Management of hereditary retinal degenerations: present status and future directions

Design and Simulation of a Ring Transducer Array for Ultrasound Retinal Stimulation

Argus II retinal prosthesis is the US Food and Drug Administration (FDA) approved medical device intended to restore sight to a patient's blind secondary to retinal degeneration (i.e., retinitis pigmentosa). However, Argus II and most reported retinal prostheses require invasive surgery to implant electrodes in the eye. Recent studies have shown that focused ultrasound can be developed into a non-invasive retinal prosthesis technology. Ultrasound energy focused on retinal neurons can trigger the activities of retinal neurons with high spatial-temporal resolution. This paper introduces a novel design and simulation of a ring array transducer that could be used as non-invasive ultrasonic retinal stimulation. The array transducer is designed in the shape of a racing ring with a hemisphere surface that mimics a contact lens to acoustically couple with the eye via the tear film and directs the ultrasound to avoid the high acoustic absorption from the crystalline lens. We will describe the design methods and simulation of the two-dimensional pattern stimulation. Finally, compared with other existing retinal prostheses, we show that the ultrasound ring array is practical and safe and could be potentially used as a non-invasive retinal prosthesis.

Self-Plugging Microneedle (SPM) for Intravitreal Drug Delivery

Intravitreal injection (IVI) is a common technology which is used to treat ophthalmic diseases inside eyeballs by delivering various drugs into the vitreous cavity using hypodermic needles. However, in some cases, there are possible side effects such as ocular tissue damage due to repeated injection or eyeball infection through the hole created during the needle retraction process. The best scenario of IVI is a one-time injection of drugs without needle retraction, keeping the system of the eyeball closed. Microneedles (MNs) have been applied to ocular tissues over 10 years, and no serious side effects on ocular tissue due to MN injection have been reported. Therefore, a self-plugging MN (SPM) is developed to perform intraocular drug delivery and to seal the scleral puncture simultaneously. The SPMs are fabricated by a thermal drawing process and then coated with a polymeric carrier of drugs and a hydrogel-based scleral plugging component. Each coated functional layer is characterized and demonstrated by in vitro and ex vivo experiments. Finally, in vivo tests using a porcine model confirms prompt sealing of SPM and sustained intraocular drug delivery.

Simulation Study of an Ultrasound Retinal Prosthesis With a Novel Contact-Lens Array for Noninvasive Retinal Stimulation

Millions of people around the world suffer from varying degrees of vision loss (including complete blindness) because of retinal degenerative diseases. Artificial retinal prosthesis, which is usually based on electrical neurostimulation, is the most advanced technology for different types of retinal degeneration. However, this technology involves placing a device into the eyeball, and such a highly invasive procedure is inevitably highly risk and expensive. Ultrasound has been demonstrated to be a promising technology for noninvasive neurostimulation, making it possible to stimulate the retina and induce action potentials similar to those elicited by light stimulation. However, the technology of ultrasound retinal stimulation still requires considerable developments before it could be applied clinically. This paper proposes a novel contact-lens array transducer for use in an ultrasound retinal prosthesis (USRP). The transducer was designed in the shape of a contact lens so as to facilitate acoustic coupling with the eye liquid. The key parameters of the ultrasound transducer were simulated, and results are presented that indicate the achievement of 2-D pattern generation and that the proposed contact-lens array is suitable for multiple-focus neurostimulation, and can be used in a USRP.

A model of electrical stimulation of a retinal cell population using a multi-electrode array

A novel computational modelling approach is employed to investigate the response of a population of retinal ganglion cells (RGCs) to external electrical stimulation. Current is delivered via a multi-electrode array design that would be employed in a future retinal prosthesis device being developed by our group. The RGCs are morphologically realistic and allow examination of the biophysical responses of intracellular compartments to externally applied currents. A number of stimulation paradigms are simulated including the use of monopolar, hexapolar and quasi-monopolar return paths. The model provides a powerful simulation tool to test and optimize electrical stimulation strategies for future retinal prosthesis devices.

An arched micro-injector (ARCMI) for innocuous subretinal injection

Several critical ocular diseases that can lead to blindness are due to retinal disorders. Subretinal drug delivery has been developed recently for the treatment of retinal disorders such as hemorrhage because of the specific ocular structure, namely, the blood retinal barrier (BRB). In the present study, we developed an Arched Micro-injector (ARCMI) for subretinal drug delivery with minimal retinal tissue damage. ARCMIs were fabricated using three major techniques: reverse drawing lithography, controlled air flow, and electroplating. In order to achieve minimal retinal tissue damage, ARCMIs were fabricated with specific features such as a 0.15 mm(-1) curvature, 45° tip bevel, 5 mm length, inner diameter of 40 µm, and an outer diameter of 100 µm. These specific features were optimized via in-vitro experiments in artificial ocular hemispherical structures and subretinal injection of indocyanine green in porcine eye ex-vivo. We confirmed that the ARCMI was capable of delivering ocular drugs by subretinal injection without unusual subretinal tissue damage, including hemorrhage.

Vitamin A supplementation ameliorates obesity-associated retinal degeneration in WNIN/Ob rats

OBJECTIVE

Obesity is associated with various health afflictions, including ocular complications such as diabetic retinopathy, high intraocular pressure, cataracts, and macular degeneration. We previously reported progressive retinal degeneration after the onset of obesity in the spontaneously obese rat (WNIN/Ob) model. In the present study, we investigated vitamin A supplementation to ameliorate obesity-associated retinal degeneration in the WNIN/Ob rat.

METHODS

Five-month-old male WNIN/Ob obese (O) and lean (L) control rats were fed with vitamin A 2.6 mg (L/O-I), 26 mg (L/O-II), 52 mg (L/O-III), and 129 mg (L/O-IV) per kilogram of diet as retinyl palmitate for 4 mo 2 wk. Retinal morphology and retinal gene expression were assessed by histologic, immunohistochemical, and real-time polymerase chain reaction methods.

RESULTS

Supplementation of vitamin A at 26 or 52 mg significantly modulated the expression of retinal genes in the O but not in the L phenotype. Vitamin A supplementation significantly upregulated the expression of genes, such as rhodopsin, rod arrestin, phosphodiesterase, transducins, and fatty acid elongase-4, that were otherwise downregulated in O rat retina. The expression of glial fibrillary acidic protein was downregulated by vitamin A feeding in O rat retina. The immunohistochemical and histologic findings corroborated the gene expression data. The effects were significant at a 26- or 52-mg dose of vitamin A.

CONCLUSION

Vitamin A supplementation alleviated obesity-associated retinal degeneration in the WNIN/Ob rat.

Preservation of retinotopic map in retinal degeneration

Retinal degenerations trigger the loss of photoreceptors and cause the remaining de-afferented neural retina to undergo remodeling. Concerns over this potential retinal synaptic reorganization following visual loss have raised questions regarding the usefulness of visual restoration via retinal electrical stimulation. We have used quantitative positron emission tomography (PET) and 2-deoxy-2-[18F]fluoro-d-glucose (FDG) to objectively evaluate the connection between the retina and the primary visual cortex under both light and transcorneal electrical stimulation (TcES) in five subjects with retinal degeneration (RD) who have had more than ten years of light-perception-only best visual acuity and five age-matched normal-sighted controls. All subjects underwent quantitative PET with FDG as the metabolic tracer during stimulation of the right eye under both light stimulation condition and transcorneal electrical stimulation (TcES) using ERG-Jet contact lens electrode. Cortical activation maps from each stimulation condition were obtained using statistical parametric mapping. TcES phosphene threshold current and qualitative visual cortex activation from both stimulation conditions were compared between the two subject groups. Average phosphene threshold current was 0.72 ± 0.18 mA for the five normal-sighted controls and 3.08 ± 2.01 mA for the retinal degenerative subjects. Phosphene threshold current was significantly higher in retinal degenerative subjects compared to normal-sighted controls (p < 0.05). We found both light stimulation and TcES resulted in retinotopically mapped primary visual cortex activation in both groups. In addition, the patterns of early visual area activation between the two subject groups are more similar during TcES than light stimulation. Our findings suggest primary visual cortex continues to maintain its retinotopy in RD subjects despite prolonged visual loss.

A REVIEW OF RETINAL PROSTHESIS APPROACHES

Age-related macular degeneration and retinitis pigmentosa are two of the most common diseases that cause degeneration in the outer retina, which can lead to several visual impairments up to blindness. Vision restoration is an important goal for which several different research approaches are currently being pursued. We are concerned with restoration via retinal prosthetic devices. Prostheses can be implemented intraocularly and extraocularly, which leads to different categories of devices. Cortical Prostheses and Optic Nerve Prostheses are examples of extraocular solutions while Epiretinal Prostheses and Subretinal Prostheses are examples of intraocular solutions. Some of the prostheses that are successfully implanted and tested in animals as well as humans can restore basic visual functions but still have limitations. This paper will give an overview of the current state of art of Retinal Prostheses and compare the advantages and limitations of each type. The purpose of this review is thus to summarize the current technologies and approaches used in developing Retinal Prostheses and therefore to lay a foundation for future designs and research directions.

Estimation of simulated phosphene size based on tactile perception

Clinical trials have successfully shown that a visual prosthesis can elicit visual perception (phosphenes) in the visual field. Psychophysical studies based on simulated prosthetic vision offer an effective means to evaluate and refine prosthetic vision. We designed three experiments to examine the effect of phosphene luminance, flicker rate, and eccentricity on the ability to estimate simulated phosphene sizes using tactile perception. Thirty subjects participated in the three experiments. There was a linear increase in reported size as visual stimulus size increased. Judgment was significantly affected by stimulus luminance and eccentricity (P < 0.05) but not by flicker rates. Brighter stimuli were perceived as being larger, and the more eccentric the position, the larger the estimated size. These simulation studies, although idealized, suggested that tactile perception is a potential way to estimate phosphene sizes.

Anatomical evidence of photoreceptor degeneration induced by iodoacetic acid in the porcine eye

Iodoacetic acid (IAA) induces photoreceptor (PR) degeneration in small animal models, however, eye size and anatomic differences detract from the usefulness of these models for studying retinal rescue strategies intended for humans. Porcine eyes are closer in size to human eyes and have a rich supply of rod and cones. This study investigated whether IAA also produced PR degeneration in the porcine retina, whether the damage was preferential for rods or cones, and whether IAA induced remodeling of the inner retina. Pigs were given a single i.v. injection of IAA and were euthanized 2-5 weeks later. Eyes were enucleated and immersed in fixative. Forty-six eyes were studied: Control (n = 13), and from pigs that had received the following IAA doses: 5.0 mg/kg (n = 7); 7.5 mg/kg (n = 10); 10.0 mg/kg (n = 6); 12.0 mg/kg (n = 6). Tissue was retrieved from four retinal locations: 8 mm and 2 mm above the dorsal margin of the optic disc, and 2 mm and 8 mm below the disc, and was processed for conventional histology, immunohistochemistry, and transmission electron microscopy. At 5.0 mg/kg IAA produced mild, variable cell loss, but remaining cells exhibited normal features. At doses above 5.0 mg/kg, a dose-dependent reduction was observed in the length of PR inner and outer segments, and in the number of PR nuclei. Specific labeling revealed a massive dropout of rod cell bodies with relative sparing of cone cell bodies, and electron microscopy revealed a reduction in the number of PR synaptic terminals. Mild dendritic retraction of rod bipolar cells and hypertrophy of Müller cell stalks was also observed, although the inner nuclear layer appeared intact. The porcine IAA model may be useful for developing and testing retinal rescue strategies for human diseases in which rods are more susceptible than cones, or are affected earlier in the disease process.

Resolution of the epiretinal prosthesis is not limited by electrode size

Epiretinal prostheses for the blind bypass diseased photosensitive cells in the retina, directly stimulating retinal neurons electrically and evoking signals that are relayed to the brain. Current clinical implants have few electrodes and provide limited visual acuity. Acuity may be improved by identifying electrode array design features and operational details that enhance or interfere with visual percept formation. We labeled all retinal ganglion cells in whole mount retina with a calcium reporter and then measured the number and pattern of cells responding, over a range of electrode diameters and stimulus durations. Span of the response scaled with electrode diameter for electrodes 60 μm and larger. Short stimulation pulse widths selectively activated cells nearest the electrode. Our measurements in the salamander retina suggest that the spatial resolution is 150 μm, which on a human retina is equivalent to 0.55(°) of human visual field and corresponding Snellen acuity of 20/660. Reading large print could be possible with such a prosthesis.

CNS targets support and sustain differentiation of cultured neuronal and retinal progenitor cells

Superior colliculus (SC) is the target of retinal neurons, allowing them to form connections. Cultured stem cells/progenitors can potentially be used as donor tissue to reconstruct degenerated retina including perhaps replacing lost ganglion cells in glaucoma. In which case, it will be essential for these cells to integrate with the central nervous system targets. Here, we have investigated if the mid-brain region containing superior colliculus (SC) provides a permissive environment for the survival and differentiation of neural progenitors, including retinal progenitor cells propagated in cultures. Neural (NPCs) and retinal progenitor cells (RPCs) from green fluorescent protein (GFP) transgenic mice were cultured. Passage two through four neural and retinal progenitor cells were subsequently cocultured with the SC organotypic slices and maintained in culture for 17 and eight days respectively. Differentiation of the neurons was studied by immunocytochemistry for retinotypic neuronal markers. Retinal progenitor cells cocultured with SC slices were able to differentiate into various neuronal morphologies. Some cocultured progenitor cells differentiated into neurons as suggested by class III β tubulin immunoreactivity. In addition, specific retinotypic neuronal differentiation of RPC was detected by immunoreactivity for calbindin and PKC. SC provides a permissive environment that supports survival and differentiation of the progenitor cells.

Predictable irregularities in retinal receptive fields

Understanding how the nervous system achieves reliable performance using unreliable components is important for many disciplines of science and engineering, in part because it can suggest ways to lower the energetic cost of computing. In vision, retinal ganglion cells partition visual space into approximately circular regions termed receptive fields (RFs). Average RF shapes are such that they would provide maximal spatial resolution if they were centered on a perfect lattice. However, individual shapes have fine-scale irregularities. Here, we find that irregular RF shapes increase the spatial resolution in the presence of lattice irregularities from approximately 60% to approximately 92% of that possible for a perfect lattice. Optimization of RF boundaries around their fixed center positions reproduced experimental observations neuron-by-neuron. Our results suggest that lattice irregularities determine the shapes of retinal RFs and that similar algorithms can improve the performance of retinal prosthetics where substantial irregularities arise at their interface with neural tissue.

Evaluation of patient suitability for a retinal prosthesis using structural and functional tests of inner retinal integrity

The purpose of this study was to assess inner retinal structure and function in patients with retinitis pigmentosa (RP) using optical coherence tomography (OCT) imaging of the retina, and electrical stimulation of the retina with a contact lens electrode. OCT images of 17 RP patients were acquired at the macula and at four quadrants of the peripheral retina in both eyes. Analysis was made of the residual inner retinal thickness and nerve fibre layer thickness in RP patients, and this was compared to normal controls. Eight of these patients further underwent contact lens electrical stimulation of one eye and thresholds for phosphene perception were obtained. OCT imaging showed a significant amount of inner retinal preservation in the peripheral retina and the macula of RP patients despite severe visual acuity and visual field loss. Phosphene thresholds were obtained across the range of pulse durations tested but were much higher than those obtained in normal controls. Phosphene thresholds in RP patients moderately correlated with inner retinal thicknesses as measured by OCT. Preservation of inner retinal structure in patients with RP and the responsiveness of these eyes to electrical stimulation suggest adequate inner retinal preservation for a retinal prosthesis to be successful.

Preconditioning protects the retinal pigment epithelium cells from oxidative stress-induced cell death

PURPOSE

The cytotoxic effects of oxidative stress, which play an important role in ocular diseases, are well known. In this study, we investigated the effect of non-lethal doses of oxidative stress on various cell functions, namely cell viability, cell attachment and cell migration in a widely used retinal pigment epithelium (RPE) cell line (ARPE-19).

METHODS

A single exposure to various concentrations of hydrogen peroxide (H(2)O(2)) was used to establish a dose response for H(2)O(2)-induced cell death. Other cellular responses, such as changes in cell attachment and migration, were monitored after exposure to increasing doses. Finally, the effects of preconditioning cells with increasing non-lethal doses of H(2)O(2), with and without a subsequent exposure to lethal doses of H(2)O(2), were determined.

RESULTS

The optimum dose for inducing cell death in ARPE-19 cells was between 900 and 1000 microm H(2)O(2). Preconditioning the cells with 1, 10 and 50 microm of H(2)O(2) provided a dose-dependent protection against cell death induced by a lethal dose (900-1000 microm) of H(2)O(2). Preconditioning with higher doses caused cells to become more susceptible to the cytotoxic effects of the lethal dose. Although H(2)O(2) increased cell attachment in lower doses, it induced a dose-dependent inhibition of cell attachment to the substrate in higher doses. H(2)O(2) did not affect cell migration in sub-lethal doses.

CONCLUSION

Preconditioning RPE cells with limited exposure to non-lethal oxidative stress confers significant protection against subsequent H(2)O(2)-induced cell death. It also affects cell attachment in a dose-specific manner. This finding may help in understanding the pathogenesis of diseases in which oxidative stress plays an important role and in determining the suitability of certain treatment strategies, in particular RPE transplantation in the treatment of age-related macular degeneration.

Dual requirement for Pax6 in retinal progenitor cells

Throughout the developing central nervous system, pre-patterning of the ventricular zone into discrete neural progenitor domains is one of the predominant strategies used to produce neuronal diversity in a spatially coordinated manner. In the retina, neurogenesis proceeds in an intricate chronological and spatial sequence, yet it remains unclear whether retinal progenitor cells (RPCs) display intrinsic heterogeneity at any given time point. Here, we performed a detailed study of RPC fate upon temporally and spatially confined inactivation of Pax6. Timed genetic removal of Pax6 appeared to unmask a cryptic divergence of RPCs into qualitatively divergent progenitor pools. In the more peripheral RPCs under normal circumstances, Pax6 seemed to prevent premature activation of a photoreceptor-differentiation pathway by suppressing expression of the transcription factor Crx. More centrally, Pax6 contributed to the execution of the comprehensive potential of RPCs: Pax6 ablation resulted in the exclusive generation of amacrine interneurons. Together, these data suggest an intricate dual role for Pax6 in retinal neurogenesis, while pointing to the cryptic divergence of RPCs into distinct progenitor pools.

Factors affecting perceptual thresholds in epiretinal prostheses

PURPOSE

The goal was to evaluate how perceptual thresholds are related to electrode impedance, electrode size, the distance of electrodes from the retinal surface, and retinal thickness in six subjects blind as a result of retinitis pigmentosa, who received epiretinal prostheses implanted monocularly as part of a U.S. Food and Drug Administration (FDA)-approved clinical trial.

METHODS

The implant consisted of an extraocular unit containing electronics for wireless data, power recovery, and generation of stimulus current, and an intraocular unit containing 16 platinum stimulating electrodes (260- or 520-microm diameter) arranged in a 4 x 4 pattern. The electrode array was held onto the retina by a small tack. Stimulation was controlled by a computer-based external system that allowed independent control over each electrode. Perceptual thresholds (the current necessary to see a percept on 79% of trials) and impedance were measured for each electrode on a biweekly basis. The distance of electrodes from the retinal surface and retinal thickness were measured by optical coherence tomography on a less regular basis.

RESULTS

Stimulation thresholds for detecting phosphenes correlated with the distance of the electrodes from the retinal surface, but not with electrode size, electrode impedance, or retinal thickness.

CONCLUSIONS

Maintaining close proximity between the electrode array and the retinal surface is critical in developing a successful retinal implant. With the development of chronic electrode arrays that are stable and flush on the retinal surface, it is likely that the influence of other factors such as electrode size, retinal degeneration, and subject age will become more apparent. (ClinicalTrials.gov number, NCT00279500.).

Fate and protective effect of marrow stromal cells after subretinal transplantation

Engraftment of marrow stromal cells (MSCs) has been proposed as a therapeutic approach for degenerative diseases. In this study we investigated the fate and dynamic progress of grafted MSCs in living retina with the aim of evaluating the use of transplanted MSCs to treat retinal degeneration. Approximately 1x10(5) gfp-MSCs in 2 microl phosphate-buffered saline were injected into the subretinal space of adult Sprague-Dawley rats. Two weeks later, approximately 0.174%+/-0.082% of the transplanted cells had survived and diffused into the subretinal space. Nine weeks after transplantation the surviving gfp-MSCs accounted for 0.049%+/-0.023% of the number of cells injected and were mainly located at the injection site. The same number of MSCs were transplanted into the left eye subretinal space of 3-week-old hereditary retinal degenerative Royal College of Surgeons rats, and phosphate-buffered saline was injected into their right eyes as a control. Five weeks after transplantation, the amount of rudimentary photoreceptors was more significantly increased in grafted eyes than in control eyes. The results indicated that grafted MSCs could survive and rescue retinal degeneration.

A prototype retinal prosthesis for visual stimulation

Vision loss has severe impacts on its victims, carrying with it physiological, psychological, social, and economic consequences thereby degrading the quality of life and depriving the individual from performing many of the daily living activities. This article describes the design and development of a prototype retinal prosthesis for visual stimulation. The system consists of a webcam, a notebook computer, and a prototype excitatory circuit. The system is driven by a MATLAB-based custom-built software. Live webcam images are converted to an 8 x 8 mosaic of 256 gray scale shades. Subsequently, electrical impulses are generated by the excitatory circuit in real-time to topographically stimulate the corresponding epiretinal cells. Following their conversion to gray scale, recorded data from the central pixel of the mosaic yielded: 36.24 nC for black, 48.48 nC for red, 55.68 nC for green, 67.68 nC for blue, and 91.92 nC for white. These results correlate well with data reported in the literature. The hallmark of this work is in the potential of partial restoration of sight that would add quality to the life of individuals with vision loss.

Visual performance using a retinal prosthesis in three subjects with retinitis pigmentosa

PURPOSE

To assess visual task performance in three blind subjects implanted with epiretinal prostheses.

DESIGN

Prospective, investigational device exemption trial.

METHODS

Three subjects with light perception or no light perception vision were enrolled at a single center. All subjects had retinitis pigmentosa (RP). Main inclusion criteria: light perception or worse vision in one eye and some visual experience as an adult before blindness. Main exclusion criteria included other ophthalmic problems. A prototype retinal prosthesis was implanted in the eye with worse light sensitivity. The prosthesis had 4 x 4 array of platinum electrodes tacked to the epiretinal surface. The prosthesis was wirelessly controlled by a computer or by a head-worn video camera. Visual function testing was performed in single masked or double masked fashion. Scores from the visual task were compared to chance to determine statistical significance.

RESULTS

The subjects performed significantly better than chance in 83% of the tests. Using the video camera, subjects scored as follows on simple visual tasks: locate and count objects (77% to 100%), differentiate three objects (63% to 73%), determine the orientation of a capital L (50% to 77%), and differentiate four directions of a moving object (40% to 90%). A subset of tests compared camera settings using multipixels vs single pixels. Using multipixel settings, subjects performed better (17%) or equivalent (83%) in accuracy and better (25%) or equivalent (75%) in reaction time.

CONCLUSIONS

Three RP implant subjects used epiretinal prostheses to perform simple visual tasks. Multipixel settings proved slightly more effective than single pixel settings.

Progress towards a high-resolution retinal prosthesis

Simulations of artificial vision suggest that 1000 electrodes may be required to restore vision to individuals with diseases of the outer retina. In order to achieve such an implant, new technology is needed, since the state-of-the-art implantable neural stimulator has at most 22 contacts with neural tissue. Considerable progress has been made towards that goal with the development of image processing, microelectronics, and polymer based electrodes and interconnects. An image processing system has been realized that is capable of real-time implementation of image decimation and filtering (for example, edge detection). Application specific integrated circuits (ASICs) have been designed and tested to demonstrate closed loop power control and efficient microstimulation. A novel packaging process has been developed that is capable of simultaneously forming a receiver coil, interconnects, and stimulating electrodes.

Towards the bionic eye--the retina implant: surgical, opthalmological and histopathological perspectives

Degenerations of the outer retina such as retinitis pigmentosa (RP) lead to blindness due to photoreceptor loss. There is a secondary loss of inner retinal cells but significant numbers of bipolar and ganglion cells remain intact for many years. Currently, no therapeutic option to restore vision in these blind subjects is available. Short-term pattern electrical stimulation of the retina using implanted electrode arrays in subjects blind from RP showed that ambulatory vision and limited character recognition are possible. To produce artificial vision by electrical retinal stimulation, a wireless intraocular visual prosthesis was developed. Images of the environment, taken by a camera are pre-processed by an external visual encoder. The stimulus patterns are transmitted to the implanted device wirelessly and electrical impulses are released by microcontact electrodes onto the retinal surface. Towards a human application, the biocompatibility of the utilised materials and the feasibility of the surgical implantation procedure were stated. In acute stimulation tests, thresholds were determined and proved to be within a safe range. The local and retinotopic activation of the visual cortex measured by optical imaging of intrinsic signals was demonstrated upon electrical retinal stimulation with a completely wireless and remotely controlled retinal implant. Potential obstacles are reviewed and further steps towards a successful prosthesis development are discussed.

Quantification of photoreceptor layer thickness in normal eyes using optical coherence tomography

OBJECTIVE

To demonstrate the ability to segment and analyze individual intraretinal layers, including the outer retinal complex (ORC; outer nuclear layer and inner and outer segments of the photoreceptor cells), in healthy eyes using images acquired from the latest commercially available optical coherence tomography (OCT) system (StratusOCT; Carl Zeiss Meditec, Inc., Dublin, CA) and from the ultrahigh resolution OCT (UHR-OCT) prototype.

METHODS

Thirty-seven eyes from 37 healthy subjects underwent complete ophthalmologic examination using StratusOCT and UHR-OCT. ORC was identified and measured using a segmentation algorithm.

RESULTS

For StratusOCT, mean weighted ORC thickness +/- SD was 91.1 +/- 7.9 microm, and mean weighted total retinal thickness +/- SD was determined to be 258.9 +/- 10.1 microm. For UHR-OCT, mean weighted ORC thickness +/- SD was 96.4 +/- 6.3 microm, and mean weighted total retinal thickness +/- SD was determined to be 263.4 +/- 9.2 mum. There was a higher rate of algorithm failure with UHR-OCT images.

CONCLUSIONS

Photoreceptor layer thickness can be calculated by measuring ORC on OCT images using a macular segmentation algorithm. ORC values may serve as a useful objective parameter in determining the efficacy of various therapeutic modalities that target the photoreceptor layer in various diseases.

Feasibility of extraocular stimulation for a retinal prosthesis

BACKGROUND

We present a new approach to developing a retinal prosthesis for blind patients based on extraocular stimulation of the eye with disc electrodes.

METHODS

Experiments to assess the feasibility of using extraocular stimulation in a retinal prosthesis were carried out in anaesthetised adult cats (n=6). A craniotomy and lateral orbital dissection were performed. Ball or disc electrodes were placed on the posterior scleral surface of the eye after incision of the periorbita. Cortical potentials evoked by electrical stimulation with these electrodes were recorded at the primary visual cortex. The viability of adapting the Nucleus 24 auditory brainstem implant (ABI) as an extraocular retinal prosthesis was also investigated.

RESULTS

Electrodes placed on the exterior of the eye could reliably evoke visual cortex responses for a variety of configurations. Threshold currents for eliciting an evoked response were lower than 100 microA with single pulses. Strength-duration curves and cortical activation maps were obtained for different stimulus paradigms. It was possible to excite the retina to evoke a cortical response using the electrodes and stimulus capabilities in a standard Nucleus 24 ABI.

INTERPRETATION

It is possible to electrically stimulate the retina with electrodes placed in an extraocular location. Threshold currents required to elicit a response were low, and comparable to epiretinal implants. Prototype electrodes, and a potential implant, were found to be effective at retinal stimulation.

Adrenomedullin plasma concentrations in patients with retinitis pigmentosa

PURPOSE

To evaluate the relationship between retinitis pigmentosa (RP) and plasma adrenomedullin (ADM) levels.

METHODS

Blood samples were obtained from a group of 40 consecutive patients with RP matched with 35 healthy subjects (HS) as control. We carried out a complete ophtalmological examination. The study group included 26 patients with RP and 14 patients with syndromic RP. Plasma ADM levels were determined in duplicate with a specific radioimmunoassay method.

RESULTS

In the HS plasma ADM levels were 13.7 +/- 6.1 pg/mL. The mean of plasma ADM concentrations in all patients with RP (23.4 +/- 10.7 pg/mL) was significantly (P < 0.0001) higher than that of HS. Moreover, in the syndromic RP patients, plasma ADM levels (28.6 +/- 14.35 pg/ml) were higher than those of HS and RP patients (P < 0.0017).

CONCLUSION

The increase of plasma ADM levels in RP patients may be a response to photoreceptor damage.

A functional profile of gene expression in ARPE-19 cells

Background

Retinal pigment epithelium cells play an important role in the pathogenesis of age related macular degeneration. Their morphological, molecular and functional phenotype changes in response to various stresses. Functional profiling of genes can provide useful information about the physiological state of cells and how this state changes in response to disease or treatment. In this study, we have constructed a functional profile of the genes expressed by the ARPE-19 cell line of retinal pigment epithelium.

Methods

Using Affymetrix MAS 5.0 microarray analysis, genes expressed by ARPE-19 cells were identified. Using GeneChip^® annotations, these genes were classified according to their known functions to generate a functional gene expression profile.

Results

We have determined that of approximately 19,044 unique gene sequences represented on the HG-U133A GeneChip^® , 6,438 were expressed in ARPE-19 cells irrespective of the substrate on which they were grown (plastic, fibronectin, collagen, or Matrigel). Rather than focus our subsequent analysis on the identity or level of expression of each individual gene in this large data set, we examined the number of genes expressed within 130 functional categories. These categories were selected from a library of HG-U133A GeneChip^® annotations linked to the Affymetrix MAS 5.0 data sets. Using this functional classification scheme, we were able to categorize about 70% of the expressed genes and condense the original data set of over 6,000 data points into a format with 130 data points. The resulting ARPE-19 Functional Gene Expression Profile is displayed as a percentage of ARPE-19-expressed genes.

Conclusion

The Profile can readily be compared with equivalent microarray data from other appropriate samples in order to highlight cell-specific attributes or treatment-induced changes in gene expression. The usefulness of these analyses is based on the assumption that the numbers of genes expressed within a functional category provide an indicator of the overall level of activity within that particular functional pathway.

Mutational analysis of the rhodopsin gene in Chinese ADRP families by conformation sensitive gel electrophoresis

Retinitis pigmentosa is a very heterogeneous group of retinal degenerations, with multiple genes identified in each mode of inheritance. For autosomal dominant retinitis pigmentosa (ADRP), the most common gene is the rhodopsin (RHO) gene, mutations in which contribute to about 25% of ADRP in Caucasian population. To investigate the frequency and pattern of RHO point mutations in Chinese patients with ADRP, we have screened the five coding exons and splice sites of the RHO gene in 50 unrelated probands from Chinese ADRP families and 100 normal controls to identify disease-associated mutations, using conformation sensitive gel electrophoresis (CSGE) and direct DNA sequencing. Two RHO mutations, Pro347Leu and Pro327 (1-bp del), were identified each in one family, thus the frequency of RHO mutations among ADRP families in this study is less than 14% (2/50=4%, 95% confidence interval: 1-14%), lower than that in Europe and North America, which may reflect an ethnic difference between Chinese and Caucasian populations. Loss of all phosphorylation sites at the C-terminus and a highly conserved sequence QVS(A)PA may occur because of Pro327(1-bp del). CSGE was found to be a sensitive, simple and practical method for the screening of a large number of samples under highly reproducible conditions, and could be utilized in routine molecular diagnostic laboratories.

Retinal prosthesis

Retinal prostheses represent the best near-term hope for individuals with incurable, blinding diseases of the outer retina. On the basis of the electrical activation of nerves, prototype retinal prostheses have been tested in blind humans and have demonstrated the capability to elicit the sensation of light and to give test subjects the ability to detect motion. To improve the visual function in implant recipients, a more sophisticated device is required. Simulations suggest that 600-1000 pixels will be required to provide visual function such as face recognition and reading. State-of-the-art implantable stimulator technology cannot produce such a device, which mandates the advancement of the state of the art in areas such as analog microelectronics, wireless power and data transfer, packaging, and stimulating electrodes.

Retinal incorporation and differentiation of neural precursors derived from human embryonic stem cells

Retinal and macular degenerations are a major cause of blindness. Cell transplantation is a possible therapeutic approach for the replacement of degenerating retinal cells. Here, we studied the potential of human embryonic stem cells (hESCs) to survive, integrate, and differentiate into retinal cells after intraocular transplantation. Highly enriched cultures of neural precursors (NPs) expressing transcripts of key regulatory genes of retinal development were developed from the hESCs. After spontaneous differentiation in vitro, the NPs gave rise to progeny expressing markers of retinal progenitors and photoreceptor development, though this was uncommon and cells expressing markers of mature photoreceptors were not observed. After transplantation into rat eyes, the NPs survived for 16 weeks, migrated large distances, and integrated in the host retina. Teratoma tumors were not observed. Human cells expressing rhodopsin, blue cone opsin, and neural retina leucine zipper transcription factor were observed in subretinal grafts, but not within vitreal and inner retinal grafts. The results suggest that hESCs have the potential to differentiate into retinal cells and that the subretinal microenvironment supports their differentiation toward a photoreceptor fate. This may be the first step toward further developments that eventually may allow the use of hESCs for transplantation in retinal degenerations.

Stimulation of the retina with a multielectrode extraocular visual prosthesis

BACKGROUND

An extraocular approach to developing a retinal prosthesis for blind patients using electrodes placed on the outer surface of the eye is suggested. Experiments were carried out to determine the feasibility of this approach, and evaluate electrode configurations and parameters for stimulation.

METHODS

In anaesthetized cats, a 21-electrode extraocular retinal prosthesis (ERP) array was sutured to the sclera over the lateral surface of the eye. Electrically evoked potentials (EEP) were recorded at the visual cortex bilaterally in response to retinal stimulation with the electrode array. Bipolar stimulation of the ERP array electrodes in horizontal and vertical configurations and at different interelectrode separations was investigated with biphasic constant-current pulses.

RESULTS

Electrical stimulation of the lateral retina with an ERP elicited EEP that were higher in the ipsilateral visual cortex. The threshold for bipolar retinal stimulation was 500 microA. EEP amplitude increased with increases in stimulus pulse duration and current intensity. Retinal stimulation was slightly more effective with electrodes in a vertical as opposed to horizontal orientation. A larger interelectrode separation resulted in a higher EEP amplitude.

CONCLUSIONS

Retinal stimulation with a prototype ERP array is demonstrated. The thresholds for retinal excitation are below safe charge-density limits for chronic neural stimulation. Ipsilateral localization of the EEP suggests that localized retinal stimulation is occurring. An ERP is a new approach to retinal prosthesis research, and might lead to the development of a low-resolution visual prosthesis for blind patients.

Evaluation of extraocular electrodes for a retinal prosthesis using evoked potentials in cat visual cortex

OBJECTIVE

To assess the efficacy of a device using extraocular electrodes as a retinal prosthesis by evaluating the responses evoked in the visual cortex to electrical stimulation.

METHODS

In anaesthetised cats, a lateral orbital dissection and ipsilateral parietal craniotomy was performed. Two extraocular retinal prosthesis (ERP) disc electrodes were sutured to the sclera on the lateral and superior aspects of the globe. Retinal stimulation was performed with charge-balanced constant-current pulses. Potentials evoked in the visual cortex were measured with a ball electrode placed on the lateral gyrus after removal of the dura.

RESULTS

Stable attachment of the ERP electrodes to the globe was achieved with scleral sutures. Visual cortex responses were recorded with the electrodes in bipolar and monopolar configurations. The evoked response consisted of an early component with a peak around 8 ms, and a late component with a peak after 50 ms. Thresholds for evoking a response occurred at current intensities as low as 500 microA. Through extrapolation from evoked response amplitude data, thresholds as low as 300 microA were calculated. Cathodal monopolar stimulation demonstrated lower thresholds than anodal stimulation for evoking cortical responses.

CONCLUSIONS

The ERP electrodes can be easily attached to the globe and are effective in electrically stimulating the retina, evoking responses in the primary visual cortex. Threshold charge-density was within safe limits for neural stimulation.

What blindness can tell us about seeing again: merging neuroplasticity and neuroprostheses

Significant progress has been made in the development of visual neuroprostheses to restore vision in blind individuals. Appropriate delivery of electrical stimulation to intact visual structures can evoke patterned sensations of light in those who have been blind for many years. However, success in developing functional visual prostheses requires an understanding of how to communicate effectively with the visually deprived brain in order to merge what is perceived visually with what is generated electrically.

Retinitis pigmentosa: understanding the clinical presentation, mechanisms and treatment options

Retinitis pigmentosa (RP) is a leading cause of human blindness due to degeneration of retinal photoreceptor cells. Causes of retinal degeneration include defects in the visual pigment, defects in the proteins important for photoreceptor function or in enzymes involved in initiating visual transduction. Despite the diversity of genetic mutations identified in inherited forms of retinal dystrophy, there is a common end result of photoreceptor death and functional blindness. In this review, pertinent anatomical and physiological pathways involved in RP and the underlying genetic mutations are outlined, including a discussion on the inheritance patterns revealed by advances in molecular biological techniques. Characteristics of progression rates of visual field loss and current management options will provide useful clinical guidelines for the management of patients with RP.

Survival and Long Distance Migration of Brain‐Derived Precursor Cells Transplanted to Adult Rat Retina

Neural precursor cells transplanted to adult retina can integrate into the host. This is especially true when the neural precursor rat cell line RN33B is used. This cell line carries the reporter genes LacZ and green fluorescent protein (GFP). In grafted rat eyes, RN33B cells are localized from one eccentricity to the other of the host retina. In the present study, whole-mounted retinas were analyzed to obtain a more appropriate evaluation of the amount of transgene-expressing cells and the migratory capacity of these cells 3 and 8 weeks post-transplantation. Quantification was made of the number of beta-galactosidase- and GFP-expressing cells with a semiautomatized stereological cell counting system. With the same system, delineation of the distribution area of the grafted cells was also performed. At 3 weeks, 68% of the grafted eyes contained marker-expressing cells, whereas at 8 weeks only 35% of the eyes contained such cells. Counting of marker-expressing cells demonstrated a lower number of transgene-expressing cells at 3 weeks compared with 8 weeks post-transplantation. The distribution pattern of marker gene-expressing cells revealed cells occupying up to 21% at 3 weeks and up to 68% at 8 weeks of the entire host retina post-grafting. The precursor cells survived well in the adult retina although the most striking feature of the RN33B cell line was its extraordinary migratory capacity. This capability could be useful if precursor cells are used to deliver necessary genes or gene products that need to be distributed over a large diseased area.

Development of the outer retina in the mouse

Mice represent a valuable species for studies of development and disease. With the availability of transgenic models for retinal degeneration in this species, information regarding development and structure of mouse retina has become increasingly important. Of special interest is the differentiation and synaptogenesis of photoreceptors since these cells are predominantly involved in hereditary retinal degenerations. Thus, some of the keys to future clinical management of these retinal diseases may lie in understanding the molecular mechanisms of outer retinal development. In this study, we describe the expression of markers for photoreceptors (recoverin), horizontal cells (calbindin), bipolar cells (protein kinase C; PKC) and cytoskeletal elements pivotal to axonogenesis (beta-tubulin and actin) during perinatal development of mouse retina. Immunocytochemical localization of recoverin, calbindin, PKC and beta-tubulin was monitored in developing mouse retina (embryonic day (E) 18.5 to postnatal day (PN) 14), whereas f-actin was localized by Phalloidin binding. Recoverin immunoreactive cells, presumably the photoreceptors, were observed embryonically (E 18.5) and their number increased until PN 14. Neurite projections from the immunoreactive cells towards the outer plexiform layer (OPL) were noted at PN 0 and these processes reached the OPL at PN 7 coincident with histological evidence for the differentiation of the OPL. Outer segments, all the cell bodies in the ONL, as well as the OPL were immunoreactive to recoverin at PN 14. Calbindin immunoreactive horizontal cells were also present in E 18.5 retinas. These cells became progressively displaced proximally as the ONL developed. A calbindin immunoreactive plexus was seen in the OPL at PN 7. PKC immunoreactive bipolar cells developed postnatally, becoming distinguished at PN 7. Both beta-tubulin and actin immunoreactive cells were present in the IPL as early as E 18.5; however, appearance of processes labeled with these markers in the OPL was delayed until PN 7, concurrent with the first appearance of photoreceptor neurites, development of the horizontal cell plexus, and development of synaptophysin immunoreactivity at this location. These results provide a developmental timeframe for the expression of recoverin, calbindin, synaptophysin, beta-tubulin and actin. Our findings suggest that the time between PN 3 and PN 7 represents a critical period during which elements of the OPL are assembled.

Advances in the development of visual prostheses

Visual prostheses are based on neuronal electrical stimulation at different locations along the visual pathway (ie, cortical, optic nerve, epiretinal, subretinal). In terms of retinal prostheses, advances in microtechnology have allowed for the development of sophisticated, high-density integrated circuit devices that may be implanted either in the subretinal or epiretinal space. Analogous to the cochlear implants for some forms of deafness, these devices could restore useful vision by converting visual information into patterns of electrical stimulation that would excite the remaining spared inner retinal neurons in patients with diseases such as retinitis pigmentosa and age-related macular degeneration. The different types of implants and recent results are discussed, but special emphasis is given to retinal implants.

Retinal prosthesis for the blind

Most of current concepts for a visual prosthesis are based on neuronal electrical stimulation at different locations along the visual pathways within the central nervous system. The different designs of visual prostheses are named according to their locations (i.e., cortical, optic nerve, subretinal, and epiretinal). Visual loss caused by outer retinal degeneration in diseases such as retinitis pigmentosa or age-related macular degeneration can be reversed by electrical stimulation of the retina or the optic nerve (retinal or optic nerve prostheses, respectively). On the other hand, visual loss caused by inner or whole thickness retinal diseases, eye loss, optic nerve diseases (tumors, ischemia, inflammatory processes etc.), or diseases of the central nervous system (not including diseases of the primary and secondary visual cortices) can be reversed by a cortical visual prosthesis. The intent of this article is to provide an overview of current and future concepts of retinal and optic nerve prostheses. This article will begin with general considerations that are related to all or most of visual prostheses and then concentrate on the retinal and optic nerve designs. The authors believe that the field has grown beyond the scope of a single article so cortical prostheses will be described only because of their direct effect on the concept and technical development of the other prostheses, and this will be done in a more general and historic perspective.

Differential occurrence of mutations causative of eye diseases in the Chinese population

Ethnic differences and geographic variations affect the frequencies and nature of human mutations. In the literature, descriptions of causative mutations of eye diseases in the Chinese population are few. In this paper we attempt to reveal molecular information on genetic eye diseases involving Chinese patients from published and unpublished works by us and other groups. Our studies on candidate genes of eye diseases in the Chinese population in Hong Kong include MYOC and TISR for primary open angle glaucoma, RHO and RP1 for retinitis pigmentosa, ABCA4 and APOE for age-related macular degeneration, RB1 for retinoblastoma, APC for familial adenomatous polyposis with congenital hypertrophy of retinal pigment epithelium, BIGH3/TGFBI for corneal dystrophies, PAX6 for aniridia and Reiger syndrome, CRYAA and CRYBB2 for cataracts, and mtDNA for Leber hereditary optic neuropathy. We have revealed novel mutations in most of these genes, and in RHO, RP1, RB1, BIGH3, and PAX6 we have reported mutations that contribute to better understanding of the functions and properties of the respective gene products. We showed absence of MYOC does not necessarily cause glaucoma. No disease causative mutations have been identified in MYOC or ABCA4. There are similarities in the patterns of sequence alterations and phenotype-genotype associations in comparison with other ethnic groups, while the MYOC, RB1, APC, and PAX6 genes have more Chinese-specific sequence alterations. Establishment of a mutation database specific for the Chinese is essential for identification of genetic markers with diagnostic, prognostic, or pharmacological values.

Bcl-2 expression during the development and degeneration of RCS rat retinae

In various hereditary retinal degenerations, including that in Royal College of Surgeons (RCS) rats, the photoreceptors ultimately die by apoptosis. Bcl-2 is one of the genes, which regulates apoptosis and is thought to promote survival of cells. This study has investigated the developmental expression of Bcl-2 in RCS rat, which is a well-studied animal model for hereditary retinal degeneration. An antibody against Bcl-2 was used for its immunohistochemical localization in dystrophic RCS rat retinae from postnatal (PN) days 4, 7, 13, 35, 45, 70, 202 and 14 months. Results were compared with Bcl-2 localization in congenic non-dystrophic rats from PN 4, 7, 13, 44, 202 and 14 months. Bcl-2 immunoreactivity in non-dystrophic retinae was already present in PN 4 retinae in the nerve fiber layer (presumably in the endfeet of immature Müller cells) and in the proximal parts of certain radially aligned neuroepithelial cells/immature Müller cell radial processes. With increasing age the immunoreactivity in relatively more mature Müller cell radial processes spread distally towards the outer retina and between PN 13 and 44 it reached the adult distribution. No cell bodies in the ganglion cell layer were found to be immunoreactive. Expression of Bcl-2 immunoreactivity in dystrophic RCS rat retinae closely resembled that of non-dystrophic retinae. No immunoreactivity was seen in photoreceptors or retinal pigment epithelium in dystrophic or non-dystrophic retinae. In conclusion, Bcl-2 expression is not altered, either in terms of its chronology or the cell type expressing it, during retinal degeneration in RCS rats.

Molecular diagnostics for retinitis pigmentosa

BACKGROUND

At least 1 million people worldwide have retinitis pigmentosa (RP), making it relatively common among the inherited forms of blindness. Mutations in many genes may cause RP. The most common known mutation, Pro347Leu in rhodopsin, is found in no more than about 1% of unrelated patients, implying the impracticality of a diagnostic test which would screen only for a few, common mutation sites.

CONCLUSIONS

Ongoing discovery and study of RP genes makes it feasible to consider a molecular diagnostic test which would screen coding regions of all known RP genes by a mutation detection method such as conformation-sensitive gel electrophoresis followed by sequencing. The parallel development of RP genetic knowledge and treatments such as gene therapy will make such tests both possible and necessary.

Development and survival of tyrosine hydroxylase containing neurons in RCS rat retinae

AIM

Dopamine serves a variety of functions in the retina. Abnormalities of the retinal dopaminergic system have been described in the Royal College of Surgeons (RCS) rat as well as other models of retinal degeneration. Dopamine has been implicated in several retinal dysfunctions of retinitis pigmentosa. Dopaminergic amacrine cells respond to light by increasing their tyrosine hydroxylase (TH) activity and the rate of dopamine turnover. This study has, therefore, examined the ontogenesis of TH containing cells in the RCS rat retina to assess whether progressive photoreceptor degeneration affects the development or survival of TH containing cells in any way.

METHODS

TH immunoreactivity in developing dystrophic RCS rat retinae (postnatal day (PN) 0, 3, 6, 14, 18, 26, 32, 56, 85, 91, 12 month and 15 month) and normal retina (PN day 0, 6, 14, 19, 26, 30, 33, 54 and adults) was compared.

RESULTS

TH immunoreactivity in dystrophic retina closely resembled that in normal retina. In both groups, very faintly immunoreactive cells were detected in the proximal retina at PN 0. Immunoreactivity increased until PN 14, when faintly immunoreactive interplexiform (IP) fibers and fibers in the outer plexiform layer could be observed. In both groups, the IP connections reached their mature level of development at about PN 30. Thus the developmental expression of TH immunoreactive cells resembled that of non-dystrophic retina in both chronology as well as types of cells. These cells survived even in the advanced stages of degeneration.

CONCLUSIONS

The results suggest that the abnormalities in the dopaminergic system of the RCS retinae are not associated with abnormal ontogeny or survival of TH synthesizing cells.