Ocular Fundus Photography Research Articles

Ocular Fundus Photography as a Tool to Study Stroke and Dementia.

Although cerebral small vessel disease has been linked to stroke and dementia, due to limitations of current neuroimaging technology, direct in vivo visualization of changes in the cerebral small vessels (e.g., cerebral arteriolar narrowing, tortuous microvessels, blood-brain barrier damage, capillary microaneurysms) is difficult to achieve. As the retina and the brain share similar embryological origin, anatomical features, and physiologic properties with the cerebral small vessels, the retinal vessels offer a unique and easily accessible "window" to study the correlates and consequences of cerebral small vessel diseases in vivo. The retinal microvasculature can be visualized, quantified and monitored noninvasively using ocular fundus photography. Recent clinic- and population-based studies have demonstrated a close link between retinal vascular changes seen on fundus photography and stroke and dementia, suggesting that ocular fundus photography may provide insights to the contribution of microvascular disease to stroke and dementia. In this review, we summarize current knowledge on retinal vascular changes, such as retinopathy and changes in retinal vascular measures with stroke and dementia as well as subclinical makers of cerebral small vessel disease, and discuss the possible clinical implications of these findings in neurology. Studying pathologic changes of retinal blood vessels may be useful for understanding the etiology of various cerebrovascular conditions; hence, ocular fundus photography can be potentially translated into clinical practice.

Ocular Fundus Photography as an Educational Tool.

The proficiency of nonophthalmologists with direct ophthalmoscopy is poor, which has prompted a search for alternative technologies to examine the ocular fundus. Although ocular fundus photography has existed for decades, its use has been traditionally restricted to ophthalmology clinical care settings and textbooks. Recent research has shown a role for nonmydriatic fundus photography in nonophthalmic settings, encouraging more widespread adoption of fundus photography technology. Recent studies have also affirmed the role of fundus photography as an adjunct or alternative to direct ophthalmoscopy in undergraduate medical education. In this review, the authors examine the use of ocular fundus photography as an educational tool and suggest future applications for this important technology. Novel applications of fundus photography as an educational tool have the potential to resurrect the dying art of funduscopy.

How can ocular fundus photography inform the neurologist?

How can ocular fundus photography inform the neurologist?

Ocular fundus photography of patients with focal neurologic deficits in an emergency department.

We evaluated the frequency and predictive value of ocular fundus abnormalities among patients who presented to the emergency department (ED) with focal neurologic deficits to determine the utility of these findings in the evaluation of patients with suspected TIA and stroke. In this cross-sectional pilot study, ocular fundus photographs were obtained using a nonmydriatic fundus camera. Demographic, neuroimaging, and ABCD(2) score components were collected. Photographs were reviewed for retinal microvascular abnormalities. The results were analyzed using univariate statistics and logistic regression modeling. Two hundred fifty-seven patients presented to the ED with focal neurologic deficits, of whom 81 patients (32%) had cerebrovascular disease (CVD) and 144 (56%; 95% confidence interval: 50%-62%) had retinal microvascular abnormalities. Focal and general arteriolar narrowing increased the odds of clinically diagnosed CVD by 5.5 and 2.6 times, respectively, after controlling for the ABCD(2) score and diffusion-weighted imaging. These fundus findings also significantly differentiated TIA from non-CVD, even after controlling for the ABCD(2) score. Focal and general arteriolar narrowing were independent predictors of CVD overall, and TIA alone, even after controlling for the ABCD(2) score and diffusion-weighted imaging lesions. The inclusion of nonmydriatic ocular fundus photographs in the evaluation of patients presenting to the ED with focal neurologic deficits may assist in the differentiation of stroke and TIA from other causes of focal neurologic deficits.

A cautionary tale about a global problem.

Direct fundoscopy vs nonmydriatic ocular fundus photography—which is more reliable in untrained hands? I read with interest the editorial on the dying (or rather already dead) ophthalmoscopic skills of neurologists and the advent and superiority of nonmydriatic ocular fundus photography over direct fundoscopic examination. There is a saying that “the eye cannot see what the mind does not know,” and the 2 cases cited by Kattah and Halmagyi1 are examples of this rather than a failure …

Nonmydriatic ocular fundus photography in neurologic emergencies.

The ocular fundus examination is infrequently and poorly performed in clinical settings, placing patients at risk for missed and delayed diagnosis of vision- and life-threatening neurologic disease. To review the importance of ocular fundus examination, the limitations of direct ophthalmoscopy, and the relative merits of nonmydriatic ocular fundus photography in emergency neurologic diagnosis. PubMed queries were reviewed for articles of relevance to this review. Queries included relevant combinations of the search terms ophthalmoscopy, nonmydriatic, neurology, and emergency, including variant spellings and endings. Nonmydriatic ocular fundus photography is more sensitive than direct ophthalmoscopy in several settings. It can be feasibly performed in emergency departments and has substantial promise in improving neurologic diagnosis, particularly headache and cerebrovascular disease. Nonmydriatic ocular fundus photography has notable advantages over direct ophthalmoscopy that likely outweigh its associated costs. More widespread deployment and integration into neurologic practice is expected to improve diagnosis and patient outcomes.

Chorioretinal scars and visual deprivation are common in children with cochlear implants after congenital cytomegalovirus infection.

The aim of this study was to compare visual function and ocular characteristics in children with cochlear implants, due to severe hearing impairment caused by the congenital cytomegalovirus (CMV) infection, with control children fitted with cochlear implants due to connexin 26 mutations (Cx26), a genetic cause of hearing impairment. We carried out ophthalmological assessments, including visual acuity, ocular alignment, Ocular Motor Score, biomicroscopy and fundus photography, on 26 children with congenital CMV (median age 8.3 years, range 1.4-16.7) and 13 Cx26 controls (median age 5.6 years, range 1.7-12.5). We found unilateral chorioretinal macular scars that reduced best-corrected visual acuity ≤0.3 in five (19%) of the children with congenital CMV, but in none of the children with Cx26 (p = 0.15). Ocular motility problems were more common among children with congenital CMV, but the difference was not significant (p = 0.20). The vestibulo-ocular reflex was more frequently pathological in children with congenital CMV (p = 0.011). Ocular complications with central chorioretinal scars and ocular motility disturbances were common in children treated with cochlear implants due to severe hearing impairment caused by the congenital CMV infection. Ophthalmological assessments are advisable in such children for early identification, intervention and follow-up.

Ocular biocompatibility evaluation of hydroxyl-functionalized graphene.

We have presented our recent efforts on genotoxicity and intraocular biocompatibility of hydroxylated graphene (G-OH) prepared by ball milling. We have previously demonstrated that the as-synthesized G-OH could be considered as an excellent alternative for graphene oxide which had been applied widely. Following our last report on G-OH, we carried out detailed studies on genotoxicity and in vivo biocompatibility of G-OH in this work. Less than 5% enhanced caspase-3 level was observed for cells exposed to more than 50 μg/mL G-OH over 72 h, suggesting G-OH caused cell apoptosis was slight. The G-OH induced DNA damage was also found to be mild since expression of p53 and ROS regeneration level was quite low even at high concentration of G-OH over a long time. Cell viability was found to be higher than 90% with 50 μg/mL G-OH and 80% with 100 μg/mL G-OH using flow cytometry. Comet results suggested that less than 5% tail could be found with 100 μg/mL G-OH. TEM results confirmed that G-OH could penetrate into and out of the cytoplasm by means of endocytosis and exocytosis without causing damage on cell membranes. In vivo biocompatibility of G-OH was studied by intravitreal injection of G-OH into rabbits. The ocular fundus photography results showed that G-OH could be diffused in the vitreous body gradually without any damage caused. Injection of G-OH had caused few damages on eyesight related functions such as intraocular pressure, electroretinogram and histological structures of the retina.

Enhanced Oxidative Stress and Other Potential Biomarkers for Retinopathy in Type 2 Diabetics: Beneficial Effects of the Nutraceutic Supplements.

We have studied the global risk of retinopathy in a Mediterranean population of type 2 diabetes mellitus (T2DM) patients, according to clinical, biochemical, and lifestyle biomarkers. The effects of the oral supplementation containing antioxidants/omega 3 fatty acids (A/ω3) were also evaluated. Suitable participants were distributed into two main groups: (1) T2DMG (with retinopathy (+DR) or without retinopathy (−DR)) and (2) controls (CG). Participants were randomly assigned (+A/ω3) or not (−A/ω3) to the oral supplementation with a daily pill of Nutrof Omega (R) for 18 months. Data collected including demographics, anthropometrics, characteristics/lifestyle, ophthalmic examination (best corrected visual acuity, ocular fundus photographs, and retinal thickness as assessed by optical coherence tomography), and blood parameters (glucose, glycosylated hemoglobin, triglycerides, malondialdehyde, and total antioxidant capacity) were registered, integrated, and statistically processed by the SPSS 15.0 program. Finally, 208 participants (130 diabetics (68 +DR/62 −DR) and 78 controls) completed the follow-up. Blood analyses confirmed that the T2DMG+DR patients had significantly higher oxidative stress (p < 0.05), inflammatory (p < 0.05), and vascular (p < 0.001) risk markers than the T2DMG−DR and the CG. Furthermore, the A/ω3 oral supplementation positively changed the baseline parameters, presumptively by inducing metabolic activation and ameliorating the ocular health after 18 months of supplementation.

Choroidal thickness in diabetic patients of Indian ethnicity.

Purpose:To evaluate choroidal thickness (CT) change in various grades of diabetic retinopathy (DR) in comparison to age-matched healthy subjects.Methods:This prospective observational study included 227 eyes of 125 subjects with diabetes (study group: 58 females) and 197 eyes of 110 age-matched healthy subjects (control group: 66 females). Collected data included age, gender, duration of diabetes, glycemic control, comprehensive ocular examination, fundus photography, and CT measurement on spectral domain ocular coherence tomography using enhanced depth imaging.Results:Mean age in the study group was 57.0 ± 9.37 years (43–73 years). The mean age was 41.48 ± 5.43 years in the control group. Subjects with diabetes with (252.8 ± 55.6 microns) and without (261.71 ± 51.8 microns) retinopathy had significantly thinner choroids when compared to the control group (281.7 ± 47.7 microns; P = 0.032). Seventy-four of 227 eyes did not have any evidence of DR, 89 eyes had features of nonproliferative diabetic retinopathy (NPDR), and 33 eyes had treatment naïve proliferative diabetic retinopathy (PDR). Thirty-one PDR eyes had received previous laser photocoagulation. Subjects with diabetes without retinopathy had a greater subfoveal choroidal thickness (SFCT) than subjects with diabetes with retinopathy (P < 0.001). Eyes with PDR (243.9 ± 56.2 microns) had thinner SFCT than those with NPDR (238.98 ± 111.23 microns). There was no difference in the SFCT between treated (laser photocoagulation done; 251.784 ± 103.72 microns) and treatment naïve PDR (258.405 ± 89.47 microns, P = 0.23).Conclusions:Control eyes had greater SFCT compared to subjects with diabetes, with and without retinopathy. The thinning progressed with increasing severity of DR. Choroidal thinning may contribute to DR pathogenesis.

Telemedicine for evaluation of retinopathy of prematurity.

Retinopathy of prematurity (ROP) remains a significant threat to vision for extremely premature infants despite the availability of therapeutic modalities capable, in most cases, of managing this disorder. It has been shown in many controlled trials that application of therapies at the appropriate time is essential to successful outcomes in premature infants affected by ROP. Bedside binocular indirect ophthalmoscopy has been the standard technique for diagnosis and monitoring of ROP in these patients. However, implementation of routine use of this screening method for at-risk premature infants has presented challenges within our existing care systems, including relative local scarcity of qualified ophthalmologist examiners in some locations and the remote location of some NICUs. Modern technology, including the development of wide-angle ocular digital fundus photography, coupled with the ability to send digital images electronically to remote locations, has led to the development of telemedicine-based remote digital fundus imaging (RDFI-TM) evaluation techniques. These techniques have the potential to allow the diagnosis and monitoring of ROP to occur in lieu of the necessity for some repeated on-site examinations in NICUs. This report reviews the currently available literature on RDFI-TM evaluations for ROP and outlines pertinent practical and risk management considerations that should be used when including RDFI-TM in any new or existing ROP care structure.

The demise of direct ophthalmoscopy: A modern clinical challenge.

Ocular funduscopy appears to be a dying art. Physicians and medical students alike lack confidence in the use of an ophthalmoscope. As a result, few clinicians perform ophthalmoscopy, and many who do are unable to reliably detect abnormalities of the ocular fundus. Approaches to remediation in undergraduate medical education have included simulators, longitudinal skill reinforcement, Web-based teaching, and other techniques. Preservation of the ophthalmoscopic art has been hindered by technical difficulty, waning enthusiasm for ophthalmoscopy, and even discouragement from preceptors in medical education. Ocular fundus photography may serve a role in medical education to help improve student confidence in interpretation of ocular fundus findings and improve awareness of the importance of examination of the ocular fundus. Because neurology clerkships and clinical practices remain an important forum for honing ocular funduscopy skills, the neurologist should be familiar with novel alternative techniques that facilitate examination of the ocular fundus.

Nonmydriatic Ocular Fundus Photography Among Patients with Focal Neurologic Deficits in an Emergency Department (ED) (P3.096)

Nonmydriatic Ocular Fundus Photography Among Patients with Focal Neurologic Deficits in an Emergency Department (ED) (P3.096)

Nonmydriatic retinal photography in the evaluation of acute neurologic conditions

Ocular fundus examination is a fundamental component of the neurologic examination. Finding papilledema in headache patients or retinal arterial emboli in stroke patients can be extremely useful. Although examination of the ocular fundus with a direct ophthalmoscope is an important skill for all neurologists, it is rarely and unreliably performed. Nonmydriatic ocular fundus photography, which allows direct visualization of high-quality photographs of the ocular fundus, has been recently proposed for screening neurologic patients in urgent care settings such as emergency departments. This new technology has many potential applications in neurology, including e-transmission of images for remote interpretation.

Nonmydriatic retinal photography in the evaluation of acute neurologic conditions

Ocular fundus examination is a fundamental component of the neurologic examination. Finding papilledema in headache patients or retinal arterial emboli in stroke patients can be extremely useful. Although examination of the ocular fundus with a direct ophthalmoscope is an important skill for all neurologists, it is rarely and unreliably performed. Nonmydriatic ocular fundus photography, which allows direct visualization of high-quality photographs of the ocular fundus, has been recently proposed for screening neurologic patients in urgent care settings such as emergency departments. This new technology has many potential applications in neurology, including e-transmission of images for remote interpretation.

Nonmydriatic ocular fundus photography among headache patients in an emergency department

Thulasi et al.1 studied the importance of funduscopic examination in patients with headache. Fundus findings are well-described in noncommunicable diseases such as hypertension, diabetes mellitus, and congenital and hereditary metabolic disorders but not in infectious diseases.2 Retinopathy has been reported in some infectious diseases like malaria, infective endocarditis, cysticercosis, HIV, and dengue.2,3 Fundus findings would aid clinicians in rural settings or underdeveloped environments in reaching a diagnosis depending on the prevalent disease in that area.

Teaching Ophthalmoscopy to Medical Students (the TOTeMS Study)

To determine medical student preferences for learning the ocular fundus examination and to assess their accuracy using different examination modalities. Prospective, randomized study of medical student education approaches. First-year medical students received training in direct ophthalmoscopy using simulators and human volunteers. Students were randomized to receive vs not receive specific training on interpreting fundus photographs prior to accuracy assessments. Students' preferences for each of the 3 methods (direct ophthalmoscopy on simulators or human volunteers, or use of fundus photographs) and recognition of normal and abnormal fundus features were assessed. Of 138 first-year medical students, 119 (86%) completed all required elements. For learning ophthalmoscopy, 85 (71%) preferred humans to simulators. For learning relevant features of the ocular fundus, 92 (77%) preferred photographs to ophthalmoscopy on simulators or humans. Accuracy of answers was better when interpreting fundus photographs than when performing ophthalmoscopy on simulators (P < .001). Performance improved after specific teaching about assessing fundus photographs before testing (P = .02). Examination of the ocular fundus was found easier and less frustrating when using photographs than when using ophthalmoscopy on simulators or humans. Eighty-four students (70%) said they would prefer to have fundus photographs instead of using the ophthalmoscope during upcoming clinical rotations. Students preferred fundus photographs for both learning and examining the ocular fundus. Identification of ocular fundus features was more accurate on photographs compared to examination by direct ophthalmoscopy. In the future, the increasing availability of nonmydriatic ocular fundus photography may allow replacement of direct ophthalmoscopy in many clinical settings for non-ophthalmologists.

Nonmydriatic ocular fundus photography among headache patients in an emergency department

Editors' Note: Direct ophthalmoscopy is sometimes omitted during the neurologic examination, even when it is necessary. There is no definite solution for this issue, Appleton et al. and Bruce et al. agree. But the former endorses appropriate and thorough clinical examination while the latter explains the benefit of nonmydriatic ocular fundus photography, especially when the ocular abnormalities are subtle. Distinguishing behavioral variant frontotemporal dementia (bvFTD) from Alzheimer disease (AD) can be challenging. In response to Hornberger, who argues that episodic memory deficit is a poor diagnostic predictor to discriminate bvFTD from AD, Mendez clarifies that their study looked at a select group of patients …

Health‐related quality of life – using the 15D instrument – of young adults with type 1 diabetes since childhood. Population‐based Oulu cohort study of diabetic retinopathy

The aim of this study was to evaluate the health-related quality of life (HRQoL) of young adults with type 1 diabetes (T1D) since childhood using the 15D instrument. The possible impact of diabetic retinopathy (DR) and proliferative diabetic retinopathy (PDR) on the HRQoL was focused on. During the years 1989-1990, the prevalence of DR was evaluated from ocular fundus photographs of a population-based cohort of children with T1D living in the Northern Osthrobothnia Hospital District, Finland. These 216 individuals were contacted 18 years later and invited for assessment of the 15D HRQoL as well as current stage of DR. The results were compared with age- and gender-standardized Finnish general population. The 15D data were obtained from 123 patients aged 29±3 years with a duration of diabetes of 23±4 years. The mean 15D score was similar in the patients with T1D and the general population [0.954±0.062 versus 0.964±0.052, respectively (p=0.085)]. However, the subgroup of patients with PDR (N=38) had a statistically significantly lower mean 15D score than those subjects with nonproliferative or no DR [0.931±0.086 versus 0.965±0.044, respectively (p=0.026)]. Young adults with T1D since childhood had 15D HRQoL score equal to that of age- and gender-standardized general population as long as no more severe than nonproliferative DR was present. Presence of PDR, not T1D of long duration per se, significantly impaired the 15D score.

Treatment of Acute Posterior Uveitis in a Porcine Model by Injection of Triamcinolone Acetonide Into the Suprachoroidal Space Using Microneedles

To evaluate the effect of triamcinolone acetonide (TA) administered into the suprachoroidal space (SCS) using a microneedle and compare it with intravitreal (IVT) TA injections in a porcine model of acute posterior segment inflammation. An IVT injection of balanced salt solution (BSS) or lipopolysaccharide (LPS) was followed 24 hours later with an injection of 0.2 mg or 2.0 mg of TA into the SCS or IVT. The SCS was accessed using microneedles in a minimally invasive procedure. Ocular inflammatory scores and IOP measurements were collected daily, whereas electroretinography, optical coherence tomography, and wide-field ocular fundus photography was performed on -1, 0, and 3 days after treatment. Aqueous and vitreous humor cell counts and protein levels and histopathology were also compared. Delivery of TA to the SCS using microneedles was simple, effective, and not associated with adverse effects or toxicity. SCS injection of low (0.2 mg) and high doses (2.0 mg) of TA was as effective in reducing acute inflammation in the ocular posterior segment as high-dose IVT injection. Low-dose SCS TA was also effective in reducing inflammation; however, low-dose IVT TA was not. Results from this study suggest that 0.2 mg and 2.0 mg of SCS TA was as effective in reducing inflammation as 2.0 mg IVT TA injection in a model of acute posterior segment inflammation. There were no adverse effects, increased IOP, or evidence of procedural or drug toxicity following injection of TA into the SCS in porcine eyes.