Yoked prisms and cerebral visual impairment: Enhancing the experience of ambient vision.

BACKGROUND: Perceptual visual impairment leads to impaired functional vision in children with cerebral visual impairment. Yoked prisms have been used in behavioral vision therapy for children with autism (dysfunctional dorsal visual processing pathway) and in neurorehabilitation to treat visual neglect, hemianopia, and abnormal egocentric localization. In particular, they are employed for treating perceptual visual problems. PURPOSE: To share our experience in implementing yoked prisms and their impact on the rehabilitation of children with cerebral visual impairment-related perceptual vision disorders. SYNOPSIS: The first child with periventricular leukomalacia exhibits no eagerness to explore her new environment along with poor grasp. With 4-PD base-down prisms, she explores her surroundings and appreciates her lateral supports. Her grasp improved as well. The second child with cerebral visual impairment exhibits difficulty in climbing downstairs with poor obstacle negotiation. This could be due to impaired inferior field awareness or optic ataxia. With 4-PD base-down prisms, the field shift toward the apex helps him to climb downstairs without difficulty with an improved obstacle negotiation. The third child prefers a closer look at the object of interest along with poor hand-eye coordination. We employed 4-PD base-down prisms in her rehabilitation session. She showed good improvement in her hand-eye coordination. HIGHLIGHTS: Poor hand-eye coordination, difficulty climbing downstairs, optic ataxia, impaired field awareness, and triggering spontaneous exploration in children with perceptual visual problems can be effectively tackled by the simple incorporation of yoked prisms. VIDEO LINK: https://youtu.be/BW3cwiGDTLY.

Long-term Follow-Up and Regeneration of Retinal Pigment Epithelium (RPE) after Tears of the Epithelium in Exudative Age-Related Macular Degeneration (AMD).

BACKGROUND: The goals of this study are to evaluate potential long-term visual deterioration associated with retinal pigment epithelial (RPE) tears in patients with neovascular age-related macular degeneration (nAMD) and to find treatment-related and morphological factors that might influence the outcomes. PATIENTS AND METHODS: This retrospective study enrolled 21 eyes of 21 patients from the database of Vista Eye Clinic Binningen, Switzerland, diagnosed with RPE tears, as confirmed by spectral domain optical coherence tomography (SD-OCT), with a minimum follow-up period of 12 months. Treatment history before and after RPE rupture with anti-VEGF therapy, visual acuity, and imaging (SD-OCT) were analyzed and statistically evaluated for possible correlations. RESULTS: Mean patient age was 80.5 ± 6.2 years. The mean length of total follow-up was 39.7 ± 13.9 months. The mean pigment epithelial detachment (PED) height increased by 363.8 ± 355.5 µm from the first consultation to 562.8 ± 251.5 µm at the last consultation prior to rupture. Therefore, a higher risk of RPE rupture is implied as a result of an increase in PED height (p = 0.004, n = 14). The mean visual acuity before rupture was 66.2 ± 16.0 letters. Mean visual acuity deteriorated to 60.8 ± 18.6 letters at the first consultation after rupture (p = 0.052, n = 21). A statistically nonsignificant decrease in vision was noted in the follow-up period. After 2 years, the mean BCVA decreased by 10.5 ± 23.7 ETDRS letters (p = 0.23, n = 19). PED characteristics before rupture and amount of anti-VEGF injections after rupture did not affect the visual outcome. None of the 21 patients included in our study showed a visual improvement in the long-term follow-up. RPE atrophy increased significantly from 3.35 ± 2.94 mm2 (baseline) to 6.81 ± 6.25 mm2 over the course of 2 years (p = 0.000 013, n = 20). CONCLUSIONS: The overall mean vision decrease after rupture was without statistical significance. There was no significant change in BCVA at the 2-year follow-up, independent of the amount of anti-VEGF injections provided. In this study, there was a significant increase in RPE defect over a follow-up of 2 years, implying progression of contraction of RPE and/or macular atrophy.

Spaceflight-associated neuro-ocular syndrome: potential etiologies and connections to the glymphatic system.

The etiology of spaceflight-associated neuro-ocular syndrome (SANS) is a developing field of research, with many current hypotheses receiving varying degrees of support. This syndrome affects ∼70% of astronauts both during and after long-duration space missions, resulting in impaired near vision and visual scotomas (blind spots). In this article, three prominent risk factors for SANS including zero gravity conditions, extraterrestrial hypercapnic environments, and individual genetic predisposition are described. These risk factors are then compared and their pathophysiological pathways are divided into five current hypotheses for the development of SANS. Finally, glymphatic system impairment is explored as a potential mutual end point for these pathways in the development of SANS.

Objectively Measured Visual Impairment and Dementia Prevalence in Older Adults in the US.

Importance: Estimates of the association between visual impairment (VI) and dementia in the US population are based on self-reported survey data or measures of visual function that are at least 15 years old. Older adults are at high risk of VI and dementia so there is a need for up-to-date national estimates based on objective assessments. Objective: To estimate the association between VI and dementia in older US adults based on objective visual and cognitive function testing. Design, Setting, and Participants: This secondary analysis of the 2021 National Health and Aging Trends Study (NHATS), a population-based, nationally representative panel study, included 3817 respondents 71 years and older. Data were analyzed from January to March 2023. Intervention: In 2021, NHATS incorporated tablet-based tests of distance and near visual acuity and contrast sensitivity (CS) with habitual correction. Main Outcomes and Measures: VI was defined as distance visual acuity more than 0.30 logMAR, near visual acuity more than 0.30 logMAR, and CS more than 1 SD below the sample mean. Dementia was defined as scoring 1.5 SDs or more below the mean in 1 or more cognitive domains, an AD8 Dementia Screening Interview Score indicating probable dementia, or diagnosed dementia. Poisson regression estimated dementia prevalence ratios adjusted for covariates. Results: Of 2967 included participants, 1707 (weighted percentage, 55.3%) were female, and the median (IQR) age was 76.9 (77-86) years. The weighted prevalence of dementia was 12.3% (95% CI, 10.9-13.7) and increased with near VI (21.5%; 95% CI, 17.7-25.3), distance VI (mild: 19.1%; 95% CI, 13.0-25.2; moderate, severe, or blind: 32.9%; 95% CI, 24.1- 41.8), and CS impairment (25.9%; 95% CI, 20.5-31.3). Dementia prevalence was higher among participants with near VI and CS impairment than those without (near VI prevalence ratio: 1.40; 95% CI, 1.16-1.69; CS impairment prevalence ratio: 1.31; 95% CI, 1.04-1.66) and among participants with moderate to severe distance VI or blindness (prevalence ratio: 1.72; 95% CI, 1.26-2.35) after adjustment for covariates. Conclusions and Relevance: In this survey study, all types of objectively measured VI were associated with a higher dementia prevalence. As most VI is preventable, prioritizing vision health may be important for optimizing cognitive function.

Causes of functional low vision in a Brazilian rehabilitation service.

There is limited information on functional low vision (FLV) in Latin America, especially in individuals under 50 years of age. In the present study, we retrospectively evaluated the medical records of 1393 consecutive subjects seen at a Brazilian tertiary rehabilitation service, from February 2009 to June 2016. We collected sociodemographic, clinical data, and information on optical aids and spectacle prescription. Subjects were divided into three age groups: 0 to 14 years old (children), 15 to 49 years old (young adults), and 50 years or older (older adults). The main etiologies leading to FLV in children were cerebral visual impairment (27.9%), ocular toxoplasmosis (8.2%), and retinopathy of prematurity (7.8%). In young adults, retinitis pigmentosa (7.4%) and cone/rod dystrophy (6.5%) were the most frequent, while in older adults, age-related macular degeneration (25.3%) and diabetic retinopathy (18.0%) were the leading causes. Our results indicate that preventable diseases are important causes of FLV in children in the area, and proper prenatal care could reduce their burden. The increasing life expectancy in Latin America and the diabetes epidemic are likely to increase the demand for affordable, people-centered rehabilitation centers, and their integration into health services should be planned accordingly.

Visual impairment and psychological distress among adults attending the University of Gondar tertiary eye care and training center, Northwest Ethiopia: A comparative cross-sectional study.

BACKGROUND: Visual impairment can severely affect the quality of life, with a tremendous negative impact on job performance and socioeconomic status. This substantially affects the psychological status of people with visual impairment. OBJECTIVE: This study aimed to determine the prevalence and factors associated with psychological distress among visually impaired Ethiopian adults attending the University of Gondar Tertiary Eye Care and Training Center. METHODS: A comparative cross-sectional study was conducted at the University of Gondar Tertiary Eye Care and Training Center in Gondar City, northwest Ethiopia. A total of 206 adults with visual impairment (a presenting VA ≤ 6/18 in at least one eye) and 206 adults with normal vision were included in the study. Psychological distress was measured using a standardized self-reporting questionnaire (SRQ-20). Chi-square and binary logistic regression analysis were performed. Variables with a P-value of less than 0.05 were considered statistically significant. RESULTS: The overall prevalence of psychological distress in the study participants was 31.07% (95% CI: 26.2, 35.8). Psychological distress was higher (43.2%; 95% CI: 36.5, 50.5) and statistically differed (p = 0.02) in visually impaired compared to adults with normal vision (18.9%; 95% CI: 14.1, 24.3). Duration of vision loss ≥ 2 years (AOR = 8.70; 95% CI: 2.38, 31.46), sudden loss of vision (AOR = 3.50; 95% CI: 1.10, 18.30), unmarried (AOR = 5.53; 95% CI: 1.66, 18.43), living lonely (AOR = 8.40; 95% CI:1.48, 4.74), College and above educational status (AOR = 2.50; 95% CI:1.47, 10.61), and loss of vision in both eyes (AOR = 1.70; 95% CI: 2.00, 14.10) were variables with a significant association with psychological distress among visually impaired adults. CONCLUSION: This study revealed that the prevalence of psychological distress was significantly higher among visually impaired adults than among adults with normal vision. The effect of visual impairment on psychological distress was significantly related to marital status, living arrangements, educational status, duration of vision loss, pattern of vision loss, and laterality of vision loss.

Spatial Dissociation of Subretinal Drusenoid Deposits and Impaired Scotopic and Mesopic Sensitivity in AMD.

Purpose: Subretinal drusenoid deposits (SDD) first appear in the rod-rich perifovea and can extend to the cone-rich fovea. To refine the spatial relationship of visual dysfunction with SDD burden, we determined the topography of mesopic and scotopic light sensitivity in participants with non-neovascular AMD with and without SDD. Methods: Thirty-three subjects were classified into three groups: normal (n = 9), AMD-Drusen (with drusen and without SDD; n = 12), and AMD-SDD (predominantly SDD; n = 12). Mesopic and scotopic microperimetry were performed using 68 targets within the Early Treatment Diabetic Retinopathy Study grid, including points at 1.7° from the foveal center (rod:cone ratio, 0.35). Age-adjusted linear regression was used to compare mesopic and scotopic light sensitivities across groups. Results: Across the entire Early Treatment Diabetic Retinopathy Study grid and within individual subfields, the three groups differed significantly for mesopic and scotopic light sensitivities (all P < 0.05). The AMD-SDD group exhibited significantly decreased mesopic and scotopic sensitivity versus both the normal and the AMD-Drusen groups (all P < 0.05), while AMD-Drusen and normal eyes did not significantly differ (all P > 0.05). The lowest relative sensitivities were recorded for scotopic light levels, especially in the central subfield, in the AMD-SDD group. Conclusions: SDD-associated decrements in rod-mediated vision can be detected close to the foveola, and these deficits are proportionately worse than functional loss in the rod-rich perifovea. This finding suggests that factors other than the previously hypothesized direct cytotoxicity to photoreceptors and local transport barrier limitations may negatively impact vision. Larger prospective studies are required to confirm these observations.

Visual and Refractive Status of Children With Down's Syndrome and Nystagmus.

Purpose: Children with Down's syndrome (DS) are known to have poorer visual acuity than neurotypical children. One report has shown that children with DS and nystagmus also have poor acuity when compared to typical children with nystagmus. What has not been established is the extent of any acuity deficit due to nystagmus and whether nystagmus affects refractive error within a population with DS. Methods: Clinical records from the Cardiff University Down's Syndrome Vision Research Unit were examined retrospectively. Binocular visual acuity and refraction data were available for 50 children who had DS and nystagmus and 176 children who had DS but no nystagmus. Data were compared between the two groups and with published data for neurotypical children with nystagmus. Results: The study confirms the deficit in acuity in DS, compared to neurotypical children, of approximately 0.2 logMAR and shows a deficit attributable to nystagmus of a further 0.2 logMAR beyond the first year of life. Children with both DS and nystagmus clearly have a significant additional impairment. Children with DS have a wide range of refractive errors, but nystagmus increases the likelihood of myopia. Prevalence and axis direction of astigmatism, on the other hand, appear unaffected by nystagmus. Conclusions: Nystagmus confers an additional visual impairment on children with DS and must be recognized as such by families and educators. Children with both DS and nystagmus clearly need targeted support.

Multi-Contrast Magnetic Resonance Imaging of Visual White Matter Pathways in Patients With Glaucoma.

Purpose: Glaucoma is a disorder that involves visual field loss caused by retinal ganglion cell damage. Previous diffusion magnetic resonance imaging (dMRI) studies have demonstrated that retinal ganglion cell damage affects tissues in the optic tract (OT) and optic radiation (OR). However, because previous studies have used a simple diffusion tensor model to analyze dMRI data, the microstructural interpretation of white matter tissue changes remains uncertain. In this study, we used a multi-contrast MRI approach to further clarify the type of microstructural damage that occurs in patients with glaucoma. Methods: We collected dMRI data from 17 patients with glaucoma and 30 controls using 3-tesla (3T) MRI. Using the dMRI data, we estimated three types of tissue property metrics: intracellular volume fraction (ICVF), orientation dispersion index (ODI), and isotropic volume fraction (IsoV). Quantitative T1 (qT1) data, which may be relatively specific to myelin, were collected from all subjects. Results: In the OT, all four metrics showed significant differences between the glaucoma and control groups. In the OR, only the ICVF showed significant between-group differences. ICVF was significantly correlated with qT1 in the OR of the glaucoma group, although qT1 did not show any abnormality at the group level. Conclusions: Our results suggest that, at the group level, tissue changes in OR caused by glaucoma might be explained by axonal damage, which is reflected in the intracellular diffusion signals, rather than myelin damage. The significant correlation between ICVF and qT1 suggests that myelin damage might also occur in a smaller number of severe cases.

Long-term outcomes of patients with acromegaly: a report from the Swedish Pituitary Register.

OBJECTIVE: To describe the treatment and long-term outcomes of patients with acromegaly from all healthcare regions in Sweden. DESIGN AND METHODS: Analysis of prospectively reported data from the Swedish Pituitary Register of 698 patients (51% females) with acromegaly diagnosed from 1991 to 2011. The latest clinical follow-up date was December 2012, while mortality data were collected for 28.5 years until June 2019. RESULTS: The annual incidence was 3.7/million; 71% of patients had a macroadenoma, 18% had visual field defects, and 25% had at least one pituitary hormone deficiency. Eighty-two percent had pituitary surgery, 10% radiotherapy, and 39% medical treatment. At the 5- and 10-year follow-ups, insulin-like growth factor 1 levels were within the reference range in 69 and 78% of patients, respectively. In linear regression, the proportion of patients with biochemical control including adjuvant therapy at 10 years follow-up increased over time by 1.23% per year. The standardized mortality ratio (SMR) (95% CI) for all patients was 1.29 (1.11-1.49). For patients with biochemical control at the latest follow-up, SMR was not increased, neither among patients diagnosed between 1991 and 2000, SMR: 1.06 (0.85-1.33) nor between 2001 and2011, SMR: 0.87 (0.61-1.24). In contrast, non-controlled patients at the latest follow-up from both decades had elevated SMR, 1.90 (1.33-2.72) and 1.98 (1.24-3.14), respectively. CONCLUSIONS: The proportion of patients with biochemical control increased over time. Patients with biochemically controlled acromegaly have normal life expectancy, while non-controlled patients still have increased mortality. The high rate of macroadenomas and unchanged age at diagnosis illustrates the need for improvements in the management of patients with acromegaly.

Simulation of photic effects after cataract surgery for off-axis light sources.

Photopsia is a phenomenon that sometimes disturbs patients after cataract surgery. To evaluate the impact of the edge design of intraocular lenses (IOL) on the location, shape and relative intensity of photic effects at the retina caused by photopsia in pseudophakic eyes, photopsia was simulated using ZEMAX software. The structural parameters of the pseudophakic eye model are based on the Liou-Brennan eye model parameters with a pupil diameter of 4.5 mm. The IOLs implanted in the eye model have a power of 21 diopter (D) with optical diameter of 6 mm and 7 mm. From the ray-tracing analysis, covering variations of incident ray angle of 50° to 90° from temporally, a photic image is detected at the fovea at specific ray angles of 77.5° (6 mm IOL) and 78.2° (7 mm IOL). This photic image disappears when a thin IOL with an edge thickness of 0 mm or a thick IOL with absorbing edges is replaced in the eye model. With an anti-reflective edge, this photic image remains, but with a fully reflecting edge it disappears at the critical angles and appears with different shapes at other angles. The intensity of this photic image can be reduced by changing the edge design to a frosted surface. Most of the photic patterns in IOLs are not observed with absorbing and thin edge designs. IOLs with anti-reflecting and fully reflecting edges generate disturbing photic effects at different angles on the fovea. IOLs with frosted edges reduce the contrast of the photic effects and make them less disturbing for patients.

Resting-state Functional Connectivity After Occipital Stroke.

BACKGROUND: Resting-state functional magnetic resonance imaging (rsfMRI) reflects spontaneous activation of cortical networks. After stroke, these networks reorganize, both due to structural lesion and reorganization of functional connectivity (FC). OBJECTIVE: We studied FC in chronic phase occipital stroke patients with homonymous visual field defects before and after repetitive transorbital alternating current stimulation (rtACS). METHODS: This spin-off study, embedded in the randomized, sham-controlled REVIS trial, comprised 16 chronic occipital stroke patients with visual field defect and 12 healthy control subjects. The patients underwent rsfMRI at baseline, after two weeks of rtACS or sham treatment, and after two months of treatment-free follow-up, whereas the control subjects were measured once. We used a multivariate regression connectivity model to determine mutual prediction accuracy between 74 cortical regions of interest. Additionally, the model parameters were included into a graph to analyze average path length, centrality eigenvector, centrality degree, and clustering of the network. The patients and controls at baseline and the two treatment groups were compared with multilevel modeling. RESULTS: Before treatment, the patients and controls had similar whole-network prediction accuracy and network parameters, whereas centrality eigenvector differed in perilesional regions, indicating local modification in connectivity. In line with behavioral results, neither prediction accuracy nor any network parameter changed systematically as a result of rtACS rehabilitation compared to sham. CONCLUSIONS: Whole-network FC showed no difference between occipital stroke patients and healthy population, congruent with the peripheral location of the visual network in relation to the high-density cortical core. rtACS treatment in the given setting did not affect FC.

Structural changes in retina (Retinal nerve fiber layer) following mild traumatic brain injury and its association with development of visual field defects.

BACKGROUND: Mild traumatic brain injury (mTBI)is the most common form of traumatic brain injury accounting for 70-80% of all brain injuries annually. There is increasing evidence that long lasting morphological and functional consequence can be present in visual system following mTBI. Among all the visual manifestation, awareness of Visual field defects is important because it may compromise the social, personal or professional life of any individual. Retinal structural changes such as thinning of Retinal nerve fiber layer (RFNL)captured using optical coherence tomography have emerged as a possible biomarker in many neurological diseases however very little is known in cases with mTBI OBJECTIVE: (I) To demonstrate the structural changes/morphological changes in retina if any following mTBI. (II) Whether the structural changes in retina have any association with the development of Visual field deficits leading to Visual function impairment following mTBI (III) Clinical relevance of structural changes in retina as a possible biomarker for visual function impairment due to visual field deficits. MATERIALS AND METHODS: Our study included 60 patients with mTBI who fulfilled the inclusion criteria. All patients underwent a detailed ophthalmic evaluation with special focus on temporal recording of Retinal nerve layer thickness using SD- Optical Coherence Tomography and Visual field (Visual field Index) by Humphrey Automated Field Analyser. RESULTS: 30% of eyes had significant thinning of RFNL (> 30% of the base line thickness) at 6 months following mTBI. Visual function impairment due to visual field deficits (VFI < 80%) at 6 months was seen in 40% of the eyes. The structural changes and visual function impairment peaked at 6 months' post injury. A strong Association was noted between RFNL thinning and manifestation of Visual field deficits (VFI < 80%) leading to visual function impairment (P < 0.001). The Correlation Co-efficient between thinning of RFNL and Visual field deficits had a positive correlation(p < 0.001). CONCLUSION: This novel study has demonstrated that visual functional impairment due to Visual field deficits is a real possibility following mTBI. Monitoring of retinal parameter such as thinning of Retinal nerve fiber layer, using Optical coherence tomography, can be a biomarker for early detection or development of visual field defects in mTBI.

Onset of Visual Snow Syndrome After the First Migraine Episode in a Pediatric Patient: A Case Report and Review of Literature.

INTRODUCTION: Visual snow syndrome (VSS) is a neurological disorder characterized by persistent positive visual disturbances. VSS is known to be a rare condition; however, it is becoming increasingly recognized by neurologists and neuroophthalmologists. Despite this, it is not commonly described in pediatric patients. METHODS: We describe a pediatric girl with onset of persistent visual phenomena at age 13 years, which she described as "TV static," with associated afterimages, photopsia, nyctalopia, and photophobia. These visual disturbances have persisted for two years. RESULTS: The patient's MRI revealed approximately 15 T2/fluid-attenuated inversion recovery hyperintensities in keeping with changes secondary to migraine. The ophthalmologic examination did not reveal an underlying cause. The patient's visual symptoms have been resistant to medications. CONCLUSION: VSS is a recently described syndrome that is debilitating to patients. Further case descriptions, characterization of presentation, and management of patients with VSS, specifically in pediatric cases, are required.

The Effect of Achieving Target Intraocular Pressure on Visual Field Worsening.

PURPOSE: To estimate the effect of achieving target intraocular pressure (IOP) values on visual field (VF) worsening in a treated clinical population. DESIGN: Retrospective analysis of longitudinal data. PARTICIPANTS: A total of 2852 eyes of 1688 patients with glaucoma-related diagnoses treated in a tertiary care practice. All included eyes had at least 5 reliable VF tests and 5 IOP measures on separate visits along with at least 1 target IOP defined by a clinician on the first or second visit. METHODS: The primary dependent variable was the slope of the mean deviation (MD) over time (decibels [dB]/year). The primary independent variable was mean target difference (measured IOP - target IOP). We created simple linear regression models and mixed-effects linear models to study the relationship between MD slope and mean target difference for individual eyes. In the mixed-effects models, we included an interaction term to account for disease severity (mild/suspect, moderate, or advanced) and a spline term to account for the differing effects of achieving target IOP (target difference ≤0) and failing to achieve target IOP (target difference >0). MAIN OUTCOME MEASURES: Rate of change in MD slope (changes in dB/year) per 1 mmHg change in target difference at different stages of glaucoma severity. RESULTS: Across all eyes, a simple linear regression model demonstrated that a 1 mmHg increase in target difference had a -0.018 dB/year (confidence interval [CI], -0.026 to -0.011; P < 0.05) effect on MD slope. The mixed-effects model shows that eyes with moderate disease that fail to achieve their target IOP experience the largest effects, with a 1 mmHg increase in target difference resulting in a -0.119 dB/year (CI, -0.168 to -0.070; P < 0.05) worse MD slope. The effects of missing target IOP on VF worsening were more pronounced than the effect of absolute level of IOP on VF worsening, where a 1 mmHg increase in IOP had a -0.004 dB/year (CI, -0.011 to 0.003; P > 0.05) effect on the MD slope. CONCLUSIONS: In treated patients, failing to achieve target IOP was associated with more rapid VF worsening. Eyes with moderate glaucoma experienced the greatest VF worsening from failing to achieve target IOP.

The effects of visual field loss from glaucoma on performance in a driving simulator.

BACKGROUND: To examine the effects of different stages of visual field loss (VFL) from advanced glaucoma on performance in a driving simulator. METHODS: Data on performance and safety from a traffic simulator test for 104 participants with withdrawn driver's licences due to visual field loss from advanced glaucoma were compared with data from 83 individuals without visual deficits in a cross-sectional study. Individuals with glaucoma that regained their driving licences after a successful simulator test were then followed in a national accident database. RESULTS: Glaucoma participants passed the test in 71% (95% confidence interval 61-79%) of the cases. Younger participants were more successful than older. No significant differences on safety or performance measures were detected between glaucoma- and normally sighted participants. Compared with passed glaucoma participants, failed glaucoma participants had more collisions, more critical failed to give way events, longer time headways, and longer reaction times. This group had also a higher extent of central visual field loss. None of the participants with a regained licence were involved in a motor vehicle accident during the 2 to 4 year follow-up after the simulator test. CONCLUSION: Severity of glaucoma predicts driver safety on a group level. However, even individuals with severe visual field loss from glaucoma might drive safely, which highlights the need for individual assessments for licencing purposes.

Multimodal Machine Learning Using Visual Fields and Peripapillary Circular OCT Scans in Detection of Glaucomatous Optic Neuropathy.

PURPOSE: To develop and validate a multimodal artificial intelligence algorithm, FusionNet, using the pattern deviation probability plots from visual field (VF) reports and circular peripapillary OCT scans to detect glaucomatous optic neuropathy (GON). DESIGN: Cross-sectional study. SUBJECTS: Two thousand four hundred sixty-three pairs of VF and OCT images from 1083 patients. METHODS: FusionNet based on bimodal input of VF and OCT paired data was developed to detect GON. Visual field data were collected using the Humphrey Field Analyzer (HFA). OCT images were collected from 3 types of devices (DRI-OCT, Cirrus OCT, and Spectralis). Two thousand four hundred sixty-three pairs of VF and OCT images were divided into 4 datasets: 1567 for training (HFA and DRI-OCT), 441 for primary validation (HFA and DRI-OCT), 255 for the internal test (HFA and Cirrus OCT), and 200 for the external test set (HFA and Spectralis). GON was defined as retinal nerve fiber layer thinning with corresponding VF defects. MAIN OUTCOME MEASURES: Diagnostic performance of FusionNet compared with that of VFNet (with VF data as input) and OCTNet (with OCT data as input). RESULTS: FusionNet achieved an area under the receiver operating characteristic curve (AUC) of 0.950 (0.931-0.968) and outperformed VFNet (AUC, 0.868 [95% confidence interval (CI), 0.834-0.902]), OCTNet (AUC, 0.809 [95% CI, 0.768-0.850]), and 2 glaucoma specialists (glaucoma specialist 1: AUC, 0.882 [95% CI, 0.847-0.917]; glaucoma specialist 2: AUC, 0.883 [95% CI, 0.849-0.918]) in the primary validation set. In the internal and external test sets, the performances of FusionNet were also superior to VFNet and OCTNet (FusionNet vs VFNet vs OCTNet: internal test set 0.917 vs 0.854 vs 0.811; external test set 0.873 vs 0.772 vs 0.785). No significant difference was found between the 2 glaucoma specialists and FusionNet in the internal and external test sets, except for glaucoma specialist 2 (AUC, 0.858 [95% CI, 0.805-0.912]) in the internal test set. CONCLUSIONS: FusionNet, developed using paired VF and OCT data, demonstrated superior performance to both VFNet and OCTNet in detecting GON, suggesting that multimodal machine learning models are valuable in detecting GON.

Disorganization of the inner retinal layers in diabetic macular edema: systematic review / Desorganização das camadas internas da retina sem edema macular diabético: uma revisão sistemática

ABSTRACT The objective of this article was to review the disorganization of inner retinal layers as a biomarker in diabetic macular edema. A systematic search was conducted in PubMed®/MEDLINE®, Cochrane and Embase until August 2021. The keywords used were: "disorganization of inner retinal layers (DRIL)", "diabetic macular edema (DME)" and "biomarkers". No restrictions were imposed on the types of study to be included. The studies selected for eligibility were those that included the diagnosis of diabetic macular edema (center involved, resolved), that were well documented with spectral domain optical coherence tomography, that included disorganization of inner retinal layers as one of the reported alterations, with a follow-up of at least 3 months, and those in which the best corrected visual acuity was evaluated pre and post. There were no limitations regarding the type of treatment established. References of identified studies were searched for additional relevant articles. Articles not published in peer review journals were excluded. All studies were evaluated by two investigators independently. When one of them was in doubt, it was assessed by a third evaluator. A total of seven studies were included. Four were retrospective, longitudinal cohort study and three cross-sectional observational. Regarding the population studied, 61.5% were men and 38.4% were women, most of them had diabetes mellitus type 2 (85.8%). Regarding the stage of diabetes, the percentage of patients with mild nonproliferative diabetic retinopathy was 28.2%, with moderate nonproliferative diabetic retinopathy was 28.5%, with severe nonproliferative diabetic retinopathy was 15.9% and with nonproliferative diabetic retinopathy was 27.4%. In 100% of the studies, the diagnosis of diabetic macular edema in the center involved was included by spectral domain optical coherence tomography (Heidelberg). In all the studies, the presence of disorganization of inner retinal layers was recorded and its association with best corrected visual acuity was evaluated. The measurement was carried out using the LogMAR scale. In all the studies, the presence or absence of disorganization of inner retinal layers was associated with the best corrected worse/better final visual acuity using p <0.05 as a statical significance. The disorganization of inner retinal layers as a biomarker and their presence have shown to be important predictors of visual acuity in the future in patients with diabetic macular edema. Histopathological studies are required to understand its mechanism of action.

RESUMO O objetivo deste artigo foi revisar sobre a desorganização das camadas internas da retina como biomarcador no edema macular diabético. Uma busca sistemática foi realizada no PubMed®/MEDLINE®, Cochrane e Embase até agosto de 2021. As palavras-chave utilizadas foram "disorganization of inner retinal layers (DRIL)", "diabetic macular edema (DME)" e "biomarkers". Não foram impostas restrições quanto aos tipos de estudo a serem incluídos. Os estudos selecionados para elegibilidade foram aqueles que incluíram o diagnóstico de edema macular diabético (centro envolvido, resolvido), que foram bem documentados com tomografia de coerência óptica de domínio espectral, que incluíram a desorganização das camadas internas da retina como uma das alterações relatadas, com acompanhamento de pelo menos 3 meses, e aqueles em que a melhor acuidade visual corrigida foi avaliada pré e pós. Não houve limitações quanto ao tipo de tratamento estabelecido. Referências de estudos identificados foram pesquisadas para artigos relevantes adicionais. Foram excluídos os artigos não publicados em revistas de revisão por pares. Todos os estudos foram avaliados por dois investigadores de forma independente. Quando havia dúvida com algum deles, a mesma era avaliada por um terceiro avaliador. Um total de sete estudos foram incluídos. Quatro eram estudos de coorte retrospectivos longitudinais e três eram observacionais transversais. Em relação à população estudada, a proporção de homens foi de 61,5% e de mulheres, 38,4%, a maioria com diabetes mellitus tipo 2 (85,8%). Em relação ao estágio do diabetes, o percentual de pacientes com retinopatia diabética não proliferativa leve foi de 28,2%, retinopatia diabética não proliferativa moderada foi de 28,5%, de retinopatia diabética não proliferativa grave foi de 15,9% e de retinopatia diabética não proliferativa foi de 27,4%. Em 100% dos estudos, o diagnóstico de edema macular diabético no centro envolvido foi incluído pela tomografia de coerência óptica de domínio espectral (Heidelberg). Em todos os estudos, foi registrada a presença de desorganização das camadas internas da retina e avaliada sua associação com a melhor acuidade visual corrigida. A medição foi realizada usando a escala LogMAR. Em todos os estudos, a presença ou ausência de desorganização das camadas internas da retina foi associada a pior/melhor acuidade visual final melhor corrigida usando p<0,05 como significância estática. A desorganização das camadas internas da retina como biomarcador e sua presença têm se mostrado importantes como preditor da acuidade visual no futuro em pacientes com edema macular diabético. Estudos histopatológicos são necessários para entender seu mecanismo de ação.