Method and use of transscleral optical imaging for detecting a disease

Abstract

The present invention relates to a method for diagnosing and / or prognosticating a disease associated with a changed structure in the posterior eye, the method comprising analyzing an image of the posterior eye obtained by a trans-scleral optical imaging (TOI) device for a structure changed with respect to a reference, wherein the changed structure indicates the presence and / or progression of a disease in a subject.

Description

Technical Field

[0001] Diseases related to changes in the structure of the posterior eye, such as glaucoma, age-related macular degeneration (AMD), and diabetic retinopathy, are the major causes of visual impairment worldwide. For example, it is estimated that 196,000,000 people will suffer from age-related macular degeneration (AMD) in 2020. The posterior eye constitutes the posterior two-thirds of the eye, including the vitreous humor, retina, choroid, and optic nerve. Among these, changes in the retina, particularly in retinal neurons and retinal pigment epithelium (RPE), are generally associated with many diseases of the posterior eye.

[0002] The retina is a ten-layered photosensitive neural tissue membrane on the innermost side of the eye. Its role is to convert the received light stimuli into nerve impulses and send them to the visual center of the brain via the optic nerve. The retinal pigment epithelium (RPE) is a single layer of pigmented retinal cells on the outermost side closest to the sclera.

[0003] Although they are located outside the neurosensory retina, RPE cells play several important roles such as light absorption, epithelial transport, and maintenance of the visual cycle. It is hypothesized that some RPE cell morphological characteristics, namely cell density, number of adjacent cells, eccentricity angle, and form factor, vary according to cell maturity and state. Some other studies have reported RPE cell loss caused by eye diseases and aging.

[0004] Several diagnostic imaging modalities enable in vivo evaluation of the human eye (e.g., optical coherence tomography (OCT), scanning laser ophthalmoscopy (SLO), and fundus autofluorescence), but these methods do not enable diagnosis at the early stages of retinal diseases because they cannot detect very small changes in RPE cell morphology. Furthermore, in vivo imaging of the RPE layer at the single-cell level is difficult due to several factors, namely, low contrast between adjacent cells, motion artifacts, retinal layer nonlinearity, and difficulty in image focusing. The equipment used in ophthalmology for routine fundus examination cannot observe the minute changes in cell morphology that exist during the early stages of the disease degeneration process.

[0005] Transscleral optical imaging (TOI), disclosed in 2017, is a novel non-invasive in vivo high-resolution imaging modality for posterior eye structures, particularly the retina. The use of both compensating optics and oblique illumination improves the contrast of macroscopic and microscopic posterior eye structures such as tissue architecture, vasculature, and RPE cells. The resulting excellent imaging resolution enables discrimination at a very high resolution, including the cellular level, e.g., the cell membrane of a single RPE cell.

[0006] The applicant described in International Publication No. WO 2017 / 195163 (A1) has disclosed a method for imaging eye tissues, the method comprising the steps of providing oblique illumination to the eye by a plurality of light-emitting regions of a light delivery device, wherein the plurality of light-emitting regions are independently controllable and are arranged to direct light to at least one of the retina and iris of the eye, providing oblique illumination; generating an output beam from light backscattered from at least one of the retina and iris by the oblique illumination; capturing the output beam with an imaging system to provide a series of images of the fundus of the eye; and extracting phase and absorption contrast images from the series of images of the fundus, wherein the series of images of the fundus in the capturing step is obtained by sequentially turning on one or more of the plurality of light-emitting regions at a time in the step of providing oblique illumination. In other words, methods for oblique illumination, including trans-scleral illumination and trans-eyelid illumination, enable dark field and phase gradient techniques by using the scattering properties of the fundus. Oblique illumination, e.g., trans-scleral oblique projection illumination, increases the contrast of many biological structures that make up the retinal layers and, in combination with compensated optical high-resolution imaging, enables the observation of cells that play an important role in disease-related degenerative processes. Obtaining high-resolution images at the cellular level enables a new perspective on the structure of the retina and leads to a better understanding of the degenerative retinal disease process.

[0007] Further developments and elements of the TOI device by the present applicant are disclosed in International Publication No. WO 2020 / 121243 (A1), International Publication No. WO 2021 / 058367 (A1), and International Publication No. WO 2021 / 191331 (A1). In International Publication No. WO 2020 / 121243 (A1), a TOI system with trans-scleral / trans-eyelid illumination of the fundus was disclosed. The TOI system included a plurality of light-emitting regions, each of the light-emitting regions being independently controllable and configured to be directed towards the sclera of the eye to be measured, providing trans-scleral oblique illumination of the fundus; an active eye aberration correction system; and an imaging system configured to create a plurality of images of the fundus on a plurality of imaging sensors. In International Publication No. WO 2021 / 191331, the light delivery device was combined with optical coherence tomography (OCT) imaging.

[0008] In vivo observation of the human retina at the cellular level is important for detecting structural changes before irreversible vision loss occurs, tracking the progression of retinal diseases, and evaluating and monitoring the initial effects of treatment. Despite remarkable progress in optical coherence tomography (OCT) and adaptive optics systems, in vivo imaging of some retinal cells remains challenging.

[0009] Laforest T. et al., "Transscleral Optical Phase Imaging of the Human Retina - TOPI" (https: / / arxiv.org / abs / 1905.06877), disclosed a transscleral optical imaging (TOI) device that enables imaging of retinal cells with high contrast, high resolution, and within an acquisition time suitable for clinical use. TOI relies on high-angle oblique illumination of the retina combined with adaptive optics to enhance the phase contrast of transparent cells.

[0010] Considering the lack in the art regarding methods for providing accurate detection of early signs of structural changes in the posterior segment of the eye related to diseases, there is an urgent and unmet need in the art for a method capable of generating high-resolution images of the posterior segment of the eye to enable analysis of the disease state.

[0011] Accordingly, the present invention provides a new method for cellular resolution imaging of the posterior segment of the eye for early diagnosis, prognosis, and treatment sensitivity of diseases related to changes in the structure of the posterior segment of the eye.

[0012] Accordingly, the technical problem underlying the present invention is to provide a method for early detection of structural changes in the posterior segment of the eye that enables early diagnosis, prognosis, and treatment of diseases related to structural changes in the posterior segment of the eye.

[0013] Accordingly, the present invention relates to the following. 1. A method for diagnosing and / or prognosticating a disease associated with an altered structure in the posterior eye, the method comprising analyzing an image of the posterior eye obtained by trans-scleral optical imaging (TOI) for the altered structure, wherein the altered structure indicates the presence and / or progression of a disease in a subject. 2. A method for treating a disease associated with an altered structure in the posterior eye, a) analyzing an image of the posterior eye obtained by TOI for the altered structure, wherein the presence of the altered structure indicates the presence of a disease or the onset of a disease in a subject; b) administering an appropriate treatment for the disease to a subject identified as having or having developed the disease according to step (a). 3. The method according to item 1 or 2, wherein the altered structure is determined with respect to a reference which is a TOI image of the posterior eye obtained from a subject in a similar state known not to have the disease or known not to be at risk of developing the disease. 4. (i) A method for evaluating a treatment effect in a subject who is a target for treatment of a disease associated with an altered structure in the posterior eye, or (ii) A method for determining a subject's compliance with a prescribed treatment for a disease associated with an altered structure in the posterior eye, the method comprising analyzing first and second images of the posterior eye of the subject obtained by TOI, (a) the first image being obtained before the treatment or before the second image, (b) the second image being obtained after the treatment or after the first image, (c) analyzing the first and second images being an analysis and comparison of the structure of the posterior eye in (a) and (b), (a) and (b) wherein the maintenance or reduction of the altered structure between (a) and (b) indicates that the treatment has a treatment effect or that the subject is compliant with the treatment. 5. The method according to item 4, wherein the changed structure is determined from an analysis of a posterior segment TOI image obtained from a subject in a similar state known to be disease-free or having no risk of developing a disease. 6. The determination of the maintenance of the changed structure between (a) and (b) is (d) a determination when the changed structure has not substantially changed between (a) and (b) as described in item 4, or (e) any further change or progression of the changed structure between (a) and (b) as described in claim 4 is not as severe or has not progressed as the change or progression between a set of reference first and second posterior segment TOI images obtained from a subject in a similar state known to have the disease and not being treated, and the reference first and second images are obtained or are to be obtained at the same intervals as the first and second images of (a) and (b) as described in item 4, the method according to item 4. 7. The method according to any one of items 4 to 6, wherein the second image is acquired at least 2 days and at most 730 days after the first image. 8. Diseases associated with the changed structure of the posterior eye include uveitis, glaucoma, macular edema, macular hole, macular pucker, diabetic macular edema, diabetic retinopathy, diabetic ophthalmopathy, retinopathy, age-related macular degeneration (AMD), exudative AMD, atrophic AMD, early AMD, intermediate AMD, central serous chorioretinopathy, scleritis, optic nerve degeneration, geographic atrophy, choroidopathy, ocular sarcoidosis, optic neuritis, choroidal neovascularization, retinitis pigmentosa, retinal tear, Stargardt disease, eye cancer, retinitis, corneal ulcer, cataract, viral infections (such as cytomegalovirus, herpes simplex, herpes zoster, etc.), fungal infections (such as histoplasmosis, etc.), parasitic infections (such as toxoplasmosis, toxocariasis, etc.), bacterial infections (such as tuberculosis, syphilis, etc.), sarcoidosis, retinal vein occlusion, central retinal vein occlusion, branch retinal vein occlusion, retinal vascular diseases, Vogt-Koyanagi-Harada syndrome, Behçet's disease, idiopathic retinal vasculitis, Vogt-Koyanagi-Harada syndrome, acute posterior multifocal placoid pigment epitheliopathy (APMPPE), presumed ocular histoplasmosis syndrome (POHS), birdshot chroidopathy, multiple sclerosis, sympathetic ophthalmia, punctate inner choroidopathy, pars planitis, iridocyclitis, diabetic retinopathy, retinopathy of prematurity (ROP), ischemic angiopathy, hereditary retinal dystrophy, retinal detachment, abnormal angiogenesis, retinal angiomatous proliferation (RAP), intraretinal microvascular abnormalities, preretinal neovascularization, choroidal neovascularization, choroidal vascular stroke, ocular hypertension, diabetes, cardiovascular diseases, premature infants, and papilledema, the method according to any one of items 1 to 7. 9. The method according to any one of items 1 to 8, wherein the image of the posterior eye is an image of the choroid, choroidal capillary lamina, Bruch's membrane, retinochoroidal tissue, neurosensory retinal tissue, nerve fiber layer, retinal pigment epithelium (RPE), photoreceptors, ganglion cell layer, retinal vascular system, subretinal space, retina, macula, lamina cribrosa, optic nerve head or optic nerve. 10. The method according to any one of items 1 to 9, wherein the changed structure is a change in the tissue structure. 11. The method according to item 10, wherein the change in the tissue structure is a change in cell pattern, cell density, cell size, cell distribution, or cell reflectance. 12. The method according to item 10, wherein the change in the tissue structure is a change in tissue reflectance that is a change in a low-reflection region, a high-reflection region, a low-reflection region within the high-reflection region, or any combination thereof. 13. The method according to any one of items 1 to 12, wherein the image is an image of the RPE. 14. The method according to any one of items 1 to 12, wherein the image is an image of the choroidal capillary lamina. 15. The method according to any one of items 1 to 12, wherein the image is an image of the nerve fiber layer, the optic nerve head, and / or the retinal vascular system. 16. The method according to item 13, wherein the disease is AMD and the changed structure is a change in RPE cell density, RPE cell size, high-reflection region, low-reflection region, and / or low-reflection region within the high-reflection region. 17. The method according to item 13 or 14, wherein the disease is central serous chorioretinopathy and the changed structure is a change in the RPE and the choroidal capillary lamina. 18. The method according to item 15, wherein the disease is glaucoma and the changed structure is a change in the nerve fiber layer (including, but not limited to, a change in the orientation of nerve fiber bundles, a change in their thickness, a change in their size), or a change in the optic nerve head morphology (including, but not limited to, a change in the optic nerve head, a change in the physiological cup, a change in the cup-to-disc ratio, a change in the lamina cribrosa). 19. The method according to item 15, wherein the disease is diabetic retinopathy and the changed structure is a change in the retinal vascular system. 20. The method according to any one of items 1 to 12, wherein the changed structure exhibits geographic atrophy, drusen, reticular pseudodrusen, neovascularization, and / or retinal pigment epithelial degeneration. Use of an image of an eye of a subject obtained by trans-scleral optical imaging (TOI) for diagnosing and / or prognosticating a disease associated with an altered structure in the posterior eye segment, the use comprising analyzing the image for the altered structure, the altered structure indicating the presence and / or progression of a disease in the subject. Use of an image of an eye of a subject obtained by TOI in the treatment of a disease associated with an altered structure in the posterior eye segment, the use comprising a) analyzing the image for the altered structure, the presence of the altered structure indicating the presence of a disease or the onset of a disease in the subject; and b) administering an appropriate treatment for the disease to the subject identified as having or having developed the disease according to step (a). Use according to item 21 or 22, wherein the altered structure is determined with respect to a reference TOI image of the posterior eye segment obtained from a subject in a similar state known not to have the disease or known not to be at risk of developing the disease. Use of first and second images of an eye of a subject obtained by trans-scleral optical imaging (TOI) (i) for evaluating the treatment effect in a subject being treated for a disease associated with an altered structure in the posterior eye segment, or (ii) for determining the compliance of a subject with a prescribed treatment for a disease associated with an altered structure in the posterior eye segment, the use comprising analyzing the first and second images, (a) the first image being obtained before the treatment or before the second image, (b) the second image being obtained after the treatment or after the first image, (c) analyzing the first and second images being an analysis and comparison of the structure of the posterior eye segment in (a) and (b), the maintenance or reduction of the altered structure between (a) and (b) indicating that the treatment has a treatment effect or that the subject is compliant with the treatment. 25. The use according to item 24, wherein the changed structure is determined from the analysis of the posterior eye TOI image obtained from a subject in a similar state known to be disease-free or having no risk of developing a disease. 26. The determination of the maintenance of the changed structure between (a) and (b) is (d) whether the determination is that the changed structure has not substantially changed between (a) and (b) as described in item 24, or (e) any further change or progression of the changed structure between (a) and (b) as described in item 24 is not as severe or has not progressed as the change or progression between a set of reference first and second posterior eye TOI images obtained from a subject in a similar state known to have a disease and not being treated, and the reference first and second images are obtained or to be obtained at the same interval as the first and second images of (a) and (b) as described in item 24. The use according to item 24. 27. The use according to any one of items 24 to 26, wherein the second image is acquired at least 2 days and at most 730 days after the first image. 28. The diseases associated with the changed structure in the posterior eye include uveitis, glaucoma, macular edema, macular hole, macular pucker, diabetic macular edema, diabetic retinopathy, diabetic ophthalmopathy, retinopathy, age-related macular degeneration (AMD), exudative AMD, atrophic AMD, early AMD, intermediate AMD, central serous chorioretinopathy, scleritis, optic nerve degeneration, geographic atrophy, choroidopathy, ocular sarcoidosis, optic neuritis, choroidal neovascularization, retinitis pigmentosa, retinal tear, Stargardt disease, eye cancer, retinitis, corneal ulcer, cataract, viral infections (such as cytomegalovirus, herpes simplex, varicella zoster, etc.), fungal infections (such as histoplasmosis, etc.), parasitic infections (such as toxoplasmosis, toxocariasis, etc.), bacterial infections (such as tuberculosis, syphilis, etc.), sarcoidosis, retinal vein occlusion, central retinal vein occlusion, branch retinal vein occlusion, retinal vascular diseases, Vogt-Koyanagi-Harada syndrome, Behçet's disease, acute idiopathic retinal vasculitis, Vogt-Koyanagi-Harada syndrome, acute posterior multifocal placoid pigment epitheliopathy (APMPPE), presumed ocular histoplasmosis syndrome (POHS), birdshot choroidopathy, multiple sclerosis, sympathetic ophthalmia, punctate inner choroidopathy, pars planitis, iridocyclitis, diabetic retinopathy, retinopathy of prematurity (ROP), ischemic angiopathy, hereditary retinal dystrophy, retinal detachment, abnormal angiogenesis, retinal angiomatous proliferation (RAP), intraretinal microvascular abnormalities, preretinal neovascularization, choroidal neovascularization, choroidal vascular stroke, ocular hypertension, diabetes, cardiovascular diseases, premature infants, and papilledema, the use according to any one of items 21 to 27. 29. The image of the posterior eye is an image of the choroid, choroidal capillary lamina, Bruch's membrane, retinochoroidal tissue, neurosensory retinal tissue, nerve fiber layer, retinal pigment epithelium (RPE), photoreceptor cells, ganglion cell layer, retinal vascular system, subretinal space, retina, macula, lamina cribrosa, optic nerve head or optic nerve, the use according to any one of items 21 to 28. 30. The changed structure is a change in the tissue structure, the use according to any one of items 21 to 29. 31. The change in the tissue structure is a change in cell pattern, cell density, cell size, cell distribution or cell reflectivity, the use according to item 30. 32. The use according to item 31, wherein the change in the tissue structure is a change in tissue reflectance that is a change in a low-reflection region, a high-reflection region, a low-reflection region within the high-reflection region, or any combination thereof. 33. The use according to any one of items 21 to 32, wherein the image is an image of the RPE. 34. The use according to any one of items 21 to 32, wherein the image is an image of the choroidal capillary lamina. 35. The use according to any one of items 21 to 32, wherein the image is an image of the nerve fiber layer, the optic nerve head and / or the retinal vascular system. 36. The use according to item 33, wherein the disease is AMD and the changed structure is a change in RPE cell density, RPE cell size, high-reflection region, low-reflection region, and / or low-reflection region within the high-reflection region. 37. The use according to item 33 or 34, wherein the disease is central serous chorioretinopathy and the changed structure is a change in the RPE and the choroidal capillary lamina. 38. The use according to item 35, wherein the disease is glaucoma and the changed structure is a change in the nerve fiber layer (including, but not limited to, a change in the orientation of nerve fiber bundles, a change in their thickness, a change in their size), or a change in the optic nerve head morphology (including, but not limited to, a change in the optic nerve head, a change in the physiological cup, a change in the cup-to-disc ratio, a change in the lamina cribrosa). 39. The use according to item 35, wherein the disease is diabetic retinopathy and the changed structure is a change in the retinal vascular system. 40. The use according to any one of items 21 to 32, wherein the changed structure exhibits geographic atrophy, drusen, reticular pseudodrusen, neovascularization and / or retinal pigment epithelial degeneration.

[0014] Accordingly, the present invention provides a very accurate method for detecting changes in the posterior eye structure, and a method for significantly improving the diagnosis, prognosis, monitoring and treatment of diseases associated with structural changes.

[0015] According to an embodiment of the present invention, the present invention is a method for diagnosing and / or prognosticating a disease related to a changed structure in the posterior eye region, the method comprising analyzing an image of the posterior eye region obtained by trans-scleral optical imaging (TOI) for the changed structure, the changed structure indicating the presence and / or progression of the disease in the subject, and providing the method.

[0016] In a further embodiment of the present invention, the present invention is a method for treating a disease related to a changed structure in the posterior eye region, comprising: a) analyzing an image of the posterior eye region obtained by TOI for the changed structure, the presence of the changed structure indicating the presence of the disease or the onset of the disease in the subject; and b) administering an appropriate treatment for the disease to the subject identified as having or having developed the disease according to step (a).

[0017] In certain embodiments, the method of the present invention may refer to a method determined with respect to a reference that is a TOI image of the posterior eye region obtained from a subject in a similar state known to be disease-free or having no risk of developing the disease, where the changed structure is determined.

[0018] The method described herein relates to the analysis of TOI images of the eye for determining a changed structure. A person skilled in the art knows the anatomical structure of the posterior eye in a disease-free state (the anatomical structure in a normal eye), and thus can empirically determine the presence or absence of a changed structure in the TOI image by methods including, but not limited to, visual inspection. However, a changed structure can also be determined by comparison with a reference. As used herein, the term "reference" refers to a predetermined or known structure of the posterior eye. A deviation in an image from an object being compared to a reference determines a change in the structure, which can indicate, for example, the presence of a disease state, the progression of a disease state, or a predisposition to the onset of a disease state. In certain embodiments, the "reference" as used herein is a reference TOI image from an object known to be disease-free or known to have no risk of developing a disease. In other embodiments, when it is desired to monitor the progression of a disease or compliance with treatment, the reference may be a TOI image or a set of TOI images obtained from a reference object known to have a disease or known to have a predisposition to developing a disease, and the object has not been treated for such a disease. In the analysis of such a method with respect to a reference to a set of images obtained from an untreated object, a changed structure is considered to be maintained if the change in the changed structure in the set of images from the object being analyzed has not progressed as much as or has not progressed at all compared to the change in the reference image.

[0019] The changed structure of the posterior eye segment can be a changed macroscopic or microscopic structure, whether determined empirically (i.e., without comparison to a reference) or determined relative to a reference. Non-limiting examples of macroscopic structures include the vasculature (e.g., but not limited to, the retinal vasculature), and the changed structure can include a changed size, a changed vascular density, or a changed vascular pattern (but not limited thereto). The changed structure can also be microscopic, such as changed intracellular or extracellular changes. The determined changed structure is preferably a changed cellular structure of the tissue of the posterior eye segment. Non-limiting changes in cellular structure can include changes in cell density, cell size, and / or cell pattern.

[0020] Microscopic changes in the structure need not be limited to changes resulting from changes in any particular cell or group of cells themselves, but can result from or be due to changes in their structure or phenotype. Such microscopic changes in the structure include changes in low-reflectivity regions or high-reflectivity regions. Thus, the changed structure can include changes in the low-reflectivity region, such as but not limited to, a change (increase or decrease) in the density, concentration, grouping, or pattern of the low-reflectivity region. The changed structure can also include changes in the high-reflectivity region, such as but not limited to, a change (increase or decrease) in the density, concentration, grouping, or pattern of the high-reflectivity region. The change to the structure can also include changes in both the high-reflectivity region and the low-reflectivity region, as described in this paragraph or elsewhere in this specification. The change to the structure can also include changes (appearance, disappearance, increase in concentration / density, or decrease in concentration / density) in a region having both a high-reflectivity region and a low-reflectivity region, e.g., a low-reflectivity region within a high-reflectivity region (known in the art as a low-reflectivity region surrounded by a high-reflectivity halo).

[0021] When a changed structure is determined relative to a reference, the reference does not necessarily have to be determined every time. The reference can be based, for example, on a TOI image obtained from the object being analyzed but at an earlier time point including before the treatment intervention. The reference image can additionally or alternatively be based on a standard TOI image, for example, an image obtained from a non-related object known not to have a related disease or known to have no risk of developing a related disease. The reference can also be the result of the normalization of a number of images. In such cases, both the normalization of the reference image(s) and the analysis of the object image can be performed by a machine learning tool, for example, a computer having appropriate image analysis software.

[0022] The posterior eye structure, whether macroscopic or microscopic, depends on several factors, such as the age and gender of the subject, whether the subject is receiving medical therapy (e.g., being treated with a therapeutic agent that may or may not be related to the disease being analyzed), and / or the lifestyle of the subject (e.g., whether the subject is a smoker, consumes alcohol, the intensity of optimal exercise, etc.). Thus, when the reference is a standard image, the reference image may be obtained from a source or group of sources in a similar situation as the subject, for example, a source or group of sources having similar physical characteristics as the subject and similar lifestyle criteria. From the perspective of potential variations, average structural features may be developed from a number of sources known not to have a disease or known to have no risk of having a disease for use as a reference.

[0023] The "TOI device" developed by the inventors of the present application is a light delivery device having a plurality of light sources, each light source being independently controllable and configured to be directed towards the sclera of the eye to provide oblique illumination of the fundus through the sclera, a light delivery device, an active eye aberration correction system, and an imaging system configured to create a plurality of images of the fundus on a plurality of imaging sensors, and refers to a device for ophthalmic illumination of the fundus. The light transmitted through the sclera forms oblique illumination of the posterior retina, which is then imaged using a through-pupil AO full-field camera system. The TOI device provides dark-field imaging, high-resolution imaging, and wide-field (field of view, FOV) imaging.

[0024] The inventors have found that the TOI device advantageously provides cell-resolution label-free high-contrast images of the posterior eye, particularly over a large FOV, without the drawback of long exposure times. Oblique illumination, including trans-scleral illumination or trans-eyelid illumination (e.g., trans-scleral projection illumination) of the retina as used in TOI, significantly increases the signal-to-noise ratio (SNR) of many retinal structures compared to trans-pupil illumination.

[0025] The TOI device used herein employs an aberration correction method. Correction of optical aberrations is performed in real time using a compensation optical closed loop comprising, but not limited to, a through-pupil probing light source, a wavefront sensor, and a wavefront corrector capable of spatially shaping the wavefront of the light creating the forward image.

[0026] The TOI device combines trans-pupil or trans-pupil illumination with trans-scleral illumination to benefit from the advantages of both types of illumination.

[0027] The term "trans-sclera" means across the sclera or white of the eye. As used herein, the term "sclera" refers to the opaque fibrous protective outer layer of the human eye that contains mainly collagen and some elastic fibers. The sclera is a connective tissue mostly composed of white collagen fibers. It lies beneath the choroid at the back and continues forward, becoming transparent over the iris and pupil, and is called the cornea.

[0028] As used herein, the term "diagnosis" means the confirmation of the presence or characteristics of a pathological condition. With respect to the present invention, diagnosis means the confirmation of the presence of an altered structure in the posterior segment of the eye. The altered structure may refer to changes in the anterior vitreous membrane, vitreous humor, retina, choroid, and / or optic nerve.

[0029] The term "prognosis", as used herein, refers to the prediction of the possible onset or outcome of a disease, or the likelihood of recovery from a disease. As will be understood by those skilled in the art, the prediction need not be accurate for 100% of the subjects being diagnosed or evaluated, although it is preferred that it be so. However, the term requires that a statistically significant portion of the subjects can be identified as having a high probability of having a given outcome.

[0030] The term "treatment" of a disorder or disease, as used herein, is well known in the art. "Treatment" of a disorder or disease implies that the disorder or disease is suspected or diagnosed in a patient / subject. A patient / subject suspected of having a disorder or disease typically exhibits certain clinical and / or pathological symptoms that can readily be ascribed by one of ordinary skill in the art to a particular pathological condition (i.e., diagnose the disorder or disease). "Treatment" of a disorder or disease can result, for example, in halting the progression of the disorder or disease (e.g., no worsening of symptoms) or delaying the progression of the disorder or disease (if the halting of progression is of only a transient nature). "Treatment" of a disorder or disease can also result in a partial response (e.g., improvement of symptoms) or a complete response (e.g., disappearance of symptoms) in the subject / patient having the disorder or disease. Thus, "treatment" of a disorder or disease can refer to, for example, an improvement of the disorder or disease that results in halting the progression of the disorder or disease or delaying the progression of the disorder or disease. Recurrence can occur after such partial or complete response. It should be understood that a subject / patient can experience a broad range of responses to treatment (e.g., exemplary responses as described above herein). Treatment of a disorder or disease can include, inter alia, curative treatment (preferably resulting in a complete response and ultimately curing the disorder or disease) and palliative treatment (including symptom relief).

[0031] The term "posterior eye segment" or grammatical variations thereof refers to the part of the eye that is behind the lens or ora serrata. This part consists of the posterior two-thirds of the eye, including the anterior vitreous membrane and all optical structures behind it: the vitreous humor, retina, choroid, and optic nerve. "Diseases of the posterior eye segment" or "diseases related to altered structures in the posterior eye segment" or grammatical variations thereof, as used herein, refer to diseases that affect the posterior eye segment. Examples of diseases of the posterior eye segment include uveitis, glaucoma, macular edema, macular hole, macular pucker, diabetic macular edema, diabetic retinopathy, diabetic ophthalmopathy, retinopathy, age-related macular degeneration (AMD), exudative AMD, atrophic AMD, early AMD, intermediate AMD, central serous chorioretinopathy, scleritis, optic nerve degeneration, geographic atrophy, choroidopathy, ocular sarcoidosis, optic neuritis, choroidal neovascularization, retinitis pigmentosa, retinal tear, Stargardt's disease, eye cancer, retinitis, corneal ulcer, cataract, viral infections (such as cytomegalovirus, herpes simplex, herpes zoster), fungal infections (such as histoplasmosis), parasitic infections (such as toxoplasmosis, toxocariasis), bacterial infections (such as tuberculosis, syphilis), sarcoidosis, retinal vein occlusion, central retinal vein occlusion, branch retinal vein occlusion, retinal vascular diseases, Vogt-Koyanagi-Harada syndrome, Behçet's disease, acute idiopathic retinal vasculitis, Vogt-Koyanagi-Harada syndrome, acute posterior multifocal placoid pigment epitheliopathy (APMPPE), presumed ocular histoplasmosis syndrome (POHS), birdshot chorioretinopathy, multiple sclerosis, sympathetic ophthalmia, punctate inner choroidopathy, pars planitis, iridocyclitis, diabetic retinopathy, retinopathy of prematurity (ROP), ischemic vascular diseases, hereditary retinal dystrophies, retinal detachment, abnormal angiogenesis, retinal angiomatous proliferation (RAP), intraretinal microvascular abnormalities, preretinal neovascularization, choroidal neovascularization, choroidal vascular stroke, ocular hypertension, diabetes, cardiovascular diseases, prematurity, and papilledema.

[0032] As used herein, the term "subject" refers to mammals including non-primates (e.g., camel, donkey, zebra, cow, pig, horse, cat, dog, rat, and mouse) and primates (e.g., monkeys, chimpanzees, and humans). In certain embodiments, the subject has or is suspected of having a disease characterized by changes in the posterior eye segment, and is preferably human.

[0033] In certain embodiments of the present invention, the method is a method for (i) evaluating the therapeutic effect in a subject being treated for a disease associated with a changed structure in the posterior eye segment or (ii) determining the compliance of a subject with a prescribed treatment for a disease associated with a changed structure in the posterior eye segment, the method comprising analyzing first and second images of the posterior eye segment of the subject obtained by TOI, wherein (a) the first image is obtained before the treatment or before the second image, (b) the second image is obtained after the treatment or after the first image, and (c) analyzing the first and second images is an analysis and comparison of the structure of the posterior eye segment in (a) and (b), and the maintenance or reduction of the changed structure between (a) and (b) indicates that the treatment has a therapeutic effect or that the subject is compliant with the treatment.

[0034] Furthermore, the method of the present invention may relate to a method in which the therapeutic effect in a subject or the compliance of a subject with a prescribed treatment is determined by analyzing the changed structure relative to the structure determined from the analysis of TOI images of the posterior eye segment of a subject in a similar state known not to have the disease or known not to be at risk of developing the disease.

[0035] In a further embodiment of the present invention, the method is such that the determination of the maintenance of the changed structure between (a) and (b) is (d) the determination when the changed structure has not substantially changed between (a) and (b) of the aforementioned method, or (e) any further change or progression of the changed structure between (a) and (b) of the aforementioned method is not as severe or has not progressed as the change or progression between a set of reference first and second TOI images of the posterior eye segment of a subject in a similar state known to have the disease and not being treated, the reference first and second images being obtained or to be obtained at the same intervals as the first and second images of (a) and (b) of the aforementioned method.

[0036] In certain embodiments of the present invention, the method relates to a method in which a second image is acquired at least 2 days and at most 730 days after a first image.

[0037] The inventors of the present invention have found that when first and second images of the posterior eye are obtained at intervals of at least 2 days and at most 730 days, the treatment effect or compliance of a subject with respect to a given therapy can be accurately predicted by analyzing the images. Thus, the excellent images obtained by the TOI device provide means and methods for early detection, intervention, and rapid analysis of the prognosis of a disease state. This is essential for improving treatment selection, treatment compliance, and disease outcome.

[0038] In one embodiment of the present invention, the method relates to a method in which diseases associated with a changed structure of the posterior eye are uveitis, glaucoma, macular edema, macular hole, macular pucker, diabetic macular edema, diabetic retinopathy, diabetic ophthalmopathy, retinopathy, age-related macular degeneration (AMD), exudative AMD, atrophic AMD, early AMD, intermediate AMD, central serous chorioretinopathy, scleritis, optic nerve degeneration, geographic atrophy, choroidopathy, ocular sarcoidosis, optic neuritis, choroidal neovascularization, retinitis pigmentosa, retinal tear, Stargardt disease, eye cancer, retinitis, corneal ulcer, cataract, viral infections (such as cytomegalovirus, herpes simplex, herpes zoster, etc.), fungal infections (such as histoplasmosis, etc.), parasitic infections (such as toxoplasmosis, toxocariasis, etc.), bacterial infections (such as tuberculosis, syphilis, etc.), sarcoidosis, retinal vein occlusion, central retinal vein occlusion, branch retinal vein occlusion, retinal vascular diseases, Vogt-Koyanagi-Harada syndrome, Behçet's disease, acute posterior multifocal placoid pigment epitheliopathy (APMPPE), presumed ocular histoplasmosis syndrome (POHS), birdshot choriopathy, multiple sclerosis, sympathetic ophthalmia, punctate inner choroidopathy, pars planitis, iridocyclitis, diabetic retinopathy, retinopathy of prematurity (ROP), ischemic angiopathy, hereditary retinal dystrophy, retinal detachment, abnormal angiogenesis, retinal angiomatous proliferation (RAP), intraretinal microvascular abnormalities, preretinal neovascularization, choroidal neovascularization, choroidal vascular disease stroke, ocular hypertension, diabetes, cardiovascular disease, prematurity, and papilledema.

[0039] In a preferred embodiment of the present invention, the method relates to a method in which an image of the posterior eye is an image of the choroid, choroidal capillary lamina, Bruch's membrane, retinochoroidal tissue, neurosensory retinal tissue, nerve fiber layer, retinal pigment epithelium (RPE), photoreceptor cells, ganglion cell layer, retinal vasculature, subretinal space, retina, macula, lamina cribrosa, optic nerve head or optic nerve.

[0040] In a preferred embodiment of the present invention, the method relates to a method in which the changed structure is a change in the tissue structure.

[0041] In a specific embodiment of the present invention, the method relates to a method in which the change in the tissue structure is a change in cell pattern, cell density, cell size, cell distribution or cell reflectivity.

[0042] The inventors have found that, in particular, the examination of the cellular structure of the posterior eye for changes in structure provides an accurate means for the early detection of diseases and the monitoring of the therapeutic effect of a given treatment for a disease.

[0043] By analyzing the cell structure to identify changes in cell pattern, density, size, distribution and reflectivity, the inventors have found that these specific features can be used to accurately evaluate the disease state.

[0044] In a further preferred embodiment of the present invention, the method relates to a method in which the change in the tissue structure is a change in tissue reflectivity that is a change in a low-reflection region, a high-reflection region, a low-reflection region within a high-reflection region, or any combination thereof.

[0045] Changes in cell reflectivity, particularly changes in low-reflection regions, high-reflection regions and / or low-reflection regions within high-reflection regions, can be used to provide important information regarding morphological changes occurring in the tissue structure. Therefore, the examination of these features is particularly advantageous for the evaluation of the posterior eye.

[0046] In a preferred embodiment of the present invention, the method relates to a method in which the image is an image of the RPE.

[0047] The inventors of the present invention have surprisingly found that by analyzing images of the RPE at the cellular level, morphological characteristics of specific cells can be identified as early indicators of disease onset. Very small changes occurring in the RPE layer, namely changes in cell density, number of adjacent cells, eccentricity angle, and form factor, cannot be examined by methods currently available in the art. This is due to the low contrast between adjacent cells, motion artifacts, non-linearity of the retinal layer, and difficulty in focusing the image. Therefore, the method of the present invention provides a specific indicator that can be used for early detection and prognosis diagnosis of diseases.

[0048] In another preferred embodiment of the present invention, the image is an image of the choroidal capillary lamina.

[0049] In yet another embodiment of the present invention, the image is an image of the nerve fiber layer, optic nerve head, and / or retinal vascular system.

[0050] In a further embodiment of the present invention, the method relates to a method in which the disease is AMD and the changed structure is a change in RPE cell density, RPE cell size, hyper-reflective region, hypo-reflective region, and / or hypo-reflective region within the hyper-reflective region.

[0051] The progression from intermediate AMD to advanced AMD can be delayed and perhaps prevented by taking certain high-dose formulations of antioxidants and zinc. Studies have shown that daily intake of a supplement containing vitamin C (500 milligrams); vitamin E 400 IU; beta-carotene (15 milligrams); zinc (as zinc oxide) (80 milligrams); and copper (as cupric oxide) (2 milligrams) reduced the risk that patients would progress from intermediate AMD to advanced AMD by 25% and reduced the risk of vision loss by 19%. (www.amd.org). Currently, four treatments are approved for exudative AMD: laser surgery, photodynamic therapy (PDT), and the intravitreal injections of the drugs Macugen® pegaptanib sodium and Lucentis® ranibizumab. Laser, PDT, and pegaptanib can slow the rate of vision loss and / or halt vision loss. Pegaptanib (Macugen®, Eyetech Pharmaceuticals Inc. and Pfizer Inc.), approved for the treatment of exudative AMD, is a pegylated oligonucleotide aptamer that targets VEGF. Ranibizumab (Lucentis®, Genentech / Novartis), an antibody fragment that targets VEGF, was recently approved by the FDA for the treatment of exudative AMD. Laser surgery attempts to destroy fragile, leaking blood vessels using a high-energy beam of light.

[0052] In a further embodiment of the invention, the method relates to a method in which the disease is central serous chorioretinopathy and the altered structure is an alteration of the RPE and the choroidal capillary lamina.

[0053] CSCR is usually a self-limiting disease that spontaneously resolves within 3 to 4 months and has an overall good visual outcome. However, recurrence is seen in up to 50% of patients within one year. Current treatment approaches include photodynamic therapy, oral aldosterone antagonism, and subthreshold multifocal laser. Also, many new treatments, including anti-vascular endothelial growth factor treatment, have been further studied.

[0054] In one embodiment of the present invention, the method relates to a method in which the disease is glaucoma and the changed structure is a change in the nerve fiber layer (including, but not limited to, a change in the orientation of nerve fiber bundles, a change in their thickness, a change in their size), or a change in the optic nerve head morphology (including, but not limited to, a change in the optic nerve head, a change in the physiological cup, a change in the cup-to-disc ratio, a change in the lamina cribrosa).

[0055] Glaucoma is simply defined as a process of ocular tissue destruction caused by a sustained increase in intraocular pressure (IOP) beyond its normal physiological limits. Although several etiologies may be involved in the glaucoma complex, the absolute determinant in treatment selection is the amount of primary and / or induced changes in pressure within the iridocorneal angle. Current treatments include medications or surgeries aimed at reducing this pressure, but the pathophysiological mechanisms by which elevated IOP causes nerve damage in glaucoma are not known. Medical suppression of elevated IOP can be attempted using four types of drugs: (1) aqueous humor formation inhibitors (e.g., carbonic anhydrase inhibitors, beta - adrenergic blockers, and alpha2 - adrenergic receptor agonists); (2) miotics (such as parasympathomimetics including cholinergic agents and anti - cholinesterase inhibitors); (3) trabecular meshwork outflow facilitators; and (4) osmotic agents (which create a high osmotic gradient across the blood flow / aqueous humor barrier in the ciliary epithelium). Neuroprotective agents, a fifth category of drugs including, for example, NOS inhibitors, excitatory amino acid antagonists, glutamate receptor antagonists, apoptosis inhibitors, and calcium channel blockers, are emerging as important additions to medical therapy.

[0056] In one embodiment of the present invention, the invention relates to a method in which the disease is diabetic retinopathy and the changed structure is a change in the retinal vasculature.

[0057] In certain embodiments of the present invention, the method relates to a method in which the changed structure exhibits geographic atrophy, drusen, reticular pseudodrusen, neovascularization, and / or retinal pigment epithelium degeneration.

[0058] As used herein, the term "geographic atrophy" refers to advanced atrophic AMD. Geographic atrophy is characterized by "islands" of atrophied photoreceptor cells. The complement alternative pathway is thought to play a role in the etiology of AMD.

[0059] As used herein, the term "drusen" refers to yellowish deposits located deep within the RPE on the inner surface of Bruch's membrane.

[0060] The method of the present invention is the use of an image of an eye of a subject obtained by TOI in the treatment of a disease associated with a changed structure in the posterior segment of the eye, the use comprising: a) analyzing the image for the changed structure, wherein the presence of the changed structure indicates the presence or onset of the disease in the subject; and b) administering an appropriate treatment for the disease to a subject identified as having or having developed the disease according to step (a).

[0061] In certain embodiments of the present invention, the use of the present invention relates to a determination made with respect to a reference TOI image of the posterior segment of the eye obtained from a subject in a similar state known not to have the disease or to be at risk of developing the disease, in which the structure has changed.

[0062] In another embodiment of the present invention, the present invention is for the use of evaluating the therapeutic effect in a subject to be treated for a disease related to a changed structure in the posterior eye part of the first and second images of the subject's eye obtained by trans-scleral optical imaging (TOI), or (ii) for determining the compliance of the subject with a prescribed treatment for a disease related to a changed structure in the posterior eye part, the use including analyzing the first and second images, (a) the first image being acquired before the treatment or before the second image, (b) the second image being acquired after the treatment or after the first image, (c) analyzing the first and second images being the analysis and comparison of the structure of the posterior eye part in (a) and (b), and the maintenance or reduction of the changed structure between (a) and (b) indicating that the treatment has a therapeutic effect or that the subject is compliant with the treatment.

[0063] Furthermore, in one embodiment, in the use of the first and second images, the changed structure is a changed structure relative to that determined from the analysis of the TOI images of the posterior eye part of a subject in a similar state known to be disease-free or having no risk of developing a disease.

[0064] In another embodiment of the present invention, the aforementioned use is such that the determination of the maintenance of the changed structure between (a) and (b) is (d) the determination when the changed structure has not substantially changed between (a) and (b) of the aforementioned method, or (e) any further change or progression of the changed structure between (a) and (b) of the aforementioned method is not as severe or has not progressed as the change or progression between a set of reference first and second TOI images of the posterior eye part of a subject in a similar state known to have a disease and not being treated, the reference first and second images being obtained or to be obtained at the same intervals as the first and second images in (a) and (b) of the aforementioned use.

[0065] In a preferred embodiment of the present invention, the use of the present invention relates to diseases associated with the changed structure of the posterior eye segment, such as uveitis, glaucoma, macular edema, macular hole, macular pucker, diabetic macular edema, diabetic retinopathy, diabetic ophthalmopathy, retinopathy, age-related macular degeneration (AMD), exudative AMD, atrophic AMD, early AMD, intermediate AMD, central serous chorioretinopathy, scleritis, optic nerve degeneration, geographic atrophy, choroidopathy, ocular sarcoidosis, optic neuritis, choroidal neovascularization, retinitis pigmentosa, retinal tear, Stargardt disease, eye cancer, retinitis, corneal ulcer, cataract, viral infections (such as cytomegalovirus, herpes simplex, varicella zoster, etc.), fungal infections (such as histoplasmosis, etc.), parasitic infections (such as toxoplasmosis, toxocariasis, etc.), bacterial infections (such as tuberculosis, syphilis, etc.), sarcoidosis, retinal vein occlusion, central retinal vein occlusion, branch retinal vein occlusion, retinal vascular diseases, Vogt-Koyanagi-Harada syndrome, Behçet's disease, acute posterior multifocal placoid pigment epitheliopathy (APMPPE), presumed ocular histoplasmosis syndrome (POHS), birdshot chorioretinopathy, multiple sclerosis, sympathetic ophthalmia, punctate inner choroidopathy, pars planitis, iridocyclitis, diabetic retinopathy, retinopathy of prematurity (ROP), ischemic angiopathy, hereditary retinal dystrophy, retinal detachment, abnormal angiogenesis, retinal angiomatous proliferation (RAP), intraretinal microvascular abnormalities, preretinal neovascularization, choroidal neovascularization, choroidal vascular stroke, ocular hypertension, diabetes, cardiovascular diseases, premature infants, and papilledema.

[0066] In a particular embodiment of the present invention, the present invention relates to the use where the image of the posterior eye segment is an image of the choroid, choroidal capillary lamina, Bruch's membrane, retinochoroidal tissue, neurosensory retinal tissue, nerve fiber layer, retinal pigment epithelium (RPE), photoreceptor cells, ganglion cell layer, retinal vasculature, subretinal space, retina, macula, lamina cribrosa, optic nerve head or optic nerve.

[0067] In a particular embodiment of the present invention, the present invention relates to the use where the changed structure is a change in the tissue structure.

[0068] In certain embodiments of the present invention, the present invention relates to uses in which a change in tissue structure is a change in cell pattern, cell density, cell size, cell distribution, or cell reflectivity.

[0069] In certain embodiments of the present invention, the present invention relates to uses in which a change in tissue structure is a change in cell pattern, cell density, cell size, cell distribution, or cell reflectivity.

[0070] In certain embodiments of the present invention, the present invention relates to uses in which a change in tissue structure is a change in tissue reflectivity that is a change in a low-reflection region, a high-reflection region, a low-reflection region within a high-reflection region, or any combination thereof.

[0071] In a preferred embodiment of the present invention, the present invention relates to the use of an image that is an image of the RPE.

[0072] In yet another preferred embodiment of the present invention, the present invention relates to the use of an image that is an image of the choroidal capillary lamina.

[0073] In certain embodiments of the present invention, the present invention relates to the use of an image that is an image of the nerve fiber layer, the optic nerve head, and / or the retinal vascular system.

[0074] In certain embodiments of the present invention, the present invention relates to uses in which the disease is AMD and the changed structure is a change in RPE cell density, RPE cell size, high-reflection region, low-reflection region, and / or low-reflection region within a high-reflection region.

[0075] In certain embodiments of the present invention, the present invention relates to uses in which the disease is central serous chorioretinopathy and the changed structure is a change in the RPE and the choroidal capillary lamina.

[0076] In certain embodiments of the present invention, the present invention relates to use where the disease is glaucoma and the changed structure is a change in the nerve fiber layer (including, but not limited to, a change in the orientation of nerve fiber bundles, a change in their thickness, a change in their size), or a change in the optic nerve head morphology (including, but not limited to, a change in the optic nerve head, a change in the physiological cup, a change in the cup-to-disc ratio, a change in the lamina cribrosa).

[0077] In certain embodiments of the present invention, the present invention relates to use where the disease is diabetic retinopathy and the changed structure is a change in the retinal vasculature.

[0078] In certain embodiments of the present invention, the present invention relates to use where the changed structure exhibits geographic atrophy, drusen, reticular pseudodrusen, neovascularization and / or retinal pigment epithelium degeneration. BRIEF DESCRIPTION OF THE DRAWINGS

[0079]

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

Figure 7

Figure 8

Figure 9

Figure 10

Figure 11

[0080] General methods and materials TOI image acquisition The TOI relies on high-angle oblique illumination of the retina combined with a projection illumination compensated fundus camera to enhance cell contrast and correct for ocular aberrations. Trans-scleral illumination of the retina was performed using two near-infrared light-emitting diodes placed on the nasal and temporal sides of the eye. The acquired images encompass a field of view of at least 4°×4°.

[0081] The RPE layer image obtained with a single TOI is characterized by a low signal-to-noise ratio (SNR). Therefore, prior to image analysis, the SNR is increased by acquiring several raw images, which are then aligned and averaged into a single TOI image. The final TOI-RPE image was exported with digital sampling of 0.73 μm to 1.5 μm per pixel.

[0082] Image processing The highly automated RPE image processing and analysis obtained by TOI are divided into four stages. First, the images are normalized with respect to contrast / attenuation, the inhomogeneity of the RPE layer, and noise, and out-of-focus (OoF) regions are discarded. Second, the shadows of the retinal vasculature present in the innermost (closest to the vitreous) retinal layer are detected and removed from the final image. Third, the cells or structures of interest are individually detected and segmented. Finally, the fourth and final stage consists of characterizing the layer of interest in terms of general and individual structures.

[0083] Image filtering and normalization Background removal is applied to adjust the non-uniformity of the background of the target layer. This can include, but is not limited to, flat field correction using a two-dimensional Gaussian smoothing kernel.

[0084] For example, for the RPE layer, to prevent filtering from the essential RPE morphology, the filter size, threshold, and values implemented through the image processing and analysis methodology in both the spatial and frequency domains are obtained experimentally and based on previously published literature in the evaluation of ex vivo and in vivo morphologies of RPE cells.

[0085] Detection and removal of blood vessels As an example, the detection of blood vessels is performed using the following method. Other methods based on machine learning may be applied.

[0086] The detection of blood vessels is performed by using four previously acquired images ( / i| lpГ , Gauss, deH, and Dist). Each image is subjected to subroutine A (SubA). SubA begins by shaping the image into a square, and its quadtree decomposition (QuaD) then returns a sparse matrix that is reconstructed as a block map. The QuaD threshold is applied at 3 * SD of the image. QuaD is a common methodology in several fields including image processing, and is used from multiresolution decomposition and analysis to compression and machine learning. The application of QuaD for RPE cell segmentation is a novel approach developed specifically for this project. QuaD square blocks >8 pixels and <10% of the original image size are included in subsequent image processing. After inversion (image complementation), the resulting square block map, the small interconnected structures at their outer boundaries are discarded using morphological filtering (erosion with a disk-shaped element of 4-pixel radius), followed by dilation with the same disk-shaped element. Finally, the last step of SubA is to reshape the resulting mask to the original image size.

[0087] The OoF mask obtained during the image filtering and normalization steps is summed with the binary averages of SubA(Bhpf)-SubA(Causs), SubA(deH), and SubA(Dist) to form a vessel-OoF mask (VOoF). The VOoF mask is used to exclude intravascular RPE cells from further image processing.

[0088] Cell detection Cell center detection is based on the method proposed by Khamidakh et al. (Ann Biomed Eng. 2016;44:3408-20) and is hereinafter referred to as subroutine B (SubB). If the distance between adjacent cell centers is <10 pixels, individual cells are detected as the same cell. The inventors applied SubB to Z?hpf-contrast-limited compensated histogram equalized Z?hpf- and filtered high-pass (kernel of the original image size of |) / i| lpГ was applied. Once again, cell centers within <10 pixels are fused. Finally, cell centers at a distance of <10 pixels from the image boundary are removed to prevent the inclusion of incompletely imaged cells in the image analysis.

[0089] Cell membrane segmentation Method example 1 Detection of the cell membrane can be performed using minimum value detection for the detection of the center of a low-reflection region or a high-reflection region. Next, a region growing algorithm is applied to define the target region.

[0090] Method example 2 The detection of cell membranes at the single-cell level begins with convolving Z-hpf using a disc-shaped structuring element (radius of 4 pixels). The resulting blurring of the image removes local salt-and-pepper noise that may occur during the conversion from the Fourier domain to the spatial domain. Next, the image is convolved with a star-shaped mask (size of 7 pixels). The convolution emphasizes local vertical edges, horizontal edges, and diagonal edges within the image. The final filter is a 7×7 pixel Mexican hat. These three filtering steps, followed by zero-crossing in the spatial domain, result in the development of a binary mask representing the cell membrane. Finally, the mask is significantly reduced, removing sporadic branches, while individual pixels are discarded. The inverted mask is convolved with a disc-shaped structuring element (radius 4 pixels) and then inverted again. Such a procedure improves cell separation and prevents the possibility of their overlapping.

[0091] Data analysis Example considering RPE cells: Cells having regions or centers overlapping with the VooF mask were discarded from the analysis of cell characteristics.

[0092] Using the previously created cell mask and the image obtained with the original TOI, the morphological and neighborhood characteristics of individual RPE cells were evaluated. The MATFAB regionprops function was used to obtain the basic morphological characteristics (area, centroid and weighted centroid, eccentricity angle, solidity, intensity, and circularity) of RPE cells. Furthermore, the evaluated characteristics included the CV of the RPE cell membrane (CMDcv), the number of adjacent cells, and the cell density of the RPE layer. To reduce the risk of potential evaluation bias, RPE cells directly adjacent to the VooF mask were excluded from the number of neighborhood evaluations. Descriptive analysis was performed for each image.

[0093] The normality of the variables was evaluated using the Shapiro-Wilk test (p>0.10) and histogram skewness (skewness -0.5 to 0.5).

[0094] On a DEFF workstation (DEFF XPS 13 9380, Windows 10, 64-bit, 2 1.80 GHz, 16.0 GB RAM) equipped with MATFAB (version R2019, with Bioinformatics Toolbox (trademark), Financial Toolbox (trademark) and Statistics and Machine Teaming Toolbox (trademark)), the image processing pipeline and underlying algorithms, as well as data management, were developed and tested. Image registration was performed using ImageJ 1.52 with a modified macro having the plug-ins TurboReg and Template Matching. For box plot creation and statistical analysis, the inventors used R studio 1.2.1335 together with the gmodels, el071, readxl, and xlsx packages.

[0095] TOI in central serous chorioretinopathy (CSCR) For the clinical diagnosis of CSCR, patients with clear visual media and good fixation were recruited. For each patient, best-corrected visual acuity (BCVA), refractive error equivalent spherical power, and axial length measurements, fundus autofluorescence (FAF), infrared imaging (IR), and spectral domain optical coherence tomography (SD-OCT) were performed in both eyes.

[0096] TOI was successfully performed on 12 patients (21 CSCR eyes and 1 normal contralateral eye) with a mean age of 43.3 ± 4 years. The RPE structure or mosaic appeared as a fine network of cells with low-reflectivity (core) regions within high-reflectivity (boundary) regions (Figure 3B).

[0097] Eyes with active CSCR (N = 7) showed insufficient resolution in the areas with retinal detachment on TOI (Figure 4). The presence of subretinal fluid in the path of light scattered from the RPE led to a decrease in the resolution of RPE monolayer imaging.

[0098] The resolved CSCR eyes (N = 14) showed a changed pattern of the RPE mosaic on the TOI (Figure 5). Changes in the scattered surfaces (RPE and choroid) secondary to CSCR result in changes in the mosaic pattern on the TOI.

[0099] High-reflective dots on the TOI were observed in all 21 eyes corresponding to either high-reflective subretinal deposits (Figure 4) or RPE detachments with highly reflective contents on OCT (Figure 6).

[0100] TOI images also revealed dark dots (hyporeflective foci) in 19 out of 21 eyes. They were associated with normal surrounding RPE, hyperreflective structures or zones (Figure 7).

[0101] TOI in Non-Neovascular Age-Related Macular Degeneration Patients with non-neovascular AMD, clear visual media and good fixation were recruited. For each patient, SD-OCT, autofluorescence, color and infrared fundus imaging as well as TOI were performed on one or both eyes. Images obtained by TOI were compared with conventional imaging including OCT en face and OCT B-scans (Figures 8 - 11).

[0102] Thirty-one eyes of 25 AMD patients (mean age 71.8 years, 56% female) were included. Prominent features on TOI images were the reticular or cellular pattern of the choroidal capillary lamina and the presence of additional irregularly distributed hyporeflective areas. These hyporeflective areas, with sizes varying from about 1 to about 15 times the mean RPE cell size, were located on hyporeflective areas of the choroidal capillary lamina, particularly at the border regions around atrophic zones and areas of visible RPE changes. A subgroup of these cells showed a bright halo (hyporeflective area within a hyperreflective area) around them and was well correlated with the drusenoid deformation of RPE strands on SD-OCT.

[0103] The TOI performed in 25 AMD patients revealed different patterns of altered tissue in the RPE layer. Therefore, TOI is an important tool in the evaluation of retinal diseases such as AMD.

Claims

1. A method for assisting the diagnosis and / or prognosis of a disease associated with altered structures in the posterior segment of the eye, the method comprising analyzing images of the posterior segment obtained by transscleral optical imaging (TOI) for the altered structures, wherein the altered structures indicate the presence and / or progression of the disease in the subject.

2. A method to assist in the treatment of diseases related to altered structures in the posterior segment of the eye, a) A step of analyzing images of the posterior segment obtained by transscleral optical imaging (TOI) regarding altered structures, wherein the presence of altered structures indicates the presence or onset of a disease in the subject, b) A method comprising the step of providing an appropriate treatment for the disease to be administered to the subject identified as having or having developed the disease in accordance with step (a).

3. The method according to claim 1 or 2, wherein the altered structure is determined with respect to a reference, which is a TOI image of the posterior segment obtained from a subject in a similar condition that is known not to have the disease or is known not to be at risk of developing the disease.

4. (i) Methods for supporting the evaluation of therapeutic effects in patients treated for diseases related to altered structures in the posterior segment of the eye, or (ii) A method for assisting in the determination of compliance with prescribed treatment for a disease relating to altered structures in the posterior segment of the eye, The method includes analyzing first and second images of the posterior portion of the target obtained by transscleral optical imaging (TOI), (a) The first image is taken before the procedure or before the second image, (b) The second image is obtained after the procedure or after the first image, (c) Analyzing the first and second images constitutes an analysis and comparison of the structure of the posterior segment in (a) and (b), A method in which the maintenance or reduction of the altered structure between (a) and (b) indicates that the treatment has a therapeutic effect or that the subject is complying with the treatment.

5. The method according to claim 4, wherein the altered structure is a structure determined from an analysis of TOI images of the posterior segment obtained from subjects in a similar condition who are known not to have the disease or who are known not to be at risk of developing the disease.

6. The decision to maintain the altered structure between (a) and (b) is (d) Whether the changed structure is substantially the same as (a) and (b) in claim 4, or (e) A determination that any further change or progression of the altered structure between (a) and (b) as described in claim 4 is not as severe or progressive as the change or progression between the first and second reference TOI images of the posterior segment obtained from a similar subject known to have the disease and not treated for the disease, wherein the first and second reference images were obtained or can be obtained at the same interval as the first and second images of (a) and (b) as described in claim 4.

7. The method according to any one of claims 4 to 6, wherein the second image is obtained at least two days and no more than 730 days after the first image.

8. The diseases associated with the altered structure of the posterior segment include uveitis, glaucoma, macular edema, macular hole, macular packer, diabetic macular edema, diabetic retinopathy, diabetic ophthalmopathy, retinopathy, age-related macular degeneration (AMD), exudative AMD, atrophic AMD, early AMD, mid-stage AMD, central serous chorioretinopathy, scleritis, optic nerve degeneration, geographic atrophy, choroidopathy, ocular sarcoidosis, optic neuritis, choroidal neovascularization, retinitis pigmentosa, retinal laceration, Stargardt disease, eye cancer, retinitis, corneal ulcer, cataract, viral infections (cytomegalovirus, herpes simplex, herpes zoster, etc.), fungal infections (histoplasmosis, etc.), parasitic infections (toxoplasmosis, toxocariasis, etc.), bacterial infections (tuberculosis, syphilis, etc.), sarcoidosis, and retinal vein occlusion. The method according to any one of claims 1, 2, and 4, wherein the condition is occlusion, central retinal vein occlusion, branch retinal vein occlusion, retinal vascular disease, Vogt-Koyanagi-Harada syndrome, Behçet's disease, idiopathic retinal vasculitis, Vogt-Koyanagi-Harada syndrome, acute posterior multiple maculoid pigment epitheliopathy (APPPE), presumptive ocular histoplasmosis (POHS), birdshot cloid pathology, multiple sclerosis, sympathetic ophthalmitis, punctate choroidal endometriosis, squamous cellulitis, iridocyclitis, diabetic retinopathy, retinopathy of prematurity (ROP), ischemic vasculopathy, hereditary retinal dystrophy, retinal detachment, abnormal angiogenesis, retinal angiomatoid proliferation (RAP), intraretinal microvascular abnormalities, preretinal neovascularization, choroidal angiogenesis, choroidal vasculopathy stroke, ocular hypertension, diabetes, cardiovascular disease, prematurity, and papilledema.

9. The method according to any one of claims 1, 2, and 4, wherein the image of the posterior segment of the eye is an image of the choroid, choroidal capillary plate, Bruch's membrane, retinal choroidal tissue, neuroretinal tissue, nerve fiber layer, retinal pigment epithelium (RPE), photoreceptor cells, ganglion cell layer, retinal vascular system, subretinal space, retina, macula, lamina cribriformis, optic disc, or optic nerve.

10. The method according to any one of claims 1, 2, and 4, wherein the changed structure is a change in the tissue structure.

11. The method according to claim 10, wherein the change in tissue structure is a change in cell pattern, cell density, cell size, cell distribution, or cell reflectivity.

12. The method according to claim 10, wherein the change in the tissue structure is a change in tissue reflectance, which is a change in low-reflectance regions, high-reflectance regions, low-reflectance regions within high-reflectance regions, or any combination thereof.

13. The method according to any one of claims 1, 2, and 4, wherein the aforementioned image is an image of the RPE.

14. The method according to any one of claims 1, 2, and 4, wherein the image is an image of a choroidal capillary plate.

15. The method according to any one of claims 1, 2, and 4, wherein the image is an image of the nerve fiber layer, the optic nerve head, and / or the retinal vascular system.

16. The method according to claim 13, wherein the disease is AMD, and the altered structure is a change in RPE cell density, RPE cell size, high-reflectivity regions, low-reflectivity regions, and / or low-reflectivity regions within high-reflectivity regions.

17. The method according to any one of claims 1, 2, and 4, wherein the disease is central serous chorioretinopathy, the altered structure is a change in the RPE and choroidal capillary plate, and the image is an image of the RPE or an image of the choroidal capillary plate.

18. The method according to claim 15, wherein the disease is glaucoma, and the altered structure is a change in the nerve fiber layer (including, but not limited to, a change in the orientation of nerve fiber bundles, a change in their thickness, or a change in their size), or a change in the optic disc morphology (including, but not limited to, a change in the optic head, a change in physiological cupping, a change in cup-to-disc ratio, or a change in the lamina cribriformis).

19. The method according to claim 15, wherein the disease is diabetic retinopathy and the altered structure is a change in the retinal vascular system.

20. The method according to any one of claims 1, 2, and 4, wherein the altered structure exhibits geographic atrophy, drusen, reticular pseudodrusen, neovascularization and / or retinal pigment epithelial degeneration.

21. A method for analyzing images of a subject eye obtained by transscleral optical imaging (TOI) for diagnosing and / or prognosing a disease associated with altered structures in the posterior segment of the eye, wherein the method comprises analyzing the images for altered structures, the altered structures indicating the presence and / or progression of the disease in the subject.

22. A method for analyzing images of a target eye obtained by transscleral optical imaging (TOI) in the treatment of a disease related to altered structures in the posterior segment of the eye, wherein the method is a) A step of analyzing an image of a changed structure, wherein the presence of the changed structure indicates the presence of the disease or the onset of the disease in the subject, and wherein, A method presenting an appropriate treatment for the disease to be administered to the subject identified as having or having developed the disease in accordance with step (a).

23. The method according to claim 21 or 22, wherein the altered structure is determined relative to a reference TOI image of the posterior segment obtained from a subject in a similar condition that is known not to have the disease or is known not to be at risk of developing the disease.

24. The first and second images of the target eye obtained by transscleral optical imaging (TOI) (i) A method for analyzing images to evaluate the therapeutic effect in a subject of treatment for a disease related to altered structures in the posterior segment of the eye, or (ii) A method for analyzing images to determine whether a subject should comply with prescribed treatment for a disease related to altered structures in the posterior segment of the eye, The method includes analyzing the first and second images, (a) The first image is taken before the procedure or before the second image, (b) The second image is obtained after the procedure or after the first image, (c) Analyzing the first and second images constitutes an analysis and comparison of the structure of the posterior segment in (a) and (b), A method in which the maintenance or reduction of the altered structure between (a) and (b) indicates that the treatment has a therapeutic effect or that the subject is complying with the treatment.

25. The method according to claim 24, wherein the altered structure is a structure determined from an analysis of TOI images of the posterior segment obtained from subjects in a similar condition who are known to be disease-free or who are not at risk of developing the disease.

26. The decision to maintain the altered structure between (a) and (b) is (d) Whether the changed structure is substantially the same as (a) and (b) in claim 24, or (e) A determination that any further change or progression of the altered structure between (a) and (b) as described in claim 24 is not as severe or progressive as the change or progression between the first and second reference TOI images of the posterior segment obtained from a similar subject known to have the disease and not treated for the disease, wherein the first and second reference images were obtained or can be obtained at the same interval as the first and second images of (a) and (b) as described in claim 24.

27. The method according to any one of claims 24 to 26, wherein the second image is obtained at least two days and no more than 730 days after the first image.

28. The diseases associated with the altered structure in the posterior segment include uveitis, glaucoma, macular edema, macular hole, macular packer, diabetic macular edema, diabetic retinopathy, diabetic ophthalmopathy, retinopathy, age-related macular degeneration (AMD), exudative AMD, atrophic AMD, early AMD, mid-stage AMD, central serous chorioretinopathy, scleritis, optic nerve degeneration, geographic atrophy, choroidopathy, ocular sarcoidosis, optic neuritis, choroidal neovascularization, retinitis pigmentosa, retinal laceration, Stargardt disease, eye cancer, retinitis, corneal ulcer, cataract, viral infections (cytomegalovirus, herpes simplex, herpes zoster, etc.), fungal infections (histoplasmosis, etc.), parasitic infections (toxoplasmosis, toxocariasis, etc.), bacterial infections (tuberculosis, syphilis, etc.), sarcoidosis, and retinal vein occlusion. The method according to any one of claims 21, 22, and 24, wherein the condition is occlusion, central retinal vein occlusion, branch retinal vein occlusion, retinal vascular disease, Vogt-Koyanagi-Harada syndrome, Behçet's disease, idiopathic retinal vasculitis, Vogt-Koyanagi-Harada syndrome, acute posterior multiple maculoid pigment epitheliopathy (APPPE), presumptive ocular histoplasmosis (POHS), birdshot cloid pathology, multiple sclerosis, sympathetic ophthalmitis, punctate choroidal endometriosis, squamous cellulitis, iridocyclitis, diabetic retinopathy, retinopathy of prematurity (ROP), ischemic vasculopathy, hereditary retinal dystrophy, retinal detachment, abnormal angiogenesis, retinal angiomatoid proliferation (RAP), intraretinal microvascular abnormalities, preretinal neovascularization, choroidal angiogenesis, choroidal vasculopathy stroke, ocular hypertension, diabetes, cardiovascular disease, prematurity, and papilledema.

29. The method according to any one of claims 21, 22, and 24, wherein the image of the posterior segment of the eye is an image of the choroid, choroidal capillary plate, Bruch's membrane, retinal choroidal tissue, neuroretinal tissue, nerve fiber layer, retinal pigment epithelium (RPE), photoreceptor cells, ganglion cell layer, retinal vascular system, subretinal space, retina, macula, lamina cribriformis, optic disc, or optic nerve.

30. The method according to any one of claims 21, 22, and 24, wherein the changed structure is a change in the tissue structure.

31. The method according to claim 30, wherein the change in tissue structure is a change in cell pattern, cell density, cell size, cell distribution, or cell reflectivity.

32. The method according to claim 31, wherein the change in the tissue structure is a change in tissue reflectance, which is a change in low-reflectance regions, high-reflectance regions, low-reflectance regions within high-reflectance regions, or any combination thereof.

33. The method according to any one of claims 21, 22, and 24, wherein the aforementioned image is an image of the RPE.

34. The method according to any one of claims 21, 22, and 24, wherein the image is an image of a choroidal capillary plate.

35. The method according to any one of claims 21, 22, and 24, wherein the image is an image of the nerve fiber layer, optic disc, and / or retinal vascular system.

36. The method according to claim 33, wherein the disease is AMD, and the altered structure is a change in RPE cell density, RPE cell size, high-reflectivity regions, low-reflectivity regions, and / or low-reflectivity regions within high-reflectivity regions.

37. The method according to any one of claims 21, 22, and 24, wherein the disease is central serous chorioretinopathy, the altered structure is a change in the RPE and choroidal capillary plate, and the image is an image of the RPE or an image of the choroidal capillary plate.

38. The method according to claim 35, wherein the disease is glaucoma, and the altered structure is a change in the nerve fiber layer (including, but not limited to, a change in the orientation of nerve fiber bundles, a change in their thickness, or a change in their size), or a change in the optic disc morphology (including, but not limited to, a change in the optic head, a change in physiological cupping, a change in cup-to-disc ratio, or a change in the lamina cribriformis).

39. The method according to claim 35, wherein the disease is diabetic retinopathy and the altered structure is a change in the retinal vascular system.

40. The method according to any one of claims 21, 22, and 24, wherein the altered structure exhibits geographic atrophy, drusen, reticular pseudodrusen, neovascularization and / or retinal pigment epithelial degeneration.

41. A step of analyzing an image of the posterior segment obtained by transscleral optical imaging (TOI), Based on the analysis results of the aforementioned images, the process includes outputting information indicating the presence and / or progression of a disease in a subject related to altered structures in the posterior segment, Information processing methods, including those mentioned above.

42. A computer, A means for analyzing images of the posterior segment obtained by transscleral optical imaging (TOI), A means for outputting information indicating the presence and / or progression of a disease in an object related to altered structures in the posterior segment, based on the results of the analysis of the aforementioned image. A program designed to function as such.

43. (i) A method for outputting information on the therapeutic effect in a subject of treatment for a disease related to altered structure in the posterior segment of the eye, or (ii) An information processing method for outputting information on the subject's compliance with prescribed treatment for a disease related to altered structure in the posterior segment of the eye, The information processing method includes the step of analyzing first and second images of the posterior portion of the target obtained by transscleral optical imaging (TOI), (a) The first image is taken before the procedure or before the second image, (b) The second image is obtained after the procedure or after the first image, (c) The step of analyzing the first and second images is the step of analyzing and comparing the structure of the posterior segment in (a) and (b), An information processing method comprising the step of outputting information indicating that the maintenance or reduction of the altered structure between (a) and (b) indicates that the treatment has a therapeutic effect or that the subject is complying with the treatment.

44. A computer, The first and second images of the target eye obtained by transscleral optical imaging (TOI) (i) means for outputting information on the therapeutic effect in a subject of treatment for a disease related to altered structure in the posterior segment of the eye, (ii) means for outputting information on the subject's compliance with prescribed treatment for a disease relating to altered structures in the posterior segment of the eye, The means includes means for analyzing the first and second images, (a) The first image is taken before the procedure or before the second image, (b) The second image is obtained after the procedure or after the first image, (c) The means for analyzing the first and second images is a means for analyzing and comparing the structure of the posterior segment in (a) and (b), The maintenance or reduction of the altered structure between (a) and (b) is a means for outputting information that the treatment has a therapeutic effect or that the subject is complying with the treatment. A program designed to function as such.

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