Binocular Visual Field and Vision-Related Quality of Life in Patients With Hemianopia.

BACKGROUND: Hemianopias can have a severe impact on functional ability and quality of life (QoL). Binocular visual field (VF) analysis is clinically more relevant to visual function than monocular VF. The aim is to analyze the binocular VF of patients with hemianopias and its association with the monocular VF and to assess the QoL of these patients through questionnaires specifically related to vision compared with healthy controls. METHODS: The case-control study included patients with hemianopias and controls. Sex, age, general history, etiology, location of the lesion, and time since the lesion appeared were recorded. Monocular VF and Esterman binocular VF were performed. VF defect, mean defect (MD), and Esterman scores were recorded. Visual Activities Questionnaire (VAQ-33) and Visual Function Questionnaire (VFQ-25) questionnaires were administered. RESULTS: Twenty patients with hemianopia and 22 healthy controls were included. The Esterman score in homonymous hemianopia patients (n = 17) correlated with best eye MD (r = -0.62, P = 0.01), worst eye MD (r = -0.70, P = 0.002), and average MD (r = -0.68, P = 0.003). Compared with healthy control subjects, patients with homonymous hemianopia had significantly lower VFQ-25 score and in 10/12 subscales (all P < 0.001). VAQ-33 scores revealed lower overall and subscales scores with the exception of light/dark adaptation (P = 0.08). Correlations were found between monocular and binocular VF scores and general vision (r = -0.55), peripheral vision (on both questionnaires, r-range -0.75 to 0.47), VFQ-25 and VAQ-33 overall scores (r = -0.59, -0.49 and 0.50), and glare disability (r = 0.53 and 0.67). CONCLUSIONS: Hemianopic VF defects involve a major alteration in the patients' vision-related QoL.

Normative database and determinants of macular vessel density measured by optical coherence tomography angiography.

IMPORTANCE: To provide a normative vessel density (VD) database for the macula through swept-source optical coherence tomography angiography (OCTA) and to assess the main determinants of this measurement. BACKGROUND: In contrast with dye angiography, the recently introduced OCTA technique allows for the non-invasive measurement of retinal and choroidal VD metrics. DESIGN: Cross-sectional study. PARTICIPANTS: The right eyes of 346 healthy subjects were studied. In 105 subjects both eyes were imaged. METHODS: Foveal and parafoveal macular VD measurements were obtained in the retinal superficial capillary plexus (SCP), deep capillary plexus (DCP), and in the choriocapillaris (CC) layer. Also recorded were age, sex, axial length (AL), foveal and choroidal thickness (CT). MAIN OUTCOME MEASURES: Normative database and determinants of macular VD measured by OCTA. RESULTS: Mean participant age was 38.3 ± 20.1 years (mean ± SD) (range 5-83). Foveal VDs in the different plexuses were: SCP 22.1% ± 5.0% (7.3-35.1), DCP 19.9% ± 6.3% (6.9-51.2) and CC: 52.8% ± 4.3% (40.2-62.1). Parafoveal VDs ranged from 45.4% ± 3.7% to 51.8% ± 4.6%. Positive correlation was observed between foveal VD and foveal thickness (R = .327), as well as between parafoveal DCP VD and CT (R = .250;P ≤ .006), while correlation with age was negative in the SCP and CC (R = -.283;P < .001). No associations were detected between macular VD and sex or AL (P ≥ .05). CONCLUSION AND RELEVANCE: Macular VD showed wide individual variation, was positively correlated with foveal thickness and with CT, negatively correlated with age, and showed no correlation with AL or sex.

Normative Pentacam anterior and posterior corneal elevation measurements: effects of age, sex, axial length and white-to-white.

PURPOSE: To provide normal corneal elevation data for a large Caucasian population and to determine the impacts on these data of age, sex, axial length (AXL) and horizontal white-to-white (WW). SETTING: Centro Internacional de Oftalmología Avanzada, Madrid, Spain. DESIGN: Retrospective, cross-sectional, observational. METHODS: In this retrospective, cross-sectional, observational study, anterior and posterior corneal elevations were measured in 789 right eyes of subjects with no ocular disease at the thinnest corneal location in relation to a fixed 8-mm best-fit sphere using the Pentacam, and AXL and WW were measured with the IOLMaster. A multiple linear regression model was used to assess the effects of age, sex, AXL and WW on the elevation data. RESULTS: Mean subject age was 50.5 ± 15 years (range 17-93 years); 64% were women. Mean anterior and posterior corneal elevations were 1.99 ± 1.75 µm (- 7 to 10 µm) and 7.70 ± 5.7 µm (- 6 to 28 µm). Anterior corneal elevations were higher by 0.165 µm and 0.033 µm for every mm reduction in AXL and every year reduction in age, respectively. Sex and WW were not significant predictors of anterior elevations (R2 = 7.7%). Posterior corneal elevation increased by 0.186 µm/year of age, 0.707 µm/mm reduction in WW and 0.819 µm/mm reduction in AXL. This variable was also 0.866 µm greater in men (R2 = 34.4%). CONCLUSION: Anterior corneal elevations decrease with age and are higher for shorter AXL but are not influenced by sex or WW. Posterior corneal elevations increase with age, decreasing AXL, decreasing WW and are higher in men.

Weakly-supervised detection of AMD-related lesions in color fundus images using explainable deep learning.

BACKGROUND AND OBJECTIVES: Age-related macular degeneration (AMD) is a degenerative disorder affecting the macula, a key area of the retina for visual acuity. Nowadays, AMD is the most frequent cause of blindness in developed countries. Although some promising treatments have been proposed that effectively slow down its development, their effectiveness significantly diminishes in the advanced stages. This emphasizes the importance of large-scale screening programs for early detection. Nevertheless, implementing such programs for a disease like AMD is usually unfeasible, since the population at risk is large and the diagnosis is challenging. For the characterization of the disease, clinicians have to identify and localize certain retinal lesions. All this motivates the development of automatic diagnostic methods. In this sense, several works have achieved highly positive results for AMD detection using convolutional neural networks (CNNs). However, none of them incorporates explainability mechanisms linking the diagnosis to its related lesions to help clinicians to better understand the decisions of the models. This is specially relevant, since the absence of such mechanisms limits the application of automatic methods in the clinical practice. In that regard, we propose an explainable deep learning approach for the diagnosis of AMD via the joint identification of its associated retinal lesions. METHODS: In our proposal, a CNN with a custom architectural setting is trained end-to-end for the joint identification of AMD and its associated retinal lesions. With the proposed setting, the lesion identification is directly derived from independent lesion activation maps; then, the diagnosis is obtained from the identified lesions. The training is performed end-to-end using image-level labels. Thus, lesion-specific activation maps are learned in a weakly-supervised manner. The provided lesion information is of high clinical interest, as it allows clinicians to assess the developmental stage of the disease. Additionally, the proposed approach allows to explain the diagnosis obtained by the models directly from the identified lesions and their corresponding activation maps. The training data necessary for the approach can be obtained without much extra work on the part of clinicians, since the lesion information is habitually present in medical records. This is an important advantage over other methods, including fully-supervised lesion segmentation methods, which require pixel-level labels whose acquisition is arduous. RESULTS: The experiments conducted in 4 different datasets demonstrate that the proposed approach is able to identify AMD and its associated lesions with satisfactory performance. Moreover, the evaluation of the lesion activation maps shows that the models trained using the proposed approach are able to identify the pathological areas within the image and, in most cases, to correctly determine to which lesion they correspond. CONCLUSIONS: The proposed approach provides meaningful information-lesion identification and lesion activation maps-that conveniently explains and complements the diagnosis, and is of particular interest to clinicians for the diagnostic process. Moreover, the data needed to train the networks using the proposed approach is commonly easy to obtain, what represents an important advantage in fields with particularly scarce data, such as medical imaging.

Subfoveal choroidal thickness as a potential predictor of treatment response after intravitreal ranibizumab injections for polypoidal choroidal vasculopathy.

OBJECTIVE: To evaluate the impact of subfoveal choroidal thickness (SFCT) and other clinical biomarkers in intravitreal anti-vascular endothelial growth factor response in treatment-naive Caucasian patients diagnosed with polypoidal choroidal vasculopathy (PCV/AT1). DESIGN: Cross-sectional study. PARTICIPANTS: Treatment-naive patients diagnosed with PCV/AT1 recruited in a single centre from January 2013 to December 2020. METHODS: Eligibility was determined in treatment-naive PCV patients who received a loading dose of 3 injections of 0.5 mg ranibizumab. A diagnosis of PCV/AT1 was made based on the diagnostic criteria in the efficacy and safety of verteporfin photodynamic therapy in combination with ranibizumab or alone versus ranibizumab monotherapy in patients with sumptomatic macular polypoidal choroidal vasculopathy study. Choroidal thickness was manually measured by enhanced depth imaging technology in Spectralis spectral domain optical coherence tomography. RESULTS: Eighty-three eyes of 83 patients were included in this study, 47 patients diagnosed with PCV/AT1 with a good response to 3 intravitreal injections of ranibizumab and 36 with a poor response. The receiver operating characteristic curve of treatment effect against the SFCT revealed that the area under the curve was 0.85 (range, 0.74-0.96). Based on the Youden index, the optimal SFCT cut-off point for predicting a poor response to anti-vascular endothelial growth factor is 257 µm. In the multivariate analysis, the SFCT remained statistically significant (odds ratio 1.02 [range, 1.01-1.04]; P = 0.008). The combined effect of treatment effect against clinical biomarkers produced an area under the curve of 0.90 (range, 0.82-0.98). CONCLUSION: SFCT is a risk factor for a poor response to the 3 loading injections of ranibizumab in treatment-naive PCV/AT1 Caucasian patients. A cut-off point of 257 µm could be a valuable parameter for defining the population at risk for an inadequate response to ranibizumab.

Cytokine profile in tear and aqueous humor of primary open-angle patients as a prognostic factor for trabeculectomy outcome.

OBJECTIVE: To evaluate the cytokine profile in tear and aqueous humor in primary open-angle glaucoma before trabeculectomy and correlate preoperative cytokine levels with the surgical outcome. METHODS: Prospective study. Twenty-nine patients with primary open-angle glaucoma undergoing primary trabeculectomy were included. Levels of 27 cytokines were measured in tear an aqueous humor using the Bio-Plex Pro Human Cytokine 27-Plex Immunoassay kit (Bio-Rad Laboratories, Hercules, CA, USA). RESULTS: 29 patients who underwent trabeculectomy were included and their first-year follow-up visits were recorded. Mean age was 76.0 ± 7.0 years (range 56-84), mean intraocular pressure was 18.2 ± 3.6 mmHg and mean number of topical medications was 2.3 ± 0.9. At the one-year visit, 5 patients were classified as surgical failure. In aqueous humor, preoperative cytokine levels of regulated on activation normal T cell expressed and secreted (RANTES) were significantly higher in those patients with surgical failure at one year. IL-8 in tear and interferon gamma-induced protein (IP-10) in aqueous humor correlated positively with one-year IOP reduction. No statistically significant correlations were found with changes in visual field mean defect or global peripapillary retinal nerve fiber layer thickness (all, p >0.05). CONCLUSIONS: Preoperative RANTES levels in aqueous humor as well as other cytokines could serve as useful biomarkers for trabeculectomy outcome.

Recommendations for ophthalmologic practice during the easing of COVID-19 control measures.

In the context of the COVID-19 pandemic, this paper provides recommendations for medical eye care during the easing of control measures after lockdown. The guidelines presented are based on a literature review and consensus among all Spanish Ophthalmology Societies regarding protection measures recommended for the ophthalmologic care of patients with or without confirmed COVID-19 in outpatient, inpatient, emergency and surgery settings. We recommend that all measures be adapted to the circumstances and availability of personal protective equipment at each centre and also highlight the need to periodically update recommendations as we may need to readopt more restrictive measures depending on the local epidemiology of the virus. These guidelines are designed to avoid the transmission of SARS-CoV-2 among both patients and healthcare staff as we gradually return to normal medical practice, to prevent postoperative complications and try to reduce possible deficiencies in the diagnosis, treatment and follow-up of the ophthalmic diseases. With this update (5th ) the Spanish Society of Ophthalmology is placed as one of the major ophthalmology societies providing periodic and systematized recommendations for ophthalmic care during the COVID-19 pandemic.

Variations in retinal nerve fiber layer measurements on optical coherence tomography after implantation of trifocal intraocular lens.

PURPOSE: To establish the changes produced after implantation of a trifocal intraocular lens (IOL) on retinal nerve fiber layer measurements performed with Fourier-domain optical coherence tomography (OCT). METHODS: This prospective study included 100 eyes of 50 patients with bilateral cataract in surgical range, no other associated ocular involvement, refractive errors between +5 and -5 spherical diopters, and less than 1.5 D of corneal astigmatism. The eyes were operated by phacoemulsification with implantation of 2 different trifocal IOLs (FineVision and AT LISA tri 839MP) in randomized equal groups. Cirrus OCT and Spectralis OCT were performed before surgery and 3 months later. Both analyzed the thickness of the nerve fiber layer and thickness divided by quadrants (6 in case of Spectralis and 4 in case of Cirrus HD). RESULTS: The mean age of patients was 67.5 ± 5.8 years. The global nerve fiber layer thickness measured with Spectralis OCT was 96.77 µm before surgery and 99.55 µm after. With Cirrus OCT, the global thickness was 85.29 µm before surgery and 89.77 µm after. Statistically significant differences in global thickness measurements between preimplantation and postimplantation of the IOL were found with both OCT in the 2 groups. Statistically significant differences were also found in temporal and superior quadrants. CONCLUSIONS: The implantation of a diffractive trifocal IOL alters the results of the optic nerve fiber layer on Fourier-domain OCT in these patients, which should be taken into account in the posterior study of these patients.

Anterior Chamber Angle Tissue as an Incidental Optical Coherence Tomography Finding in a Large Healthy Caucasian Child Population.

PURPOSE: The aim of this study was to describe the presence of anterior chamber angle (ACA) tissue as an incidental optical coherence tomography (OCT) finding in healthy children. METHODS: For this cross-sectional study, we reviewed Fourier-domain OCT images obtained in 422 children, who were chosen as candidates for inclusion in a prior study, and who visited our clinic for a routine vision test. The presence of angle tissue was assessed in the nasal and temporal quadrants. On tomographies showing angle tissue, several measurements were made, including ACA width and trabecular meshwork length and size. RESULTS: Hyperreflective tissue was observed in the ACA recess in 14 eyes of 13 children subjected to OCT (3.3%). This tissue was only present in 1 quadrant. The mean age of the affected children was 10.1±2.5 years (range, 7 to 14); 69% were female patients. Spherical refractive error was -0.5 to +1.75 D. ACA width was 45.9±9.1 (24.8 to 57.9) in the nasal quadrant and 44.3±10.1 (23.9 to 60.1) in the temporal quadrant. Trabecular meshwork length and size were 494±94 µm (322 to 732) and 0.064±0.018 mm (0.03 to 0.11), respectively. In all 13 children, intraocular pressure was ≤18 mm Hg, the appearance of the optic nerve head was normal, and none had a family history of glaucoma. CONCLUSIONS: We, here, report the incidental observation of angle tissue in a small percentage of healthy Caucasian children. The follow-up of these children in future work could clarify the possible clinical implications of this observation.

Uvemaster: A Mobile App-Based Decision Support System for the Differential Diagnosis of Uveitis.

Purpose: To examine the diagnostic accuracy and performance of Uvemaster, a mobile application (app) or diagnostic decision support system (DDSS) for uveitis. The app contains a large database of knowledge including 88 uveitis syndromes each with 76 clinical items, both ocular and systemic (total 6688) and their respective prevalences, and displays a differential diagnoses list (DDL) ordered by sensitivity, specificity, or positive predictive value (PPV). Methods: In this retrospective case-series study, diagnostic accuracy (percentage of cases for which a correct diagnosis was obtained) and performance (percentage of cases for which a specific diagnosis was obtained) were determined in reported series of patients originally diagnosed by a uveitis specialist with specific uveitis (N = 88) and idiopathic uveitis (N = 71), respectively. Results: Diagnostic accuracy was 96.6% (95% confidence interval [CI], 93.2-100). By sensitivity, the original diagnosis appeared among the top three in the DDL in 90.9% (95% CI, 84.1-96.6) and was the first in 73.9% (95% CI, 63.6-83.0). By PPV, the original diagnosis was among the top DDL three in 62.5% (95% CI, 51.1-71.6) and the first in 29.5% (95% CI, 20.5-38.6; P < 0.001). In 71 (31.1%) patients originally diagnosed with idiopathic uveitis, 19 new diagnoses were made reducing this series to 52 (22.8%) and improving by 8.3% the new rate of diagnosed specific uveitis cases (performance = 77.2%; 95% CI, 71.1-82.9). Conclusions: Uvemaster proved accurate and based on the same clinical data was able to detect more cases of specific uveitis than the original clinician only-based method.

Anterior Chamber Angle and Trabecular Meshwork Measurements Made by Fourier-domain Optical Coherence Tomography in Healthy White Children.

PURPOSE: To obtain anterior chamber angle and trabecular meshwork (TM) measurements by Fourier-domain optical coherence tomography (FD-OCT) in a population of healthy white children. MATERIALS AND METHODS: This was a cross-sectional study examining 409 right eyes of 409 children. Trabecular-iris angle (TIA) and TM length and area were measured by FD-OCT (RTVue 100) in the nasal and temporal quadrants to analyze correlations between angle or TM measurements and age, sex, and refractive error. RESULTS: Mean participant age was 10.5±3.4 years (range, 3 to 18 y); 51% were boys. Mean spherical error was 0.56±2.4 D (range, -9 to +7.5 D). TIA could be measured in 99%, whereas TM measurements could only be made in 83%. Mean TIA was 43.1±10.0 degrees (range, 16 to 76 degrees). No differences were observed in angle width according to sex (P=0.299; t test). TIA was correlated with age (R=0.204; P<0.001) and with spherical error (R=-0.457; P<0.001). Mean TM length was 530±106 µm (range, 299 to 891 µm) and mean TM area was 0.065±0.021 mm (range, 0.030 to 0.180 mm). No correlation was observed between TM metrics and age, sex or refractive error (R<0.08; P≥0.172). CONCLUSIONS: FD-OCT proved useful for the noninvasive measurement of TIA and TM metrics in children. Spherical error was the main determinant of TIA.

Morphometry of the trabecular meshwork in vivo in a healthy population using fourier-domain optical coherence tomography.

PURPOSE: We measured the length, thickness, and area of the trabecular meshwork (TM) in vivo using Fourier domain optical coherence tomography (FD-OCT) in a Caucasian population of healthy subjects. METHODS: A cross-sectional study was done of 1006 healthy subjects. Left eyes were randomly selected. Age, sex, IOP, and spherical refractive error were noted. The depth and volume of the anterior chamber and the central corneal thickness were measured with Pentacam, while IOL Master was used to measure the axial length. The length, thickness, and area of the TM were measured through FD-OCT RTVue. A study was done to determine the correlation between TM size, and other demographic and ocular parameters. Finally, the reproducibility of the measurements was assessed for a subgroup of 50 eyes from 50 patients. RESULTS: We were able to measure the TM in 91.1% of the total eyes studied. The mean TM length was 496.99 ± 92.77 µm (range, 275-800), TM thickness was 174.16 ± 28.14 µm (range, 100-276), and TM area was 0.069 ± 0.031 mm(2) (range, 0.023-0.133). No differences were found in terms of length and area for sex, although the TM was slightly thicker in men (P = 0.046). No correlation was observed between the TM measurements and any of the studied demographic or ocular parameters (R < 0.09, P < 0.001). Intra- and interobserver reproducibility of the measurements were good (intraclass correlation coefficient > 0.750, P < 0.001). CONCLUSIONS: The FD-OCT is an effective and reproducible examination technique to measure the length, thickness, and area of the TM in vivo.