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Edinburgh Research Explorer Edinburgh Research Explorer Lateral thinking – interocular symmetry and asymmetry in neurovascular patterning, in health and disease Citation for published version: Cameron, J, Megaw, R, Tatham, A, McGrory, S, MacGillivray, T, Doubal, F, Wardlaw, J, Trucco, E, Chandran, S & Dhillon, B 2017, 'Lateral thinking – interocular symmetry and asymmetry in neurovascular patterning, in health and disease', Progress in Retinal and Eye Research. https://doi.org/10.1016/j.preteyeres.2017.04.003 Digital Object Identifier (DOI): 10.1016/j.preteyeres.2017.04.003 Link: Link to publication record in Edinburgh Research Explorer Document Version: Peer reviewed version Published In: Progress in Retinal and Eye Research Publisher Rights Statement: This is author's peer-reviewed manuscript as accepted for publication General rights Copyright for the publications made accessible via the Edinburgh Research Explorer is retained by the author(s) and / or other copyright owners and it is a condition of accessing these publications that users recognise and abide by the legal requirements associated with these rights. Take down policy The University of Edinburgh has made every reasonable effort to ensure that Edinburgh Research Explorer content complies with UK legislation. If you believe that the public display of this file breaches copyright please contact [email protected] providing details, and we will remove access to the work immediately and investigate your claim. Download date: 09. Oct. 2021 Lateral thinking – interocular symmetry and asymmetry in neurovascular patterning, in health and disease James R. Cameron a, b, * Roly D. Megaw c, d Andrew J. Tatham d Sarah McGrory b Thomas J. MacGillivray b, e Fergus N. Doubal b Joanna M. Wardlaw b Emanuele Trucco f Siddharthan Chandran a, b Baljean Dhillon b, d a Anne Rowling Regenerative Neurology Clinic, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK b Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK c Scottish Centre for Regenerative Medicine, University of Edinburgh, 5 Little France Drive, Edinburgh, EH16 4UU, UK d Princess Alexandra Eye Pavilion, Chalmers Street, Edinburgh, EH3 9HA, UK e VAMPIRE project, Clinical Research Imaging Centre, University of Edinburgh, Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK f VAMPIRE project, Computer Vision and Image Processing Group, School of Science and Engineering (Computing), University of Dundee, Queen Mother Building, Dundee, DD1 4HN, UK * Corresponding Author Dr. James R Cameron Anne Rowling Regenerative Neurology Clinic, University of Edinburgh Tel: +44 (0)131 465 9500 Email: [email protected] 1 Contents 1. Introduction 1.1. Reflections 1.2. The birds and bees 2. Embryology and eye development 2.1. Lateral patterning in embryogenesis 2.2. Mammalian eye development 2.3. Asymmetrical human developmental disease 2.4. Asymmetrical development in animal models 2.5. Is normal eye development asymmetrical? 3. Retinal symmetry 3.1. Neuroretina 3.1.1. Retinal thickness measures in health 3.1.2. Hereditary retinal disease 3.1.3. Age-related macular degeneration 3.1.4. Retinal detachment 3.2. Retinal vasculature morphology 3.2.1. Retinal vascular biomarkers 3.2.2. Retinal vasculature software analysis 3.2.3. Assessments of vessel symmetry 3.2.4. Which vessel parameters define symmetry? 3.2.5. Choice of statistical measures of symmetry and agreement 3.2.6. Quantifying measurement uncertainty and error 3.2.7. Linking vessel measures to known physiological outcomes 4. Brain and visual pathway symmetry 4.1. Optic nerve 4.1.1. Optic nerve anatomy and normal ageing 4.1.2. Glaucoma 4.1.3. Optic neuritis 4.1.4. Hereditary optic neuropathies 4.2. Thalamus, optic radiation and visual cortex 4.2.1. Visual pathway symmetry in the healthy brain 4.2.2. Cerebrovascular disease impacting the visual pathway 4.2.3. Other brain disease 5. Implications for studies and statistics 5.1. Assumptions of symmetry 5.2. “2n eyes of n subjects…” 6. Discussion 7. Future Directions 2 Abstract No biological system or structure is likely to be perfectly symmetrical, or have identical right and left forms. This review explores the evidence for eye and visual pathway asymmetry, in health and in disease, and attempts to provide guidance for those studying the structure and function of the visual system, where recognition of symmetry or asymmetry may be essential. The principal question with regards to asymmetry is not ‘are the eyes the same?’, for some degree of asymmetry is pervasive, but ‘when are they importantly different?’. Knowing if right and left eyes are ‘importantly different’ could have significant consequences for deciding whether right or left eyes are included in an analysis or for examining the association between a phenotype and ocular parameter. The presence of significant asymmetry would also have important implications for the design of normative databases of retinal and optic nerve metrics. In this review, we highlight not only the universal presence of asymmetry, but provide evidence that some elements of the visual system are inherently more asymmetric than others, pointing to the need for improved normative data to explain sources of asymmetry and their impact on determining associations with genetic, environmental or health-related factors and ultimately in clinical practice. Acknowledgements JC is supported by a Rowling Scholarship from the Anne Rowling Regenerative Neurology Clinic, University of Edinburgh. AT is supported with an NHS Research Scotland (NRS) Fellowship. FD is supported by a joint Stroke Association/Garfield Weston Foundation Senior Clinical Fellowship. The VAMPIRE team acknowledges support from ESPRC grant SIDD EP/M005976/1 “Multimodal retinal biomarkers for vascular dementia”. Part of this research has been conducted using the UK Biobank Resource. 3 List of Abbreviations ALKB alkylated DNA repair protein B ARMD age-related macular degeneration AVR arteriole-to-venule ratio BMO Bruch’s membrane opening BMP bone morphogenetic protein BOLD-MRI blood oxygenation level dependent magnetic resonance imaging CCA common carotid artery CI confidence interval cpRNFL circumpapillary retinal nerve fibre layer CRAE central retinal arteriolar equivalent CRVE central retinal venular equivalent CNV choroidal neovascular membrane CT computed tomography Cyc cyclops DOA Autosomal dominant optic atrophy ENU N-ethyl-N-nitrosourea GA geographic atrophy GCC ganglion cell complex GCL ganglion cell layer GC-IPL ganglion cell and inner plexiform layer HRT Heidelberg Retina Tomograph ICA internal carotid artery ICC intraclass correlation coefficient INL inner nuclear layer IOP intraocular pressure LGN lateral geniculate nucleus LHON Leber hereditary optic neuropathy MRI magnetic resonance imaging MS multiple sclerosis OCT optical coherence tomography Oep one-eyed pinhead ONSD optic nerve sheath diameter OTX orthodenticle homeobox Pax paired box protein PCA posterior cerebral artery Pitx paired-like homeodomain transcription factor PPAA posterior pole asymmetry analysis Ptdsr phosphatidylserine receptor 4 RAPD relative afferent pupillary defect RGC retinal ganglion cell RNFL retinal nerve fibre layer RP retinitis pigmentosa RRD rhegmatogenous retinal detachment SD-OCT spectral-domain optical coherence tomography SLO scanning laser ophthalmoscope Sox SRY-Box transcription factor TBX T-box transcription factor TCD transcranial Doppler ultrasonography TD-OCT time-domain optical coherence tomography TGFβ transforming growth factor β TMX thioredoxin-related transmembrane protein USH2A usherin gene VAMPIRE vessel assessment and measurement platform for images of the retina WMH white matter hyperintensities Wnt wingless-related integration site 5 1. Introduction 1.1. Reflections Symmetry is observed in much of biology, with many plants and animals demonstrating some degree of symmetry of anatomical structure. The symmetry observed can be defined as two or more matching regions, identical (or nearly identical) by either mirror or rotational reflection. As humans, we are familiar with our gross anatomical symmetry, but also the important asymmetries within us. Clinically, we expect our eyes and visual systems to behave somewhat symmetrically. The visual system is designed to be fully bilaterally integrated and this is essential for full field vision. We also observe a pattern of symmetry in many (but not all) ocular diseases, further emphasising the convergence of the two halves of our visual pathway. However, unanswered questions remain about the pathophysiology of diseases, in those that affect one, and both eyes. In addition, assumptions are made about the symmetry of the eyes in research, for example in studies that analyse retinal vascular morphology. These assumptions may not be correct, and in fact, there may be a consistent pattern of asymmetry between our eyes and visual pathways. We now have access to tools that are providing increasingly precise measures of ocular structure, such as optical coherence tomography (OCT) of the retina, and automated software analysis of the retinal vascular morphology revealed by fundus imaging. We can therefore begin to challenge assumptions of anatomical symmetry by analysis of sophisticated ocular measurements from large studies utilising these tools. Simultaneously, clues to the patterning of the neuroretina are emerging from advances in developmental genetics, with
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