Ultra-widefield Imaging Research Articles

Longitudinal Assessment of AMD using Ultrawide Field Imaging – The Optos PEripheral RetinA (OPERA) Follow-up Study

PurposeWith the widespread availability of ultrawide field imaging, peripheral retinal abnormalities in age-related macular degeneration (AMD) have garnered attention. However, longitudinal studies on AMD peripheral findings are limited. This study aims to characterize and quantify these features over five years. DesignLongitudinal ancillary study. ParticipantsOptos PEripheral RetinA (OPERA) is an ancillary study of the Age-Related Eye Disease Study 2. A total of 137 OPERA participants (265 eyes) with gradable ultrawide field (UWF) color and autofluorescence imaging at year 5 (Y5) and year 10 (Y10) were included. MethodsUWF color and autofluorescence images were captured using Optos ultrawide field devices (Optos, Dunfermline, Scotland) and graded at the Wisconsin Reading Center for macular and peripheral AMD features using the 3-zone OPERA grid. Main Outcome MeasuresPresence of peripheral retinal lesions (Neovascular AMD, geographic atrophy (GA), drusen, increased pigment, decreased pigment, reticular pseudodrusen, reticular pigmentary changes, and cobblestone degeneration) and their association with central AMD progression. ResultsUWF color: In zone 1 at Y5, AMD severity scale (AMDSS) was ≤5 in 8%, 6-8 in 49%, noncentral and central GA in 15%, and neovascular AMD in 28%. In zone 1 at Y10, AMDSS was ≤5 in 6%, 6-8 in 30%, noncentral and central geographic atrophy in 27%, and neovascular AMD in 37%. In zone 2, peripheral AMD abnormalities in Y5 versus Y10 included: drusen 99% vs 99%, hyperpigmentation 11% vs 11%, and hypopigmentation 4% vs 7% respectively. Non-AMD peripheral degenerations were present in Y5 versus Y10: cobblestone 19% vs 30% and reticular pigmentary changes 25% vs 33% respectively. Among eyes with AMDSS 6-8 at Y5, progression to late AMD occurred in 41% without substantial peripheral findings and 41% with such findings, which include drusen of ≥1 disc area and/or any hypo or hyperpigmentation in zones 2 or 3. UWF autofluorescence: Reticular autofluorescence pattern was present in 22% of eyes at Y5 and 39% at Y10 with 5% and 6% of cases being most prominent outside of zone 1. GA was present in 53 eyes with mean area of 3.4mm2 (SD = 5.4) at Y5 and 91 eyes with mean area 7.7mm2 (SD = 9.7) at Y10. ConclusionsThe OPERA study reveals that AMD features often extend beyond the macula, suggesting that AMD is a panretinal disease. In this study peripheral findings were not associated with increased risk of progression to late AMD.

Open ultrawidefield fundus image dataset with disease diagnosis and clinical image quality assessment

Ultrawidefield fundus (UWF) images have a wide imaging range (200° of the retinal region), which offers the opportunity to show more information for ophthalmic diseases. Image quality assessment (IQA) is a prerequisite for applying UWF and is crucial for developing artificial intelligence-driven diagnosis and screening systems. Most image quality systems have been applied to the assessments of natural images, but whether these systems are suitable for evaluating the UWF image quality remains debatable. Additionally, existing IQA datasets only provide photographs of diabetic retinopathy (DR) patients and quality evaluation results applicable for natural image, neglecting patients’ clinical information. To address these issues, we established a real-world clinical practice ultra-widefield fundus images dataset, with 700 high-resolution UWF images and corresponding clinical information from six common fundus diseases and healthy volunteers. The image quality is annotated by three ophthalmologists based on the field of view, illumination, artifact, contrast, and overall quality. This dataset illustrates the distribution of UWF image quality across diseases in clinical practice, offering a foundation for developing effective IQA systems.

Morphology and incidence of drusen-like deposits in peripheral retina of eyes with high myopia.

To determine the morphology and incidence of peripheral drusen-like deposits (DLDs) in eyes with pathological myopia (PM) using ultra-widefield (UWF) fundus photographs and UWF optical coherence tomographic (OCT) images. Retrospective, observational case series study. We reviewed the medical records of 676 patients (1352 eyes) with high myopia (HM) who were examined in the Advanced Clinical Centre for Myopia between 2017 and 2021. The main outcome measures were the incidence and morphological characteristics of the DLDs in the peripheral retina detected by ultra-widefield (UWF) imaging devices. Sixty-six of the 1352 (4.9%) eyes had peripheral DLDs. In 5 eyes, the DLDs were found at the staphyloma edge. The mean age of the patients was 70.0 ± 13.0 (range, 46.0-92.0) years, and the mean axial length was 29.8 ± 2.4 mm. Myopic macular neovascularization (MNV) was found in 41 of the 66 eyes with DLDs (62.1%). Patients with drusen in Zone 2 were significantly older than those in Zone 3 (80 ± 13 vs 64 ± 13 years; P < 0.001). Ultra-widefield images showed that peripheral DLDs were present in 4.9% of highly myopic eyes. The findings in eyes with DLDs may provide a basis for the evaluations of the natural progression of peripheral retinal changes in eyes with PM.

Comparison of Geographic Atrophy Measurements Between Blue-Light Heidelberg Standard Field and Green-Light Optos Ultrawide Field Autofluorescence.

This study compared geographic atrophy (GA) measurements in the macula using standard 30° field and ultrawide field (UWF) fundus autofluorescence (FAF) imaging. Participants from Age-Related Eye Disease Study 2 (AREDS2) and Optos PEripheral RetinA (OPERA) studies with GA were included for comparison between standard field FAF with Heidelberg Spectralis and Optos 200Tx UWF FAF. Two time points 5years apart were evaluated. GA area (mm2) was recorded in the macular area for both imaging types and in the peripheral field for UWF. Of 102 paired images (73 subjects), the mean (SD) baseline GA area was 5.32 (6.36)mm2 with standard and 4.79 (5.87)mm2 with UWF FAF (P < 0.001). The mean difference between the two modalities was 0.52mm2 (95% confidence interval, -2.41 to 1.37). Progression of GA in 25 eyes over 5years showed a median annual growth rate of 1.28mm2 (range, 0.02 to 4.7) for standard and 1.34mm2 (range, 0.04 to 5.3) for UWF FAF (P = 0.49). The measurement of GA is larger on standard than on UWF FAF imaging. The observed difference may be due to image averaging and the use of blue versus green FAF. Similar GA progression with standard and UWF FAF suggests either may be used longitudinally, although not interchangeably. Further investigation is required with updated UWF technology. With the increasing adoption of UWF imaging modalities, this study suggests that Optos UWF FAF may be used longitudinally as an alternative to standard field FAF to monitor GA.

THE MINI-STEAMROLL: An Abbreviated Variation of the Steamroller Maneuver After Pneumatic Retinopexy for Rhegmatogenous Retinal Detachment.

To describe a novel positioning maneuver for patients with rhegmatogenous retinal detachment after pneumatic retinopexy (PnR). Single-center prospective case series of primary rhegmatogenous retinal detachments referred to St. Michael's Hospital, Toronto, Canada, between 2021 and 2023. All patients underwent PnR. Baseline ultra-widefield fundus imaging and repeat imaging 10 minutes after the gas injection was performed. After PnR, patients were instructed to perform the mini-steamroll maneuver, which consists of a face-down position for 10 minutes followed by positioning to the retinal break. The reduction of subretinal fluid volume after the initial face-down position was evaluated with clinical examination and ultra-widefield imaging. Six patients who presented with primary bullous rhegmatogenous retinal detachment and a sizable superior break were enrolled. The mini-steamroll maneuver resulted in a rapid and significant reduction of subretinal fluid in all patients with bullous rhegmatogenous retinal detachment and large superior breaks, allowing subretinal fluid to be expressed into the vitreous cavity with 10 minutes of face-down positioning. One patient required a sequential PnR. Primary retinal reattachment was achieved in all cases. This approach was well-tolerated by patients. This case series demonstrates that the mini-steamroll maneuver may be a suitable alternative for patient positioning after PnR in certain cases. The mini-steamroll is a simpler positioning regimen with the potential benefits of direct-to-break and full steamroller maneuver.

Successful Adjunctive Treatment of Bilateral Diffuse Uveal Melanocytic Proliferation (BDUMP) with High-Dose Intravenous Immunoglobulin Therapy (IVIG).

Purpose: The management of bilateral diffuse uveal melanocytic proliferation is controversial, with most earlier reports advocating for plasmapheresis. Here, we report a case of bilateral diffuse uveal melanocytic proliferation secondary to gastric adenocarcinoma that was successfully treated with adjunctive intravenous immunoglobulin, using a loading dose followed by a treat-and-extend strategy. Methods: Clinical case report with 3 years of follow-up including serial ophthalmologic examinations. Functional assessments included visual acuity and subjective visual complaints. Periodic anatomic assessments were performed including serial optical coherence tomography, ultra-widefield fundus imaging, multimodal angiography, and ophthalmic ultrasound. Results: A 75-year-old man presented with a 6-month history of blurry vision and difficulty with dark and light adaptation in both eyes. A diagnosis of bilateral diffuse uveal melanocytic proliferation was established based on clinical findings and subsequent discovery of an underlying gastric malignancy; the diagnosis of a paraneoplastic syndrome was further substantiated by documentation of cancer-associated antiretinal antibodies and serum reactivity against human retina by immunohistochemistry. Treatment with high-dose (2 g/kg) intravenous immunoglobulin was initiated with biweekly, followed by monthly, then q2-3 monthly dosing intervals. Meanwhile, the patient received surgical resection and systemic chemotherapy resulting in complete radiographic remission of the primary cancer. Over the course of 3 years, the patient has demonstrated clinically significant improvements in visual acuity and subjective visual function. Rapid and sustained anatomic improvements were observed in serous retinopathy and choroidal thickness. Conclusion: Intravenous immunoglobulin may be a viable adjunctive treatment option for some patients with bilateral diffuse uveal melanocytic proliferation.

Ultrawidefield Imaging of Nanophthalmos with Choroidal Congestion

Ultrawidefield Imaging of Nanophthalmos with Choroidal Congestion

Microvascular and Structural Characterization of Birdshot Chorioretinitis in Active and Inactive Phases.

Objective: This study aimed to examine microvascular changes and identify predictors of short-term quiescence in active birdshot chorioretinitis (BSCR). Methods: An observational, prospective, 12-month follow-up cohort study was conducted. BSCR eyes were clinically assessed at baseline, categorized as active or inactive, and reevaluated at 12 months. Based on their clinical activity at both timepoints, eyes were divided into three subgroups: active-to-inactive (A-I), consistently active (A-A), and consistently inactive (I-I). Structural OCT, OCT-angiography (OCT-A), and ultra-widefield imaging were utilized. Exam data from fundus and nasal subfields were analyzed for microvascular changes and quiescence predictors. Results: Sixty eyes from 30 BSCR patients (47% women, 53% men, mean age 59.7 ± 12.3 years) were included. In the A-I group (16 eyes), vascular density and perfusion indices increased in all subfields post-quiescence, contrasting with the other groups. Perifoveal looping in the superficial capillary plexus predicted quiescence at 12 months compared with the A-A group. Conclusions: Vascular density rises after complete inflammation control in BSCR, and perifoveal capillary loops serve as potential predictors of short-term quiescence in active BSCR.

Prevalence and spectrum of manifestations of tamoxifen retinopathy as assessed by multimodal and ultra-widefield retinal imaging

Background/ObjectivesTamoxifen has well-known retinal toxicity, but the epidemiology of this toxicity is poorly defined. This study aims to 1) evaluate the prevalence of tamoxifen retinopathy in a major northeastern metropolitan area based on multimodal retinal imaging and 2) determine whether the additional peripheral retina captured in ultra-widefield (UWF) imaging aids in the diagnosis of tamoxifen retinopathy. MethodsThis retrospective cohort study examined female patients initiated on tamoxifen for at least 12 months prior to their first retinal exam. Two independent graders performed blinded review of spectral-domain optical coherence tomography (OCT) images for evidence of macular toxicity and UWF images for signs of central and peripheral toxicity. A one-tailed two-proportion Z-test determined whether peripheral pigmentary changes were more prevalent in the tamoxifen cohort than age- and gender-matched controls. Results241 eyes from 123 patients were included in the tamoxifen cohort, and 258 eyes from 132 patients were included in the control cohort. Two patients demonstrated definitive tamoxifen retinopathy, for a prevalence of 1.6%. One patient demonstrated crystalline maculopathy on OCT and UWF imaging, while another demonstrated pseudocystic cavitations on OCT imaging. Neither patient had peripheral findings on UWF imaging. Peripheral pigmentary changes were not significantly more prevalent in the tamoxifen cohort. ConclusionsThese findings suggest that UWF imaging does not contribute to diagnosis of tamoxifen retinopathy, and OCT may be the most valuable tool in diagnosing tamoxifen retinopathy. Our prevalence (1.6%) diverges from higher rates in studies screening with similarly advanced retinal imaging. Further large population studies are needed.

PREVALENCE OF DIDANOSINE-RELATED RETINAL TOXICITY AT AN URBAN ACADEMIC CENTER AS DIAGNOSED WITH ULTRA-WIDEFIELD IMAGING.

Antiretroviral therapy has revolutionized HIV treatment with didanosine (DDI) as a pioneering drug. However, DDI has been associated with retinal toxicity, characterized by peripheral chorioretinal degeneration with macular sparing. Despite its clinical recognition, the prevalence and risk factors for didanosine-induced retinopathy are not well described. This retrospective case series analyzed 127 DDI-treated patients at Weill Cornell Medicine Department of Ophthalmology. Inclusion criteria included at least 6 months of DDI use and available ultra-widefield imaging. Patients were categorized as affected or unaffected based on retinal imaging assessed by two reviewers. The affected group was further divided into "probable" or "possible" retinopathy. Patient demographics, DDI usage characteristics, and imaging findings were analyzed with statistical comparisons drawn between affected and unaffected cohorts. Of the 127 patients, 9 (7%) showed signs of didanosine-induced retinal toxicity. On average, the affected group was older compared with the unaffected group (65.1 vs. 56.5 years, P = 0.025), with lower BMI (23.2 vs. 27.4, P = 0.04), and older at the start of the treatment (51.6 vs. 40.8 years, P = 0.026). Mild phenotypes with peripheral pigmentary changes were also identified using ultra-widefield imaging. This pioneering academic study highlighted a notable prevalence of DDI-induced retinal toxicity. Statistical analysis demonstrated age, BMI, and age at treatment initiation as potential risk factors. Ultra-widefield autofluorescence emerged as a valuable tool in detecting and delineating findings. Follow-up studies are needed to determine the necessity of regular screening for individuals on or with a history of didanosine use.

Fundus screening for peripheral retinal lesions in myopic patients before refractive surgery using ultra-wide field scanning laser ophthalmoscopy

Purpose The aim of this study was to evaluate the ultra-wide field (UWF) scanning laser ophthalmoscopy using the Optomap 200Tx (Optos) in detecting peripheral retinal lesions in myopic patients. Patients and methods A prospective cross-sectional observational study was conducted from June 2023 to March 2024 at the Department of Ophthalmology, Alexandria University, Alexandria, Egypt. It included 162 eyes of 81 myopic patients (35 males and 46 females). The mean age of the participants was 23.85±3.81 years (range=18–33 years). The mean spherical equivalent of the refractive error was −4.83±1.38 D (range=−1.50 to −7.75 D). All patients were subjected to full ophthalmic assessment. UWF scanning laser ophthalmoscopy using Optomap 200Tx (Optos) without pupillary dilatation with both standard and eye-steering imaging was done and the findings were compared to findings of the dilated fundus examination with slit-lamp biomicroscopy using a 90 D fundus lens. Results Variable degrees of tessellated fundus were observed in 38.3% of the cases with the mydriatic slit-lamp fundus examination with 90 D lens and in 39.5% with Optomap (Optos) imaging, with no statistically significant difference (P=0.837). Similarly, peripheral pigmentary degenerations were noted in 28.4% and in 30.2% of the cases, respectively, with no significant difference between the two methods (P=0.708). Lattice degenerations were identified in 19.8% and in 20.4% of the cases, respectively, with no significant difference (P=0.825). White without pressure lesions were present in 5.5 and 6.8% of the cases, respectively, with no significant difference (P=0.695). Additionally, atrophic holes and vitreoretinal adhesions were observed in 0.6% of the cases using both methods, indicating no significant difference (P=1.000). Conclusion Optomap 200Tx (Optos) UWF imaging using the eye-steering technique was a valuable method for detecting peripheral retinal lesions in myopic patients.

Mapping uterine calcium dynamics during the ovulatory cycle in live mice.

Uterine contraction patterns vary during the ovulatory cycle and throughout pregnancy, but prior measurements have produced limited and conflicting information on these patterns. We combined a virally delivered genetically encoded calcium reporter (GCaMP8m) and ultra-widefield imaging in live nonpregnant mice to characterize uterine calcium dynamics at organ scale throughout the estrous cycle. Prior to ovulation (proestrus and estrus), uterine excitations primarily initiated in a region near the oviduct, but after ovulation (metestrus and diestrus), excitations initiated at loci homogeneously distributed throughout the organ. The frequency of excitation events was lowest in proestrus and estrus, higher in metestrus, and highest in diestrus. These results establish a platform for mapping uterine activity and demonstrate that an anatomically localized trigger for uterine excitations depends on the estrous cycle phase.

The Current and Novel Imaging Modalities for Ocular Vasculitis in Behcet's Disease: A Review.

Behcet's syndrome is a multisystem inflammatory disorder characterized by a chronic relapsing course and diverse clinical manifestations, prominently affecting young adults along the ancient Silk Road and beyond. The disease pathogenesis involves complex interactions between genetic predisposition, environmental triggers, and dysregulated immune responses, leading to systemic vasculitis and tissue damage. Ocular involvement, a hallmark of Behcet's Disease (BD), significantly impacts morbidity, with uveitis as a common initial presentation that can progress to severe vision-threatening complications like retinal vasculitis and occlusive disease. This review consolidates current knowledge on ocular manifestations in BD, emphasizing the pivotal role of multimodal imaging in diagnostic evaluation and management. Fundus photography serves as a baseline tool for documenting intraocular lesions and monitoring treatment responses. Fluorescein angiography remains the gold standard for detecting acute inflammatory changes and vascular leakage patterns essential for disease staging and prognostication. Recent advancements in imaging, such as ultra-wide field imaging (UWF), indocyanine green angiography (ICGA), Doppler ultrasonography, Optical Coherence Tomography (OCT), OCT angiography (OCTA), adaptive optics (AO), and retinal function imaging (RFI), provide unprecedented insights into microvascular dynamics, structural changes, and functional impairments associated with ocular BD. Integration of these advanced imaging modalities enhances early detection of subclinical disease, facilitates precise localization of inflammatory lesions, guides therapeutic interventions, and monitors treatment efficacy. OCT and OCTA, in particular, offer non-invasive, high-resolution assessments of macular edema, vascular perfusion abnormalities, and choroidal thickness alterations critical for optimizing patient care. In conclusion, multimodal imaging represents the cornerstone in the comprehensive management of ocular manifestations in Behcet's Disease, offering clinicians invaluable tools for accurate diagnosis, treatment planning, and long-term monitoring of disease progression and treatment outcomes.

Diabetic Retinopathy Lesion Types and Distribution on Ultrawide Field Imaging and the Risk of Disease Worsening Over Time.

To evaluate the effect of diabetic retinopathy (DR) lesion type [hemorrhages and/or microaneurysms (H/Ma), intraretinal microvascular abnormalities (IRMA), new vessels elsewhere (NVE), venous beading], severity and distribution on disease worsening based on the Early Treatment Diabetic Retinopathy Study (ETDRS)-Diabetic Retinopathy Severity Scale (DRSS). Post-hoc analysis of a multi-center observational study of 544 eyes with nonproliferative DR and an ETDRS-DRSS score of Level 35-53. Disease worsening was defined as ETDRS-DRSS worsening by ≥2 steps from baseline or receipt of DR treatment over 4 years. DR lesions were evaluated based on the entire visible area in the ultrawide field color (UWF-color) and UWF-fluorescein angiography (UWF-FA) images. A significantly greater risk of disease worsening was associated with the presence of more severe lesion grades outside the ETDRS fields for H/Ma (HR:1.74 [95% CI:1.28-2.36]) on UWF-color; and for H/Ma (1.90 [1.38-2.61]), IRMA (1.68 [1.13-2.49]), and NVE (1.99 [1.36-2.93]) on UWF-FA. These results suggest that features on UWF-color and UWF-FA may provide additional prognostic value in determining the risk of disease worsening. The use of UWF-FA improves identification of DR lesions and disease progression. However, the optimal method of disease risk assessment on UWF imaging still needs to be determined.

ETDRS grading with CLARUS ultra-widefield images shows agreement with 7-fields colour fundus photography

BackgroundTo analyse and compare the grading of diabetic retinopathy (DR) severity level using standard 35° ETDRS 7-fields photography and CLARUS™ 500 ultra-widefield imaging system.MethodsA cross-sectional analysis of retinal images of patients with type 2 diabetes (n = 160 eyes) was performed for this study. All patients underwent 7-fields colour fundus photography (CFP) at 35° on a standard Topcon TRC-50DX® camera, and ultra-widefield (UWF) imaging at 200° on a CLARUS™ 500 (ZEISS, Dublin, CA, USA) by an automatic montage of two 133° images (nasal and temporal). 35° 7-fields photographs were graded by two graders, according to the Early Treatment Diabetic Retinopathy Study (ETDRS). For CLARUS UWF images, a prototype 7-fields grid was applied using the CLARUS review software, and the same ETDRS grading procedures were performed inside that area only. Grading of DR severity level was compared between these two methods to evaluate the agreement between both imaging techniques.ResultsImages of 160 eyes from 83 diabetic patients were considered for analysis. According to the 35° ETDRS 7-fields images, 22 eyes were evaluated as DR severity level 10–20, 64 eyes were evaluated as DR level 35, 41 eyes level 43, 21 eyes level 47, 7 eyes level 53, and 5 eyes level 61. The same DR severity level was achieved with CLARUS 500 UWF images in 92 eyes (57%), showing a perfect agreement (k > 0.80) with the 7-fields 35° technique. Fifty-seven eyes (36%) showed a higher DR level with CLARUS UWF images, mostly due to a better visualization of haemorrhages and a higher detection rate of intraretinal microvascular abnormalities (IRMA). Only 11 eyes (7%) showed a lower severity level with the CLARUS UWF system, due to the presence of artifacts or media opacities that precluded the correct evaluation of DR lesions.ConclusionsUWF CLARUS 500 device showed nearly perfect agreement with standard 35° 7-fields images in all ETDRS severity levels. Moreover, CLARUS images showed an increased ability to detect haemorrhages and IRMA helping with finer evaluation of lesions, thus demonstrating that a UWF photograph can be used to grade ETDRS severity level with a better visualization than the standard 7-fields images.Trial registrationApproved by the AIBILI - Association for Innovation and Biomedical Research on Light and Image Ethics Committee for Health with number CEC/009/17- EYEMARKER.

ARTIFICIAL INTELLIGENCE-ENHANCED ANALYSIS OF RETINAL VASCULATURE IN AGE-RELATED MACULAR DEGENERATION.

To investigate associations between quantitative vascular measurements derived from intravenous fluorescein angiography (IVFA) and baseline characteristics on optical coherence tomography (OCT) in neovascular age-related macular degeneration (nAMD) patients. The authors prospectively recruited patients with active choroidal neovascularization secondary to AMD over 50 years old, presenting to a single center in Toronto, Canada from 2017 to 2023. Ultra-widefield IVFA images were processed using the artificial intelligence RETICAD FAassist system to extract quantitative information on blood flow, perfusion, and blood-retinal-barrier (BRB) permeability. Associations between IVFA parameters with functional and anatomical outcomes were examined using univariable and multivariable regression models. Eighty-one nAMD eyes and seven healthy control eyes were included. Compared with healthy controls, BRB permeability in the central and peripheral retina was significantly higher in nAMD patients (P < 0.001). On univariable analysis, BRB permeability measured centrally was significantly associated with central macular thickness (P = 0.035), whereas perfusion and blood flow measured centrally were significantly associated with macular volume (P = 0.043 and 0.037, respectively). On multivariable analysis, BRB permeability remained significantly associated with central macular thickness (P = 0.026). Central BRB permeability measured on IVFA was significantly associated with baseline central macular thickness in nAMD patients. Future work should longitudinally explore associations between IVFA parameters and clinical characteristics in diverse nAMD populations.

Developing an image-based grading scale for peripheral drusen to investigate associations of peripheral drusen type with age-related macular degeneration

Age-related macular degeneration (AMD) is a leading cause of blindness. It is associated with peripheral drusen which has not been categorized. We investigated peripheral drusen to validate an image grading system and to understand possible associations between peripheral drusen and AMD. We collated clinical data, ultra-widefield (UWF) pseudocolor fundus images and Spectral-Domain Optical Coherence Tomography (SD-OCT) scans from consecutive retinal patients. SD-OCT scans were used to determine AMD stage. A masked retinal specialist recorded the types of peripheral drusen observed in UWF images. Eyes whose UWF images did not pass quality screening and those without AMD and peripheral drusen were excluded from the study. Statistical tests were utilized to determine the validity of our grading system and associations of peripheral drusen with AMD. A total of 481 eyes (283 subjects) were included in the study (mean age 73.1 ± 1.2years, 64.3% female). Interobserver and test–retest statistical analyses to evaluate the UWF image grading system resulted in Cohen’s Kappa 0.649 (p < 0.001) and 0.922 (p < 0.001) respectively. A total of 284 (59.0%), 28 (5.8%), 15 (3.1%), 22 (4.6%), 4 (0.8%), 39 (8.1%), and 32 (6.7%) eyes had hard, soft, reticular, cuticular, atrophic, mixed drusen, and mixed drusen and atrophy respectively in at least one peripheral retinal quadrant. Hard peripheral drusen was significantly associated with the presence of AMD (p = 0.010). Peripheral drusen types were variably seen in retinal patients with and without AMD. We validated a peripheral drusen grading system and provided an image library to assist in the identification of peripheral drusen. Our study found an association between peripheral hard drusen and an AMD diagnosis but did not find a link between peripheral drusen and severity of AMD.

Ultra-Widefield and Early Treatment Diabetic Retinopathy Study 7-Field Grading of Diabetic Retinopathy

High concordance in diabetic retinopathy (DR) outcomes between 7-field (7F) and ultra-widefield (UWF) images would allow for combining longitudinal assessments based on the 2 modalities both in clinical studies and clinical care. To compare 7F and UWF imaging with regard to DR severity and the associations of DR severity with risk factors, such as hemoglobin A1c, age, diabetes duration, and sex. This cross-sectional study describes the outcomes of the randomized clinical Diabetes Control and Complications Trial (DCCT) and its subsequent observational study, the Epidemiology of Diabetes Interventions and Complications (EDIC) study. Of the 1441 participants with type 1 diabetes in the DCCT, 1375 were enrolled in the EDIC study. Of the 1171 participants who were active between March 2019 and December 2021, 200° UWF color imaging and 7F fundus photographs were obtained for 785 participants once at the same visit. Central graders assessed 7F-UWF with a 7F template masking the retinal periphery and the full UWF image (UWF-global). Data were analyzed from January 2022 to March 2023. Hemoglobin A1c was assessed quarterly during the DCCT and annually during the EDIC study using high-performance liquid chromatography. Retinopathy was determined independently for all imaging as mild, moderate, or severe nonproliferative DR (SNPDR) using the Early Treatment Diabetic Retinopathy Study (ETDRS) grading scale for the 7F images and the global ETDRS grading scale for the UWF images. Panretinal and focal photocoagulation were self-reported or based on scarring location and pattern observed during grading. Proliferative DR (PDR) was defined by observed neovascularization or evidence of panretinal photocoagulation. Among the 785 participants included in this study, 420 (53%) were male and 365 (47%) were female. The mean (SD) age was 61 (7) years. DR grading between UWF-7F and 7F imaging was correlated for all outcomes, including for severe outcomes, such as SNPDR (κ, 0.73; concordance, 96%), PDR (κ, 0.74; concordance, 97%), scatter photocoagulation (κ, 0.97; concordance, 99%), and focal photocoagulation (κ, 0.71; concordance, 98%). Most DR severity scores were within 1 step (1410 of 1529 [92%]), and 3% (51 of 1529) were more than 2 steps apart (κ, 0.45; 95% CI, 0.42-0.49; weighted κ, 0.63; 95% CI, 0.60-0.67) on the ETDRS severity scale. DR severity assessed within the UWF-global area was higher compared to 7F (median [IQR] UWF-global score, 3 [2-3] vs median 7F level score, 2.0 [1-3]; P < .001), although the 2 modalities were correlated (1225 of 1508 [81%] 1-step agreement; weighted κ, 0.41). Standard ETDRS 7F and UWF evaluations of DR were comparable for ETDRS severity levels as previously reported by Diabetic Retinopathy Clinical Research Retina Network reports. In addition, these evaluations of DR were comparable for DCCT/EDIT study outcomes and major study conclusions, suggesting that use of UWF imaging is not likely to introduce relevant measurement biases in future longitudinal studies. ClinicalTrials.gov Identifiers: NCT00360815.

Enhancing the ophthalmic AI assessment with a fundus image quality classifier using local and global attention mechanisms.

The assessment of image quality (IQA) plays a pivotal role in the realm of image-based computer-aided diagnosis techniques, with fundus imaging standing as the primary method for the screening and diagnosis of ophthalmic diseases. Conventional studies on fundus IQA tend to rely on simplistic datasets for evaluation, predominantly focusing on either local or global information, rather than a synthesis of both. Moreover, the interpretability of these studies often lacks compelling evidence. In order to address these issues, this study introduces the Local and Global Attention Aggregated Deep Neural Network (LGAANet), an innovative approach that integrates both local and global information for enhanced analysis. The LGAANet was developed and validated using a Multi-Source Heterogeneous Fundus (MSHF) database, encompassing a diverse collection of images. This dataset includes 802 color fundus photography (CFP) images (302 from portable cameras), and 500 ultrawide-field (UWF) images from 904 patients with diabetic retinopathy (DR) and glaucoma, as well as healthy individuals. The assessment of image quality was meticulously carried out by a trio of ophthalmologists, leveraging the human visual system as a benchmark. Furthermore, the model employs attention mechanisms and saliency maps to bolster its interpretability. In testing with the CFP dataset, LGAANet demonstrated remarkable accuracy in three critical dimensions of image quality (illumination, clarity and contrast based on the characteristics of human visual system, and indicates the potential aspects to improve the image quality), recording scores of 0.947, 0.924, and 0.947, respectively. Similarly, when applied to the UWF dataset, the model achieved accuracies of 0.889, 0.913, and 0.923, respectively. These results underscore the efficacy of LGAANet in distinguishing between varying degrees of image quality with high precision. To our knowledge, LGAANet represents the inaugural algorithm trained on an MSHF dataset specifically for fundus IQA, marking a significant milestone in the advancement of computer-aided diagnosis in ophthalmology. This research significantly contributes to the field, offering a novel methodology for the assessment and interpretation of fundus images in the detection and diagnosis of ocular diseases.

Prospective validation of a virtual post-operative clinic in vitreoretinal surgery.

To evaluate the clinical efficacy and safety of asynchronous virtual post-operative assessments following vitreoretinal surgery and procedures compared to traditional face-to-face assessments in a high-volume tertiary eye centre. Prospective comparative clinical series study of patients who had undergone vitreoretinal surgery or post-laser retinopexy. Patients received both virtual and face-to-face assessments. The virtual assessment included clinical questions, visual acuity measurement, and virtual retinal imaging using ultra-wide field (UWF) imaging and macular optical coherence tomography (OCT). Face-to-face assessments involved standard clinical examinations. We included 142 patients undergoing a variety of vitreoretinal procedures. We showed comparable results between virtual and face-to-face assessments in both, post-operative and post-laser treatments. UWF imaging with macular OCT demonstrated potential for effective virtual post-operative assessment. The virtual assessment has a sensitivity of 91% and specificity of 100% for detecting retinal detachments with 100% specificity and 100% sensitivity for detecting new retinal tears or insufficient laser treatment. The implementation of asynchronous virtual post-operative assessments following a variety of vitreoretinal procedures is a promising alternative to traditional face-to-face assessments. Virtual assessments using UWF imaging and macular OCT showed high sensitivity and specificity. Virtual post-operative clinics offer the potential to improve patient access and decrease the clinical burden, especially with the continuing evolution of telemedicine technologies and imaging modalities.