Assessment of Macular Microvasculature in Healthy Eyes of Infants and Children Using OCT Angiography.


PURPOSE:To assess macular vasculature in healthy infants and children using OCT angiography (OCTA). DESIGN:Prospective cross-sectional study. PARTICIPANTS:One hundred thirty-five normal maculae of 89 healthy infants and children (mean age, 8.5±5.3 years; range, 9 weeks-17 years) treated at the Duke University Eye Center. METHODS:We imaged 135 maculae of 89 pediatric patients using the standard Spectralis tabletop and investigational Spectralis with Flex module devices, both equipped with investigational OCTA software (Heidelberg Engineering, Heidelberg, Germany). OCT angiography images of the superficial vascular complex (SVC) and deep vascular complex (DVC) were analyzed for foveal avascular zone (FAZ) area and superficial and deep vessel density. We assessed effects of age, gender, race, axial length (AL), and central subfield thickness on FAZ and vessel density. Patients with both eyes imaged were assessed for agreement between the FAZ and vessel densities of the left and right eyes. MAIN OUTCOME MEASURES:The FAZ area, as well as vessel area density (VAD) and vessel length density (VLD) in the SVC and DVC. RESULTS:The FAZ varied significantly with race; white patients showed a significantly smaller FAZ than black patients (mean difference, 0.11 mm2; P = 0.004). The FAZ did not vary with age, gender, or AL (P > 0.05). In the SVC, VAD and VLD varied significantly with age (P < 0.001) and AL (R2 = 0.46; P < 0.001) but not gender (P > 0.05). The SVC VLD was significantly different between races and ethnicities (P = 0.037), but VAD was not (P < 0.05). In the DVC, VAD and VLD also varied significantly with age (P < 0.001) and AL (R2 = 0.46; P < 0.001) but not gender or race (P > 0.05). There was excellent agreement between the right and left eyes for FAZ (intraclass correlation [ICC], 0.97), SVC VLD (ICC, 1.00), and DVC VLD (ICC, 1.00). CONCLUSIONS:Quantitative studies of pediatric perifoveal vasculature should consider age, race, and AL. In eyes with unilateral disease, the perifoveal vasculature in the unaffected eye may be used as a control comparison because there is excellent agreement between eyes.





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Publication Info

Hsu, S Tammy, Hoan T Ngo, Sandra S Stinnett, Nathan L Cheung, Robert J House, Michael P Kelly, Xi Chen, Laura B Enyedi, et al. (2019). Assessment of Macular Microvasculature in Healthy Eyes of Infants and Children Using OCT Angiography. Ophthalmology, 126(12). pp. 1703–1711. 10.1016/j.ophtha.2019.06.028 Retrieved from

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Sandra Sue Stinnett

Associate Professor of Biostatistics & Bioinformatics

Analysis of data for ophthalmology including observational studies and clinical trials. Assessment of reproducibility in grading measurements for ophthalmic studies. Teaching medical statistics.


Nathan Cheung

Assistant Professor of Ophthalmology

Dr. Cheung specializes in pediatric optometry and infant aphakia contact lens fittings.

As a new faculty member at Duke, Dr. Cheung plans to investigate further into various methods of myopia control and its validity. He is also very interested in establishing a pediatric optometry residency at Duke to train future optometry residents and equip them with the skills needed to work in a medical center.

He hopes to make every child’s visit at Duke Eye Center an unforgettable experience. He enjoys to educating and talking to patients and parents concerning their child’s eye condition.

Dr. Cheung came to Duke for the opportunity to reach his maximum potential and to work with the best and brightest minds in the field.


Xi Chen

Associate Professor of Ophthalmology

Dr. Xi Chen is dedicated to being a clinician-scientist who provides great medical and surgical care to patients with vitreoretinal diseases, with a research focus in retinal neurovascular development and disease. Her current research interest is studying human retinal and vascular development and their coordination using advanced imaging techniques.
Dr. Chen's basic science training in neural development gives her a unique perspective in her research in human retinal neurovascular development and disease. She hopes to eventually bring the information gathered from the bedside back to the laboratory in order to develop strategies to improve care of premature infants, and pediatric and adult patients with retinal vascular diseases. 

She is very excited to work closely with Dr. Cynthia Toth and Dr. Joseph Izatt, who have pioneered the world in the development of bedside OCT technology and its adaptation for pediatric use. The many gifted clinician-scientists at Duke Eye Center as mentors and role models will also be key to Dr. Chen's research development.
Dr. Chen arrived at Duke for fellowship training in vitreoretinal surgery after spending eight years in Boston. She says that she loved her mentors, the staff and the patients at Duke and found the environment to be warm, caring, fun and collaborative. She is grateful to work alongside colleagues and staff who work hard and go out of their way to provide the best possible care to patients.


Laura Barlow Enyedi

Professor of Ophthalmology

Childhood and Adult Strabismus

Amblyopia: I am the Duke Prinicipal Investigator for the Pediatric Eye Disease Investigator Group. I am currently involved in a number of clinical trials for amblyopia treatment.

Strabismus associated with macular translocation surgery


Grace Prakalapakorn

Associate Professor of Ophthalmology

S. Grace Prakalapakorn, MD, MPH is a pediatric ophthalmology fellowship-trained clinician scientist with expertise in the diagnosis and treatment of retinopathy of prematurity. She initially joined the faculty at Duke University as a Clinician Scientist in 2011 and was awarded a K12 Mentored Clinical Scientist Development Program Award by the department of ophthalmology (2011-2014). She later applied for and was awarded a K23 Career Development Award by the National Institutes of Health (NIH) (2014-2018).

Her research focus is on improving access to care and outcomes in underserved communities by adapting innovative strategies to address clinically relevant problems. The majority of her research has focused on retinopathy of prematurity (ROP), a leading cause of preventable blindness in children worldwide. While appropriate screening and treatment can decrease the risk of blindness due to ROP, there is a lack of ophthalmologists trained to screen for ROP and there are difficulties with access to care. Because the number of trained ophthalmologists able and willing to screen for ROP is limited and is unlikely to meet the continuing need worldwide, innovative strategies to screen for ROP and expand our workforce in ROP screening are needed. Her program involves looking at alternative screening devices that could be used in store-and-forward telemedicine applications for ROP teaching and screening.

She has shown that videos acquired by an indirect ophthalmoscopy system can demonstrate important features of ROP and that images captured by an indirect ophthalmoscopy system are of high enough quality to be graded for ROP screening. She has also shown that a FDA-approved narrow-field, handheld non-contact digital retinal camera can capture retinal images of prematurely-born infants of sufficient quality to be accurately graded for the presence of posterior pole vascular changes by both human graders and semi-automated computer programs (i.e. ROPtool). These publications describe alternative strategies that could be used in an ROP telemedicine screening scenario which could change the way ROP is screened for in the future, especially in areas without access to a trained ROP specialist.

 In addition to her role as a clinician-scientist, Dr. Prakalapakorn is a recognized expert in infantile Pompe disease. Pompe disease is an inherited lysosomal storage disorder. Prior to the advent of enzyme replacement therapy (ERT), most patients with infantile-onset Pompe disease did not survive past 1 year of age. In her role as an academic physician, she has developed a knowledge base and niche in ocular findings in this population. In collaboration with the pediatric genetics department at Duke, she has published on ophthalmic findings in a series of children with infantile Pompe disease treated with ERT. Her group established the current recommendations for annual comprehensive eye examinations in this population.

 Dr. Prakalapakorn attended Duke University where she earned a B.S.E in Biomedical and Electrical Engineering with a minor in Chemistry. She was then awarded a Fulbright scholarship to study the role of directly-observed therapy short course in tuberculosis control in Bangkok, Thailand. Next she pursued a M.D./M.P.H. at Emory University as a Woodruff Scholar (full tuition, merit-based scholarship). She earned her M.P.H. with a focus on epidemiology. She then completed a transitional year internship at Scripps Mercy Hospital in San Diego, California and then returned to Emory University to complete her residency in ophthalmology. She then spent a year working as a staff ophthalmologist for ORBIS international aboard their Flying Eye Hospital. She then returned to Duke University to complete a fellowship in pediatric ophthalmology before accepting a faculty position at the Duke Eye Center.

 Dr. Prakalapakorn has also established a national and international presence in the field of public health and international health. Because of her expertise in pediatric ophthalmology and public health, she was invited to work with the Centers for Disease Control and Prevention (CDC) as a consultant and collaborator on Zika Virus and pediatric ophthalmology. She has been involved in guiding future CDC recommendations on screening for Zika. In addition, Dr. Prakalapakorn works with the NIH on the Partnership for Research on Ebola Vaccine in Liberia (PREVAIL) III study based in Monrovia, Liberia. Since her time at Duke University, she has also been invited to speak internationally on the topics of both ROP and global blindness.

 Dr. Prakalapakorn has also been selected and served as a member of various committees for both the American Academy of Ophthalmology (AAO) and the American Association for Pediatric Ophthalmology and Strabismus (AAPOS). She was recognized for “special contributions to the Academy and ophthalmology outside the scope of the current Achievement Awards program” by the AAO with a Secretariat Award in 2017.


Miguel Angel Materin

Professor of Ophthalmology

Ocular oncologist Miguel Materin, MD joined Duke Eye Center as Professor of Ophthalmology and Director of Ophthalmic Oncology in September 2016. He joins Duke from Yale University School of Medicine where he was an Associate Professor of Ophthalmology & Visual Science. Prior to his appointment at Yale, he was at Wills Eye Hospital at Thomas Jefferson University in Philadelphia, where he served as Director of Diagnostic Studies for the Ocular Oncology Service.

Dr. Materin’s clinical practice involves diagnosis and treatment of patients with ocular tumors, including benign and malignant tumors of the eye. He has special interests in ocular melanoma, retinoblastoma, choroidal hemangiomas, retinal hemangioblastomas, metastases, astrocytic tumors and tumors related to other conditions or syndromes, like von Hippel Lindau disease, Tuberous Sclerosis among others. 

He is an internationally recognized ocular oncologist, who has served as a member of the International Advisory Board (Ocular Oncology) for the Canadian Journal of Ophthalmology. Dr. Materin has published extensively in the peer-reviewed literature, including journals and book chapters. He has been invited as visiting professor in US, Canada, Israel, Spain, Brazil, Puerto Rico, Argentina, and gave lectures worldwide.

Dr. Materin has received the Achievement Award from the American Academy of Ophthalmology and he is a Member of Merit of Clinica Barraquer (Barcelona, Spain). He has served as Director of Diagnostic Studies at the Ocular Oncology Service at Wills Eye Hospital for 7 years. He is an active member of the International Society of Ocular Oncology, American Academy of Ophthalmology, Pan American Association of Ophthalmology and Argentine Society of Ophthalmology.

Dr. Materin serves on the education committee of the American Association of Ocular Oncology and Pathology and is the President Elect for the Pan American Society of Ocular Oncology.


Mays Antoine Dairi

Associate Professor of Ophthalmology

1. Pediatric and adult optic neuropathies
2. Optic nerve imaging (mainly optical coherence tomography)
3. Idiopathic intracranial hypertension
4. Optic neuritis


Glenn Jay Jaffe

Robert Machemer M.D. Distinguished Professor of Ophthalmology

I have an active basic and clinical research program. I have been principal investigator on several funded clinical studies including investigations of an oral ganciclovir prodrug to treat CMV retinitis and a study to determine the safety of a cyclosporine sustained drug delivery implant in the treatment of uveitis. I am principal investigator of an ongoing multicenter trial of a fluocinolone sustained drug delivery implant to treat patients with severe uveitis and a trial of this same implant to treat diabetic macular edema. Recently, I have investigated the use of ultrasonography and optical coherence tomography to diagnose macular edema in a variety of ocular diseases. I have maintained an ongoing basic research program to test the hypothesis that cytokines are important in the development of proliferative vitreoretinopathy, an important intraocular wound healing disorder. Education: I am actively involved in resident and fellow education. I give lectures to residents and fellows on a variety of topics related to uveitis and vitreoretinal diseases and train fellows to perform vitreoretinal surgery. I train post-doctoral students and medical students to conduct clinically relevant research. I serve as a mentor for the Duke third year medical school research program. I have served on a yearly basis as course faculty at many national and international meetings.


Sharon Fridovich Freedman

Professor of Ophthalmology

My current research interests include:

Childhood glaucomas - With a large referral practice of children with pediatric glaucomas of all types, Freedman is evaluating existing and new management strategies for treating refractory congenital and childhood glaucomas, including the use of pharmacologic agents, as well as modification of surgical interventions. Freedman has an on-going collaboration with Duke colleagues to study the genetics of pediatric glaucoma. In addition to an active clinical research program, she regularly lectures and directs workshop at national meetings aimed at educating other ophthalmologists about current strategies and controversies in managing children with refractory glaucoma.

Retinopathy of Prematurity - Freedman was the principal investigator at the Duke-UNC Center for the NIH-sponsored, multi-center trial to evaluate early treatment for retinopathy of prematurity (ETROP). Together with colleague David Wallace, she provides eye care and treatment to the many premature children who graduate from the Neonatal Intensive Care units at DUHS. Freedman and Wallace are involved in clinical research involving the computerized evaluation of retinal blood vessels in ROP. Freedman and Wallace collaborate with Cynthia Toth and her Duke research team in applying the new imaging technique of Spectral Domain Optical Coherence Tomography to image children with retinopathy of prematurity and other retinal disorders. Efforts are ongoing to investigate the role of the anti-vascular endothelial growth factor drug, bevasizumab in treating severe ROP.

Strabismus associated with macular translocation surgery - Together with Cynthia Toth, Freedman continues to surgically treat the cyclotorsion and strabismus resulting from macular translocation surgery (now reserved for special cases of macular degeneration that are resistent to injection therapy. She has developed and published on new extraocular muscle surgical techniques to deal with this problem.

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