Someone particularly inventive in the Joslin Diabetes Center development office came up with the idea of auctioning off a “Lab Crawl” this year at our annual fundraising gala. The winning bidder received a private group tour of several research labs at Joslin, including my own. I admit, I was a little dubious at first, since the idea of a “no beer, all science” crawl initially seemed to be the antithesis of a typical rowdy, fun-filled pub tour.
Fortunately, the Crawl was a blast for everyone. An extended family of 7 showed up at our door, including 2 teenage boys and 1 preteen. Their enthusiastic support for Joslin’s mission to improve the lives of diabetic patients through care, education, and research was heartwarming. But what was most exciting was to view our ophthalmic endeavors anew through the eyes of the kids. My clinical research group focuses on identifying biomarkers for diabetic retinopathy using retinal imaging techniques. Over the years I’ve come to take standard clinical tools such as fundus photography and optical coherence tomography for granted, especially in light of advances such as adaptive optics scanning laser ophthalmoscopy and optical coherence tomography angiography. The boys, however, were wowed by all of our imaging techniques. They were particularly fascinated by the chance to photograph the inside of their own eyes and they were amazed at the beauty of their retinas.
Introducing this family to our eye research efforts made me realize how far we’ve come in our ability to visualize the retina and its neural and vascular components over the last 2 decades. It is humbling to realize that ultrawide field fundus photographs now capture in a single image, within a quarter of a second, retinal fields that used to take 12 hours to fully photograph and montage. More importantly, there are strong preliminary results that suggest that peripheral lesions on these ultrawide field photographs may aid us in better identifying patients who are at risk for more rapid worsening of their diabetic retinopathy. This finding is being further evaluated in a prospective observational DRCR Network study that will follow nearly 400 patients with diabetic retinopathy over 4 years to determine whether predominantly peripheral lesions can help predict increased risk for retinopathy severity worsening. Optical coherence tomography has revolutionized our approach to diagnosing and treating a number of retinal conditions, including diabetic macular edema, vitreomacular traction, macular holes, and age-related macular degeneration. Despite the only modest correlation between central retinal thickness and visual acuity outcomes, we have grown dependent on optical coherence tomography B scans and pseudocolor maps to determine when to start, continue, and stop treatments for many types of macular pathology. Techniques such as optical coherence tomography angiography and adaptive optics scanning laser ophthalmoscopy have even greater potential through higher-resolution imaging to unlock mysteries of how and why vascular and neural abnormalities develop in the retina. These insights may give ultimately give rise to novel, vision-saving therapies.
So, what are the yet undiscovered territories in retinal imaging? Despite the rapidly emerging technologies of the last decade, there is still a wish list to be filled. Metabolic imaging would advance our understanding of how retinal function relates to cellular activity. The ability to distinguish specific cell types within the human retina would allow us to better understand differential local effects of diverse retinal diseases. Although many of our current imaging modalities provide static pictures, dynamic imaging of both retinal vasculature and neural components might provide a more sophisticated understanding of moment-to-moment changes in the retinal microenvironment. The promise of retinal imaging is even greater as we develop computerized methods of analysis to assess textural and other features that may not be appreciable by the human eye.
The family that toured our lab went home delightedly with hard copies of their very own optical coherence tomography angiography images. What did I take away? I gained a renewed sense of inspiration and appreciation for the retinal imaging tools currently at our disposal and for the new insights that are sure to arrive with future generations of imaging advances.