Deletion of the KH1 Domain of Fmr1 Leads to Transcriptional Alterations and Attentional Deficits in Rats.

Fragile X syndrome (FXS) is a neurodevelopmental disorder caused by mutations in the FMR1 gene. It is a leading monogenic cause of autism spectrum disorder and inherited intellectual disability and is often comorbid with attention deficits. Most FXS cases are due to an expansion of CGG repeats leading to suppressed expression of fragile X mental retardation protein (FMRP), an RNA-binding protein involved in mRNA metabolism. We found that the previously published Fmr1 knockout rat model of FXS expresses an Fmr1 transcript with an in-frame deletion of exon 8, which encodes for the K-homology (KH) RNA-binding domain, KH1. Notably, 3 pathogenic missense mutations associated with FXS lie in the KH domains. We observed that the deletion of exon 8 in rats leads to attention deficits and to alterations in transcriptional profiles within the medial prefrontal cortex (mPFC), which map to 2 weighted gene coexpression network modules. These modules are conserved in human frontal cortex and enriched for known FMRP targets. Hub genes in these modules represent potential therapeutic targets for FXS. Taken together, these findings indicate that attentional testing might be a reliable cross-species tool for investigating FXS and identify dysregulated conserved gene networks in a relevant brain region.

Using a Macro Lens for Anterior Segment Imaging in Rural Panama.

Background: Visual impairment, specifically anterior segment pathology, presents a significant burden of disease in the world. Introduction: Inexpensive tools are necessary to improve eye health of residents in developing countries where care is difficult to access. Our study aimed at determining whether a $5 macro lens attached to a smartphone camera is an effective anterior segment imaging method for screening diseases. Materials and Methods: Fifty four (n = 54) patients had anterior segment imaging performed by using an Easy Macro lens and an iPhone. Imaging was performed at the Floating Doctors' mobile clinic sites in Panama. Images were sent back and graded by two board-certified ophthalmologists using a modified version of the FOTO-ED scale. Statistical analysis was performed by using a Wilcoxon signed-rank test to compare grades between the two imaging modalities. Results: There was no significant difference in overall clinical utility of images obtained by the iPhone versus Easy Macro lens. The iPhone was significantly superior in imaging of the lens and conjunctiva, whereas the Easy Macro lens was superior in regards to the anterior chamber, iris, and lens. Discussion: The imaging modality that best captures pathology is dependent on what part of the anterior segment is being examined. An imaging protocol with a pair of images, one from a smartphone and one from a macro lens, would have significant clinical utility. Conclusion: Our study demonstrates how minimally trained users can deliver effective eye screening via a telemedicine-based approach in a resource-deprived setting. Future directions would be to develop a telemedicine protocol and determine whether it improves clinically measurable outcomes in patients.

Animal models of radiation retinopathy - From teletherapy to brachytherapy.

Radiation retinopathy is a serious vision-impairing complication of radiation therapy used to treat ocular tumors. Characterized by retinal vasculopathy and subsequent retinal damage, the first sign of radiation retinopathy is the preferential loss of vascular endothelial cells. Ensuing ischemia leads to retinal degradation and late stage neovascularization. Despite the established disease progression, the pathophysiology and cellular mechanisms contributing to radiation retinopathy remain unclear. Clinical experience and basic research for other retinal vasculopathies, such as diabetic retinopathy and retinopathy of prematurity, can inform our understanding of radiation retinopathy; however, the literature investigating the fundamental mechanisms in radiation retinopathy is limited. Treatment trials have shown modest success but, ultimately, fail to address the cellular events that initiate radiation retinopathy. Animal models of radiation retinopathy could provide means to identify effective therapies. Here, we review the literature for all animal models of radiation retinopathy, summarize anatomical highlights pertaining to animal models, identify additional physiological factors to consider when investigating radiation retinopathy, and explore the use of clinically relevant tests for studying in vivo models of radiation retinopathy. We encourage further investigation into the mechanistic characterization of radiation retinopathy in the hope of discovering novel treatments.

Concurrent antitumor and bone-protective effects of everolimus in osteotropic breast cancer.

BACKGROUND: The mammalian target of rapamycin inhibitor everolimus is approved as an antitumor agent in advanced estrogen receptor-positive breast cancer. Surrogate bone marker data from clinical trials suggest effects on bone metabolism, but the mode of action of everolimus in bone biology remains unclear. In this study, we assessed potential bone-protective effects of everolimus in the context of osteotropic tumors. METHODS: The effects of everolimus on cancer cell viability in vitro and on tumor growth in vivo were assessed. Everolimus-regulated osteoclastogenesis and osteoblastogenesis were also assessed in vitro before we assessed the bone-protective effect of everolimus in a model where bone loss was induced in ovariectomized (OVX) mice. Finally, the role of everolimus in the progression of osteolytic bone disease was assessed in an intracardiac model of breast cancer bone metastases. RESULTS: At low concentrations (1 nM) in vitro, everolimus reduced the viability of human and murine cancer cell lines and impaired the osteoclastogenesis of osteoclast progenitors as assessed by quantitative real-time polymerase chain reaction and counting tartrate-resistant acid phosphatase-positive, multinucleated osteoclasts (p < 0.001). Everolimus had little or no deleterious effect on osteoblastogenesis in vitro, with concentrations of 1 and 10 nM increasing the messenger RNA expression of osteoblast marker genes (p ≤ 0.05) and leaving mineralization in differentiated human mesenchymal stem cells unchanged. Everolimus treatment (1 mg/kg body weight/day) prevented the bone loss observed in OVX mice and concurrently inhibited the metastatic growth of MDA-MB-231 cells by 70% (p < 0.002) while preserving bone mass in an intracardiac model of bone metastasis. CONCLUSIONS: These results underline the antitumor effects of everolimus and highlight its bone-protective efficacy, warranting further research on the potential implications on bone health in populations prone to osteoporosis and bone metastases, such as postmenopausal women with breast cancer.

Adjuvant tamoxifen but not aromatase inhibitor therapy decreases serum levels of the Wnt inhibitor dickkopf-1 while not affecting sclerostin in breast cancer patients.

PURPOSE: Endocrine therapies, including tamoxifen or aromatase inhibitors, are indispensable for the treatment of patients with estrogen receptor (ER)- and/or progesterone-positive breast cancer. Whereas tamoxifen displays partial ER agonistic effects in bone, aromatase inhibitors increase bone resorption and fracture risk. The Wnt inhibitors dickkopf-1 (DKK-1) and sclerostin negatively impact bone formation and are considered targets for the treatment of bone disorders. However, the effect of endocrine therapies on serum DKK-1 and sclerostin levels in patients with primary breast cancer remains elusive. METHODS: Serum DKK-1 and sclerostin levels were measured at primary diagnosis as well as 3-5 days and 12 months after surgery in a cohort of 45 pre- and postmenopausal women with primary estrogen receptor-positive breast cancer treated with adjuvant tamoxifen or aromatase inhibitors. RESULTS: Mean baseline levels ±SD for DKK-1 and sclerostin were 29.7 ± 14.6 and 27.1 ± 16.2 pmol/l, respectively. A significant negative correlation of DKK-1 levels and age was observed (r = -0.32; p < 0.05), but not for sclerostin. Of note, DKK-1 levels were significantly lower in peri- and postmenopausal women compared to premenopausal patients (-47%; p < 0.05). In tamoxifen-treated patients, DKK-1 levels were reduced by 35% (p < 0.01) one year after surgery but remained unaltered in patients treated with aromatase inhibitors. No significant changes were observed for sclerostin. CONCLUSION: DKK-1 serum levels were reduced in breast cancer patients receiving an adjuvant therapy with tamoxifen, possibly contributing to its bone-protective properties.

P38 regulates the Wnt inhibitor Dickkopf-1 in breast cancer.

Dickkopf-1 (DKK-1) is an inhibitor of canonical Wnt signalling and has been associated with the progression of osteolytic bone metastases by impairing osteoblast activity. In addition, there is growing evidence supporting a direct anti-tumour effect of DKK-1. The p38 mitogen-activated protein kinase (MAPK) regulates intracellular responses that have been linked to cell cycle, apoptosis and tumorigenesis. P38 inhibitors are currently under clinical evaluation for the treatment of malignancies. However, the influence of p38 on DKK-1 in breast cancer remains elusive. In this work, we show that p38 inhibition using SB202190 or LY2228820 potently suppressed DKK-1 expression by MDA-231 and MCF-7 breast cancer cell lines as well melanoma derived MDA-435 cells. Vice versa, activation of p38 signalling by anisomycin induced DKK-1 expression. Immunohistochemical analysis of DKK-1 expression in 97 breast cancer samples revealed that high expression of p38 was associated with a higher expression of DKK-1 compared to tumours with low p38 expression. In conclusion, these results support a role of p38 in the regulation of DKK-1 in osteolytic tumours and warrant further research on the potential of p38 inhibition for the treatment of malignant bone disease.

Potentiated suppression of Dickkopf-1 in breast cancer by combined administration of the mevalonate pathway inhibitors zoledronic acid and statins.

The Wnt-inhibitor dickkopf-1 (DKK-1) promotes cancer-induced osteolytic bone lesions by direct inhibition of osteoblast differentiation and indirect activation of osteoclasts. DKK-1 is highly expressed in human breast cancer cells and can be suppressed by inhibitors of the mevalonate pathway such as statins and amino-bisphosphonates. However, supraphysiological concentrations are required to suppress DKK-1. We show that a sequential mevalonate pathway blockade using statins and amino-bisphosphonates suppresses DKK-1 more significantly than the individual agents alone. Thus, the reduction of the DKK-1 expression and secretion in the human osteotropic tumor cell lines MDA-MB-231, MDA-MET, and MDA-BONE by zoledronic acid was potentiated by the combination with low concentrations of statins (atorvastatin, simvastatin, and rosuvastatin) by up to 75% (p < 0.05). The specific rescue of prenylation using farnesyl pyrophosphate or geranylgeranyl pyrophosphate revealed that these effects were mediated by suppressed geranylgeranylation rather than by suppressed farnesylation. Moreover, combining low concentrations of statins (1 µM atorvastatin or 0.25 µM simvastatin) and zoledronic acid at low concentrations resulted in an at least 50% reversal of breast cancer-derived DKK-1-mediated inhibition of osteogenic markers in C2C12 cells (p < 0.05). Finally, the intratumoral injection of atorvastatin and zoledronic acid in as subcutaneous MDA-MB-231 mouse model reduced the serum level of human DKK-1 by 25% compared to untreated mice. Hence our study reveals that a sequential mevalonate pathway blockade allows for the combined use of low concentration of statins and amino-bisphosphonates. This combination still significantly suppresses breast cancer-derived DKK-1 to levels where it can no longer inhibit Wnt-mediated osteoblast differentiation.

High serum levels of Dickkopf-1 are associated with a poor prognosis in prostate cancer patients.

BACKGROUND: The Wnt inhibitor Dickkopf-1 (DKK-1) has been linked to the progression of malignant bone disease by impairing osteoblast activity. In addition, there is increasing data to suggest direct tumor promoting effects of DKK-1. The prognostic role of DKK-1 expression in prostate cancer remains unclear. METHODS: A prostate cancer tissue microarray (n = 400) was stained for DKK-1 and DKK-1 serum levels were measured in 80 patients with prostate cancer. The independent prognostic value of DKK-1 expression was assessed using multivariate analyses. RESULTS: DKK-1 tissue expression was significantly increased in prostate cancer compared to benign disease, but was not correlated with survival. However, high DKK-1 serum levels at the time of the diagnosis were associated with a significantly shorter overall and disease-specific survival. Multivariate analyses defined high serum levels of DKK-1 as an independent prognostic marker in prostate cancer (HR 3.73; 95%CI 1.44-9.66, p = 0.007). CONCLUSION: High DKK-1 serum levels are associated with a poor survival in patients with prostate cancer. In light of current clinical trials evaluating the efficacy of anti-DKK-1 antibody therapies in multiple myeloma and solid malignancies, the measurement of DKK-1 in prostate cancer may gain clinical relevance.

Optimizing precision in toric lens selection by combining keratometry techniques.

PURPOSE: To increase precision in toric intraocular lens selection by reducing the frequency of outliers that arise from technology-dependent variability during the preoperative assessment for routine cataract surgery. METHODS: Mean preoperative values for absolute sphere, amount of astigmatism, and steepest cylindrical axis were obtained for 87 eyes (54 patients) each with a manual keratometer and four automated keratometers. The mean sphere, amount of astigmatism, and steepest cylindrical axis across five technologies for each eye were defined as the meld sphere, meld astigmatism, and meld axis, respectively. Each technology was evaluated against the meld by Bland­Altman analysis, Student's paired t test, and correlation coefficients. Further comparison between individual technologies and the meld quantified the number of outlier measurements each technology produced. RESULTS: The number of outliers between individual keratometers and the meld differed with specific measurement of sphere, axis, or amount of astigmatism. Although statistical analysis using Bland­Altman plots, correlation coefficients, and paired t tests suggested insignificant difference from meld measurements for each parameter, precision-guided analysis presented more clinically significant outliers. The number of outliers can be reduced for sphere (range: 2%-46% to 1%-6%), astigmatism (range: 6%-23% to 0%-2%), and axis outliers (range: 15%-27% to 3%-6%) by averaging measurements from automated and manual keratometers. CONCLUSIONS: Although multiple keratometry technologies produced similar, average measurements, the authors found a disturbing number of outliers that may be overlooked when employing a single technology. Measurement errors can be dramatically reduced by averaging measurements from manual keratometry with any automated technology to make toric lens selection more precise.

Imaging performance of portable and conventional ultrasound imaging technologies for ophthalmic applications.

PURPOSE: The aim of this study was to evaluate the imaging capabilities of Butterfly iQ with conventional ophthalmic (piezoelectric) ultrasound (COU) for ophthalmic imaging. METHODS: Custom phantom molds were designed and imaged with Butterfly iQ and COU to compare spatial resolution capabilities. To evaluate the clinical imaging performance of Butterfly iQ and COU, a survey containing pathological conditions from human subjects, imaged with both Butterfly iQ and COU probes, was given to three retina specialists and graded on image detail, resolution, quality, and diagnostic confidence on a ten-point Likert scale. Kruskal-Wallis analysis was performed for survey responses. RESULTS: Butterfly iQ and COU had comparable capabilities for imaging small axial and lateral phantom features (down to 0.1 mm) of high and low acoustic reflectivity. One of three retina specialists demonstrated a statistically significant preference for COU related to resolution, detail, and diagnostic confidence, but the remaining graders showed no significant preference for Butterfly iQ or COU across all sample images presented. CONCLUSION: The emergence of portable ultrasound probes offers an affordable alternative to COU technologies with comparable qualitative imaging resolution down to 0.1 mm. These findings suggest the value to further study the use of portable ultrasound systems and their utility in routine eye care.

Deep Learning Assisted Imaging Methods to Facilitate Access to Ophthalmic Telepathology.

Purpose: To investigate the use of super-resolution imaging techniques to enable telepathology using low-cost commercial cameras. Design: Experimental study. Participants: A total of 139 ophthalmic pathology slides obtained from the Ophthalmic Pathology service at the University of California, Irvine. Methods: Denoising Diffusion Probabilistic Model (DDPM) was developed to predict super-resolution pathology slide images from low-resolution inputs. The model was pretrained using 150 000 images randomly sampled from the ImageNet dataset. Patch aggregation was used to generate large images with DDPM. The performance of DDPM was evaluated against that of generative adversarial networks (GANs) and Robust UNet, which were also trained on the same dataset. Main Outcome Measures: The performance of models trained to generate super-resolution output images from low-resolution input images can be evaluated by using the mean squared error (MSE) and Structural Similarity Index Measure (SSIM), as well as subjective grades provided by expert pathologist graders. Results: In total, our study included 110 training images, 9 validation images, and 20 testing images. The objective performance scores were averaged over patches generated from 20 test images. The DDPM-based approach with pretraining produced the best results, with an MSE score of 1.35e-5 and an SSIM score of 0.8987. A qualitative analysis of super-resolution images was conducted by expert 3 pathologists and 1 expert ophthalmic microscopist, and the average accuracy of identifying the correct ground truth images ranged from 25% to 70% (with an average accuracy of 46.5%) for widefield images and 25% to 60% (with an average accuracy of 38.25%) for individual patches. Conclusions: The DDPM-based approach with pretraining is assessed to be effective at super-resolution prediction for ophthalmic pathology slides both in terms of objective and subjective measures. The proposed methodology is expected to decrease the reliance on costly slide scanners for acquiring high-quality pathology slide images, while also streamlining clinical workflow and expanding the scope of ophthalmic telepathology. Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Comparison of a custom Photogrammetry for Anatomical CarE (PHACE) system with other Low- Cost Facial Scanning Devices.

Purpose: To compare a custom Photogrammetry for Anatomical CarE (PHACE) system with other cost-effective 3-dimensional (3D) facial scanning systems to objectively characterize morphology and volume of periorbital and adnexal anatomy. Methods: The imaging systems evaluated include the low-cost custom PHACE system and commercial software product for the iPhone called Scandy Pro (iScandy) application (Scandy, USA), and the mid-priced Einscan Pro 2X (Shining3D Technologies, China) device and Array of Reconstructed Cameras 7 (ARC7) facial scanner (Bellus3D, USA). Imaging was performed on a manikin facemask and humans with various Fitzpatrick scores. Scanner attributes were assessed using mesh density, reproducibility, surface deviation, and emulation of 3D printed phantom lesions affixed above the superciliary arch (brow line). Results: The Einscan served as a reference for lower cost imaging systems because it qualitatively and quantitatively renders facial morphology with the highest mesh density, reproducibility (0.13 ± 0.10 mm), and volume recapitulation (approximately 2% of 33.5 µL). Compared to the Einscan, the PHACE system (0.35 ± 0.03 mm, 0.33 ± 0.16 mm) demonstrated non-inferior mean accuracy and reproducibility root mean square (RMS) compared to the iScandy (0.42 ± 0.13 mm, 0.58 ± 0.09 mm), and significantly more expensive ARC7 (0.42 ± 0.03 mm, 0.26 ± 0.09 mm). Similarly, the PHACE system showed non-inferior volumetric modeling when rendering a 124 µL phantom lesion compared to the iScandy and more costly ARC7 (mean percent difference from the Einscan: 4.68 ± 3.73%, 9.09 ± 0.94%, and 21.99 ± 17.91% respectively). Conclusions: The affordable PHACE system accurately measures periorbital soft tissue as well as other established mid-cost facial scanning systems. Additionally, the portability, affordability, and adaptability of PHACE can facilitate widespread adoption of 3D facial anthropometric technology as an objective measurement tool in ophthalmology.

Vitreoretinal Surgical Instrument Tracking in Three Dimensions Using Deep Learning.

Purpose: To evaluate the potential for artificial intelligence-based video analysis to determine surgical instrument characteristics when moving in the three-dimensional vitreous space. Methods: We designed and manufactured a model eye in which we recorded choreographed videos of many surgical instruments moving throughout the eye. We labeled each frame of the videos to describe the surgical tool characteristics: tool type, location, depth, and insertional laterality. We trained two different deep learning models to predict each of the tool characteristics and evaluated model performances on a subset of images. Results: The accuracy of the classification model on the training set is 84% for the x-y region, 97% for depth, 100% for instrument type, and 100% for laterality of insertion. The accuracy of the classification model on the validation dataset is 83% for the x-y region, 96% for depth, 100% for instrument type, and 100% for laterality of insertion. The close-up detection model performs at 67 frames per second, with precision for most instruments higher than 75%, achieving a mean average precision of 79.3%. Conclusions: We demonstrated that trained models can track surgical instrument movement in three-dimensional space and determine instrument depth, tip location, instrument insertional laterality, and instrument type. Model performance is nearly instantaneous and justifies further investigation into application to real-world surgical videos. Translational Relevance: Deep learning offers the potential for software-based safety feedback mechanisms during surgery or the ability to extract metrics of surgical technique that can direct research to optimize surgical outcomes.

Optimization of a Novel Automated, Low Cost, Three-Dimensional Photogrammetry System (PHACE).

Introduction: Clinical tools are neither standardized nor ubiquitous to monitor volumetric or morphological changes in the periorbital region and ocular adnexa due to pathology such as oculofacial trauma, thyroid eye disease, and the natural aging process. We have developed a low-cost, three dimensionally printed PHotogrammetry for Automated CarE (PHACE) system to evaluate three-dimensional (3D) measurements of periocular and adnexal tissue. Methods: The PHACE system uses two Google Pixel 3 smartphones attached to automatic rotating platforms to image a subject's face through a cutout board patterned with registration marks. Photographs of faces were taken from many perspectives by the cameras placed on the rotating platform. Faces were imaged with and without 3D printed hemispheric phantom lesions (black domes) affixed on the forehead above the brow. Images were rendered into 3D models in Metashape (Agisoft, St. Petersburg, Russia) and then processed and analyzed in CloudCompare (CC) and Autodesk's Meshmixer. The 3D printed hemispheres affixed to the face were then quantified within Meshmixer and compared to their known volumes. Finally, we compared digital exophthalmometry measurements with results from a standard Hertel exophthalmometer in a subject with and without an orbital prosthesis. Results: Quantification of 3D printed phantom volumes using optimized stereophotogrammetry demonstrated a 2.5% error for a 244µL phantom, and 7.6% error for a 27.5µL phantom. Digital exophthalmometry measurements differed by 0.72mm from a standard exophthalmometer. Conclusion: We demonstrated an optimized workflow using our custom apparatus to analyze and quantify oculofacial volumetric and dimensions changes with a resolution of 244µL. This apparatus is a low-cost tool that can be used in clinical settings to objectively monitor volumetric and morphological changes in periorbital anatomy.

Genome editing in the treatment of ocular diseases.

Genome-editing technologies have ushered in a new era in gene therapy, providing novel therapeutic strategies for a wide range of diseases, including both genetic and nongenetic ocular diseases. These technologies offer new hope for patients suffering from previously untreatable conditions. The unique anatomical and physiological features of the eye, including its immune-privileged status, size, and compartmentalized structure, provide an optimal environment for the application of these cutting-edge technologies. Moreover, the development of various delivery methods has facilitated the efficient and targeted administration of genome engineering tools designed to correct specific ocular tissues. Additionally, advancements in noninvasive ocular imaging techniques and electroretinography have enabled real-time monitoring of therapeutic efficacy and safety. Herein, we discuss the discovery and development of genome-editing technologies, their application to ocular diseases from the anterior segment to the posterior segment, current limitations encountered in translating these technologies into clinical practice, and ongoing research endeavors aimed at overcoming these challenges.

Quantitative cone contrast threshold testing in patients with differing pathophysiological mechanisms causing retinal diseases.

BACKGROUND: Cone contrast threshold testing (CCT) provides quantitative measurements of color and contrast function to reveal changes in vision quality that are not standard endpoints in clinical trials. We utilize CCT to measure visual function in patients with multiple sclerosis (MS), age-related macular degeneration (AMD), epiretinal membrane (ERM), and retinal vein occlusion (RVO). METHODS: Retrospective data was gathered from 237 patients of the Gavin Herbert Eye Institute. Subjects included 17 patients with MS, 45 patients with AMD, 41 patients with ERM, 11 patients with RVO, and 123 healthy controls. Patients underwent the primary measurement outcome, CCT testing, as well as Sloan visual acuity test and spectral domain optical coherence tomography during normal care. RESULTS: Color and contrast deficits were present in MS patients regardless of history of optic neuritis. AMD with intermediate or worse disease demonstrated reduced CCT scores. All 3 stages of ERM demonstrated cone contrast deficits. Despite restoration of visual acuity, RVO-affected eyes demonstrated poorer CCT performance than unaffected fellow eyes. CONCLUSIONS: CCT demonstrates color and contrast deficits for multiple retinal diseases with differing pathophysiology. Further prospective studies of CCT in other disease states and with larger samples sizes is warranted.

Seeing invisible light: 2-photon microperimetry to measure visual function.

Purpose: The accuracy of conventional visual function tests, which emit visible light, decreases in patients with corneal scars, cataracts, and vitreous hemorrhages. In contrast, infrared (IR) light exhibits greater tissue penetrance than visible light and is less susceptible to optical opacities. We therefore compared conventional visual function tests against infrared 2-phton microperimetry (2PM-IR) in a subject with a brunescent nuclear sclerotic and posterior subcapsular cataract before and after cataract surgery. Methods: Testing using infrared light microperimetry from a novel device (2PM-IR), visible light microperimetry from a novel device (2PM-Vis), conventional microperimetry, and the cone contrast threshold (CCT) test were performed before and after cataract surgery. Results: Retinal sensitivity assessed using 2PM-IR, 2PM-Vis, and cMP improved by 3.4 dB, 17.4 dB, and 18 dB, respectively. Cone contrast threshold testing improved for the S-cone, M-cone, and l-cone by 111, 14, and 30. Conclusions and Importance: 2PM-IR, unlike conventional visual function tests, showed minimal variability in retinal sensitivity before and after surgery. Thus, IR visual stimulation may provide a more accurate means of measuring neurosensory retinal function by circumventing optical media opacities, aiding in the diagnosis of early macular disease.

Feasibility of telemedicine program using a hand-held nonmydriatic retinal camera in Panama.

AIM: To evaluate the image quality of a telemedicine screening program for retinal disease using a nonmydriatic camera among rural island communities in Bocas del Toro, Panama. METHODS: In June 2018, a group of three medical students volunteered at clinics operated by the Floating Doctors in the province of Bocas del Toro, Panama. Non-mydriatic images of the retina were obtained using the Pictor Plus (Volk Optical, Mentor OH), randomized, and sent to two board-certified ophthalmologists at the University of California, Irvine for analysis using a modified version of the FOTO-ED scale. Inter-rater reliability was calculated using the kappa statistic. RESULTS: Seventy patients provided a total of 127 images. Average image quality was 3.31, and most frequent image quality was 4/5 on the FOTO-ED scale. Thirty patients had at least one eye image with ideal quality (42.86%), while only one patient had no adequate photos taken (1.43%). However, high quality images were obtained in both eyes in only 12 patients (17.14%). The inter-rater reliability between the two ophthalmologists was 0.614. CONCLUSION: Further improvements are necessary to acquire higher quality images more reliably. This may include further training and experience or mydriasis.