Clinical and neuroimaging characteristics in mild-type infantile acute subdural hematoma: report of four cases.

PURPOSE: Infantile acute subdural hematoma (IASDH) has a limited age distribution and mostly benign clinical features. Mild-type IASDH has a stereotypical clinical course which, however, has been described in only a few studies. METHODS: Four male infants (aged 6-10 months; mean age: 7.5 months) were diagnosed as mild-type IASDH associated with retinal hemorrhage (RH) after suffering from occipital impact in a fall. The present case series reviews their clinical features and neuroimaging findings, including CT and MRI findings. RESULTS: All the infants fell backwards from a standing or sitting position onto a soft surface, striking the occipital region. They began crying on impact and then soon afterwards exhibited seizure-like activity or recurrent vomiting. CT and MRI revealed a thin, unclotted subdural hematoma (SDH) without mass effect or brain parenchymal abnormality. Various degrees of bilateral RH were observed. On the day of symptom onset, all infants returned to baseline, and follow-up more than 5 years revealed normal development with no deficits. CONCLUSIONS: Mild-type IASDH with retinal hemorrhage presents with seizure-like activity or recurrent vomiting preceded by crying after an occipital impact on a soft surface. The clinical course of IASDH is followed by rapid recovery on the day of symptom onset. CT and MRI findings reveal a small, unclotted SDH without a mass effect or cerebral parenchymal abnormality.

Utility of balanced steady-state field precession sequence in the evaluation of retinal and subdural hemorrhages in patients with abusive head trauma.

Abusive head trauma is the leading cause of physical child abuse deaths in children under 5 years of age in the United States. To evaluate suspected child abuse, radiologic studies are typically the first to identify hallmark findings of abusive head trauma including intracranial hemorrhage, cerebral edema, and ischemic injury. Prompt evaluation and diagnosis are necessary as findings may change rapidly. Current imaging recommendations include brain magnetic resonance imaging with the addition of a susceptibility weighted imaging (SWI) sequence which can detect additional findings that suggest abusive head trauma including cortical venous injury and retinal hemorrhages. However, SWI is limited due to blooming artifacts and artifacts from the adjacent skull vault or retroorbital fat, which can affect the evaluation of retinal, subdural, and subarachnoid hemorrhages. This work explores the utility of the high-resolution, heavily T2 weighted balanced steady-state field precession (bSSFP) sequence to identify and characterize retinal hemorrhage and cerebral cortical venous injury in children with abusive head trauma. The bSSFP sequence provides distinct anatomical images to improve the identification of retinal hemorrhage and cortical venous injury.

The role of retinal imaging in the management of abusive head trauma cases.

BACKGROUND: As retinal hemorrhage (RH) is the most frequent and reliable finding of abusive head trauma (AHT), an ophthalmology consultation should be systematically required in suspected cases. Full retinal examination through pharmacologically dilated pupil can detect the type and pattern of RHs, helping to distinguish abusive from non-abusive head trauma. METHODS: We performed a retrospective analysis of a case series of 6 infants (aged 0.6-10 months) with AHT who were admitted to the Emergency Department of Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome with severe intracranial hemorrhages. Children underwent full multidisciplinary assessment including dilated fundus examination, optical coherence tomography (OCT) and digital wide-field fundus photography (DWFFP - in our case RetCam). In our paper we report the clinical presentation, the ocular findings and outcome at discharge. RESULTS: The mean age at the hospital admission was 6.28 months. In all infants, intracranial hemorrhages were found. Preretinal and intraretinal hemorrhages were detected, collecting good-quality retinal images. CONCLUSIONS: Imaging of retinal hemorrhages represents a fundamental moment of AHT diagnosis and documentation. Although RetCam is the gold standard for the acquisition of retinal images in suspected cases, OCT is extremely valuable in forensic evaluation since it can detect even small macular hemorrhages. Therefore, the combination of RetCam and OCT imaging can give relevant hints for the diagnosis of AHT, allowing to evaluate the extent, spread and morphology of RHs.

Automatic Diagnosis of Diabetic Retinopathy Stage Focusing Exclusively on Retinal Hemorrhage.

Background and Objectives: The present study evaluated the detection of diabetic retinopathy (DR) using an automated fundus camera focusing exclusively on retinal hemorrhage (RH) using a deep convolutional neural network, which is a machine-learning technology. Materials and Methods: This investigation was conducted via a prospective and observational study. The study included 89 fundus ophthalmoscopy images. Seventy images passed an image quality review and were graded as showing no apparent DR (n = 51), mild nonproliferative DR (NPDR; n = 16), moderate NPDR (n = 1), severe NPDR (n = 1), and proliferative DR (n = 1) by three retinal experts according to the International Clinical Diabetic Retinopathy Severity scale. The RH numbers and areas were automatically detected and the results of two tests-the detection of mild-or-worse NPDR and the detection of moderate-or-worse NPDR-were examined. Results: The detection of mild-or-worse DR showed a sensitivity of 0.812 (95% confidence interval: 0.680-0.945), specificity of 0.888, and area under the curve (AUC) of 0.884, whereas the detection of moderate-or-worse DR showed a sensitivity of 1.0, specificity of 1.0, and AUC of 1.0. Conclusions: Automated diagnosis using artificial intelligence focusing exclusively on RH could be used to diagnose DR requiring ophthalmologist intervention.

Novel in vivo depiction of optic nerves hemorrhages in child abuse: a 3D-SWI pilot study.

PURPOSE: Until now, the diagnosis of optic nerves hemorrhages in abusive head trauma (AHT) has been obtained only in the postmortem setting. The aim of the IRB-approved study was to assess the presence of optic nerves hemorrhages in AHT patients using 3D-SWI. METHODS: Thirteen children with a final confirmed multidisciplinary diagnosis of AHT underwent coronal and axial 3D-SWI imaging of the orbits. The presence of optic nerve sheath (ONS) hemorrhages was defined by thickening and marked 3D-SWI hypointensity of the ONS, resulting in mass effect upon the CSF space. Optic nerve (ON) hemorrhages were defined by areas of susceptibility artifacts in the ON parenchyma. Superficial siderosis was defined by susceptibility artifact coating the ON. Furthermore, data about post-traumatic deformity of the ONS at the head of the optic nerve were collected. RESULTS: The average age of the population was 7.9 ± 5.9 months old. The average GCS was 11.8 ± 4.5. The male to female ratio was 7:6. ONS hemorrhages were identified in 69.2% of cases. Superficial siderosis and ON hemorrhages were identified in 38.5 and 76.9% of cases, respectively. 3D-SWI also depicted traumatic deformity of the ONS at the level of the optic nerve head in 10 cases (76.9%). No statistical correlations were identified between RetCam findings and 3D-SWI findings or GCS and ON hemorrhages. CONCLUSION: This research shows that dedicated MRI with volumetric SWI of the orbits can depict hemorrhages in the ON, ONS, and ONS injury, in AHT victims.

BACILLARY LAYER DETACHMENT BECAUSE OF MACULAR NEOVASCULARIZATION.

PURPOSE: To describe the clinical and multimodal imaging features of bacillary layer detachment (BD), and its response to intravitreal anti-vascular endothelial growth factor therapy, in eyes with macular neovascularization. METHODS: Retrospective, observational case series of 14 eyes (14 patients, 7 men) imaged with eyes (14 patients, 7 men) were imaged with spectral-domain optical coherence tomography, and either fluorescein angiography or optical coherence tomography angiography. Therapeutic response was monitored with serial imaging and best-corrected visual acuity assessments. RESULTS: The mean age was 75 ± 13 (range: 45-96) years, with mean follow-up duration of 27 ± 21 (range: 1-56) months. Neovascular age-related macular degeneration was found in 71% (10/14) eyes. Type 2 macular neovascularization lesions were associated with BD in all 14 eyes. Subretinal hemorrhage was noted in 79% (11/14) eyes. BD promptly resolved after intravitreal antivascular endothelial growth factor therapy in all eyes. The baseline best-corrected visual acuity improved from logarithm of the minimum angle of resolution 0.84 ± 0.32 (Snellen equivalent 20/138) to logarithm of the minimum angle of resolution 0.48 ± 0.31 (Snellen equivalent 20/60) at the last follow-up, with treatment of the macular neovascularization. CONCLUSION: Type 2 macular neovascularization and subretinal hemorrhage are associated with BDs, which may be due to a rapid influx of exudative fluid into the potential space between the external limiting membrane and ellipsoid zone. Intravitreal antivascular endothelial growth factor therapy results in rapid resolution of BDs and visual improvement in most eyes.

Magnetic resonance imaging of optic nerve and optic sheath hemorrhages in child abuse.

In abusive head trauma victims, optic nerves and optic sheath hemorrhages are commonly associated with retinal hemorrhages. Until now, optic nerve and optic nerve sheath hemorrhages related to abusive head trauma have been identified by exenteration and soft-tissue sectioning during postmortem examination. In 2013, we proposed the use of tailored high-resolution susceptibility-weighted imaging (SWI) MRI sequences to depict retinal hemorrhages in lieu of the gold standard dilated fundus exam, in select patients, and in 2017 we showed how the same high-resolution sequences used in the coronal plane can depict ruptured bridging veins in abusive head trauma. This paper describes the new potential diagnostic application of high-resolution axial and coronal SWI in the diagnosis of optic nerve and optic sheath hemorrhages.

Neuroimaging of retinal hemorrhage utilizing adjunct orbital susceptibility-weighted imaging.

Retinal hemorrhages are an integral part of the evaluation of abusive head trauma (AHT). Timely detection of retinal hemorrhage not only facilitates the diagnosis of AHT, but has the potential to prevent further abuse to the child and the siblings and to identify the abuser. The gold standard for diagnosing retinal hemorrhage is a dilated fundoscopy exam, which requires pharmacological dilation. As such, there is a small percentage of patients for whom the dilated fundoscopy exam might be delayed. Evolving literature suggests that MRI, specifically susceptibility-weighted imaging (SWI), of the orbits might provide an alternative diagnostic tool for noninvasively detecting retinal hemorrhages, particularly when there is a delay in administering the dilated fundoscopy exam. In this paper we review the utility of SWI for detecting retinal hemorrhages in abusive head trauma, including discussion of diagnostic limitations and future research.

Grading Diabetic Retinopathy from Stereoscopic Color Fundus Photographs - An Extension of the Modified Airlie House Classification: ETDRS Report Number 10.

The modified Airlie House classification of diabetic retinopathy has been extended for use in the Early Treatment Diabetic Retinopathy Study (ETDRS). The revised classification provides additional steps in the grading scale for some characteristics, separates other characteristics previously combined, expands the section on macular edema, and adds several characteristics not previously graded. The classification is described and illustrated and its reproducibility between graders is assessed by calculating percentages of agreement and kappa statistics for duplicate gradings of baseline color non- simultaneous stereoscopic fundus photographs. For retinal hemorrhages and/ or microaneurysms, hard exudates, new vessels, fibrous proliferations, and macular edema, agreement was substantial (weighted kappa, 0.61 to 0.80). For soft exudates, intraretinal microvascular abnormalities, and venous beading, agreement was moderate (weighted kappa, 0.41 to 0.60). A double grading system, with adjudication of disagreements of two or more steps between duplicate gradings, led to some improvement in reproducibility for most characteristics.

Histopathological Changes and Clinical Outcomes following Intervention for Sub-Internal Limiting Membrane Haemorrhage.

INTRODUCTION: Haemorrhage confined to the sub-internal limiting membrane (ILM) space can be associated with good visual recovery. There is controversy as to the best management of purely sub-ILM haemorrhage, which ranges from observation to immediate surgical intervention. METHODS: We studied a retrospective case series of patients with sub-ILM haemorrhage who underwent vitrectomy with subsequent histological analysis of the removed ILM. RESULTS: Sixteen patients underwent vitrectomy for sub-ILM haemorrhage. Five patients had underlying Terson syndrome, 6 had ruptured macro-aneurysms, and 5 had Valsalva retinopathy. Seven patients demonstrated cellular proliferation on the retinal surface of the ILM with staining for glial fibrillary acidic protein and cytokeratin 7, as well as CD68pg and Prussian blue. All but 1 of these cases were isolated from patients undergoing surgery >4 weeks following initial symptoms, the other presented at >2 weeks. Serial optical coherence tomography (OCT) was available in 8 patients; serial OCT in patients with delayed intervention demonstrated persistent inner retinal layer hyper-reflectance. Fourteen of 15 patients demonstrated symptomatic recovery and showed visual improvement with acuity ranging from -0.1 to 1.8 (mean 0.43) within 3 months of intervention (1 was lost to follow-up). The post-operative vision was 0.11 logMAR (mean; range -0.1 to 0.4) at 3 months in the group with intervention within 2 weeks of symptoms, and 0.9 logMAR (mean; range 0.0 to HM) in the group with delayed surgery. CONCLUSIONS: Early surgical intervention for sub-ILM haemorrhage resulted in good visual outcomes; delayed surgery may lead to proliferative vitreoretinopathy-like changes on the inner retinal surface of the ILM, and untreated cases may demonstrate persistent inner retinal changes potentially limiting visual prognosis despite subsequent surgical intervention.

New grading criterion for retinal haemorrhages in term newborns based on deep convolutional neural networks.

BACKGROUND: To define a new quantitative grading criterion for retinal haemorrhages in term newborns based on the segmentation results of a deep convolutional neural network. METHODS: We constructed a dataset of 1543 retina images acquired from 847 term newborns, and developed a deep convolutional neural network to segment retinal haemorrhages, blood vessels and optic discs and locate the macular region. Based on the ratio of areas of retinal haemorrhage to optic disc, and the location of retinal haemorrhages relative to the macular region, we defined a new criterion to grade the degree of retinal haemorrhages in term newborns. RESULTS: The F1 scores of the proposed network for segmenting retinal haemorrhages, blood vessels and optic discs were 0.84, 0.73 and 0.94, respectively. Compared with two commonly used retinal haemorrhage grading criteria, this new method is more accurate, objective and quantitative, with the relative location of the retinal haemorrhages to the macula as an important factor. CONCLUSIONS: Based on a deep convolutional neural network, we can segment retinal haemorrhages, blood vessels and optic disc with high accuracy. The proposed grading criterion considers not only the area of the haemorrhages but also the locations relative to the macular region. It provides a more objective and comprehensive evaluation criterion. The developed deep convolutional neural network offers an end-to-end solution that can assist doctors to grade retinal haemorrhages in term newborns.

Spontaneous neonatal subdural haemorrhage: always non-accidental injury?

In any neonate or infant presenting with an acute onset of encephalopathy, and/or retinal haemorrhages with no history of major trauma and imaging showing subdural haemorrhage (SDH), the diagnostic priority is to exclude a non-accidental injury (NAI), given the association of these clinical features with the shaken baby syndrome. However, other causes of SDH may present in a similar manner in neonates and infants, in particular vascular lesions such as aneurysms. A four week old neonate presenting with seizures and retinal haemorrhages, was diagnosed with an acute subdural haemorrhage (ASDH) on imaging with significant midline shift needing surgical evacuation. As there was some blood extending into the left sylvian fissure, further imaging was considered before surgical intervention. This showed a distally located middle cerebral artery aneurysm, which was successfully treated and the neonate made a remarkable recovery. We present a case of a neonate presenting with spontaneous acute subdural haematoma in the absence of classical diffuse subarachnoid haemorrhage, intracerebral haemorrhage or intraventricular haemorrhage, secondary to a ruptured middle cerebral artery aneurysm. The distribution of aneurysms in the neonatal age group is different to adults, with middle cerebral artery aneurysms and more distally located peripheral aneurysms being more common. Vigilance should be borne to exclude the aforementioned as causes for this presentation especially prior to undertaking surgical intervention.

Sub-hyaloid and sub-internal limiting membrane macular hemorrhage after laser exposure at music festival: a case report.

PURPOSE: To describe the first case of a combined sub-hyaloid and sub-internal limiting membrane macular hemorrhage after recreational laser exposure. METHODS: A 23-year-old patient presented with an acute loss of vision in his right eye (OD) immediately after a brief exposure to a laser beam at a music festival. Color photography, spectral-domain optical coherence tomography (SD-OCT), and multifocal electroretinogram (mfERG) were performed for diagnosis and follow-up. RESULTS: On presentation, visual acuity was 20/400 in the OD and 20/20 in the left eye. Posterior segment examination of his OD revealed a preretinal hemorrhage at the macula. SD-OCT images exposed a combined sub-hyaloid and sub-internal limiting membrane localization. Successful VPP with ILM peeling was carried out. Although sequential mfERG displayed almost complete restoration of the P1 amplitude 6 months posterior to VPP, SD-OCT demonstrated permanent damage to outer retinal layers. Final BCVA on OD was 20/30. CONCLUSION: The expanding and unregulated use of lasers in everyday life has created an increasing amount of cases of laser-induced retinopathy in recent years. Much more attention should be addressed in laser safety and awareness to prevent future ocular injuries. In acute phases of sub-hyaloid hemorrhages blocking direct visualization of the posterior pole, mfERG is a valuable tool to address initial macular pathology.

NEW PROPOSAL FOR THE PATHOPHYSIOLOGY OF TYPE 3 NEOVASCULARIZATION AS BASED ON MULTIMODAL IMAGING FINDINGS.

PURPOSE: To investigate the imaging characteristics of early Type 3 neovascularization and propose a new pathophysiologic sequence for early disease. METHODS: Patients were evaluated with a comprehensive ophthalmologic examination to include fundus photography, optical coherence tomography, optical coherence tomography angiography, fluorescein angiography, and volume-rendered optical coherence tomography angiography. Relevant literature was also reviewed. RESULTS: There were 10 eyes of 9 patients who had a mean age of 87 (range 79-93) years and 7 were women. The patients were seen to have distributed areas of cystoid macular edema, not necessarily contiguous with areas of fluorescein or optical coherence tomography angiographic evidence of neovascularization, which colocalized with each other. Areas of hemorrhage were not necessarily contiguous with observed neovascularization. In some patients, massive amounts of edema were imaged, although the associated neovascular invasion was small and did not reach deeper portions of the retina. These findings were readily responsive to intravitreal injections of anti-vascular endothelial growth factor (VEGF) medication. Review of published literature showed conflicting pathophysiologic proposals, which did not abide with contemporaneous imaging findings. CONCLUSION: Type 3 neovascularization likely grows in response to increased cytokine levels, particularly VEGF, in a permissive environment. Elevated levels of VEGF have been shown to cause hemorrhage, edema, and telangiectasis in the macula, suggesting some of the manifestations of Type 3 neovascularization are related to increased tissue VEGF levels and not necessarily to the neovascularization alone. A proposal based on imaging and histopathologic findings and known physiologic effects of VEGF is presented.

Susceptibility-weighted imaging of retinal hemorrhages in abusive head trauma.

BACKGROUND: Retinal hemorrhages are one of the most important supportive evidences for abusive head trauma (AHT). Susceptibility-weighted imaging (SWI) is highly suited to identify various forms of intracranial hemorrhage in AHT. However its utility in imaging retinal hemorrhage is not well established. OBJECTIVE: SWI is a sensitive sequence for identifying retinal hemorrhage on MRI. MATERIALS AND METHODS: In this retrospective analysis, 26 consecutive infants and young children with a suspected admission diagnosis of AHT underwent indirect ophthalmoscopy and brain MRI protocol for AHT along with SWI. Brain susceptibility-weighted images of 14 age-matched children were used as controls. For detecting retinal hemorrhage, susceptibility-weighted images of patients and controls were reviewed randomly and independently by two neuroradiologists who were blinded to the history and ophthalmology findings. A pediatric ophthalmologist graded the indirect ophthalmoscopy images. RESULTS: A diagnosis of AHT was confirmed in all 26 cases from a multidisciplinary meeting. Indirect ophthalmoscopy images were available in 21 cases. Ophthalmoscopy was positive for retinal hemorrhage in the right eye in 18 cases (85.7%) and in the left eye in 16 cases (76.2%). On SWI, retinal hemorrhage was identified in the right eye in 9/21 cases (42.8%) and in the left eye in 8/21 cases (38.1%) of AHT. Analysis of SWI in 21 cases of AHT demonstrated a sensitivity of 50%, specificity of 100%, positive predictive value of 100% and negative predictive value of 32% for detecting retinal hemorrhage. CONCLUSION: SWI is moderately sensitive and highly specific for identifying retinal hemorrhage in AHT. Further studies are needed to identify steps to improve the efficiency of SWI in detecting retinal hemorrhage.

Fundus images analysis using deep features for detection of exudates, hemorrhages and microaneurysms.

BACKGROUND: Convolution neural networks have been considered for automatic analysis of fundus images to detect signs of diabetic retinopathy but suffer from low sensitivity. METHODS: This study has proposed an alternate method using probabilistic output from Convolution neural network to automatically and simultaneously detect exudates, hemorrhages and microaneurysms. The method was evaluated using two approaches: patch and image-based analysis of the fundus images on two public databases: DIARETDB1 and e-Ophtha. The novelty of the proposed method is that the images were analyzed using probability maps generated by score values of the softmax layer instead of the use of the binary output. RESULTS: The sensitivity of the proposed approach was 0.96, 0.84 and 0.85 for detection of exudates, hemorrhages and microaneurysms, respectively when considering patch-based analysis. The results show overall accuracy for DIARETDB1 was 97.3% and 86.6% for e-Ophtha. The error rate for image-based analysis was also significantly reduced when compared with other works. CONCLUSION: The proposed method provides the framework for convolution neural network-based analysis of fundus images to identify exudates, hemorrhages, and microaneurysms. It obtained accuracy and sensitivity which were significantly better than the reported studies and makes it suitable for automatic diabetic retinopathy signs detection.

Retinal Microvascular Abnormalities as Surrogate Markers of Cerebrovascular Ischemic Disease: A Meta-Analysis.

BACKGROUND: To determine the predictive value of retinal microvascular abnormalities for cerebrovascular ischemic diseases (CVDs), we aimed to investigate the quantitative association between retinal microvascular changes and CVD subcategories: white matter hyperintensities (WMHIs), lacunar infarcts (LIs), and cerebral infarctions (CIs). METHODS: Using Meta-analyses Of Observational Studies in Epidemiology guidelines, we searched 6 databases through September 2016 for studies evaluating the linkage between retinal microvascular abnormalities and WMHI, and LI and CI. Studies were included if they reported odds ratios (ORs) and 95% confidence intervals or raw patient level data (that were computed into ORs). Unadjusted and vascular risk-factor adjusted ORs were pooled into meta-analysis using DerSimonian Laird random effects model. Study quality and dissemination biases were assessed and integrated. RESULTS: From 24,444 search-identified records, 28 prospective studies encompassing 56,379 patients were eligible for the meta-analysis. After vascular risk-factor adjustment, focal arteriolar narrowing was associated with WMHI (OR, 1.24 [1.01-1.79]), LI (OR, 1.77 [1.14-2.74]), and CI (OR, 1.75 [1.14-2.69]). Venular dilation was associated with LI (OR, 1.46 [1.10-1.93]), and retinal hemorrhages with WMHI (OR, 2.23 [1.34-3.70]). Any retinopathy exhibited significant association with CI (OR, 1.96 [1.65-2.50]). Heterogeneity was significant (I2>50%) for all syntheses except retinal hemorrhages and WMHI, and retinopathy and CI (I2=0 ⋅ 0%). Associations remained significant after adjustments for quality and publication bias. CONCLUSIONS: We found the most significant association between retinal hemorrhages and WMHI. Focal arteriolar narrowing and retinopathy predicted CVD subtypes after risk-factor adjustment, suggesting that features different than traditional vascular risk factors, are involved in CVD pathophysiology.

Higher skin autofluorescence in young people with Type 1 diabetes and microvascular complications.

AIM: To test the hypothesis that non-invasive skin autofluorescence, a measure of advanced glycation end products, would provide a surrogate measure of long-term glycaemia and be associated with early markers of microvascular complications in adolescents with Type 1 diabetes. METHODS: Forearm skin autofluorescence (arbitrary units) was measured in a cross-sectional study of 135 adolescents with Type 1 diabetes [mean ± sd age 15.6 ± 2.1 years, diabetes duration 8.7 ± 3.5 years, HbA1c 72 ± 16 mmol/mol (8.7 ± 1.5%)]. Retinopathy, assessed using seven-field stereoscopic fundal photography, was defined as ≥1 microaneurysm or haemorrhage. Cardiac autonomic function was measured by standard deviation of consecutive RR intervals on a 10-min continuous electrocardiogram recording, as a measure of heart rate variability. RESULTS: Skin autofluorescence was significantly associated with age (R2 = 0.15; P < 0.001). Age- and gender-adjusted skin autofluorescence was associated with concurrent HbA1c (R2 = 0.32; P < 0.001) and HbA1c over the previous 2.5-10 years (R2 = 0.34-0.43; P < 0.002). Age- and gender-adjusted mean skin autofluorescence was higher in adolescents with retinopathy vs those without retinopathy [mean 1.38 (95% CI 1.29, 1.48) vs 1.22 (95% CI 1.17, 1.26) arbitrary units; P = 0.002]. In multivariable analysis, retinopathy was significantly associated with skin autofluorescence, adjusted for duration (R2 = 0.19; P = 0.03). Cardiac autonomic dysfunction was also independently associated with skin autofluorescence (R2 = 0.11; P = 0.006). CONCLUSIONS: Higher skin autofluorescence is associated with retinopathy and cardiac autonomic dysfunction in adolescents with Type 1 diabetes. The relationship between skin autofluorescence and previous glycaemia may provide insight into metabolic memory. Longitudinal studies will determine the utility of skin autofluorescence as a non-invasive screening tool to predict future microvascular complications.

Optic disc hemorrhage in glaucoma: pathophysiology and prognostic significance.

PURPOSE OF REVIEW: This article reviews the recent findings with regard to the pathophysiology and clinical significance of optic disc hemorrhage in glaucoma. RECENT FINDINGS: Even though the pathophysiology of disc hemorrhage has been investigated in depth, its underlying mechanism remains unclear. The key disc hemorrhage mechanisms currently under discussion are mechanical vascular disruption and associated vascular susceptibilities. Recent technical advances in spectral-domain optical coherence tomography have yielded more compelling evidence of mechanical vascular disruption behind the pathogenesis of disc hemorrhage in glaucoma. Studies show that disc hemorrhage is associated with structural and functional glaucoma progression. Furthermore, recent findings suggest that disc hemorrhage can have different significances according to its location, recurrence, and associated underlying mechanism. SUMMARY: The underlying mechanism of disc hemorrhage is complex like that of glaucoma. The ongoing controversy respecting the role of disc hemorrhage as a risk factor for glaucoma progression notwithstanding, special attention entailing closer follow-up and/or treatment escalation is recommended for patients with disc hemorrhage. Further studies investigating the unrevealed pathogenesis of disc hemorrhage and its prognostic value in glaucoma are warranted.