Clinical electrophysiology of the retinal pigment epithelium

Non-invasive technique to detect diabetic retinopathy based on Electrooculography signal using machine learning classifiers

Single-channel Electrooculogram (EOG) is proposed for detecting diabetic retinopathy. The Corneal-retinal potential of the eyes plays a vital role in the acquisition of Electrooculography. Diabetes is the most prevalent disease and for one out of three people with diabetes above 40 years, diabetic retinopathy occurs. It is necessary for the early detection of diabetic retinopathy as it is one of the primary reasons for blindness in the population. The potential difference between cornea and retina leads to the acquisition of EOG signal. The proposed study aims to design a low-cost miniaturized hardware circuit to obtain EOG signal using second order filters without compromising in accuracy of the outcome signal and to classify the signal into normal and diabetic retinopathy subjects by extracting the statistical features like kurtosis, mean, median absolute deviation, standard deviation, and range from software filtered EOG signal. Among the classifiers used, Support vector machine (SVM) shows a higher accuracy of 93.33%. The sensitivity, specificity and Area Under Curve (AUC) values of SVM are 96.43%, 90.625%, 0.93% is considered as more favorable outcome for the proposed method and it supports the developed prototype and processing methodology. The novelty of the research is based on proposing and exploring a non-invasive methodology for Diabetic retinopathy diagnosis based on EOG signal. Thus, the designed hardware is simple in operation and cost effective, provides an affordable and non-invasive diagnostic tool for diabetic retinopathy patients

No flow through the vitreous humor: How strong is the evidence?

When analyzing vitreal drug delivery, or the pharmacological effects of drugs on intraocular pressure, or when interpreting outflow facility measurements, it is generally accepted that the fluid in the vitreous humor is stagnant. It is accepted that for all practical purposes, the aqueous fluid exits the eye via anterior pathways only, and so there is negligible if any posteriorly directed flow of aqueous through the vitreous humor. This assumption is largely based on the interpretation of experimental data from key sources including Maurice (1957), Moseley (1984), Gaul and Brubaker (1986), Maurice (1987) and Araie et al. (1991). However, there is strong independent evidence suggesting there is a substantial fluid flow across the retinal pigment epithelium from key sources including Cantrill and Pederson (1984), Chihara and Nao-i, Tsuboi (1985), Dahrouj et al. (2014), Smith and Gardiner (2017) and Smith et al. (2019). The conflicting evidence creates a conundrum-how can both interpretations be true? This leads us to re-evaluate the evidence. We demonstrate that the data believed to be supporting no aqueous flow through the vitreous are in fact compatible with a significant normal aqueous flow. We identify strong and independent lines of evidence supporting fluid flow across the RPE, including our new outflow model for the eye. On balance it appears the current evidence favors the view that there is normally a significant aqueous flow across the RPE in vivo. This finding suggests that past and future analyses of outflow facility, interpretations of some drug distributions and the interpretation of some drug effects on eye tissues, may need to be revised.

The retinal pigment epithelium in health and disease

Retinal pigment epithelial cells (RPE) constitute a simple layer of cuboidal cells that are strategically situated behind the photoreceptor (PR) cells. The inconspicuousness of this monolayer contrasts sharply with its importance [1]. The relationship between the RPE and PR cells is crucial to sight; this is evident from basic and clinical studies demonstrating that primary dysfunctioning of the RPE can result in visual cell death and blindness. RPE cells carry out many functions including the conversion and storage of retinoid, the phagocytosis of shed PR outer segment membrane, the absorption of scattered light, ion and fluid transport and RPE-PR apposition. The magnitude of the demands imposed on this single layer of cells in order to execute these tasks, will become apparent to the reader of this review as will the number of clinical disorders that take origin from these cells.

Light-evoked responses of the retinal pigment epithelium: changes accompanying photoreceptor loss in the mouse

Mutations in genes expressed in the retinal pigment epithelium (RPE) underlie a number of human inherited retinal disorders that manifest with photoreceptor degeneration. Because light-evoked responses of the RPE are generated secondary to rod photoreceptor activity, RPE response reductions observed in human patients or animal models may simply reflect decreased photoreceptor input. The purpose of this study was to define how the electrophysiological characteristics of the RPE change when the complement of rod photoreceptors is decreased. To measure RPE function, we used an electroretinogram (dc-ERG)-based technique. We studied a slowly progressive mouse model of photoreceptor degeneration (Prph(Rd2/+)), which was crossed onto a Nyx(nob) background to eliminate the b-wave and most other postreceptoral ERG components. On this background, Prph(Rd2/+) mice display characteristic reductions in a-wave amplitude, which parallel those in slow PIII amplitude and the loss of rod photoreceptors. At 2 and 4 mo of age, the amplitude of each dc-ERG component (c-wave, fast oscillation, light peak, and off response) was larger in Prph(Rd2/+) mice than predicted by rod photoreceptor activity (Rm(P3)) or anatomical analysis. At 4 mo of age, the RPE in Prph(Rd2/+) mice showed several structural abnormalities including vacuoles and swollen, hypertrophic cells. These data demonstrate that insights into RPE function can be gained despite a loss of photoreceptors and structural changes in RPE cells and, moreover, that RPE function can be evaluated in a broader range of mouse models of human retinal disease.

Light and alcohol evoked electro-oculograms in cystic fibrosis

Cystic fibrosis (CF) is caused by a defect in the cystic fibrosis transmembrane conductance regulator (CFTR) which is a chloride channel. CFTR is expressed in the retinal pigment epithelium (RPE) where it is believed to be important in generating the fast oscillations (FOs) and potentially contributing to the light-electro-oculogram (EOG). The role of CFTR in the alcohol-EOG is unknown. We recruited six individuals with CF (three homozygotes for Delta508 and three heterozygous for Delta508) and recorded the light- and alcohol-EOGs as well as the FOs and compared them to a control group. The results showed that in the CF group the amplitude of the alcohol- and light-EOGs were normal. However, the time to peak of the light- and alcohol-rises were significantly faster than in the control group. We conclude that CFTR is not primarily responsible for the alcohol- or light-rises but is involved in altering the timing of these responses. The FOs showed differences between the homozygotes, heterozygotes and the controls. The amplitudes were significantly higher and the time to the dark troughs were significantly slower in the heterozygote group compared to both controls and the homozygotes. In contrast, the homozygotes did not differ in either amplitude or the timing of the FOs compared to the controls.

Alcohol- and light-induced electro-oculographic responses in age-related macular degeneration & central serous chorioretinopathy. alcohol- and light-induced EOG responses in ARMD & CSC

The non-photic electro-oculographic (EOG) response induced by alcohol has been proposed as an indicator of retinal pigment epithelial (RPE) integrity, and reported to be abnormal in age-related macular degeneration (ARMD). To evaluate this proposal, we have measured the alcohol-EOG as well as the ISCEV-standard EOG in patients with ARMD (n=11 patients, 4 eyes with drusen, 8 eyes with 'dry' and 7 eyes with 'wet' lesions) and central serous chorioretinopathy (CSC, n=11 patients, 7 eyes with active and 6 eyes with inactive lesions), compared with 29 normal controls. We recorded the alcohol-induced EOG response after a single oral administration of ethanol at 160 mg/kg, followed by an ISCEV-standard EOG. Blood alcohol levels were monitored with a breath analyzer. We found that neither the alcohol-EOG nor the light-induced EOG response showed any difference between either ARMD or CSC patients and normal controls. Nor was there difference among eyes of different ARMD or CSC subgroups. In addition, blood alcohol concentrations near the time of the alcohol-EOG peak showed no obvious relationship with peak/baseline ratios. These data suggest that neither the alcohol- nor the light-induced EOG is a sensitive indicator of these diseases.

Alcohol- and light-induced electro-oculographic responses: variability and clinical utility

The alcohol-induced electro-oculographic (EOG) response has been proposed by Arden as an indicator of retinal pigment epithelial (RPE) integrity. We have evaluated the consistency of the alcohol-EOG with respect to clinical applicability and compared this response to the ISCEV-standard EOG. We recorded, in a group of normal subjects (n=29, 14 men with mean age 42+/-11 years and 15 women with mean age 36+/-13 years), the alcohol response to a single oral dose of ethanol at 160 mg/kg (as 40 proof vodka, drunk in 15 s after 12 h of fasting), followed by an ISCEV-standard EOG 90 min after alcohol administration. Blood alcohol levels were monitored at regular intervals with a breath analyzer. We found a wide range of amplitudes in both light and alcohol responses among participants, from minimal to large values. Subjects had a wide range of blood alcohol concentrations from 0.02 to 0.10%; near the time of the response peak, but there was no relationship between alcohol levels and peak/baseline ratios. In addition, there was no relationship between alcohol peak/baseline ratio and the Arden ratio. Neither the alcohol nor the light response parameters showed any relationship with age or gender. Some of the inter-individual variability in the EOG response to alcohol may reflect variable absorption of oral alcohol. The alcohol-induced EOG has too broad a range of responses to be useful clinically for the one-time evaluation of individual patients. We have similar concerns regarding clinical applications of the standard light-induced EOG.

An Overview of Drug Development with Special Emphasis on the Role of Visual Electrophysiological Testing

Visual electrophysiological techniques, such as electroretinography (ERG) and visual evoked potentials (VEP) can provide useful information on the safety, efficacy, and proper dosing of chemical entities under development as new drug therapies. During post-marketing safety surveillance, a variety of visual electrophysiological measures can be used to objectively assess and document individual patient response to ophthalmic drugs and ocular or visual system side effects of non-ophthalmic drugs. In this paper, the discovery, exploratory development, full-development and post-marketing stages of drug development are briefly outlined. The potential role of visual electrophysiological techniques in each of these stages is described and discussed.

Electrophysiologic evaluation of retinal pigment epithelial damage induced by photic exposure

PURPOSE

To evaluate the retinal pigment epithelial damage induced by light exposure.

METHODS

One eye of 20 rabbits was exposed to xenon light for 2 hours at an irradiance of 140 mW/cm2 at the surface of the cornea. The contralateral eye served as a control. Forty-eight hours after the light exposure, corneal direct-coupled electroretinograms and the 7% NaHCO3 (bicarbonate) responses of the standing potential were recorded.

RESULTS

The amplitudes of the a-, b-, and c-waves of the electroretinograms were significantly reduced in the light-exposed eyes, with the c-waves more reduced than the a- and b-waves. The bicarbonate response was also significantly reduced in the irradiated eyes.

CONCLUSIONS

The decrease of the bicarbonate response of the standing potential indicated that significant functional damage of the retinal pigment epithelium was induced by the light exposure.

Recording of the fast oscillations in the human electro-oculogram

The fast oscillations (FO) of the electro-oculogram were recorded in 102 eyes of 51 normal subjects. We evaluated the normal range and variability of FO parameters, i.e. Rf, which is the average ratio in percentage of the average amplitude in the dark period (AD) and the average amplitude in the light period (AL), and df, which is the average difference between AD and AL in microV. The standing potential was recorded continuously during six subsequent cycles, each consisting of a one minute period in the dark and one minute period in the light. The mean +/- standard error for Rf was 112.9 +/- 1.3% and 69.6 +/- 5.3 microV for df. There was no statistically significant difference between both genders or different age groups. Rf and df were calculated using a different number of dark-light cycles. In normal subjects both the Rf and df show no difference when only 4 dark-light cycles are used in calculating these values. Therefore there seems no additional advantage in performing as many as 6 cycles. Using 4 dark-light cycles reduces the duration of the examination (8 vs. 12 min) of the fast oscillations and in particular when examining both fast and slow oscillations successively it might be useful to reduce the time of the examination.

Episodic acute hypotonia after Nd:YAG laser capsulotomy--retinal function and choroidal swelling

In a patient with uveitis who had been treated with Nd:YAG laser capsulotomy after cataract surgery, several episodes of acute hypotonia occurred which were associated with changes in clinical tests of the eye and of visual function. Immunosuppressive and immunomodulating treatment appeared to reverse the changes in intraocular pressure and normalise the test results. The significance of these observations is discussed.

Electrophysiology of the retinal pigment epithelium in central serous chorioretinopathy

The pathophysiology of central serous chorioretinopathy is incompletely understood but appears to involve the retinal pigment epithelium. We recorded consecutively the fast oscillation, hyperosmolarity response, acetazolamide response, and light peak from four patients with active central serous chorioretinopathy and three normal subjects to determine whether the affected eyes showed any electrophysical abnormalities. We found essentially no differences in any of the four responses between the active and the inactive eyes of the patients or between patients and normal subjects. Whatever retinal pigment epithelial dysfunction exists in central serous chorioretinopathy is unassociated with clinically evident changes in these retinal pigment epithelial electrophysiologic responses.

The c-wave of the electroretinogram possesses a third component from the proximal retina

ERG and light-induced extracellular potassium ([K+]o) changes have been measured in isolated retinas of both Rana esculenta and Rana temporaria. The conditions of the preparations have been varied. Isolated frog retinas kept receptor side-upward in a moist chamber without perfusion showed the well-known slow PIII in the ERG. Retinas superfused from the receptor side, with O2 enrichment at their vitreal surface, however, exhibit a slow cornea-positive potential in the ERG. The slow ERG-potentials relate to different light-induced potassium changes in the proximal retina. There was a long lasting and larger proximal potassium increase in adequately maintained retinas but a smaller and shorter one in preparations lacking superfusion and oxygen. There was no significant difference between the size of potassium decrease around receptors of retinas superfused from their vitreal side and those superfused from receptor side. A reduction of slow PIII should therefore not be responsible for the slow cornea-positive potential. The long lasting and larger (by 59%) potassium increase in the proximal retina may counteract the potential in the Müller cells caused by the potassium decrease around receptors and thereby cancel slow PIII and generate a third component of the electroretinogram c-wave.

Sequential recording of photic and nonphotic electro-oculogram responses in patients with extensive extramacular drusen

At present, no clinical electrophysiologic test defines dysfunction of the retinal pigment epithelium. We studied four electrophysiologic responses of the retinal pigment epithelium to compare results from three normal subjects with those from three patients with a diffuse retinal pigment epithelial disorder, extramacular drusen. We recorded the fast oscillation, hyperosmolarity response, acetazolamide response, and light peak by means of a clinical protocol in which these could be elicited consecutively. We found no significant differences between the normal subjects and patients with drusen for any of the four responses. These results suggest that retinal pigment epithelial electrophysiologic function is well maintained despite the widespread physical abnormalities of the retinal pigment epithelium in extramacular drusen. This combined test was well tolerated and may prove useful in characterizing other diseases involving the retinal pigment epithelium.