Adjunctive use of systematic retinal thickness map analysis to monitor disease activity in punctate inner choroidopathy

A challenge in the management of 'white dot syndromes' is the lack of sensitive objective measures of disease activity. Retinal thickness maps from spectral domain optical coherence tomography (SD-OCT) inform treatment decisions in other retinal conditions such as age-related macular degeneration and diabetic maculopathy. In this report, we demonstrate their value in providing quantitative monitoring of a patient with punctate inner choroidopathy (PIC). Retinal thickness maps referenced against a baseline scan reliably detected focal areas of increased macular volume in active PIC lesions during symptomatic episodes, highlighting these as 'hot spots' that could be quantified, providing an objective basis for treatment decisions

Biomarkers and Surrogate Endpoints in Uveitis: The Impact of Quantitative Imaging

PURPOSE: Uveitis is a major cause of sight loss across the world. The reliable assessment of intraocular inflammation in uveitis (‘disease activity') is essential in order to score disease severity and response to treatment. In this review, we describe how ‘quantitative imaging', the approach of using automated analysis and measurement algorithms across both standard and emerging imaging modalities, can develop objective instrument-based measures of disease activity. METHODS: This is a narrative review based on searches of the current world literature using terms related to quantitative imaging techniques in uveitis, supplemented by clinical trial registry data, and expert knowledge of surrogate endpoints and outcome measures in ophthalmology. RESULTS: Current measures of disease activity are largely based on subjective clinical estimation, and are relatively insensitive, with poor discrimination and reliability. The development of quantitative imaging in uveitis is most established in the use of optical coherence tomographic (OCT) measurement of central macular thickness (CMT) to measure severity of macular edema (ME). The transformative effect of CMT in clinical assessment of patients with ME provides a paradigm for the development and impact of other forms of quantitative imaging. Quantitative imaging approaches are now being developed and validated for other key inflammatory parameters such as anterior chamber cells, vitreous haze, retinovascular leakage, and chorioretinal infiltrates. CONCLUSIONS: As new forms of quantitative imaging in uveitis are proposed, the uveitis community will need to evaluate these tools against the current subjective clinical estimates and reach a new consensus for how disease activity in uveitis should be measured. The development, validation, and adoption of sensitive and discriminatory measures of disease activity is an unmet need that has the potential to transform both drug development and routine clinical care for the patient with uveitis

Patent foramen ovale presenting as visual loss

Retinal artery occlusion in an otherwise healthy, young patient is rare. In this context it is important to consider patent foramen ovale as a differential. Early referral to a cardiology specialist for diagnosis and treatment is important for preventing further ocular and non-ocular events

The utility of wide-field optical coherence tomography angiography in diagnosis and monitoring of proliferative diabetic retinopathy in pregnancy

Purpose: Diabetic retinopathy is an increasingly common complication of diabetes mellitus that benefits from early diagnosis and frequent monitoring, especially in pregnancy where there is a greater risk of progression. Fundus fluorescein angiography is currently the gold standard method of investigation for neovascularization. However, this has risks of unpleasant and potentially dangerous side effects, with an added theoretical risk to the fetus in pregnancy. Wide-field optical coherence tomography angiography (PLEX Elite 9000, Carl Zeiss Meditec, Inc. USA and DRI Swept Source OCT Triton, Topcon Medical Systems, Inc. USA) potentially offers a safer, faster and equally effective alternative method for diagnosis and monitoring of diabetic retinopathy in pregnant patients. Observations: In the 3 cases reviewed from our clinic, we found that wide-field optical coherence tomography angiography was successfully used as an alternative to fundus fluorescein angiography in early diagnosis and ongoing monitoring of diabetic retinopathy in pregnant patients. Conclusions and importance: Wide-field optical coherence tomography angiography can be considered as a useful alternative to fundus fluorescein angiography when reviewing pregnant diabetic retinopathy patients. This allows avoidance of any unpleasant and potentially dangerous side effects associated with fluorescein injection, and appears to be just as effective in diagnosis and detecting disease progression

Use of Mechanical Turk as a MapReduce Framework for Macular OCT Segmentation

PURPOSE: To evaluate the feasibility of using Mechanical Turk as a massively parallel platform to perform manual segmentations of macular spectral domain optical coherence tomography (SD-OCT) images using a MapReduce framework. METHODS: A macular SD-OCT volume of 61 slice images was map-distributed to Amazon Mechanical Turk. Each Human Intelligence Task was set to 0.01 and required the user to draw five lines to outline the sublayers of the retinal OCT image after being shown example images. Each image was submitted twice for segmentation, and interrater reliability was calculated. The interface was created using custom HTML5 and JavaScript code, and data analysis was performed using R. An automated pipeline was developed to handle the map and reduce steps of the framework. RESULTS: More than 93,500 data points were collected using this framework for the 61 images submitted. Pearson’s correlation of interrater reliability was 0.995 () and coefficient of determination was 0.991. The cost of segmenting the macular volume was 1.21. A total of 22 individual Mechanical Turk users provided segmentations, each completing an average of 5.5 HITs. Each HIT was completed in an average of 4.43 minutes. CONCLUSIONS: Amazon Mechanical Turk provides a cost-effective, scalable, high-availability infrastructure for manual segmentation of OCT images

The Application of Infrared Imaging and Optical Coherence Tomography of the Lacrimal Punctum in Patients Undergoing Punctoplasty for Epiphora

Purpose To determine the application of imaging the stenotic lacrimal punctum with infrared photographs and optical coherence tomography (OCT) and to identify characteristics of the lacrimal punctum in patients who benefit from punctoplasty. Design Case-control study. Participants Twenty patients with epiphora who were listed for punctoplasty and 20 healthy controls. Methods Prospectively, 20 patients listed for punctoplasty were asked to rate their epiphora, using the Munk score, before and after punctoplasty. They also underwent preoperative OCT and infrared imaging of the affected punctum. They were divided into 2 groups, depending on whether the epiphora improved, and were compared with 20 healthy controls. Main Outcome Measures Measurements of puncta from infrared and OCT images were obtained along with Munk scores of patient epiphora. Results The infrared image measurements were significantly smaller in those patients whose epiphora improved compared with those whose did not in both the area of the punctal aperture and in the maximum punctal diameter. Additionally, those patients with improvement in epiphora had a significantly smaller preoperative punctal diameter at 100 μm depth on OCT compared with healthy controls; this was not observed in patients whose epiphora failed to improve. There was no significant difference in the punctum diameter among the 3 groups at the punctum surface entrance or at 500 μm depth. Patients with epiphora had a higher tear meniscus within the punctum compared with healthy controls. Conclusions Lacrimal punctum infrared and OCT imaging may be helpful in predicting patients more likely to benefit symptomatically from punctoplasty, with patients with smaller puncta having greater symptomatic improvement. However, the results suggest that inner punctum diameter (not readily measurable by slit-lamp examination), rather than the surface diameter, is correlated with outcome. Additionally, OCT measurements of the tear meniscus height within the punctum may be related to the degree of epiphora

Characterizing the Occluded Lacrimal Punctum Using Anterior Segment Optical Coherence Tomography.

PURPOSE: Epiphora is sometimes associated with an absent or occluded lacrimal drainage punctum (or puncta). This study uses noninvasive "enhanced depth" anterior segment optical coherence tomography (OCT) to give improved characterization and understanding of absent or fully occluded puncta and the underlying canaliculus. METHODS: Anterior segment spectral domain OCT images were collected prospectively from 9 lower puncta of 6 patients with epiphora and absent or fully occluded puncta, not amenable to dilation in clinic, to see if a canaliculus was visible on OCT imaging below the occluded punctum. RESULTS: An epithelial lined canalicular lumen was visible on OCT in 4 lower eyelid puncta from 2 patients and OCT identified 80% (4/5) of the canaliculi that were located on microscope-assisted punctal exploration. These lumens were seen within 580 μm depth from the eyelid margin surface. A half of the eyes in which a canaliculus was identified on OCT (the 2 eyes in a single patient) had resolution of epiphora following punctoplasty, and the other patient was found to have coexisting nasolacrimal duct stenosis and required later dacryocystorhinostomy. The positive predictive value for identifying a canaliculus on lower eyelid punctal exploration in acquired complete punctal occlusion (excluding the congenital case) was 1, with a negative predictive value of 1. CONCLUSIONS: This study demonstrates that canaliculi can be imaged with OCT where formal access is precluded by an occluded punctum. This noninvasive investigation might help predict the likelihood of successful retrieval of a canaliculus at surgical exploration

The potential application of artificial intelligence for diagnosis and management of glaucoma in adults

BACKGROUND: Glaucoma is the most frequent cause of irreversible blindness worldwide. There is no cure, but early detection and treatment can slow the progression and prevent loss of vision. It has been suggested that artificial intelligence (AI) has potential application for detection and management of glaucoma. SOURCES OF DATA: This literature review is based on articles published in peer-reviewed journals. AREAS OF AGREEMENT: There have been significant advances in both AI and imaging techniques that are able to identify the early signs of glaucomatous damage. Machine and deep learning algorithms show capabilities equivalent to human experts, if not superior. AREAS OF CONTROVERSY: Concerns that the increased reliance on AI may lead to deskilling of clinicians. GROWING POINTS: AI has potential to be used in virtual review clinics, telemedicine and as a training tool for junior doctors. Unsupervised AI techniques offer the potential of uncovering currently unrecognized patterns of disease. If this promise is fulfilled, AI may then be of use in challenging cases or where a second opinion is desirable. AREAS TIMELY FOR DEVELOPING RESEARCH: There is a need to determine the external validity of deep learning algorithms and to better understand how the 'black box' paradigm reaches results