at 6 and 12 months but do not correlate with disease duration, the number of relapses, and degree of disability.
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Currant H, Hysi P, Fitzgerald TW, Gharahkhani P, Bonnemaijer PWM, Senabouth A, Hewitt AW, Atan D, Aung T, Charng J, Choquet H, Craig J, Khaw PT, Klaver CCW, Kubo M, Ong JS, Pasquale LR, Reisman CA, Daniszewski M, Powell JE, Pébay A, Simcoe MJ, Thiadens AAHJ, van Duijn CM, Yazar S, Jorgenson E, MacGregor S, Hammond CJ, Mackey DA, Wiggs JL, Foster PJ, Patel PJ, Birney E, Khawaja AP. Genetic variation affects morphological retinal phenotypes extracted from UK Biobank optical coherence tomography images. PLoS Genet 2021; 17:e1009497. [PMID: 33979322 PMCID: PMC8143408 DOI: 10.1371/journal.pgen.1009497] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 05/24/2021] [Accepted: 03/18/2021] [Indexed: 12/15/2022] Open
Abstract
Optical Coherence Tomography (OCT) enables non-invasive imaging of the retina and is used to diagnose and manage ophthalmic diseases including glaucoma. We present the first large-scale genome-wide association study of inner retinal morphology using phenotypes derived from OCT images of 31,434 UK Biobank participants. We identify 46 loci associated with thickness of the retinal nerve fibre layer or ganglion cell inner plexiform layer. Only one of these loci has been associated with glaucoma, and despite its clear role as a biomarker for the disease, Mendelian randomisation does not support inner retinal thickness being on the same genetic causal pathway as glaucoma. We extracted overall retinal thickness at the fovea, representative of foveal hypoplasia, with which three of the 46 SNPs were associated. We additionally associate these three loci with visual acuity. In contrast to the Mendelian causes of severe foveal hypoplasia, our results suggest a spectrum of foveal hypoplasia, in part genetically determined, with consequences on visual function.
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Affiliation(s)
- Hannah Currant
- European Molecular Biology Laboratory, European Bioinformatics Institute, Wellcome Genome Campus, Cambridge, United Kingdom
| | - Pirro Hysi
- School of Life Course Sciences, Section of Ophthalmology, King’s College London, London, United Kingdom
- Department of Twin Research and Genetic Epidemiology, King’s College London, London, United Kingdom
| | - Tomas W. Fitzgerald
- European Molecular Biology Laboratory, European Bioinformatics Institute, Wellcome Genome Campus, Cambridge, United Kingdom
| | - Puya Gharahkhani
- Statistical Genetics, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Pieter W. M. Bonnemaijer
- Department of Ophthalmology, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
- The Rotterdam Eye Hospital, Rotterdam, The Netherlands
| | - Anne Senabouth
- Garvan Weizmann Centre for Cellular Genomics, Garvan Institute of Medical Research, The Kinghorn Cancer Centre, Darlinghurst, Australia
| | - Alex W. Hewitt
- Menzies Institute for Medical Research, School of Medicine, University of Tasmania, Tasmania, Australia
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | | | | | - Denize Atan
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
- Bristol Eye Hospital, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Tin Aung
- Singapore Eye Research Institute, Singapore National Eye Centre, Singapore
- Ophthalmology & Visual Sciences Academic Clinical Program, Duke-NUS Medical School, Singapore
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jason Charng
- Centre for Ophthalmology and Visual Science, Lions Eye Institute, The University of Western Australia, Perth, Australia
| | - Hélène Choquet
- Kaiser Permanente Northern California Division of Research, Oakland, California, United States of America
| | - Jamie Craig
- Department of Ophthalmology, Flinders University, Flinders Medical Centre, Bedford Park, Australia
| | - Peng T. Khaw
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Caroline C. W. Klaver
- Department of Ophthalmology, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
- Department of Ophthalmology Radboud University Medical Center, Nijmegen, The Netherlands
- Institute of Molecular and Clinical Ophthalmology, Basel, Switzerland
| | - Michiaki Kubo
- RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Jue-Sheng Ong
- Statistical Genetics, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Louis R. Pasquale
- Eye and Vision Research Institute, Icahn School of Medicine at Mount Sinai, New York, New York, United States of America
| | - Charles A. Reisman
- Topcon Healthcare Solutions R&D, Oakland, New Jersey, United States of America
| | - Maciej Daniszewski
- Department of Anatomy and Physiology, The University of Melbourne, Parkville, Australia
| | - Joseph E. Powell
- Garvan Weizmann Centre for Cellular Genomics, Garvan Institute of Medical Research, The Kinghorn Cancer Centre, Darlinghurst, Australia
- UNSW Cellular Genomics Futures Institute, University of New South Wales, Sydney, Australia
| | - Alice Pébay
- Department of Anatomy and Physiology, The University of Melbourne, Parkville, Australia
- Department of Surgery, The University of Melbourne, Parkville, Australia
| | - Mark J. Simcoe
- Department of Ophthalmology, Kings College London, London, United Kingdom
- Institute of Ophthalmology, University College London, London, United Kingdom
| | | | - Cornelia M. van Duijn
- Nuffield Department Of Population Health, University of Oxford, Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, Oxford, United Kingdom
| | - Seyhan Yazar
- Garvan-Weizmann Centre for Single Cell Genomics, Garvan Institute of Medical Research, Sydney, Australia
| | - Eric Jorgenson
- Kaiser Permanente Northern California Division of Research, Oakland, California, United States of America
| | - Stuart MacGregor
- Statistical Genetics, QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Chris J. Hammond
- School of Life Course Sciences, Section of Ophthalmology, King’s College London, London, United Kingdom
| | - David A. Mackey
- Centre for Ophthalmology and Visual Science, Lions Eye Institute, The University of Western Australia, Perth, Australia
| | - Janey L. Wiggs
- Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear, Boston, Massachusetts, United States of America
| | - Paul J. Foster
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Praveen J. Patel
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Ewan Birney
- European Molecular Biology Laboratory, European Bioinformatics Institute, Wellcome Genome Campus, Cambridge, United Kingdom
| | - Anthony P. Khawaja
- NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
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12
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Parizek T, Skulec R, Liehneova I, Prasek P, Cerny V. No significant retinal damage induced by major orthopedic surgery - a pilot study. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2021; 166:217-221. [PMID: 33885047 DOI: 10.5507/bp.2021.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 04/07/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Perioperative visual loss is one of the rare but devastating complications of anesthesia and surgery. The incidence of less severe or even subclinical postoperative visual dysfunction is unknown. Therefore, we decided to perform a pilot prospective observational clinical study to evaluate whether structural changes of the retina can be detected in patients undergoing elective orthopaedic surgery by optical coherence tomography (OCT). METHODS Adult patients indicated for elective knee replacement surgery with the absence of known retinal or optic nerve disease were included. Each patient underwent baseline OCT examination of the eyes one day before surgery and it was repeated 4-7 days after the surgery. The surgery was done under general and epidural anesthesia. RESULTS A total of 18 patients (6 men and 12 women) at the age of 70.8±7.1 years were enrolled. We found statistically significant changes in the Macular central thickness and in a few areas of the Retinal Nerve Fiber Layer between the baseline and postoperative measurements. CONCLUSIONS Even though we found significant changes in some parameters, we did not confirm that general anesthesia and/or surgical damage causes significant damage of the retina using OCT measurement. TRIAL REGISTRATION ClinicalTrials.gov (NCT04311801).
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Affiliation(s)
- Tomas Parizek
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital Usti nad Labem, Socialni pece 3316/12A, Usti nad Labem 400 11, Czech Republic.,Emergency Medical Service of the Usti Region, Socialni Pece 799/71, Usti nad Labem 400 11, Czech Republic.,Department of Surgery, Faculty of Medicine, Charles University in Hradec Kralove and University Hospital Hradec Kralove, Simkova 870, Hradec Kralove 500 03, Czech Republic
| | - Roman Skulec
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital Usti nad Labem, Socialni pece 3316/12A, Usti nad Labem 400 11, Czech Republic.,Emergency Medical Service of the Central Bohemian Region, Vancurova 1544, Kladno 272 01, Czech Republic.,Department of Anesthesiology and Intensive Care, Faculty of Medicine, Charles University in Hradec Kralove and University Hospital Hradec Kralove, Sokolska 581, Hradec Kralove 500 05, Czech Republic.,Department of Nursing and Midwifery, Faculty of Health Studies, J.E. Purkinje University, Pasteurova 3544/1, Usti nad Labem 400 96, Czech Republic
| | - Ivana Liehneova
- Department of Ophtalmology, J.E. Purkinje University, Masaryk Hospital Usti nad Labem, Socialni pece 3316/12A, Usti nad Labem 400 11, Czech Republic
| | - Petr Prasek
- Department of Ophtalmology, J.E. Purkinje University, Masaryk Hospital Usti nad Labem, Socialni pece 3316/12A, Usti nad Labem 400 11, Czech Republic
| | - Vladimir Cerny
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital Usti nad Labem, Socialni pece 3316/12A, Usti nad Labem 400 11, Czech Republic.,Department of Anesthesiology and Intensive Care, Faculty of Medicine, Charles University in Hradec Kralove and University Hospital Hradec Kralove, Sokolska 581, Hradec Kralove 500 05, Czech Republic.,Department of Research and Development, Faculty of Medicine, Charles University in Hradec Kralove and University Hospital Hradec Kralove, Sokolska 581, Hradec Kralove 500 05, Czech Republic.,Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia B3H 4R2, Canada
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13
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Srinivasan S, Efron N. Optical coherence tomography in the investigation of systemic neurologic disease. Clin Exp Optom 2021; 102:309-319. [DOI: 10.1111/cxo.12858] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 10/21/2018] [Accepted: 10/28/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
- Sangeetha Srinivasan
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia,
| | - Nathan Efron
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia,
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14
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Orduna-Hospital E, Cordón B, Vilades E, Garcia-Martin E, Garcia-Campayo J, López-Del-Hoyo Y, Polo V, Larrosa JM, Pablo LE, Satue M. Ganglion Cell and Retinal Nerve Fiver Layers Correlated with Time Disease of Bipolar Disorder Using 64 Cell Grid OCT Tool. Curr Eye Res 2021; 46:1214-1222. [PMID: 33455447 DOI: 10.1080/02713683.2021.1877313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
MATERIALS AND METHODS Twenty-five eyes of 25 patients with bipolar disorder and 74 eyes of 74 healthy controls underwent retinal measurements of retinal nerve fiber layer (RNFL) and ganglion cell layer (GCL) thickness. Measurements were obtained using the Spectralis-OCT device with the new Posterior Pole protocol which assesses the macular area by analyzing retinal thickness in a grid of 64 (8*8) cells. RESULTS Significant differences (p < 0.05) in RNFL and GCL thickness were found between BD patients and healthy controls, in parafoveal and perifoveal cells respectively. Significant inverse correlations were found between RNFL and GCL thinning at their thickest location and the duration of bipolar disorder. Several predictive variables were observed with a binary logistic regression for the presence/absence of BD: cell 1.3 RNFL (p = 0.028) and GCL in cells 7.8 (p = 0.012), 2.7 (p = 0.043) and 1.3 (p = 0.047). CONCLUSION Posterior Pole OCT protocol is a useful tool to assess changes in the inner retinal layers in bipolar disorder. These observed changes, especially those affecting the GCL, may be associated with disease evolution and may be predictive of the presence of the disease. OCT data could potentially be a useful tool for clinicians to diagnose and monitor BD patients.
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Affiliation(s)
- Elvira Orduna-Hospital
- Miguel Servet Ophthalmology Research and Innovative Group (GIMSO), Aragon Institute for Health Research (IIS Aragón), University of Zaragoza, Zaragoza, Spain.,Ophthalmology Department, Miguel Servet University Hospital, Zaragoza, Spain
| | - Beatriz Cordón
- Miguel Servet Ophthalmology Research and Innovative Group (GIMSO), Aragon Institute for Health Research (IIS Aragón), University of Zaragoza, Zaragoza, Spain.,Ophthalmology Department, Miguel Servet University Hospital, Zaragoza, Spain
| | - Elisa Vilades
- Miguel Servet Ophthalmology Research and Innovative Group (GIMSO), Aragon Institute for Health Research (IIS Aragón), University of Zaragoza, Zaragoza, Spain.,Ophthalmology Department, Miguel Servet University Hospital, Zaragoza, Spain
| | - Elena Garcia-Martin
- Miguel Servet Ophthalmology Research and Innovative Group (GIMSO), Aragon Institute for Health Research (IIS Aragón), University of Zaragoza, Zaragoza, Spain.,Ophthalmology Department, Miguel Servet University Hospital, Zaragoza, Spain
| | | | - Yolanda López-Del-Hoyo
- Aragon Institute for Health Research (IIS Aragón), University of Zaragoza, Zaragoza, Spain
| | - Vicente Polo
- Miguel Servet Ophthalmology Research and Innovative Group (GIMSO), Aragon Institute for Health Research (IIS Aragón), University of Zaragoza, Zaragoza, Spain.,Ophthalmology Department, Miguel Servet University Hospital, Zaragoza, Spain
| | - Jose M Larrosa
- Miguel Servet Ophthalmology Research and Innovative Group (GIMSO), Aragon Institute for Health Research (IIS Aragón), University of Zaragoza, Zaragoza, Spain.,Ophthalmology Department, Miguel Servet University Hospital, Zaragoza, Spain
| | - Luis E Pablo
- Miguel Servet Ophthalmology Research and Innovative Group (GIMSO), Aragon Institute for Health Research (IIS Aragón), University of Zaragoza, Zaragoza, Spain.,Ophthalmology Department, Miguel Servet University Hospital, Zaragoza, Spain
| | - Maria Satue
- Miguel Servet Ophthalmology Research and Innovative Group (GIMSO), Aragon Institute for Health Research (IIS Aragón), University of Zaragoza, Zaragoza, Spain.,Ophthalmology Department, Miguel Servet University Hospital, Zaragoza, Spain
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15
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Barreiro-González A, Sanz MT, Carratalà-Boscà S, Pérez-Miralles F, Alcalá C, Carreres-Polo J, España-Gregori E, Casanova B. Magnetic resonance imaging and optical coherence tomography correlations in multiple sclerosis beyond anatomical landmarks. J Neurol Sci 2020; 419:117180. [PMID: 33091751 DOI: 10.1016/j.jns.2020.117180] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 09/14/2020] [Accepted: 10/10/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To investigate multiple sclerosis (MS) optical coherence tomography (OCT) cross-sectional correlations with central nervous system (CNS) magnetic resonance imaging (MRI). MATERIAL AND METHODS Peripapillary retinal nerve fiber layer (pRNFL), ganglion cell layer (GCL), inner plexiform layer (IPL), inner (INL) and outer nuclear layer (ONL) of 54 relapsing remitting (RRMS) and 38 progressive (PMS, 9 primary and 29 secondary) patients were measured. With less than 3 months brain parenchymal fraction (BPF), spinal cord (SC), total gray matter (GM) and white matter volumes were calculated. Demographical and clinical data was compared according to the history of optic neuritis (HON). Relationships between OCT and MRI data were assessed using multivariable linear regression models, adjusting for age, gender and disease duration, taking into account HON and disease subtype. RESULTS Cerebellum (p = 0.008), pRNFL (p = 0.001), GCL (p = 0.001) and IPL (p = 0.001) were thinner, while INL was thicker (p = 0.02) if HON. SC correlated better with nasal pRNFL sectors in eyes with HON (all eyes: average pRNFL p = 0.035 η2 = 0.213; N-pRNFL p = 0.04 η2 = 0.36, NI-pRNFL p = 0.0001 η2 = 0.484. RRMS eyes: N-pRNFL p = 0.034 η2 = 0.348; NI-pRNFL p = 0.013 η2 = 0.441), while it correlates with PMB (p = 0.032 η2 = 0.144), GCL (p = 0.03 η2 = 0.147) and IPL (p = 0.028 η2 = 0.151) in eyes without HON regardless of the disease subtype. INL presented no microcystic macular oedema and was inversely associated with BPF (p = 0.029 η2 = 0.363) and cerebellum (p = 0.015 η2 = 0.428) in PMS eyes without HON. CONCLUSIONS OCT data correlates with different CNS compartments, even with no anatomical or functional linkage, serving as useful neurodegeneration and inflammation surrogate marker.
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Affiliation(s)
| | - Maria T Sanz
- Departamento de Didáctica de la Matemática, Universidad de Valencia, Valencia, Spain
| | - Sara Carratalà-Boscà
- Neuroimmunology Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| | | | - Carmen Alcalá
- Neuroimmunology Unit, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Joan Carreres-Polo
- Radiology Department, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Enrique España-Gregori
- Ophthalmology Department, La Fe University and Polytechnic Hospital, Valencia, Spain; Surgery Department, Faculty of Medicine, University of Valencia, Spain
| | - Bonaventura Casanova
- Neuroimmunology Unit, La Fe University and Polytechnic Hospital, Valencia, Spain; Medicine Department, Faculty of Medicine, University of Valencia, Spain
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16
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Abstract
PURPOSE To evaluate visual and retinal changes in patients with bipolar disorder. To analyze the correlation between structural changes and visual function parameters. METHODS Thirty patients with bipolar disorder and 80 healthy controls underwent visual function evaluation with Early Treatment Diabetic Retinopathy Study charts at 100%, 2.50%, and 1.25% contrast, Pelli-Robson chart, and color vision Farnsworth and Lanthony tests. Analysis of the different retinal layers was performed using Spectralis optical coherence tomography with automated segmentation software. Correlation analysis between structural and functional parameters was conducted. RESULTS Patients with bipolar disorder presented worse color vision compared with controls (Lanthony's index, P = 0.002). Full macular thickness, the retinal nerve fiber layer (RNFL), ganglion cell layer, and inner plexiform layer were reduced in patients compared with healthy individuals (P < 0.005). The inner nuclear layer was significantly thickened in patients (P < 0.005). Peripapillary RNFL thickness was reduced in all temporal sectors (P < 0.005). Significant correlations were found between visual acuity and the RNFL thickness, the Pelli-Robson score and the inner plexiform layer, and between the Lanthony's color index and the ganglion cell layer thickness. CONCLUSION Patients with bipolar disorder present quantifiable thinning of the macular RNFL, ganglion cell layer, and inner plexiform layer, as well as in the peripapillary RNFL thickness, and increasing thinning in the inner nuclear layer.
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17
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Gavín A, Garcia-Martin E, Garcia-Campayo J, Viladés E, Orduna E, Satué M. The use of optical coherence tomography in the evaluation of patients with bipolar disorder. ACTA ACUST UNITED AC 2020; 96:141-151. [PMID: 32912807 DOI: 10.1016/j.oftal.2020.07.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/12/2020] [Indexed: 11/16/2022]
Abstract
Bipolar disorder (BD) is a mental disorder characterised by episodes of extremal mood changes. In recent years, some researchers found neurodegeneration in patients with BD using Magnetic Resonance Imaging. Evaluation of the optic nerve and the retinal layers using optical coherence tomography (OCT) has proved to be a useful, non-invasive tool for diagnosis and monitoring of neurodegenerative diseases. Accordingly, a decrease in the retinal nerve fibre layer and the ganglion cell complex measured by OCT was found in patients with BD in different studies, suggesting that BD is a neurodegenerative process in addition to a psychiatric disorder. Therefore, the neuro-ophthalmological evaluation of these patients could be used as a marker for diagnosis of this disease. This work analyses literature on retinal degeneration in bipolar disorder patients, and evaluates the ability of OCT devices in the detection of neuronal degeneration affecting the different retinal layers in these patients, and its possible role in the diagnosis and monitoring of the disease.
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Affiliation(s)
- A Gavín
- Servicio de Oftalmología, Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Grupo de Investigación e Innovación Miguel Servet Oftalmología (GIMSO), Zaragoza, España.
| | - E Garcia-Martin
- Servicio de Oftalmología, Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Grupo de Investigación e Innovación Miguel Servet Oftalmología (GIMSO), Zaragoza, España
| | - J Garcia-Campayo
- Servicio de Psiquiatría, Hospital Universitario Miguel Servet, Zaragoza, España; Departamento de Psicología y Sociología, facultad de ciencias sociales y humanas, Universidad de Zaragoza, Zaragoza, España
| | - E Viladés
- Servicio de Oftalmología, Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Grupo de Investigación e Innovación Miguel Servet Oftalmología (GIMSO), Zaragoza, España
| | - E Orduna
- Servicio de Oftalmología, Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Grupo de Investigación e Innovación Miguel Servet Oftalmología (GIMSO), Zaragoza, España
| | - M Satué
- Servicio de Oftalmología, Hospital Universitario Miguel Servet, Zaragoza, España; Instituto de Investigación Sanitaria de Aragón (IIS Aragón), Grupo de Investigación e Innovación Miguel Servet Oftalmología (GIMSO), Zaragoza, España
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18
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Abstract
The search for an ideal multiple sclerosis biomarker with good diagnostic value, prognostic reference and an impact on clinical outcome has yet to be realized and is still ongoing. The aim of this review is to establish an overview of the frequent biomarkers for multiple sclerosis that exist to date. The review summarizes the results obtained from electronic databases, as well as thorough manual searches. In this review the sources and methods of biomarkers extraction are described; in addition to the description of each biomarker, determination of the prognostic, diagnostic, disease monitoring and treatment response values besides clinical impact they might possess. We divided the biomarkers into three categories according to the achievement method: laboratory markers, genetic-immunogenetic markers and imaging markers. We have found two biomarkers at the time being considered the gold standard for MS diagnostics. Unfortunately, there does not exist a single solitary marker being able to present reliable diagnostic value, prognostic value, high sensitivity and specificity as well as clinical impact. We need more studies to find the best biomarker for MS.
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19
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Yap TE, Balendra SI, Almonte MT, Cordeiro MF. Retinal correlates of neurological disorders. Ther Adv Chronic Dis 2019; 10:2040622319882205. [PMID: 31832125 PMCID: PMC6887800 DOI: 10.1177/2040622319882205] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 09/20/2019] [Indexed: 12/11/2022] Open
Abstract
Considering the retina as an extension of the brain provides a platform from which to study diseases of the nervous system. Taking advantage of the clear optical media of the eye and ever-increasing resolution of modern imaging techniques, retinal morphology can now be visualized at a cellular level in vivo. This has provided a multitude of possible biomarkers and investigative surrogates that may be used to identify, monitor and study diseases until now limited to the brain. In many neurodegenerative conditions, early diagnosis is often very challenging due to the lack of tests with high sensitivity and specificity, but, once made, opens the door to patients accessing the correct treatment that can potentially improve functional outcomes. Using retinal biomarkers in vivo as an additional diagnostic tool may help overcome the need for invasive tests and histological specimens, and offers the opportunity to longitudinally monitor individuals over time. This review aims to summarise retinal biomarkers associated with a range of neurological conditions including Alzheimer’s disease (AD), Parkinson’s disease (PD), multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS) and prion diseases from a clinical perspective. By comparing their similarities and differences according to primary pathological processes, we hope to show how retinal correlates can aid clinical decisions, and accelerate the study of this rapidly developing area of research.
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Affiliation(s)
- Timothy E Yap
- The Western Eye Hospital, Imperial College Healthcare NHS Trust (ICHNT), London, UK
| | - Shiama I Balendra
- Glaucoma and Retinal Neurodegeneration Group, Department of Visual Neuroscience, UCL Institute of Ophthalmology, London, UK
| | - Melanie T Almonte
- The Imperial College Ophthalmic Research Group (ICORG), Imperial College London, UK
| | - M Francesca Cordeiro
- The Western Eye Hospital, Imperial College Healthcare NHS Trust (ICHNT), London, NW1 5QH, UK
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20
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Functional Evaluation of the Visual Pathway in Patients with Multiple Sclerosis Using a Multifunction Stimulator Monitor. J Ophthalmol 2019; 2019:2890193. [PMID: 31641531 PMCID: PMC6769350 DOI: 10.1155/2019/2890193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 07/30/2019] [Indexed: 12/04/2022] Open
Abstract
Objectives To assess the capability of the vision monitor unit Monpack One of detecting visual function alterations in patients with multiple sclerosis (MS) and to evaluate the correlation between structural retinal parameters and functional measurements obtained with this device. Methods Forty-eight patients with MS and 46 healthy controls were included in a cross-sectional study. All participants underwent a complete functional evaluation of the visual pathway, which included low-contrast visual acuity (LCVA), contrast sensitivity vision (CSV), automated perimetry, multifocal visual evoked potentials (mfVEPs), and pattern electroretinogram (ERG). All tests were performed using the vision monitor unit Monpack One (Metrovision, France), a multifunction stimulator device. Retinal structural measurements were obtained in all subjects using Triton swept source optical coherence tomography (Topcon, Japan). Results Patients with MS presented reduced low-contrast VA (p < 0.001) and reduced CSV at medium (p=0.001, p=0.013) and low (p=0.001, p=0.002) spatial frequencies. All visual field parameters were found to be altered in MS patients compared with controls (≤0.001). Patients with MS presented lower amplitude of the P100 waveform of the mfVEP in areas corresponding to central (p < 0.001), inferonasal (p=0.001), and inferotemporal (p=0.003) retina. The pattern ERG did not show significant differences. Significant correlations were observed between structural retinal measurements and functional parameters, especially between the inner macular areas and measurements corresponding to contrast sensitivity and perimetry indexes. Conclusions Patients with MS present visual dysfunction detectable with the vision monitor unit Monpack One. This device may be a fast and useful tool to provide a full evaluation of axonal damage in patients with multiple sclerosis.
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21
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Gajamange S, Stankovich J, Egan G, Kilpatrick T, Butzkueven H, Fielding J, van der Walt A, Kolbe S. Early imaging predictors of longer term multiple sclerosis risk and severity in acute optic neuritis. Mult Scler J Exp Transl Clin 2019; 5:2055217319863122. [PMID: 31384479 PMCID: PMC6651676 DOI: 10.1177/2055217319863122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/11/2019] [Indexed: 11/26/2022] Open
Abstract
Background Biomarkers are urgently required for predicting the likely progression of multiple sclerosis (MS) at the earliest stages of the disease to aid in personalised therapy. Objective We aimed to examine early brain volumetric and microstructural changes and retinal nerve fibre layer thinning as predictors of longer term MS severity in patients with clinically isolated syndromes (CIS). Methods Lesion metrics, brain and regional atrophy, diffusion fractional anisotropy and retinal nerve fibre layer thickness were prospectively assessed in 36 patients with CIS over the first 12 months after presentation and compared with clinical outcomes at longer term follow-up [median (IQR) = 8.5 (7.8–8.9) years]. Results In total, 25 (69%) patients converted to MS and had greater baseline lesion volume (p = 0.008) and number (p = 0.03)than CIS patients. Over the initial 12 months, new lesions (p = 0.0001), retinal nerve fibre layer thinning (p = 0.04) and ventricular enlargement (p = 0.03) were greater in MS than CIS patients. In MS patients, final Expanded Disability Status Scale score correlated with retinal nerve fibre layer thinning over the first 12 months (ρ = −0.67, p = 0.001). Conclusions Additional to lesion metrics, early measurements of fractional anisotropy and retinal nerve fibre layer thinning are informative about longer term clinical outcomes in CIS.
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Affiliation(s)
- Sanuji Gajamange
- Department of Medicine and Radiology, University of Melbourne, Australia
| | - Jim Stankovich
- Department of Neuroscience, Central Clinical School, Monash University, Australia
| | - Gary Egan
- Monash Biomedical Imaging, Monash University, Australia
| | | | - Helmut Butzkueven
- Department of Neuroscience, Central Clinical School, Monash University, Australia
| | - Joanne Fielding
- Department of Neuroscience, Central Clinical School, Monash University, Australia
| | - Anneke van der Walt
- Department of Neuroscience, Central Clinical School, Monash University, Australia
| | - Scott Kolbe
- Department of Neuroscience, Central Clinical School, Monash University, Australia
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22
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González Gómez A, García-Ben A, Soler García A, García-Basterra I, Padilla Parrado F, García-Campos J. Longitudinal study of visual function in patients with relapsing-remitting multiple sclerosis with and without a history of optic neuritis. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2017.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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González Gómez A, García-Ben A, Soler García A, García-Basterra I, Padilla Parrado F, García-Campos J. Estudio longitudinal de la función visual en pacientes con esclerosis múltiple remitente-recurrente con y sin antecedentes de neuritis óptica. Neurologia 2019; 34:241-247. [DOI: 10.1016/j.nrl.2017.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 12/21/2016] [Accepted: 01/08/2017] [Indexed: 10/19/2022] Open
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24
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Polo V, Satue M, Gavin A, Vilades E, Orduna E, Cipres M, Garcia-Campayo J, Navarro-Gil M, Larrosa JM, Pablo LE, Garcia-Martin E. Ability of swept source OCT to detect retinal changes in patients with bipolar disorder. Eye (Lond) 2018; 33:549-556. [PMID: 30382239 DOI: 10.1038/s41433-018-0261-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 05/15/2018] [Accepted: 06/04/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To evaluate the ability of swept source optical coherence tomography (SS-OCT) to detect retinal changes in patients with bipolar disorder (BD). METHODS Twenty-three patients with BD and 23 controls underwent retinal evaluation using SS deep range imaging (DRI) Triton OCT. Full retinal thickness, the ganglion cell layer (GCL), the retinal nerve fiber layer (RNFL), and choroidal thickness were evaluated with automated segmentation software. RESULTS Patients with BD were shown to have significant thinning of the macular full retinal thickness in the center (p = 0.049), inner temporal (p = 0.045), inner nasal (p = 0.016), and inner inferior (p = 0.016) of the ETDRS areas. The macular GCL layer was reduced in patients compared with controls (average, p = 0.002; superior, p = 0.009; superonasal, p = 0.009; inferonasal, p = 0.003; and inferior, p = 0.009). Peripapillary reduction of full retinal thickness (average, p < 0.001; superotemporal, p < 0.001; superonasal, p = 0.003; nasal, p = 0.005; and inferotemporal, p = 0.033), GCL (nasal, p = 0.025), and RNFL thickness (average, p = 0.002; superotemporal, p < 0.001; and superonasal, p = 0.045) was observed in patients compared with controls. No significant differences were observed in choroidal thickness measurements. CONCLUSIONS BD patients were shown to have quantifiable thinning of full retinal thickness and the GCL in the macular area, as well as a peripapillary reduction of the RNFL and GCL thickness. The analysis of the retinal sublayers with SS-OCT may be a useful indicator to show degeneration and monitor disease progression in bipolar disorder.
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Affiliation(s)
- Vicente Polo
- Department of Ophthalmology, Miguel Servet University Hospital, Zaragoza, Spain.,Aragon Health Research Institute (IIS Aragon, IACS), Zaragoza, Spain
| | - Maria Satue
- Department of Ophthalmology, Miguel Servet University Hospital, Zaragoza, Spain. .,Aragon Health Research Institute (IIS Aragon, IACS), Zaragoza, Spain.
| | - Alicia Gavin
- Department of Ophthalmology, Miguel Servet University Hospital, Zaragoza, Spain.,Aragon Health Research Institute (IIS Aragon, IACS), Zaragoza, Spain
| | - Elisa Vilades
- Department of Ophthalmology, Miguel Servet University Hospital, Zaragoza, Spain.,Aragon Health Research Institute (IIS Aragon, IACS), Zaragoza, Spain
| | - Elvira Orduna
- Department of Ophthalmology, Miguel Servet University Hospital, Zaragoza, Spain.,Aragon Health Research Institute (IIS Aragon, IACS), Zaragoza, Spain
| | - Marta Cipres
- Department of Ophthalmology, Miguel Servet University Hospital, Zaragoza, Spain.,Aragon Health Research Institute (IIS Aragon, IACS), Zaragoza, Spain
| | - Javier Garcia-Campayo
- Aragon Health Research Institute (IIS Aragon, IACS), Zaragoza, Spain.,Department of Psychiatry, Miguel Servet University Hospital, Zaragoza, Spain
| | - Mayte Navarro-Gil
- Department of Psychology and Sociology, Faculty of Social and Human Sciences, University of Zaragoza, Zaragoza, Spain
| | - Jose M Larrosa
- Department of Ophthalmology, Miguel Servet University Hospital, Zaragoza, Spain.,Aragon Health Research Institute (IIS Aragon, IACS), Zaragoza, Spain
| | - Luis E Pablo
- Department of Ophthalmology, Miguel Servet University Hospital, Zaragoza, Spain.,Aragon Health Research Institute (IIS Aragon, IACS), Zaragoza, Spain
| | - Elena Garcia-Martin
- Department of Ophthalmology, Miguel Servet University Hospital, Zaragoza, Spain.,Aragon Health Research Institute (IIS Aragon, IACS), Zaragoza, Spain
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Longitudinal study of retinal nerve fiber layer thickness changes in a multiple sclerosis patients cohort: A long term 5 year follow-up. Mult Scler Relat Disord 2018; 19:124-128. [DOI: 10.1016/j.msard.2017.11.017] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/17/2017] [Accepted: 11/20/2017] [Indexed: 11/21/2022]
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26
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Moccia M, de Stefano N, Barkhof F. Imaging outcome measures for progressive multiple sclerosis trials. Mult Scler 2017; 23:1614-1626. [PMID: 29041865 PMCID: PMC5650056 DOI: 10.1177/1352458517729456] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 07/28/2017] [Indexed: 11/16/2022]
Abstract
Imaging markers that are reliable, reproducible and sensitive to neurodegenerative changes in progressive multiple sclerosis (MS) can enhance the development of new medications with a neuroprotective mode-of-action. Accordingly, in recent years, a considerable number of imaging biomarkers have been included in phase 2 and 3 clinical trials in primary and secondary progressive MS. Brain lesion count and volume are markers of inflammation and demyelination and are important outcomes even in progressive MS trials. Brain and, more recently, spinal cord atrophy are gaining relevance, considering their strong association with disability accrual; ongoing improvements in analysis methods will enhance their applicability in clinical trials, especially for cord atrophy. Advanced magnetic resonance imaging (MRI) techniques (e.g. magnetization transfer ratio (MTR), diffusion tensor imaging (DTI), spectroscopy) have been included in few trials so far and hold promise for the future, as they can reflect specific pathological changes targeted by neuroprotective treatments. Positron emission tomography (PET) and optical coherence tomography have yet to be included. Applications, limitations and future perspectives of these techniques in clinical trials in progressive MS are discussed, with emphasis on measurement sensitivity, reliability and sample size calculation.
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Affiliation(s)
- Marcello Moccia
- NMR Research Unit, Queen Square MS Centre, UCL Institute of Neurology, University College London, London, UK; Multiple Sclerosis Clinical Care and Research Centre, Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples Federico II, Naples, Italy
| | - Nicola de Stefano
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Frederik Barkhof
- NMR Research Unit, Queen Square MS Centre, UCL Institute of Neurology, University College London, London, UK; Translational Imaging Group, UCL Institute of Healthcare Engineering, University College London, London, UK; Department of Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, The Netherlands
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27
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Klistorner A, Graham EC, Yiannikas C, Barnett M, Parratt J, Garrick R, Wang C, You Y, Graham SL. Progression of retinal ganglion cell loss in multiple sclerosis is associated with new lesions in the optic radiations. Eur J Neurol 2017; 24:1392-1398. [PMID: 28799222 DOI: 10.1111/ene.13404] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 07/04/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE The mechanism of retinal ganglion cell and retinal nerve fiber layer loss in multiple sclerosis (MS) remains unknown. This study aimed to investigate the association between temporal retinal nerve fiber layer (tRNFL) thinning and disease activity in the brain determined by T2 lesions on magnetic resonance imaging (MRI). METHODS Fifty-five consecutive patients with relapsing-remitting MS and 25 controls were enrolled. All patients underwent annual optical coherence tomography and high-resolution MRI scans for tRNFL thickness and brain lesion volume analysis, respectively. RESULTS Significant tRNFL thickness reduction was observed over the 3-year follow-up period at a relatively constant rate (1.02 μm/year). Thinning of tRNFL fibers was more prominent in younger patients (P = 0.01). The tRNFL loss was associated with new MRI lesions in the optic radiations (ORs). There was significantly greater tRNFL thinning in patients with new lesional activity in the ORs compared with patients with new lesions outside the ORs (P = 0.009). CONCLUSIONS This study supports the notion that retrograde transneuronal degeneration caused by OR lesions might play a role in progressive retinal nerve fiber layer loss. In addition, the results of the study also indicate that the disease-related neurodegenerative changes in the retina start much earlier than the clinical diagnosis of MS.
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Affiliation(s)
- A Klistorner
- Save Sight Institute, Sydney Medical School, University of Sydney, Sydney, NSW.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW.,Sydney Neuroimaging Analysis Centre, Sydney, NSW
| | - E C Graham
- Save Sight Institute, Sydney Medical School, University of Sydney, Sydney, NSW
| | | | - M Barnett
- Sydney Neuroimaging Analysis Centre, Sydney, NSW.,Brain and Mind Centre, University of Sydney, Sydney, NSW
| | - J Parratt
- Royal North Shore Hospital, Sydney, NSW
| | - R Garrick
- St Vincent's Hospital, Sydney, NSW, Australia
| | - C Wang
- Sydney Neuroimaging Analysis Centre, Sydney, NSW.,Brain and Mind Centre, University of Sydney, Sydney, NSW
| | - Y You
- Save Sight Institute, Sydney Medical School, University of Sydney, Sydney, NSW.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW
| | - S L Graham
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW
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28
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Garcia-Martin E, Ara JR, Martin J, Almarcegui C, Dolz I, Vilades E, Gil-Arribas L, Fernandez FJ, Polo V, Larrosa JM, Pablo LE, Satue M. Retinal and Optic Nerve Degeneration in Patients with Multiple Sclerosis Followed up for 5 Years. Ophthalmology 2017; 124:688-696. [DOI: 10.1016/j.ophtha.2017.01.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 01/03/2017] [Accepted: 01/03/2017] [Indexed: 11/30/2022] Open
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Abstract
Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system. Magnetic resonance imaging (MRI) is sensitive to lesion formation both in the brain and spinal cord. Imaging plays a prominent role in the diagnosis and monitoring of MS. Over a dozen anti-inflammatory therapies are approved for MS and the development of many of these medications was made possible through the use of contrast-enhancing lesions on MRI as a phase II outcome. A similar phase II outcome method for the neurodegeneration that underlies progressive courses of the disease is still unavailable. Although magnetic resonance is an invaluable tool for the diagnosis and monitoring of treatment effects in MS, several imaging barriers still exist. In general, MRI is less sensitive to gray matter lesions, lacks pathological specificity, and does not provide quantitative data easily. Several advanced imaging methods including diffusion tensor imaging, magnetization transfer, functional MRI, myelin water fraction imaging, ultra-high field MRI, positron emission tomography, and optical coherence tomography of the retina study promising ways of overcoming the difficulties in MS imaging.
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Affiliation(s)
- Daniel Ontaneda
- Mellen Center for Multiple Sclerosis, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA.
| | - Robert J Fox
- Mellen Center for Multiple Sclerosis, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
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30
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Abstract
Due to the heterogeneous nature of the disease, it is a challenge to capture disease activity of multiple sclerosis (MS) in a reliable and valid way. Therefore, it can be difficult to assess the true efficacy of interventions in clinical trials. In phase III trials in MS, the traditionally used primary clinical outcome measures are the Expanded Disability Status Scale and the relapse rate. Secondary outcome measures in these trials are the number or volume of T2 hyperintense lesions and gadolinium-enhancing T1 lesions on magnetic resonance imaging (MRI) of the brain. These secondary outcome measures are often primary outcome measures in phase II trials in MS. Despite several limitations, the traditional clinical measures are still the mainstay for assessing treatment efficacy. Newer and potentially valuable outcome measures increasingly used or explored in MS trials are, clinically, the MS Functional Composite and patient-reported outcome measures, and on MRI, brain atrophy and the formation of persisting black holes. Several limitations of these measures have been addressed and further improvements will probably be proposed. Major improvements are the coverage of additional functional domains such as cognitive functioning and assessment of the ability to carry out activities of daily living. The development of multidimensional measures is promising because these measures have the potential to cover the full extent of MS activity and progression. In this review, we provide an overview of the historical background and recent developments of outcome measures in MS trials. We discuss the advantages and limitations of various measures, including newer assessments such as optical coherence tomography, biomarkers in body fluids and the concept of 'no evidence of disease activity'.
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Affiliation(s)
- Caspar E. P. van Munster
- Department of Neurology, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, De Boelelaan 1117, 1081 Amsterdam, The Netherlands
| | - Bernard M. J. Uitdehaag
- Department of Neurology, Amsterdam Neuroscience, VUmc MS Center Amsterdam, VU University Medical Center, De Boelelaan 1117, 1081 Amsterdam, The Netherlands
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Optical Coherence Tomography as a Biomarker for Diagnosis, Progression, and Prognosis of Neurodegenerative Diseases. J Ophthalmol 2016; 2016:8503859. [PMID: 27840739 PMCID: PMC5093273 DOI: 10.1155/2016/8503859] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 06/28/2016] [Accepted: 09/27/2016] [Indexed: 01/28/2023] Open
Abstract
Neurodegenerative diseases present a current challenge for accurate diagnosis and for providing precise prognostic information. Developing imaging biomarkers for multiple sclerosis (MS), Parkinson disease (PD), and Alzheimer's disease (AD) will improve the clinical management of these patients and may be useful for monitoring treatment effectiveness. Recent research using optical coherence tomography (OCT) has demonstrated that parameters provided by this technology may be used as potential biomarkers for MS, PD, and AD. Retinal thinning has been observed in these patients and new segmentation software for the analysis of the different retinal layers may provide accurate information on disease progression and prognosis. In this review we analyze the application of retinal evaluation using OCT technology to provide better understanding of the possible role of the retinal layers thickness as biomarker for the detection of these neurodegenerative pathologies. Current OCT analysis of the retinal nerve fiber layer and, specially, the ganglion cell layer thickness may be considered as a good biomarker for disease diagnosis, severity, and progression.
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32
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Hamurcu M, Orhan G, Sarıcaoğlu MS, Mungan S, Duru Z. Analysis of multiple sclerosis patients with electrophysiological and structural tests. Int Ophthalmol 2016; 37:649-653. [PMID: 27538913 DOI: 10.1007/s10792-016-0324-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 08/11/2016] [Indexed: 01/12/2023]
Abstract
We aimed to analyze the effects of progressive myelin loss and neurodegeneration seen in patients with multiple sclerosis (MS) on visual tract with electrophysiological and structural tests. Fifty-one patients diagnosed with MS in the Neurology Department were followed up in neuro-ophthalmology outpatient clinic irrespective of their visual symptoms, and were included in our study. The patients were classified as the ones with the history of optic neuritis (group II) and ones without the history (group I) of optic neuritis. The data, including clinical presentation, retinal nerve fiber layer thickness (RNFLT) measurements, pattern visual evoked potential (pVEP) and flash electro retino grams (ERG) test results, were recorded. In our study, comparison of pVEP test latencies of groups I and II with each other, and with those of healthy subjects revealed statistically significant differences (p < 0.05). The analysis of rod functions on ERG did not show any significant changes (p > 0.05). However, both groups showed significantly decreased cone b-wave amplitudes, elongation of latencies, and decreased flicker amplitudes on cone and flicker potentials obtained after light adaptation (p < 0.05). There was significant thinning in RNFLT of the both groups when compared to the normal standards. The difference between two groups was statistically significant (p < 0.05). Axon loss is seen in the optic nerve with subclinical or acute optic neuritis in patients with MS. RNFLT analysis and electrophysiological tests are of great importance in diagnosis of MS, as well as to determine progression and to direct neuroprotective therapy in patients diagnosed with MS. Objective analysis methods gain more importance in the diagnosis and follow-up of MS patients, parallel to technological advancements.
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Affiliation(s)
- Mualla Hamurcu
- Department of Ophthalmology, Ankara Numune Education and Research Hospital, Ankara, Turkey.
| | - Gürdal Orhan
- Department of Neurology, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Murat Sinan Sarıcaoğlu
- Department of Ophthalmology, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Semra Mungan
- Department of Neurology, Ankara Numune Education and Research Hospital, Ankara, Turkey
| | - Zeynep Duru
- Department of Ophthalmology, Ankara Numune Education and Research Hospital, Ankara, Turkey
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33
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Leocani L, Rocca MA, Comi G. MRI and neurophysiological measures to predict course, disability and treatment response in multiple sclerosis. Curr Opin Neurol 2016; 29:243-53. [DOI: 10.1097/wco.0000000000000333] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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34
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Chilińska A, Ejma M, Turno-Kręcicka A, Guranski K, Misiuk-Hojlo M. Analysis of retinal nerve fibre layer, visual evoked potentials and relative afferent pupillary defect in multiple sclerosis patients. Clin Neurophysiol 2015; 127:821-826. [PMID: 26251105 DOI: 10.1016/j.clinph.2015.06.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 06/24/2015] [Accepted: 06/27/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of this study was to analyse retinal nerve fibre layer (RNFL), pattern-reversal visual evoked potentials (pVEPs) and relative afferent pupillary defect (RAPD) changes in multiple sclerosis (MS) patients with the consideration of past optic neuritis (ON). METHODS Ophthalmological, neurological, OCT, RNFL and pVEP studies were conducted in 59 MS patients. RAPD tests were performed in 47 of them. Control group consisted of 28 healthy volunteers. RESULTS Abnormal RNFL was found in 59% of cases of eyes with ON and 28% of eyes without ON. In eyes with ON, significantly lower RNFL values were indicated in the temporal and lower quadrants. Elongation of pVEP latency was found in 83% of eyes with ON and 60% of eyes without ON. The average value of pVEP latency was larger and the amplitude was lower in the subgroup of eyes with RNFL at the borderline or below the norm. RAPD was observed only in eyes with ON and with RNFL thinning. No association was found between the RAPD and pVEP parameters. CONCLUSIONS VEPs were more frequently abnormal than RNFL in MS patients. RNFL damage in eyes without ON may indicate neurodegenerations in CNS of MS patients; it can also be the consequence of subclinical ON. SIGNIFICANCE An analysis of RNFL and VEP can be useful for evaluating the optic nerve in MS patients.
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Affiliation(s)
- Adriana Chilińska
- Department of Ophthalmology, Wroclaw Medical University, Wroclaw, Poland
| | - Maria Ejma
- Department of Neurology, Wroclaw Medical University, Wroclaw, Poland
| | | | | | - Marta Misiuk-Hojlo
- Department of Ophthalmology, Wroclaw Medical University, Wroclaw, Poland
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MacGillivray TJ, Trucco E, Cameron JR, Dhillon B, Houston JG, van Beek EJR. Retinal imaging as a source of biomarkers for diagnosis, characterization and prognosis of chronic illness or long-term conditions. Br J Radiol 2014; 87:20130832. [PMID: 24936979 PMCID: PMC4112401 DOI: 10.1259/bjr.20130832] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 05/09/2014] [Accepted: 06/16/2014] [Indexed: 11/05/2022] Open
Abstract
The black void behind the pupil was optically impenetrable before the invention of the ophthalmoscope by von Helmholtz over 150 years ago. Advances in retinal imaging and image processing, especially over the past decade, have opened a route to another unexplored landscape, the retinal neurovascular architecture and the retinal ganglion pathways linking to the central nervous system beyond. Exploiting these research opportunities requires multidisciplinary teams to explore the interface sitting at the border between ophthalmology, neurology and computing science. It is from the detail and depth of retinal phenotyping that novel metrics and candidate biomarkers are likely to emerge. Confirmation that in vivo retinal neurovascular measures are predictive of microvascular change in the brain and other organs is likely to be a major area of research activity over the next decade. Unlocking this hidden potential within the retina requires integration of structural and functional data sets, that is, multimodal mapping and longitudinal studies spanning the natural history of the disease process. And with further advances in imaging, it is likely that this area of retinal research will remain active and clinically relevant for many years to come. Accordingly, this review looks at state-of-the-art retinal imaging and its application to diagnosis, characterization and prognosis of chronic illness or long-term conditions.
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Affiliation(s)
- T J MacGillivray
- Vampire Project, Clinical Research Imaging Centre, University of Edinburgh, Edinburgh, UK
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36
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Lavery AM, Verhey LH, Waldman AT. Outcome measures in relapsing-remitting multiple sclerosis: capturing disability and disease progression in clinical trials. Mult Scler Int 2014; 2014:262350. [PMID: 24883205 PMCID: PMC4026972 DOI: 10.1155/2014/262350] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 02/25/2014] [Indexed: 11/24/2022] Open
Abstract
Multiple sclerosis (MS) is a chronic inflammatory and neurodegenerative disease that manifests as acute relapses and progressive disability. As a primary endpoint for clinical trials in MS, disability is difficult to both characterize and measure. Furthermore, the recovery from relapses and the rate of disability vary considerably among patients. Given these challenges, investigators have developed and studied the performance of various outcome measures and surrogate endpoints in MS clinical trials. This review defines the outcome measures and surrogate endpoints used to date in MS clinical trials and presents challenges in the design of both adult and pediatric trials.
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Affiliation(s)
- Amy M. Lavery
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Leonard H. Verhey
- The Pediatric Demyelinating Disease Program, Program in Neuroscience & Mental Health, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada M5G 1X8
| | - Amy T. Waldman
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
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37
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Martínez-Lapiscina EH, Ortiz-Pérez S, Fraga-Pumar E, Martínez-Heras E, Gabilondo I, Llufriu S, Bullich S, Figueras M, Saiz A, Sánchez-Dalmau B, Villoslada P. Colour vision impairment is associated with disease severity in multiple sclerosis. Mult Scler 2014; 20:1207-16. [DOI: 10.1177/1352458513517591] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2013] [Accepted: 11/29/2013] [Indexed: 01/21/2023]
Abstract
Background: Colour vision assessment correlates with damage of the visual pathway and might be informative of overall brain damage in multiple sclerosis (MS). Objective: The objective of this paper is to investigate the association between impaired colour vision and disease severity. Methods: We performed neurological and ophthalmic examinations, as well as magnetic resonance imaging (MRI) and optical coherence tomography (OCT) analyses, on 108 MS patients, both at baseline and after a follow-up of one year. Colour vision was evaluated by Hardy, Rand and Rittler plates. Dyschromatopsia was defined if colour vision was impaired in either eye, except for participants with optic neuritis (ON), for whom only the unaffected eye was considered. We used general linear models adjusted for sex, age, disease duration and MS treatment for comparing presence of dyschromatopsia and disease severity. Results: Impaired colour vision in non-ON eyes was detected in 21 out of 108 patients at baseline. At baseline, patients with dyschromatopsia had lower Multiple Sclerosis Functional Composite (MSFC) scores and Brief Repeatable Battery-Neuropsychology executive function scores than those participants with normal colour vision. In addition, these patients had thinner retinal nerve fiber layer (RNFL), and smaller macular volume, normalized brain volume and normalized gray matter volume (NGMV) at baseline. Moreover, participants with incident dyschromatopsia after one-year follow-up had a greater disability measured by the Expanded Disability Status Scale and MSFC-20 and a greater decrease in NGMV than participants with normal colour vision. Conclusions: Colour vision impairment is associated with greater MS severity.
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Affiliation(s)
| | - Santiago Ortiz-Pérez
- Department of Ophthalmology, Institut D’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, Spain
| | - Elena Fraga-Pumar
- Center of Neuroimmunology and Department of Neurology, Hospital Clinic of Barcelona, Spain
| | - Eloy Martínez-Heras
- Center of Neuroimmunology and Department of Neurology, Hospital Clinic of Barcelona, Spain
| | - Iñigo Gabilondo
- Center of Neuroimmunology and Department of Neurology, Hospital Clinic of Barcelona, Spain
| | - Sara Llufriu
- Center of Neuroimmunology and Department of Neurology, Hospital Clinic of Barcelona, Spain
| | - Santiago Bullich
- Center of Neuroimmunology and Department of Neurology, Hospital Clinic of Barcelona, Spain
| | - Marc Figueras
- Department of Ophthalmology, Institut D’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, Spain
| | - Albert Saiz
- Center of Neuroimmunology and Department of Neurology, Hospital Clinic of Barcelona, Spain
| | - Bernardo Sánchez-Dalmau
- Center of Neuroimmunology and Department of Neurology, Hospital Clinic of Barcelona, Spain
- Department of Ophthalmology, Institut D’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic of Barcelona, Spain
| | - Pablo Villoslada
- Center of Neuroimmunology and Department of Neurology, Hospital Clinic of Barcelona, Spain
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38
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Garcia-Martin E, Calvo B, Malvè M, Herrero R, Fuertes I, Ferreras A, Larrosa JM, Polo V, Pablo LE. Three-dimensional geometries representing the retinal nerve fiber layer in multiple sclerosis, optic neuritis, and healthy eyes. Ophthalmic Res 2013; 50:72-81. [PMID: 23774269 DOI: 10.1159/000350413] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 01/24/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND To represent and interpret the three-dimensional (3D) geometry and the distribution of the axonal damage to the retinal nerve fiber layer (RNFL) in patients with multiple sclerosis (MS) compared with healthy subjects. To analyze alterations in RNFL morphology in eyes of MS patients with or without previous episodes of optic neuritis (ON). METHODS MS patients (n = 122) and age-matched healthy subjects (n = 108) were enrolled. The Spectralis optical coherence tomography system was used to determine the circumpapillary RNFL thickness. The 768 RNFL thickness measurements were used to evaluate thickness measurements in patients with or without antecedent ON and to design a 3D reconstruction of the RNFL thickness representing the mechanobiologic tissue response to neurodegeneration caused by MS and ON episodes. RESULTS RNFL thickness was decreased in MS patients, and was higher in the MS group with previous ON. Statistical analysis and 3D RNFL reconstruction revealed greater damage to the ganglionar cells in the superonasal RNFL area (101.77 µm in MS vs. 125.47 µm in healthy subjects) and in the inferotemporal RNFL (119.05 µm in MS eyes and 149.26 µm in healthy eyes). CONCLUSIONS The 3D representation of RNFL thickness based on measurements allows physicians to better observe damage in the temporal areas, especially in patients with previous ON.
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Affiliation(s)
- E Garcia-Martin
- Ophthalmology Department, Miguel Servet University Hospital, Zaragoza, Spain.
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Cetin EN, Erdogan C, Acer S, Sarac G, Yıldırım C, Bir LS. Decreased Ocular Pulse Amplitude and Retinal Nerve Fibre Layer in Multiple Sclerosis. Neuroophthalmology 2013; 37:95-99. [PMID: 28163762 DOI: 10.3109/01658107.2013.785001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 02/14/2013] [Accepted: 02/23/2013] [Indexed: 01/28/2023] Open
Abstract
This study was conducted to assess ocular pulse amplitude and retinal nerve fibre layer in patients with multiple sclerosis and their correlation with disease duration and with severity. Retinal nerve fibre layer thickness was measured by Heidelberg Retinal Tomography II (HRT-II; Heidelberg Engineering, Dossenheim, Germany) and ocular pulse amplitude was measured by dynamic contour tonometry (Ziemer Ophthalmic Systems, Port, Switzerland) in 37 multiple sclerosis patients and 72 age- and gender-matched controls. Ocular pulse amplitude was significantly reduced and retinal nerve fibre layer was significantly thinner in temporal, superotemporal, and nasal sectors in patients with multiple sclerosis regardless of having an optic neuritis attack. The retinal nerve fibre layer was thinner in eyes with a previous optic neuritis attack compared with the eyes without an attack, but the difference was not significant. Ocular pulse amplitude showed a positive correlation with visual evoked potential amplitude and a negative correlation with visual evoked potential latency. Retinal nerve fibre layer thickness showed a significant negative correlation with the disease duration but not with visually evoked potential, disease severity, nor previous optic neuritis. These findings indicate that the process of degeneration starts in the early period of the disease, as our study group is composed of early-middle-stage multiple sclerosis patients, and is independent of relapses.
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Affiliation(s)
| | - Cagdas Erdogan
- Neurology, Faculty of Medicine, Pamukkale University Denizli Turkey
| | | | | | | | - Levent S Bir
- Neurology, Faculty of Medicine, Pamukkale University Denizli Turkey
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Huseyinoglu N, Ozben S, Ekinci M, Buyukuysal C, Yıldırım M, Safak H, Huseyin H. Optical Coherence Tomography in Patients with Relapsing-Remitting Multiple Sclerosis without Optic Neuritis: A 20-Month Longitudinal Study. Neuroophthalmology 2013; 37:104-110. [PMID: 28163764 DOI: 10.3109/01658107.2013.792358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 03/06/2013] [Accepted: 03/21/2013] [Indexed: 11/13/2022] Open
Abstract
Optical coherence tomography is supported and used as a technique for visualisation of neuro-axonal loss in multiple sclerosis, but there are also a few studies expressing the opposite view. The aim of our study was to investigate retinal nerve fibre layer and optic nerve head parameters in patients with multiple sclerosis without a history of prior optic neuritis and symptoms of a new clinical attack during the follow-up for a total of 20-month period. Full ophthalmic evaluation was performed for all of the participants. The baseline retinal nerve fibre layer and macular thicknesses and focal and global loss of macular volume values were significantly lower in the eyes of the patients with multiple sclerosis compared with the healthy controls. No significant change between baseline and follow-up scans were found in all optical coherence tomography parameters in the multiple sclerosis group. Statistical analyses revealed significant retinal nerve fibre layer and macular thickness differences between baseline and second measurements in the controls. No significant difference in percent change between baseline and second measurements was observed between the patient and control groups. We conclude that whereas healthy subjects have an age-related tendency toward a decrease in retinal nerve fibre layer thickness, patients with multiple sclerosis patients are likely to pass through different stages of retinal thinning and thickening due to subclinical optic neuritis and, as a result, we could not detect any statistically significant change between baseline and second measurements in our multiple sclerosis patients.
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Affiliation(s)
| | | | - Metin Ekinci
- Department of Ophthalmology Kafkas University Medical Faculty Kars, Turkey
| | - Cagatay Buyukuysal
- Department of Biostatistics Bülent Ecevit University Medical Faculty, Zonguldak Turkey
| | | | | | - Halil Huseyin
- Department of Ophthalmology Kafkas University Medical Faculty Kars, Turkey
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Biomarkers in Multiple Sclerosis: An Up-to-Date Overview. Mult Scler Int 2013; 2013:340508. [PMID: 23401777 PMCID: PMC3564381 DOI: 10.1155/2013/340508] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Revised: 12/13/2012] [Accepted: 12/18/2012] [Indexed: 12/16/2022] Open
Abstract
During the last decades, the effort of establishing satisfactory biomarkers for multiple sclerosis has been proven to be very difficult, due to the clinical and pathophysiological complexities of the disease. Recent knowledge acquired in the domains of genomics-immunogenetics and neuroimmunology, as well as the evolution in neuroimaging, has provided a whole new list of biomarkers. This variety, though, leads inevitably to confusion in the effort of decision making concerning strategic and individualized therapeutics. In this paper, our primary goal is to provide the reader with a list of the most important characteristics that a biomarker must possess in order to be considered as reliable. Additionally, up-to-date biomarkers are further divided into three subgroups, genetic-immunogenetic, laboratorial, and imaging. The most important representatives of each category are presented in the text and for the first time in a summarizing workable table, in a critical way, estimating their diagnostic potential and their efficacy to correlate with phenotypical expression, neuroinflammation, neurodegeneration, disability, and therapeutical response. Special attention is given to the "gold standards" of each category, like HLA-DRB1∗ polymorphisms, oligoclonal bands, vitamin D, and conventional and nonconventional imaging techniques. Moreover, not adequately established but quite promising, recently characterized biomarkers, like TOB-1 polymorphisms, are further discussed.
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