NMA 2024: Hot technologies in neuro-ophthalmology
Ore-ofe O. Adesina, MD, described the advances in diagnostics and therapeutics in Neuro-Ophthalmology at the National Medical Association annual meeting.
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Reviewed by Ore-ofe O. Adesina, MD
Ore-ofe O. Adesina, MD, the director of neuro-ophthalmologist at the Ruiz Department of Ophthalmology and Visual Science, University of Texas Health Houston, McGovern Medical School, Houston, described the advances in diagnostics and therapeutics in Neuro-Ophthalmology at the National Medical Association annual meeting—Ophthalmology Session in New York.
Neuro-Ophthalmology is a unique specialty, he explained, in that both the patients and the disease processes are complex and the diagnoses are often vision-threatening. However, treating patients with neuro-ophthalmic diseases can be problematic because the specialists are not available in all areas.
New technologies in this field both expand physicians’ ability to diagnose and care for patients and potentially help to alleviate some of the burden of care on the practitioners in the specialty as there is a shortage of neuro-ophthalmologists nationwide, Dr. Adesina pointed out.
OCT
Optical coherence tomography (OCT) diagnostics are becoming more and more valuable with refinements in imaging. This optical imaging procedure facilitates the diagnosis of optic neuropathies, measurement of the retinal nerve fiber layer (RNFL), and visualization of the various retinal layers. Pathologies that once appeared similar can be differentiated because of the OCT’s enhanced visualization capabilities.
ODD and PHOMS
One example of the usefulness of OCT is for diagnosing optic disc drusen (ODD).1 Dr. Adesina enumerated that ODD are always above the lamina cribrosa, always have a signal-poor core, often have a hyperreflective margin most prominent superiorly, and are sometimes seen as conglomerates of smaller ODD with internal reflectivity in the signal-poor core.
Enhanced-depth OCT imaging of the optic nerve can help to differentiate ODD from true optic disc edema when they are present.
Peripapillary hyperreflective ovoid mass-like structures (PHOMS) are a newer described entity in optic nerve imaging and are thought to represent axoplasmic stasis of the optic nerve. PHOMS are distinct from and on OCT images, they overlay the edge of Bruch’s membrane and deflect at least 2 overlying retinal layers superiorly. PHOMS are associated with optic disc edema in multiple neuro-ophthalmic pathologies, ODD, and anomalous discs, but the prevalence rates in the general population and their implications remain uncertain, according to Dr. Adesina.
Other OCT applications
OCT is also a valuable aid in the diagnosis of optic neuritis (ON) because it provides an accurate quantitative metric, adds detailed qualitative information, and the technology can show patterns among different entities that cause ON. He explained that the earliest atrophic changes are seen in the macular ganglion cell inner plexiform layer (mGCIPL). OCT can show an inter-eye difference in the mGCIPL or the peripapillary RNFL of 3% to 5% diagnostic for optic neuritis (ON) with sensitivities ranging from 61% to 100%.
Artificial intelligence
According to a recent study,2 the Brain and Optic Nerve Study with Artificial Intelligence Group, a deep learning system outperformed clinicians in accuracy and significantly less time spent in identifying abnormalities of the optic disc.
The 30 participating clinicians had an error rate of 15.3%; the deep learning system outperformed all participants with higher accuracy rates than 100%, 86.7%, and 93.3% when classifying papilledema, normal, and other disc abnormalities, respectively, and the DLS completed the task in 25 seconds compared with an average 70 minutes for the clinicians, according to Dr. Adesina.
New therapies
A randomized, placebo-controlled trial3 of exenatide (Presendin, Invex Therapeutics), a glucagon-like peptide (GLP)-1 receptor agonist, to treat idiopathic intracranial hypertension (IIH) found that the drug decreased intracranial pressure (ICP) acutely and that chronic treatment with GLP-1 receptor agonists may be a new way to treat IIH.
In 15 of 16 patients who completed the study, the ICP decreased significantly at all time points evaluated, the number of monthly headaches decreased, and vision improved.
New long-term immunosuppression treatments target specific disease entities, such as multiple sclerosis (MS) and Neuromyelitis optica spectrum disorders (NMO as it is important to note that immunomodulatory therapy to treat MS can worsen NMO. Research is currently being done to develop disease-specific treatment for myelin oligodendrocyte glycoprotein (MOG).
References
Malmqvist L, Bursztyn L, Costello F, et al. The optic disc drusen studies consortium recommendations for diagnosis of optic disc drusen using optical coherence tomography. J Neuroophthalmol. 2018;38:299-307; DOI: 10.1097/WNO.0000000000000585
Vasseneix C, Nusinovici S, Xu X, et al. Deep learning system outperforms clinicians in identifying optic disc abnormalities. J Neuroophthalmol. 2023;43:159-167.
Mitchell J, Mollan S, Walker J, et al. A randomized controlled, trial of the GLP-1 receptor agonist exenatide in idiopathic intracranial hypertension. American Board of Neurology abstract. 2022; https://doi.org/10.1136/jnnp-2022-ABN.317
Adesina O-O O. Hot topics in neuro-ophthalmology. Presented at the National Medical Association annual meeting, August 3, 2024, in New York. Session: Hot Topics in Ophthalmology.
