The Trajectory of Retinal Microcirculation Imaging: From Angiography to Artificial Intelligence

Retinal and choroidal microcirculation are highly specialized vascular networks essential for vision and are increasingly recognized as indicators of systemic diseases. For decades, its assessment relied on invasive dye-based angiography, which infers pathology from secondary effects such as vascular leakage. A paradigm shift is now underway, driven by non-invasive imaging modalities that directly visualize and quantify the microvasculature with unprecedented resolution. Chief among these is optical coherence tomography angiography, which provides depth-resolved, three-dimensional maps of perfused vessels, enabling the generation of objective biomarkers for vascular integrity and ischemia. Complementary techniques further probe absolute blood flow, high-frequency hemodynamics, and cellular-level perfusion, creating a rich, multi-scale dataset. This technological evolution is transforming clinical practice, facilitating preclinical detection of diabetic retinopathy, refining therapeutic strategies for neovascular age-related macular degeneration, and providing new insights into the vascular contributions to glaucoma. Looking ahead, integrating these multimodal data streams with artificial intelligence promises to convert the wealth of information into predictive models of disease risk and progression. This heralds a new era in precision ophthalmology and oculomics (the large-scale, data-driven analysis of ocular imaging biomarkers to assess systemic health and predict disease risk), with transformative gains in processing, quantification, and access.