Investigative Ophthalmology & Visual Science

Oxidative stress is proposed to be a driver of age-related diseases. Age-related macular degeneration is one such disease, where the retinal pigment epithelium (RPE) is affected early in the disease. Vasculature damage also occurs, sometimes preceding RPE damage. To model some aspects of dry AMD, we used the NaIO3 mouse model of oxidative damage. Disruption of the deep retinal vascular plexus, disorganization and death of capillaries within the choriocapillaris, and marked electroretinographic decline were observed. AAV overexpressing the transcription factor, NRF2, which induces anti-oxidation enzymes and represses inflammation, was tested for protection of damage. The BEST1 promoter limited expression to the RPE. The RPE, photoreceptors, and vascular architecture in both retinal and choroidal compartments were protected. Conditioned medium from RPE-choroid explants, infected by AAV8/BEST1-NRF2, was sufficient to transfer partial protection in vivo, indicating that NRF2 induces a protective secreted factor(s). Analysis of RNA-seq data identified growth differentiation factor 15 (GDF15) as a candidate downstream mediator. Injection of recombinant GDF15 reproduced key protective phenotypes in vivo, whereas Gdf15-deficiency attenuated NRF2-mediated rescue. Pharmacologic inhibition of TGF-{beta} receptor signaling diminished NRF2 associated protection, supporting involvement of this signaling pathway. In a laser-induced choroidal neovascularization model, intravitreal GDF15 injection reduced fluorescein leakage and lesion size. These findings support a model in which NRF2 activation in the RPE induces expression of GDF15, which is capable of protecting the RPE, photoreceptors, and the retinal and choroidal vasculature. NRF2 and GDF15 have therapeutic potential for ocular diseases, as well as for other diseases with vascular pathology.

Pathogenic variants in IFT140 are associated with a spectrum of syndromic and non-syndromic ciliopathies, with retinal degeneration as a common feature. Despite advances in understanding IFT140 function across various tissues, human retina-specific models are lacking. Here, we show that knock-in mice homozygous for the IFT140 patient variant c.932A>G (p.Y311C) did not develop retinal degeneration, while mice with the homozygous variant c.1451C>T (p.T484M), associated with non-syndromic retinal dystrophy, were embryonic lethal. Therefore, to understand the effect of these variants on retinal homeostasis, we generated novel human in vitro models of IFT140-associated retinal dystrophy, including CRISPR/Cas9 IFT140 knock-out (IFT140KO) induced pluripotent stem cells (iPSC) and patient-derived iPSC retinal pigment epithelium (iPSC-RPE) and retinal organoids (iPSC-ROs). IFT140KO iPSC-RPE cells display stubby cilia compared to isogenic controls, while IFT140T484M/T484Mpatient-derived iPSC-RPE cells exhibit slightly shorter cilia and cilia tip protein accumulation. Both IFT140KO and IFT140T484M/T484M iPSC-ROs show accumulation of cilia proteins at the connecting cilium and outer segment of photoreceptors, and mislocalization of rhodopsin to the inner segments and outer nuclear layer. Pharmacological screening of compounds previously reported to improve cilia structure identified the flavonoid eupatilin as the most effective molecule. Treatment with eupatilin improved cilium length and IFT traffic in iPSC-RPE, and IFT traffic and rhodopsin localization in iPSC-ROs. These findings emphasize the importance of human stem cell derived models to investigate tissue specific disease mechanisms and highlight the therapeutic potential of eupatilin to ameliorate cilia defects in retinal tissue.

PurposeTo characterize the frequency-dependent bioimpedance properties of major ocular tissues in intact ex vivo porcine eyes under simulated surgical conditions and evaluate tissue separability at discrete frequencies. MethodsBioimpedance spectra were acquired from sclera, corneal epithelium, iris, lens, vitreous, and retina in intact ex vivo porcine eyes using a two-electrode probe and a precision LCR meter over 5 kHz to 1 MHz. Measurements were obtained under balanced salt solution and ophthalmic viscosurgical device conditions. Probe-tissue contact was verified by microscope visualization and optical coherence tomography. Tissue separability at 5, 50, 100, and 900 kHz was evaluated using global and pairwise statistical comparisons, effect sizes, and ROC-based separability metrics. Robotic-stabilized and handheld measurements were also compared. ResultsOcular tissues demonstrated distinct, frequency-dependent impedance magnitude distributions. Across sampled frequencies, 60% to 80% of tissue pairs showed significant differences after multiplicity correction. Median pairwise effect sizes ranged from Cohens d = 0.48 at 5 kHz to 1.04 to 1.06 at 50 to 100 kHz. Median ROC-based separability was 0.91 at 5 kHz and 0.76 to 0.77 at 50 to 900 kHz. Robotic-stabilized measurements showed lower variance than handheld measurements, although tissue-specific impedance ranges and frequency-dependent trends were preserved across acquisition modes. ConclusionsMajor ocular tissues exhibit reproducible, frequency-dependent bioimpedance signatures in intact ex vivo eyes under simulated surgical preparation. These findings establish a physiologically relevant ocular impedance reference dataset and support bioimpedance as a complementary modality for tissue differentiation in ophthalmic microsurgery.

Unlike the conventional mature neutrophils, immature neutrophils have been investigated for their regenerative properties; however, their limited availability necessitates alternative generation strategies. Here, we used a combination of dimethylsulfoxide (DMSO) and 1,25-dihydroxyvitamin D3 (D3) to differentiate myeloid leukemia (HL-60) cells into immature neutrophil-like cells. Differentiated cells exhibited reduced cell size, loss of uniformity, decreased nuclear-to-cytoplasmic ratio, band-shaped nuclei, increased proportion of CD11b+CD14+ cells (indicative of immature neutrophils), decreased proportion of CD11b+CD16+ cells (indicative of mature neutrophils), higher levels of arginase 1, TGF{beta}1 (markers of immature neutrophils), and no expression of CD16, MRC1 (markers of mature neutrophils and M2 macrophages, respectively). Proteomic analysis revealed enrichment of proteins associated with immature neutrophils and wound healing. Functionally, these cells supported limbal stem cell growth and wound closure in vitro, indicating relevance for corneal regeneration. Administration of these cells to ex-vivo and in-vivo alkali-injured corneas, resulted in significant effect on promotion of wound healing, with epithelial regeneration and decreased fibrotic markers, proving that such cells hold promise for clinical translation as a therapeutic tool for tissue repair.

Inherited retinal diseases (IRDs) are a heterogeneous group of genetic disorders that cause progressive vision loss. A subset of IRDs is associated with ubiquitously expressed genes involved in fundamental cellular processes, often resulting in multisystem disease. Among these is Zellweger spectrum disorder (ZSD), caused by pathogenic variants in PEX genes required for peroxisome biogenesis and function. There are no proven targeted disease-modifying treatments for ZSD, and it is unclear whether localized restoration of peroxisome function is sufficient to mitigate retinal degeneration. We previously demonstrated that HsPEX1 retinal gene augmentation therapy in a mouse model of mild ZSD homozygous for the murine equivalent (PEX1-p.[Gly844Asp]) of the most common deleterious allele in patients (PEX1-c.[2528G>A], PEX1-p.[Gly843Asp]), improved retinal electrophysiological response. Here, we present a comprehensive, dose-range evaluation of a re-designed, clinically relevant AAV8-delivered HsPEX1 subretinal gene therapy, employing expanded outcome measures. We observed a marked improvement in functional vision, retinal response, photoreceptor structure, retinal pigment epithelium integrity, subretinal inflammation, and peroxisomal metabolites, durable to the endpoint of 6 months post single subretinal injection. These studies provide preclinical proof-of-concept that localized retinal gene replacement can mitigate vision loss in peroxisome-mediated IRD.

The effect of sortilin inhibition on acute inner retinal neurodegeneration induced by optic nerve crush was investigated. Pharmacological sortilin inhibition using intravitreal delivery of a polyclonal antibody or a small-molecule inhibitor was evaluated in C57BL/6JRj male mice subjected to unilateral crush. Inner retinal thickness was evaluated by optical coherence tomography, and retinal ganglion cell density was determined in retinal flat mounts. Furthermore, the effect of constitutive sortilin deficiency was examined using Sort1-/- mice. Changes in protein and mRNA levels of sortilin, p75NTR, and associated injury markers were analyzed. Neither pharmacological inhibition or constitutive loss of sortilin protected against inner retinal thinning or retinal ganglion cell loss following optic nerve crush. A transient 1.4-fold increase in p75NTR mRNA was observed early after injury, accompanied by a two-fold increase in protein levels. While sortilin expression remained largely unchanged, sortilin deficiency was associated with an altered baseline retinal state, including increased GFAP, p75NTR, and proBDNF levels. Following optic nerve crush, the induction of p75NTR was significantly attenuated in sortilin-deficient retinas compared with wild type, without affecting the extent of RGC degeneration. In summary, sortilin inhibition does not preserve inner retinal structure following optic nerve crush, but modulates glial activation, inflammatory signaling, and proneurotrophin dynamics. These findings indicate that sortilin-dependent pathways are not key drivers of optic nerve crush-induced neurodegeneration but may be more relevant in disease contexts characterized by chronic stress and neuroinflammation.

Purpose: To evaluate the safety and exploratory outcomes of a single intravitreal injection of OGX110, a peptide agonist of CXCR3, in eyes with persistent fluid secondary to neovascular age-related macular degeneration (nAMD) despite ongoing anti-vascular endothelial growth factor (anti-VEGF) therapy. Methods: This prospective, open-label, sequential dose-escalation phase I study (NCT05904691) enrolled subjects receiving standard-of-care intravitreal anti-VEGF therapy. Subjects received a single intravitreal injection of OGX110 at 0.5 mg, 1.0 mg, or 2.0 mg (n=3 per cohort), 7 to 14 days after the anti-VEGF injection. Results: All nine enrolled subjects completed follow-up through day 56. Two subjects (22%) experienced at least 1 adverse event (AE); all were mild and unrelated to study treatment. Exploratory analyses showed a BCVA change of +1.4 letters following anti-VEGF injection and +4.4 letters from OGX110 baseline to 4 weeks (P < 0.05). Six of 9 subjects gained at least 3 ETDRS letters after OGX110. Anatomic responses were heterogeneous. Four eyes showed a reduction in CRT after anti-VEGF injection that was maintained after OGX110 administration. One additional eye demonstrated a substantial reduction in CRT after OGX110 despite minimal response to anti-VEGF treatment. Conclusions: A single intravitreal injection of OGX110 was well tolerated. Exploratory functional and anatomic findings suggest biologic activity; interpretation is limited by small sample size, open-label design, absence of a concurrent control group, and inter-subject heterogeneity. These results support further study in a controlled trial. Translational Relevance: OGX110 represents a mechanistically distinct investigational approach for nAMD that may warrant further evaluation in eyes with persistent.

Age-related macular degeneration (AMD) is a progressive complex eye disease and one of the leading causes of blindness. AMD progression is marked by molecular changes in the retinal pigmented epithelium (RPE) which include increased reactive oxygen species (ROS) accumulation, mitochondrial dysfunction - eventually leading to dysfunctional RPE. Mitophagy regulator, Pink1, is reduced in the RPE of AMD patients and Pink1 loss leads to a shift from mitochondrial respiration to glycolysis. Serine is a non-essential amino acid which is de novo synthesized from glycolytic intermediate 3-PG via the rate limiting enzyme PHGDH. Serine is tightly integrated into anabolic processes like glutathione (GSH) cycling, maintaining NADH/NADPH pools leading to changes in AMPK signaling. Here, we show that Pink1 loss leads to a reduction in PHGDH and serine levels in the RPE leading to impaired mitochondrial structure and function, increased ROS mediated damage, increased inflammation, and hampered retinal function. Serine supplementation rescued ROS accumulation, balanced GSH abundance, and increased retinal function. Overall, our study highlights the potential of dietary serine in ROS management in AMD.

Albino individuals are clinically recognized to exhibit heightened susceptibility to light-induced retinal injury, yet the cellular and metabolic mechanisms underlying this vulnerability remain poorly defined. Here, we investigated whether retinal pigment epithelium (RPE) pigmentation governs mitochondrial structure, metabolism, and inflammatory responses that ultimately determine retinal resilience to blue light stress. Using pigmented (C57BL/6J) and albino (Balb/c) mice, we demonstrate that albino animals exhibit markedly increased retinal phototoxicity following blue light exposure, manifested by fundus lesions, outer nuclear layer (ONL) disruption, and structural degeneration evident by OCT. Primary RPE cultures derived from albino mice exhibited profound difference in mitochondrial morphology, characterized by increased mitochondrial number, reduced size, and enhanced fragmentation, accompanied by elevated mitochondrial DNA copy number. These structural changes correlated with transcriptional skewing toward mitochondrial fission (increased Drp1) and suppression of mitochondrial fusion (Mfn1, Mfn2, OPA1). Functionally, albino and depigmented RPE displayed impaired oxidative phosphorylation, reduced ATP production, and diminished reliance on mitochondrial pyruvate carrier (MPC)-dependent metabolism. In parallel, albino RPE demonstrated cell-cycle accumulation at G2/M and heightened basal and blue light-induced secretion of pro-inflammatory cytokines, particularly IFN-{beta}1, IL-6, and TNF-. Importantly, exogenous melanin supplementation partially restored mitochondrial fusion gene expression, pyruvate-dependent respiration, and inflammatory restraint. Together, these findings identify melanin as a critical regulator of RPE mitochondrial architecture, metabolic substrate utilization, and inflammatory signaling, providing a mechanistic framework to explain enhanced photo-vulnerability in the albino retina. These insights establish pigmentation-dependent mitochondrial metabolism as a determinant of retinal resilience and suggest mitochondrial bioenergetics as a therapeutic target.

Purpose: To characterize peripheral immune alterations in treated birdshot uveitis (BU) patients using high-dimensional mass cytometry and multiplex serology. Design: Cohort study. Subjects: 36 BU patients on immunomodulatory treatment (IMT) and 31 healthy controls (HCs). Methods: Detailed ophthalmologic examinations were performed, and peripheral blood and serum samples were collected for immune profiling using mass cytometry and multiplex cytokine analysis. Main Outcome Measures: Imaging-based indicators of ocular inflammation; peripheral immune cell frequencies; serum cytokine levels. Results: Compared to HCs, BU patients showed increased frequencies of Th17, CD146+ T cells, intermediate effector/central memory T cells co-expressing CXCR3 and CCR4, CD56dim NK cells and elevated IL-18 levels. Patients were clinically stratified by an expert ophthalmologist into three disease activity groups: Inactive, Active (comprising combinations of surface retina, deep retina and choroid activity) and Burned-out. Inactive patients harbored more quiescent effector T cells, e.g. Tim-3+ Tc17-Tc22 intermediates and more CD8+ TSCM, potentially representing a resting pool of autoimmune T cells. Active patients exhibited increased in vivo activation of relevant T cells, with stronger HLA-DR, CD38 or PD-1 expression, and highest levels of CD56dim NK cells. Immune profiles were also linked to treatment subgroups: csDMARDs (conventional synthetic disease-modifying antirheumatic drugs) were associated with higher CD56bright NK frequencies, and absence of therapy showed elevated PD-1/SLAMF7 Tc17+1 and PD-1CD57 CD8 TEMRA cells. IL-6R blockade (tocilizumab) resulted in loss of IL-6R T-cells accompanied by increased SLAMF7 T cells, due to epitope masking. Conclusions: Peripheral CyTOF profiling anchored to thorough clinical stratification revealed disease activity-associated immune signatures and therapy-associated imprints in BU.

Manufacturer-defined signal-strength indices are frequently employed as quality benchmarks for automated optical coherence tomography analysis, yet their empirical relationship with deep learning segmentation accuracy remains unclear. Because these metrics were originally developed for conventional image-processing pipelines, their ability to predict modern model-based segmentation accuracy has not been empirically validated. To address this gap, we evaluated the Heidelberg Spectralis Q-score against U-Net segmentation performance across 5,047 B-scans from 103 eyes for three anatomical boundaries of the posterior segment of the eye: the Ellipsoid Zone (EZ), Bruch's Membrane (BM), and Choroid Outer Boundary (COB). Alongside standard boundary agreement metrics (MAE, MSE, Dice Similarity Coefficient), we adapted the Earth Mover's Distance (EMD) from optimal transport theory as a boundary evaluation metric. Unlike column-wise averages, EMD quantifies boundary agreement as a 2-D geometric displacement, directly measuring residual spatial displacement between the model segmented boundary and the ground-truth boundary. Our results demonstrate that the Q-score - originally designed to gate image-processing-based automated analysis - is a poor predictor of deep learning boundary segmentation accuracy, with explained variance (R2) failing to exceed 1.4% across all three boundaries. We further observed a monotonically increasing error hierarchy with anatomical depth (EZ < BM < COB), consistent across metrics, which is unexplained by the signal strength. At the COB, correlations were paradoxically positive, explained by a B-scan-level mediation chain: higher Q-scores correspond to greater choroidal thickness (r=0.113, {rho}=0.158), which in turn predicts higher COB segmentation error (r=0.165, {rho}=0.191) - a localization difficulty that global signal strength cannot capture. Collectively, these findings challenge the implicit assumption that signal-strength-based quality thresholds are a reliable proxy for deep learning model performance, and motivate a shift toward task-specific acquisition quality criteria calibrated to model performance rather than signal interpretability.

Objective: To define CSC genetic architecture and identify implicated ocular tissues, cell types, genes, and circulating proteins. Data Sources: Genome-wide data were assembled from FinnGen, All of Us, Mass General Brigham Biobank, Million Veteran Program, and a Dutch chronic CSC cohort. Serum protein quantitative trait loci, human single-cell ocular atlases, and UK Biobank macular optical coherence tomography (OCT) imaging were used for downstream analyses. Study Selection: Five European-ancestry cohorts with genome-wide data and cohort-specific CSC case-control definitions were included, comprising 2,584 cases and 1,044,455 controls. Variants present in at least 2 cohorts were meta-analyzed. Data Extraction and Synthesis: Cohort-level GWASs were adjusted for age, age squared, sex, genotyping array or batch, and 10 genetic principal components, then combined using fixed-effects inverse-variance meta-analysis. Post-GWAS analyses included gene prioritization, colocalization, Mendelian randomization, single-cell disease-relevance scoring, and testing of a CSC genetic risk score in UK Biobank OCT images. Main Outcome(s) and Measure(s): Genome-wide significant CSC loci, effector genes and proteins, tissue and cell-type enrichment, and CSC-relevant OCT abnormalities. Results: Across 11,068,938 variants, 10 loci reached genome-wide significance (P < 5e-8), including 3 novel loci near TGFB1, LINC00551, and LOC105375630 and 7 replicated loci near CFH, CD46, NOTCH4, PREX1, PTPRB, GATA5, and TNFRSF10A. Integrative analyses prioritized 10 candidate effector genes. Colocalization and Mendelian randomization implicated circulating TNFRSF10A, TGFB1, and CASP10 levels. Single-cell analyses localized genetic risk to sclera (P = 2.0e-4) and vascular endothelial cells (P = 4.0e-4), with fibroblast enrichment. In UK Biobank, OCT abnormalities were more frequent in the top vs bottom 1% of CSC genetic risk (18 of 109 [16.5%] vs 8 of 134 [6.0%]; odds ratio, 4.05; 95% CI, 1.65-10.87; P = .002). Conclusions and Relevance: In this GWAS meta-analysis, CSC susceptibility localized predominantly to scleral and vascular biology rather than primary retinal pigment epithelial dysfunction. These findings support CSC as a sclerovascular disorder and nominate complement regulation, endothelial signaling, and extracellular matrix pathways for future study.

Purpose: To predict retinal nerve fiber layer thickness (RNFLT) norms from fundus images. Methods: We selected 18,000 OCT scans and visual fields (VF) from the Massachusetts Eye and Ear Glaucoma Service. A U-Net-based deep learning model was developed to predict RNFLT norms from OCT en face fundus images. A total of 10,000 OCT scans with normal VFs (mean deviation [MD] [&ge;] -1 dB, glaucoma hemifield test within normal limits, and pattern standard deviation probability > 5%) tested within 30 days were used for training, while the remaining 8,000 OCT scans (mean VF MD: 3.3 +/- 4.9 dB), including 2,419 scans with normal VFs, were used for evaluation. Structure-function correlations between RNFLT maps and VFs were assessed using linear regression and VGG-16 across original RNFLT maps, deviation maps, and their combination. Performance was evaluated using correlation coefficients, mean absolute error (MAE), and R-squared. Results: Predicted RNFLT norm maps showed agreement with baseline RNFLT maps in eyes with normal VFs (R-squared = 0.81 +/- 0.13). RNFLT deviation maps correlated more strongly with VF MD than original RNFLT maps (R = 0.42 vs. 0.19, p < 0.01). In deep learning-based VF prediction, combining original and deviation maps achieved the best performance (MAE = 3.31 dB, R-squared = 0.39), outperforming the model (p < 0.05) using original RNFLT maps alone (MAE = 3.36 dB, R-squared = 0.35). Conclusions: Deep learning can estimate individualized RNFLT norms and improve structure-function assessment in glaucoma. Translational Relevance: Personalized RNFLT norm prediction may improve detection of glaucomatous damage.

PurposeAssessing visual function in patients with ultralow vision (ULV), particularly those with retinitis pigmentosa (RP), remains a significant challenge in therapeutic development. Full-field stimulus test (FST) provides a quantitative measure of retinal light sensitivity and may serve as a valuable clinical endpoint. We investigated FST in ULV RP by examining its associations with functional measures and daily activity-based tasks. DesignObservational, cross-sectional study. ParticipantsPatients with RP and visual acuity in the worse-seeing eye below counting fingers (CF) were enrolled. MethodsAfter dilation and 45-minute dark adaptation, FST was performed monocularly with brief full-field white-light flashes across three visits. Visual acuity was classified into four groups: no light perception (NLP), light perception (LP), hand motion (HM), and CF or better. We assessed functional vision using two tabletop object-recognition and exploration tasks, two mobility tasks, and three vision-related questionnaires. FST thresholds were compared across visual acuity groups, and associations with functional outcomes were analyzed. Main Outcome MeasuresFST thresholds and their associations with functional vision outcomes. ResultsThirty-five patients (70 eyes; median age, 62 years, range 39-84) were included. Median FST thresholds (log cd*s/m{superscript 2}) by visual acuity group were as follows: NLP, 1.13 (-0.63-2.54); LP, -0.27 (-2.70-2.91); HM, -1.13 (-6.24-0.51); CF or better, -2.82 (-5.67- -1.73) (p < 0.001). Measurable FST thresholds were obtained in 9 of 14 NLP eyes (64.3%). FST thresholds showed significant correlations with tabletop performance (r = -0.70 to - 0.46) and mobility performance (r = -0.65), whereas no significant association was observed with questionnaire scores. Test-retest variability across three visits showed no systematic bias, with a coefficient of repeatability of {+/-}0.66 to {+/-}0.82 log cd{middle dot}s/m{superscript 2}. ROC analyses identified FST cutoffs of -1.75 to -0.87 log cd{middle dot}s/m{superscript 2} at which patients first achieved nonzero functional task performance. ConclusionsFST quantifies residual visual function in ULV RP and correlates strongly with performance-based measures of functional vision in daily life. These findings support FST as a clinically meaningful endpoint for therapeutic trials in advanced RP and other severe visual impairments and highlight the value of anchoring FST thresholds to functional task performance.

ObjectiveTo describe the ophthalmic examination protocol within the German National Cohort (NAKO) / NAKO Gesundheitsstudie, to report the baseline profile of participants undergoing ophthalmological assessment, and to illustrate the potential of these data as a population-based open resource for artificial intelligence (AI) research in eye health. DesignBaseline analysis of ophthalmic data within the nationwide, population-based multicenter prospective NAKO study. Participants48,460 adults in the ophthalmological level 2 module of 205,053 adults enrolled in NAKO, aged 19-74 years, with mean age 48.9 {+/-} 12.5 years and 52.7% male. MethodsAll participants underwent standardized assessments of a wide range of biomedical examinations and detailed questionnaire-based data collection, including non-dilated color fundus imaging, visual acuity testing, recording of a brief ocular history. Ocular and systemic health measures were summarized using descriptive statistics. Fundus image quality and morphological features (e.g. cup-to-disc ratio, ateriole-to-venule-ratio) were assessed using open-source deep learning models. Standard deep learning architectures were trained on the fundus images to predict age, sex and blood pressure. Main Outcome MeasuresPercentage of fundus images graded as good quality; mean absolute error for age and blood pressure prediction; accuracy for sex prediction. ResultsThe analysis includes 48,460 participants who successfully completed the level 2 ophthalmological baseline examination across 18 study sites in Germany. Mean visual acuity (logMAR) was 0.01 {+/-} 0.20 (left eye) and 0.03 {+/-} 0.21 (right eye). Self-reported ocular disease prevalence was 4.2% for cataract, 2.0% for glaucoma, and 0.9% for macular degeneration. 68.2% of fundus images were classified as gradable as a consensus of four deep learning-based quality grading models Morphological features such as cup-to-disc ratio and arteriole-to-venule-ratio showed systematic differences across age groups. Standard deep learning architectures showed comparative performance to the state-of-the-art for age, sex and blood pressure prediction (2.96 MAE for age prediction, 0.84 accuracy for sex prediction, 10.78 and 7.01 MAE for systolic and diastolic blood pressure prediction). ConclusionsNAKO provides a large-scale, nationwide population-based resource with visual acuity measurements and systemic health indicators, as well as color fundus images in about 50,000 NAKO participants. The data sets the ground for studying eye health in the general adult population in Germany and can serve as a strong foundation for developing and validating AI tools in eye health research.

Purpose: To develop and evaluate a deep learning model that predicts optical coherence tomography (OCT)-equivalent retinal nerve fiber layer thickness (RNFLT) maps directly from color fundus photographs and to assess their diagnostic value for glaucoma detection. Design: Retrospective model development and evaluation study. Participants: 15,031 paired fundus photographs and spectral-domain OCT scans collected at Massachusetts Eye and Ear between 2011 and 2022. Methods: Paired fundus and OCT images were used to train a U-Net-based model to predict pixel-wise RNFLT maps with artifact-corrected supervision. Diagnostic performance was evaluated across single-modality models (fundus photos only, real RNFLT maps, predicted RNFLT maps) and multimodal fusion models (fundus + predicted RNFLT maps). Stratified analyses examined model performance across glaucoma severity and demographic subgroups. Glaucoma was defined based on standard criteria applied to Humphrey 24-2 visual field testing. Main Outcome Measures: Mean absolute error (MAE) and structural similarity index (SSIM) for RNFLT map prediction. Area under the ROC curve (AUC) and accuracy for glaucoma detection. Results: RNFLT map prediction achieved a MAE = 15.4 m and a SSIM = 0.65, measured against artifact-corrected RNFLT maps derived from OCT. For glaucoma detection, the predicted RNFLT-only classifier outperformed the fundus-only classifier (AUC 0.889 vs 0.883, p < 0.005; Accuracy 82.0% vs 78.0%), but performed worse than the real-RNFLT-only classifier (AUC 0.889 vs 0.903, p < 0.005). Multimodal fusion of fundus images with predicted RNFLT maps improved performance, achieving an AUC of 0.909, outperforming all single-modality inputs (p < 0.005 vs fundus-only, predicted-RNFLT-only, and real-RNFLT-only). Performance gains between the fundus-only and the multimodal classifier were greater in early-stage glaucoma compared to severe cases: accuracy increased from 55.3% to 64.0% in mild cases, from 71.5% to 80.4% in moderate cases, and from 90.0% to 94.6% in severe cases. Conclusions: Predicted RNFLT maps derived from fundus photographs provide quantitative, OCT-like structural information and improve glaucoma detection. Unlike prior work that predicted only summary RNFLT values, our model generates full RNFLT maps that better support glaucoma classification than fundus images alone. This approach offers a scalable pathway for early glaucoma screening and expands diagnostic access in resource-limited settings.

Purpose: To evaluate the impact of ''not commonly considered risk factors '' on glaucoma surgical outcomes. Methods: This study included 339 eyes that underwent glaucoma surgery. Surgical procedures included microhook ab-interno trabeculotomy (TLO), Preserflo ab-externo microshunt implantation, trabeculectomy (Trab), and Ahmed Glaucoma Valve (AGV) implantation. In addition to conventional background factors, we examined a set of ''not commonly considered risk factors, '' including very elderly age ([&ge;]85 years), avitreous status, aphakia, use of antithrombotic agents, difficulty attending frequent postoperative visits, small palpebral fissure, corneal endothelial dysfunction, poor vision in the fellow eye, dementia, hearing loss, mental illness, atopic dermatitis, pseudophacodonesis, glaucoma eye drop allergy, and conditions contraindicating {beta}-blocker use. Surgical success was defined as intraocular pressure (IOP) [&le;]21 mmHg, [&ge;]20% reduction from baseline, and no additional glaucoma surgery at 1 year. Logistic regression was performed to identify potential risk factors; significant factors were further evaluated using propensity score matching. Results: Of the 339 cases, surgical success rates were 65% for TLO, 82% for Preserflo, 91% for Trab, and 82% for AGV. Multivariate logistic regression identified two independent predictors of surgical failure: small palpebral fissure (odds ratio 2.52, p < 0.01) and hearing loss (odds ratio 3.94, p = 0.04). Propensity score matching of patients with small versus large palpebral fissures (111 per group) confirmed significantly worse postoperative outcomes in the small-palpebral-fissure group despite balanced baseline characteristics. Conclusion: Small palpebral fissure is an independent and previously unnoticed risk factor for glaucoma surgical failure, affecting both minimally invasive and filtration procedures.

Purpose To investigate the relative efficacy of nine distinct visual field (VF) denoising artificial intelligence (AI) methods and a pathology-aware AI strategy to discourage over-correction of glaucomatous defects. Design Retrospective study. Participants 87,940 paired visual field (VF) and optical coherence tomography (OCT) samples from a tertiary academic center. Methods Denoising models were trained on a separate VF-only dataset and evaluated on an independent structure-function dataset of paired VF-OCT samples. We implemented and evaluated nine distinct VF denoising strategies representing three broad categories: baseline measurements, self-supervised and image restoration models (including Noise2Noise, Noise2Void, and NAFNet), and latent variable compression-based models (autoencoders and variational autoencoders). All models were designed to reconstruct VF sensitivity maps. We then predicted retinal nerve fiber layer thickness (RNFLT) maps from the denoised VFs using a fixed, independently trained VF-to-RNFLT prediction model. Main Outcome Measures Predicted VF and RNFLT maps and resultant evaluation metrics. Results The raw VF baseline achieved a global R2 of 0.5468 and MAE of 16.83 um. Restoration-based models maintained or slightly improved concordance, with the pathology-aware NAFNet achieving the highest global R2 of 0.5485 and a comparable MAE of 16.82 um. In contrast, compression-based models degraded concordance, with CNN-VAE showing a significant reduction (R2 approximately 0.50). In severe glaucoma, concordance decreased across all methods; however, compression architectures exhibited disproportionately greater degradation compared with restoration-based approaches. Conclusions We present a comparative benchmark of AI-based VF denoising strategies paired with structure-function evaluation. While restoration-based models can reduce variability without loss of biological signal, latent compression risks attenuating clinically meaningful defects. Visually smoother fields are not necessarily more biologically accurate.

PurposeConventional polygenic scores predict an individuals phenotype based on their genetics. By contrast, variance polygenic scores (vPGS) quantify genetic predisposition to phenotypic variance. We tested the hypothesis that a vPGS for refractive error can identify individuals with increased susceptibility to environmental risk factors for myopia. MethodsSix vPGS construction strategies were evaluated in UK Biobank participants: three variance heterogeneity genome-wide association studies (vGWAS) methods and two reweighting schemes. vPGS performance was assessed using two metrics: (i) Diff - difference in phenotypic variance in vPGS decile one vs. ten; (ii) Spearman correlation of phenotypic variance vs. vPGS decile. The optimal vPGS was used to test for vPGS x time spent reading or vPGS x time spent outdoors interactions in children aged 15 years (ALSPAC cohort; n=3471). ResultsOf the vGWAS methods, conditional quantile regression outperformed SCAMPI and Levenes Test. Of the re-weighting schemes, LDpred2 outperformed pruning and thresholding (P+T). In an independent sample of UK Biobank participants (n=19470), the top-performing vPGS successfully stratified individuals into groups with increasing variance in refractive error, even after adjusting for a conventional PGS (Diff: 2.55, 95% CI: 1.64-3.47; Spearman correlation: 0.87, 95% CI: 0.43-0.93). However, in ALSPAC participants, there was minimal support for vPGS interactions with time reading (P=0.80) or time outdoors (P=0.89). ConclusionA novel vPGS successfully stratified individuals into groups with relatively high or low genetic susceptibility to refractive error variance. However, the vPGS could not identify individuals at enhanced risk from lifestyle risk factors for myopia.

PurposeAlthough electroretinography (ERG) is vital for evaluating retinal function, conventional corneal electrodes slide or detach in animals. This study aimed to investigate the effectiveness of a novel approach to ERG recording using a metal eyelid speculum for both active and reference electrodes in conjunction with a skin electrode-based ERG device. MethodsWe tested a stainless-steel eyelid speculum as both active and reference electrodes with a skin-electrode ERG system (HE-2000vet) in six healthy Japanese White rabbits. Dark-adapted rod and maximal responses and light-adapted cone and 30 Hz flicker ERGs were recorded in three weekly sessions. ResultsReproducible waveforms with identifiable a- and b-waves were obtained in every eye; rod b-waves reached 50-90 {micro}V and cone b-waves 40-55 {micro}V. Intraclass correlation coefficients revealed substantial interocular agreement and moderate-to-substantial inter-session reproducibility for b-wave amplitude and implicit time, whereas a-wave metrics were less reliable owing to lower amplitudes. The advantages of speculum electrode over corneal electrodes are that it requires no fur shaving, maintains stable contact regardless of globe orientation, and allows real-time observation. ConclusionsThis study demonstrated that an eyelid-speculum electrode is a practical, non-invasive alternative for veterinary and experimental ERG recordings, producing signal quality sufficient for longitudinal and interocular analyses while avoiding cosmetic and technical drawbacks of conventional methods.