Retinal vascular fractal dimension in bipolar disorder and schizophrenia

Abhishek Appaji, Bhargavi Nagendra, Dona Maria Chako, Ananth Padmanabha, Chaitra V. Hiremath, Arpitha Jacob, Shivarama Varambally, Muralidharan Kesavan, Ganesan Venkatasubramanian, Shyam Vasudeva Rao, Carroll A. B. Webers, Tos T. J. M. Berendschot, Naren P. Rao*

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review

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Background: Bipolar disorder (BD) and schizophrenia (SCZ), are associated with greater vascular co-morbidities and adverse vascular events. Owing to shared developmental origins and morphology, retinal vasculature is a proxy assessment measure of the cerebral vasculature. Although retinal vascular fractal dimension (D-f), a measure of vascular geometry and complexity of branching, has been shown to be directly associated with cerebrovascular pathology, it has not been examined in SCZ and BD.

Methods: We studied 277 participants (92 healthy volunteers, 98 SCZ, and 87 BD) from 18 to 50 years of age. Images were acquired by trained personnel using a non-mydriatic fundus camera and the retinal vascular D-f was calculated by the box-counting method using an automated algorithm. The average D-f across the left and right eyes were calculated.

Results: Both SCZ and BD had significantly increased D-f compared to HV despite controlling for possible confounding factors. However, there was no significant difference between SCZ and BD. These findings suggest abnormal retinal vascular D-f in psychoses.

Limitations: The study design was cross-sectional, and patients were on medications. Confound of lifestyle factors such as diet and exercise, if any, was not controlled. Sub-group analysis between BD-I and BD-II was not performed in view of the small sample.

Conclusions: Considering the easy accessibility, affordability, and non-invasive nature of the examination, retinal vascular D-f could serve as a surrogate marker for cerebral vascular abnormality and could potentially identify BD and SCZ patients at risk of developing adverse vascular events.

Original languageEnglish
Pages (from-to)98-103
Number of pages6
JournalJournal of Affective Disorders
Publication statusPublished - 1 Dec 2019


  • Bipolar disorder
  • Fractal dimension
  • Fundus
  • Neurodevelopment
  • Psychoses
  • RISK
  • Retinal vasculature
  • Schizophrenia

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