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Purpose: To investigate the association between rim area focal hyperautofluorescence (RAFH) signals and geographic atrophy (GA) growth rates, as well as the impact of oral metformin on the longitudinal change of RAFH., Design: Secondary analysis of a randomized controlled trial., Participants: Seventy-one eyes from 44 participants with GA and ≥6 months of follow-up in the METformin for the MINimization of geographic atrophy progression study., Methods: Fundus autofluorescence images were captured using a 488 nm excitation wavelength. Two masked graders identified and measured RAFH lesions using proprietary semiautomatic segmentation software and ImageJ. We calculated RAFH by dividing the areas of hyperautofluorescence within a 450-μm rim circumscribing the GA by the total area enclosed within this rim., Main Outcome Measures: Longitudinal changes in RAFH and GA area., Results: Baseline RAFH was positively associated with the baseline square root of GA area 0.065/year ( P < 0.001). In the entire study cohort, higher baseline RAFH was associated with a faster GA area growth rate in mm 2 /year (Spearman's ρ = 0.53; P < 0.001). The association became weaker in square root-transformed GA area growth (ρ = 0.19, P  = 0.11) and perimeter-adjusted GA growth rate (ρ = 0.28, P  = 0.02), achieving statistical significance only in the latter. When this analysis was stratified into 3 baseline GA tertiles, the first and second tertiles showed weak to moderate association with statistical significance in all 3 modes of GA growth rates. Rim area focal hyperautofluorescence increased slightly but significantly over time at 0.020/year ( P < 0.01). Rim area focal hyperautofluorescence increased slightly but significantly over time at 0.020/year ( P < 0.01). The use of oral metformin was not significantly associated with the change in RAFH over time compared with the observation group (0.023/year vs. 0.016/year; P  = 0.29)., Conclusions: Increased baseline RAFH is associated with faster GA area progression. However, the effect size of this association may depend on the baseline GA lesion size such that small to medium-sized GA lesions display this relationship regardless of the mode of the calculation of GA growth rate., Financial Disclosures: Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (© 2024 by the American Academy of Ophthalmology.)

Purpose: To assess safety, tolerability, and feasibility of subcutaneous administration of the mitochondrial-targeted drug elamipretide in patients with intermediate age-related macular degeneration (AMD) and high-risk drusen (HRD) and to perform exploratory analyses of change in visual function., Design: Phase 1, single-center, open-label, 24-week clinical trial with preplanned HRD cohort., Participants: Adult patients ≥55 years of age with intermediate AMD and HRD., Methods: Participants received subcutaneous elamipretide 40 mg daily, with safety and tolerability assessed throughout the study. Ocular assessments included normal-luminance best-corrected visual acuity (BCVA), low-luminance best-corrected visual acuity (LLVA), normal-luminance binocular reading acuity (NLRA), low-luminance binocular reading acuity (LLRA), spectral-domain OCT, fundus autofluorescence (FAF), mesopic microperimetry, dark adaptation, and low-luminance questionnaire (LLQ)., Main Outcome Measures: The primary end point was safety and tolerability. Prespecified exploratory end points included changes from baseline in BCVA, LLVA, NLRA, LLRA, retinal pigment epithelium (RPE)-drusen complex (DC) volume by OCT, FAF, mesopic microperimetry, dark adaptation, and LLQ results., Results: Subcutaneous administration of elamipretide was highly feasible. All participants with HRD (n = 21) experienced 1 or more adverse events (AEs), but all were mild (57%) or moderate (43%), with the most common events related to injection site reactions. No serious systemic AEs occurred. One participant discontinued because of injection site reaction, 1 participant withdrew because they did not wish to continue study visits, and 1 participant withdrew after experiencing transient visual impairment. Among the 18 participants who completed the study, mean change in BCVA from baseline to 24 weeks was +3.6 letters ( P = 0.014) and LLVA was +5.6 letters ( P = 0.004). Compared with baseline, mean NLRA improved by -0.11 logarithm of the minimum angle of resolution (logMAR) units ( P = 0.001), and LLRA by -0.28 logMAR units ( P < 0.0001). Significant improvements were found in 6 of 7 subscales of the LLQ ( P < 0.0015). No significant changes were observed for RPE-DC volume, FAF, mesopic microperimetry, or dark adaptation., Conclusions: Elamipretide appeared to be generally safe and well tolerated in treating intermediate AMD and HRD. Exploratory analyses demonstrate a positive effect on visual function, particularly under low-luminance conditions. Further study of elamipretide for treatment of intermediate AMD with HRD is warranted., (© 2022 Published by Elsevier Inc. on behalf of the American Academy of Ophthalmology.)

Purpose: Assess the safety, tolerability, and feasibility of subcutaneous administration of the mitochondrial-targeted drug elamipretide in patients with dry age-related macular degeneration (AMD) and noncentral geographic atrophy (NCGA) and to perform exploratory analyses of change in visual function., Design: Phase 1, single-center, open-label, 24-week clinical trial with preplanned NCGA cohort., Participants: Adults ≥ 55 years of age with dry AMD and NCGA., Methods: Participants received subcutaneous elamipretide 40-mg daily; safety and tolerability assessed throughout. Ocular assessments included normal-luminance best-corrected visual acuity (BCVA), low-luminance BCVA (LLBCVA), normal-luminance binocular reading acuity (NLBRA), low-luminance binocular reading acuity (LLBRA), spectral-domain OCT, fundus autofluorescence (FAF), and patient self-reported function by low-luminance questionnaire (LLQ)., Main Outcome Measures: Primary end point was safety and tolerability. Prespecified exploratory end-points included changes in BCVA, LLBCVA, NLBRA, LLBRA, geographic atrophy (GA) area, and LLQ., Results: Subcutaneous elamipretide was highly feasible. All participants (n = 19) experienced 1 or more nonocular adverse events (AEs), but all AEs were either mild (73.7%) or moderate (26.3%); no serious AEs were noted. Two participants exited the study because of AEs (conversion to neovascular AMD, n = 1; intolerable injection site reaction, n = 1), 1 participant discontinued because of self-perceived lack of efficacy, and 1 participant chose not to continue with study visits. Among participants completing the study (n = 15), mean ± standard deviation (SD) change in BCVA from baseline to week 24 was +4.6 (5.1) letters ( P = 0.0032), while mean change (SD) in LLBCVA was +5.4 ± 7.9 letters ( P = 0.0245). Although minimal change in NLBRA occurred, mean ± SD change in LLBCVA was -0.52 ± 0.75 logarithm of the minimum angle of resolution units ( P = 0.005). Mean ± SD change in GA area (square root transformation) from baseline to week 24 was 0.14 ± 0.08 mm by FAF and 0.13 ± 0.14 mm by OCT. Improvement was observed in LLQ for dim light reading and general dim light vision., Conclusions: Elamipretide seems to be well tolerated without serious AEs in patients with dry AMD and NCGA. Exploratory analyses demonstrated possible positive effect on visual function, particularly under low luminance. A Phase 2b trial is underway to evaluate elamipretide further in dry AMD and NCGA., (© 2022 Published by Elsevier Inc. on behalf of the American Academy of Ophthalmology.)

Anti-vascular endothelial growth factor (VEGF) agents are widely regarded as the first line of therapy for diabetic macular edema (DME) but are not universally effective. An automatic method that can predict whether a patient is likely to respond to anti-VEGF therapy can avoid unnecessary trial and error treatment strategies and promote the selection of more effective first-line therapies. The objective of this study is to automatically predict the efficacy of anti-VEGF treatment of DME in individual patients based on optical coherence tomography (OCT) images. We performed a retrospective study of 127 subjects treated for DME with three consecutive injections of anti-VEGF agents. Patients' retinas were imaged using spectral-domain OCT (SD-OCT) before and after anti-VEGF therapy, and the total retinal thicknesses before and after treatment were extracted from OCT B-scans. A novel deep convolutional neural network was designed and evaluated using pre-treatment OCT scans as input and differential retinal thickness as output, with 5-fold cross-validation. The group of patients responsive to anti-VEGF treatment was defined as those with at least a 10% reduction in retinal thickness following treatment. The predictive performance of the system was evaluated by calculating the precision, sensitivity, specificity, and area under the receiver operating characteristic curve (AUC). The algorithm achieved an average AUC of 0.866 in discriminating responsive from non-responsive patients, with an average precision, sensitivity, and specificity of 85.5%, 80.1%, and 85.0%, respectively. Classification precision was significantly higher when differentiating between very responsive and very unresponsive patients. The proposed automatic algorithm accurately predicts the response to anti-VEGF treatment in DME patients based on OCT images. This pilot study is a critical step toward using non-invasive imaging and automated analysis to select the most effective therapy for a patient's specific disease condition., Competing Interests: The authors declare that there is no conflict of interest., (© 2020 Optical Society of America under the terms of the OSA Open Access Publishing Agreement.)

Purpose: To determine the effects of aldosterone exposure on retinal edema and retinopathy in a mouse model of retinal vein occlusion (RVO)., Methods: RVO was induced immediately following intravenous injection of Rose bengal (66 mg/kg) using a 532-nm wavelength laser to place three to seven applications at 80 mW and 50-μm spot size directed at the superior retinal vein one disc diameter away from the nerve. Negative control consisted of placing an equal number of laser spots without targeting the vein. Male and female C57BL/6J mice aged 7 to 9 months with confirmed absence of Crb1rd8 were used. Aldosterone pellets releasing a daily dose of 0.83 μg/day were implanted subcutaneously 4 weeks prior to RVO. Retinal imaging by optical coherence tomography (OCT) was performed using a Micron IV rodent imaging system. Retinas were analyzed by immunohistochemistry using standard techniques. Retinal imaging and tissue analysis were performed 2, 4, and 7 days following RVO. Comparisons were made using Student's t-test, ANOVA, and Pearson's χ2., Results: RVO caused retinal edema in the form of cystic spaces and retinal thickening detectable by both OCT and histology. RVO also caused Müller glia (MG) dysfunction manifest as upregulated glial fibrillary acidic protein (GFAP) and altered localization of aquaporin 4 (AQP4) and Kir4.1. Treatment with aldosterone caused a significant increase in retinal edema and more severe retinopathy manifest as retinal whitening and extensive intraretinal hemorrhage. MG dysfunction was more severe and persistent in aldosterone-treated mice. Finally, aldosterone greatly increased the number of infiltrating mononuclear phagocytes following RVO., Conclusions: Systemic aldosterone exposure causes a more severe RVO phenotype manifest as increased severity and duration of retinal edema and more severe retinopathy. The effects of aldosterone may be mediated by MG dysfunction and increased infiltration of mononuclear phagocytes. This suggests that small increases in aldosterone levels may be a risk factor for severe RVO.

Purpose: We use semiautomated segmentation of fluorescein angiography (FA) to determine whether anti-vascular endothelial growth factor (VEGF) treatment for diabetic macular edema (DME) differentially affects microaneurysm (MA)-associated leakage, termed focal leakage, versus non-MA-associated leakage, termed diffuse leakage., Methods: We performed a retrospective study of 29 subjects treated with at least three consecutive injections of anti-VEGF agents for DME (mean 4.6 injections; range, 3-10) who underwent Heidelberg FA before and after anti-VEGF therapy. Inclusion criteria were macula center involving DME and at least 3 consecutive anti-VEGF injections. Exclusion criteria were macular edema due to cause besides DME, anti-VEGF within 3 months of initial FA, concurrent treatment for DME besides anti-VEGF, and macular photocoagulation within 1 year. At each time point, total leakage was semiautomatically segmented using a modified version of our previously published software. Microaneurysms were identified by an expert grader and leakage within a 117 μm radius of each MA was classified as focal leakage. Remaining leakage was classified as diffuse leakage. The absolute and percent changes in total, diffuse, and focal leakage were calculated for each subject., Results: Mean pretreatment total leakage was 8.2 mm 2 and decreased by a mean of 40.1% ( P < 0.0001; 95% confidence interval [CI], [-28.6, -52.5]) following treatment. Diffuse leakage decreased by a mean of 45.5% ( P < 0.0001; 95% CI, [-31.3, -59.6]) while focal leakage decreased by 17.9% ( P = 0.02; 95% CI, [-1.0, -34.8]). The difference in treatment response between focal and diffuse leakage was statistically significant ( P = 0.01)., Conclusions: Anti-VEGF treatment for DME results in decreased diffuse leakage but had relatively little effect on focal leakage as assessed by FA. This suggests that diffuse leakage may be a marker of VEGF-mediated pathobiology. Patients with predominantly focal leakage may be less responsive to anti-VEGF therapy., Translational Relevance: Fluorescein angiography can define focal and diffuse subtypes of diabetic macular edema and these may respond differently to anti-VEGF treatment.

Background: Diabetic retinopathy (DR) is a leading cause of low vision and blindness. We evaluated the feasibility of using a handheld, noncontact digital retinal camera, Pictor, to obtain retinal images in dilated and undilated eyes for DR screening. We also evaluated the accuracy of ophthalmologists with different levels of training/experience in grading these images to identify eyes with vision-threatening DR., Methods: A prospective study of diabetic adults scheduled to have dilated eye exams at Duke Eye Center from January to May 2014 was conducted. An imager acquired retinal images pre- and postdilation with Pictor and selected 1 pre- and 1 postdilation image per eye. Five masked ophthalmologists graded images for gradability (based on image focus and centration) and the presence of no, mild, moderate, or severe nonproliferative DR (NPDR) or proliferative DR (PDR). Referable disease was defined as moderate or severe NPDR or PDR on image grading. We evaluated feasibility based on the graders' evaluation of image gradability. We evaluated accuracy of identifying vision-threatening disease (severe NPDR or PDR documented on dilated clinical examination) based on the graders' sensitivity and specificity of grading referable disease., Results: Images were gradable in 86-94% of predilation and 94-97% of postdilation photos. Compared to the dilated clinical exam, overall sensitivity for identifying vision-threatening DR was 64-88% and specificity was 71-90%., Conclusions: Pictor can capture retinal images of sufficient quality to screen for DR with and without dilation. Single retinal images obtained using Pictor can identify eyes with vision-threatening DR with high sensitivity and acceptable specificity compared to clinical exam.

Purpose: To develop image analysis software usable by nonexpert graders to segment geographic atrophy (GA) from dry AMD and to quantify rim area focal hyperautofluorescence (RAFH) surrounding GA on fundus autofluorescence (FAF) images. To compare the GA progression predictions based on RAFH with those of a validated qualitative classification system., Methods: Retrospective analysis of serial FAF images from 49 eyes of 30 subjects with GA was performed using MATLAB-based software (MathWorks, Natick, MA, USA). Correlation between RAFH and progression of GA was analyzed using Spearman correlation. Comparisons of lesion growth rate between RAFH tertiles used generalized estimating equations and Kruskal-Wallis testing. Interobserver variability in lesion size, growth rate and RAFH were compared between two expert and one nonexpert grader using Bland-Altman statistics., Results: Rim area focal hyperautofluorescence was positively correlated with GA progression rate (ρ = 0.49, P < 0.001). Subjects in the middle or highest RAFH tertile were at greater risk of progression (P = 0.005 and P = 0.001, respectively). Mean difference in RAFH was 0.012 between expert and -0.005 to 0.017 between expert and nonexperts. Mean difference in lesion size (mm2) was 0.11 between expert and -0.29 to 0.41 between expert and nonexperts. Mean difference in lesion growth rate (mm2/mo) was 0.0098 between expert and -0.027 to 0.037 between expert and nonexperts. Risk stratification based on RAFH tertile was 96% identical across all graders., Conclusions: Our semiautomated image analysis software facilitates stratification of progression risk based on RAFH and enabled a nonexpert grader with minimal training to obtain results comparable to expert graders. Predictions based on RAFH were similar to those of a validated qualitative classification system.

We propose a novel, graph-theoretic framework for distinguishing arteries from veins in a fundus image. We make use of the underlying vessel topology to better classify small and midsized vessels. We extend our previously proposed tree topology estimation framework by incorporating expert, domain-specific features to construct a simple, yet powerful global likelihood model. We efficiently maximize this model by iteratively exploring the space of possible solutions consistent with the projected vessels. We tested our method on four retinal datasets and achieved classification accuracies of 91.0%, 93.5%, 91.7%, and 90.9%, outperforming existing methods. Our results show the effectiveness of our approach, which is capable of analyzing the entire vasculature, including peripheral vessels, in wide field-of-view fundus photographs. This topology-based method is a potentially important tool for diagnosing diseases with retinal vascular manifestation.

We present a fully automatic algorithm to identify fluid-filled regions and seven retinal layers on spectral domain optical coherence tomography images of eyes with diabetic macular edema (DME). To achieve this, we developed a kernel regression (KR)-based classification method to estimate fluid and retinal layer positions. We then used these classification estimates as a guide to more accurately segment the retinal layer boundaries using our previously described graph theory and dynamic programming (GTDP) framework. We validated our algorithm on 110 B-scans from ten patients with severe DME pathology, showing an overall mean Dice coefficient of 0.78 when comparing our KR + GTDP algorithm to an expert grader. This is comparable to the inter-observer Dice coefficient of 0.79. The entire data set is available online, including our automatic and manual segmentation results. To the best of our knowledge, this is the first validated, fully-automated, seven-layer and fluid segmentation method which has been applied to real-world images containing severe DME.

Purpose: To create and validate software to automatically segment leakage area in real-world clinical fluorescein angiography (FA) images of subjects with diabetic macular edema (DME)., Methods: Fluorescein angiography images obtained from 24 eyes of 24 subjects with DME were retrospectively analyzed. Both video and still-frame images were obtained using a Heidelberg Spectralis 6-mode HRA/OCT unit. We aligned early and late FA frames in the video by a two-step nonrigid registration method. To remove background artifacts, we subtracted early and late FA frames. Finally, after postprocessing steps, including detection and inpainting of the vessels, a robust active contour method was utilized to obtain leakage area in a 1500-μm-radius circular region centered at the fovea. Images were captured at different fields of view (FOVs) and were often contaminated with outliers, as is the case in real-world clinical imaging. Our algorithm was applied to these images with no manual input. Separately, all images were manually segmented by two retina specialists. The sensitivity, specificity, and accuracy of manual interobserver, manual intraobserver, and automatic methods were calculated., Results: The mean accuracy was 0.86 ± 0.08 for automatic versus manual, 0.83 ± 0.16 for manual interobserver, and 0.90 ± 0.08 for manual intraobserver segmentation methods., Conclusions: Our fully automated algorithm can reproducibly and accurately quantify the area of leakage of clinical-grade FA video and is congruent with expert manual segmentation. The performance was reliable for different DME subtypes. This approach has the potential to reduce time and labor costs and may yield objective and reproducible quantitative measurements of DME imaging biomarkers., (Copyright 2015 The Association for Research in Vision and Ophthalmology, Inc.)

The endothelial lining of the vasculature forms the physical barrier between the blood and underlying tissues. Junctions between adjacent endothelial cells are dynamically modulated to sustain vascular homeostasis and to support the transendothelial migration of leukocytes during inflammation. A variety of factors initiate intracellular signaling pathways that regulate the opening and resealing of junctional complexes. This review focuses on three primary signaling pathways initiated within endothelial cells by the binding of vasoactive factors and leukocyte adhesion: Rho GTPases, reactive oxygen species, and tyrosine phosphorylation of junctional proteins. These pathways converge to regulate junctional permeability, either by affecting the stability of junctional proteins or by modulating their interactions. Although much progress has been made in understanding the relationships of these pathways, many questions remain to be answered. A full understanding of the signaling cascades that affect endothelial junctions should identify novel therapeutic targets for diseases that involve excessive permeability or inappropriate leukocyte infiltration into tissues.

During trans-endothelial migration (TEM), leukocytes use adhesion receptors such as intercellular adhesion molecule-1 (ICAM1) to adhere to the endothelium. In response to this interaction, the endothelium throws up dynamic membrane protrusions, forming a cup that partially surrounds the adherent leukocyte. Little is known about the signaling pathways that regulate cup formation. In this study, we show that RhoG is activated downstream from ICAM1 engagement. This activation requires the intracellular domain of ICAM1. ICAM1 colocalizes with RhoG and binds to the RhoG-specific SH3-containing guanine-nucleotide exchange factor (SGEF). The SH3 domain of SGEF mediates this interaction. Depletion of endothelial RhoG by small interfering RNA does not affect leukocyte adhesion but decreases cup formation and inhibits leukocyte TEM. Silencing SGEF also results in a substantial reduction in RhoG activity, cup formation, and TEM. Together, these results identify a new signaling pathway involving RhoG and its exchange factor SGEF downstream from ICAM1 that is critical for leukocyte TEM.