Application of visually evoked response near the threshold of vision to objective measurement of dark adaptation

Human retinal dark adaptation tracked in vivo with the electroretinogram: insights into processes underlying recovery of cone- and rod-mediated vision

The substantial time taken for regaining visual sensitivity (dark adaptation) following bleaching exposures has been investigated for over a century. Psychophysical studies yielded the classic biphasic curve representing recovery of cone-driven and rod-driven vision. The electroretinogram (ERG) permits direct assessment of recovery at the level of the retina (photoreceptors, bipolar cells), with the first report over 70 years ago. Over the last two decades, ERG studies of dark adaptation have generated insights into underlying physiological processes. After large bleaches, rod photoreceptor circulating current, estimated from the rod-isolated bright-flash ERG a-wave, takes 30 min to recover, indicating that products of bleaching, thought to be free opsin (unbound to 11-cis-retinal), continue to activate phototransduction, shutting off rod circulating current. In contrast, cone current, assessed with cone-driven bright-flash ERG a-waves, recovers within 100 ms following similar exposures, suggesting that free opsin is less able to shut off cone current. The cone-driven dim-flash a-wave can be used to track recovery of cone photopigment, showing regeneration is 'rate-limited' rather than first order. Recoveries of the dim-flash ERG b-wave are consistent also with rate-limited rod photopigment regeneration (where free opsin, desensitising the visual system as an 'equivalent background', is removed by rate-limited delivery of 11-cis-retinal). These findings agree with psychophysical and retinal densitometry studies, although there are unexplained points of divergence. Post-bleach ERG recovery has been explored in age-related macular degeneration and in trials of visual cycle inhibitors for retinal diseases. ERG tracking of dark adaptation may prove useful in future clinical contexts.

Portable Diagnostic System for Age-Related Macular Degeneration Screening Using Visual Evoked Potentials

Background

Delayed Dark-Adapted vision Recovery (DAR) is a biomarker for Age-related Macular Degeneration (AMD), however its measurement is burdensome for patients and examiners.

Methods

In this study, we developed a portable, wireless and user-friendly system that employs a headset with a smartphone to deliver controlled photo-bleach and monocular pattern reversal stimuli, while using custom electroencephalography (EEG) electrodes and electronics in order to measure Dark-Adapted Visual Evoked Potentials (DAVEP) objectively and separately at the peripheral and central visual field. This is achieved in one comfortable 20-minute session, without requiring subject reporting. DAVEP responses post photo-bleach for up to 15 minutes were measured concurrently from both eyes in 12 AMD-patients, 1 degenerative myopia patient, and 8 controls who had no diagnosed macular vision loss.

Results

Robust positive polarity DAVEP responses were observed at 200-500 ms from stimulus onset to scotopic stimuli that have been seldom reported and analyzed previously. The amplitude recovery of the DAVEP response was significantly delayed in AMD patients as compared to controls. We developed DAVEP1 scores, a simple metric for DAR, which classified 90% of subject eyes correctly, indicating the presence of AMD in at least one eye of all pre-confirmed subjects with this diagnosis.

Conclusion

We developed a user-friendly, portable VEP system and DAVEP1 metric, which show a high potential to identify DAR-deficits in AMD-patients. This novel technology could aid in early diagnosis of AMD.

Objective determination of dark adaptation: accuracy of the evoked potential method

The psychophysical threshold and the appearance of the visually evoked potential (VEP) were compared in the dark adapted state. Nineteen normal subjects and 11 persons with defective dark adaptation were studied. The VEP threshold was an average of 0.2 log units (standard deviation 0.2) above the subjective threshold in the normal group, and 0.4 log units above it in the night-blind subjects. In 7 normal subjects, the alpha-activity of the electroencephalogram interfered with the VEP recording and rendered the evaluation more difficult. The results indicate that the VEP can be used as an accurate method of objectively measuring dark adaptation.

Pattern and flash visual evoked responses in multiple sclerosis

In multiple sclerosis (MS), increase of delay may be important, but the earlier change is the behavior of the wave shape; amplitude is always lower even in MS patients without visual subjective symptomatology, provided not only flash but also pattern stimulation is performed. Normal amplitude with pattern stimulation does not necessarily mean normal with flash. Combining both stimulation methods, we obtained lowering of amplitude and change of wave shape in 100% of cases while latency was increased in only 77% of cases. Sectorial ischemic neuropathy, and open angle glaucoma patients show the same findings, which emphasizes that the method is not specific for demyelinating diseases, nor selective for papillomacular bundle involvement, but that VER, considering only its first components, reflects axonal damage somewhere in the visual pathway. Flash and pattern VER might be even more pathognomonic in MS than oligoclonal gammaglobulin fractionation on agar, positive in 75% of cases. It is suggested that subclinical MS cases should be submitted to full electro-ophthalmographic investigation.