Unilateral light-dark transitions affect choroidal blood flow in both eyes

Comparison of Retinal and Choroidal Microvasculature Changes in Monocular Amblyopic and Non-amblyopic Eyes following Short-term Patch Occlusion Treatment

PURPOSE

Our objective was to investigate whether there were differences in the short-term changes of retinal and choroidal microvasculature between amblyopic and non-amblyopic eyes after patch occlusion treatment in patients with monocular amblyopia. Additionally, we aimed to determine if these changes were associated with improvements in clinical parameters.

METHODS

We conducted a retrospective, longitudinal paired-eye case-control study by analyzing the medical records of patients under the age of 12 who had monocular amblyopia and underwent patch occlusion treatment for a duration of 2 to 12 months. Using optical coherence tomography angiography images, we compared the foveal avascular zone width, retinal blood vessel density (VD), choroidal thickness (CT), and choroidal vascularity index (CVI) in amblyopic and non-amblyopic eyes before and after patch occlusion treatment. We analyzed the correlations between the aforementioned parameters and changes in best-corrected visual acuity (BCVA) and stereopsis.

RESULTS

Overall, 114 eyes from 57 patients were enrolled. At baseline, parafoveal superficial plexus VD, foveal and parafoveal deep capillary plexus VD (DCPD) were lower by 0.994 ± 3.312% (p = .026), 2.403 ± 8.273% (p = .033), and 2.469 ± 4.095% (p < .001), respectively; CT was thicker by 30.6 ± 90.7 μm (p = .014); and CVI was higher by 1.920 ± 3.432% (p < 001) in the amblyopic eyes than in the non-amblyopic eyes. Following short-term patch occlusion treatment, foveal and parafoveal DCPD increased by 1.264 ± 3.829% (p = .017) and 1.028 ± 3.662% (p = .036), respectively, CT thinned by 15.5 ± 51.5 μm (p = .019), and CVI decreased by 1.296 ± 3.997% (p = .018) in the amblyopic eyes. Following patch occlusion treatment, as the foveal DCPD decreased and CVI increased, the BCVA improved (p = .017 and .035, respectively).

CONCLUSION

Following patch occlusion treatment, increased foveal DCPD and decreased CVI were associated with improved BCVA.

Short-term effects of occlusion therapy and optical correction on microvasculature in monocular amblyopia: a retrospective case-control study

This retrospective longitudinal case-control study investigated the short-term effects of patch occlusion treatment compared with optical correction on the microvasculature in monocular amblyopia. We included patients with monocular amblyopia treated for 2-12 months; they were classified into two groups according to the treatment regimen: patch occlusion or optical correction. Children aged < 12 years who presented to our clinic for examination without amblyopia diagnosis were enrolled as the control group. Changes in retinal and choroid microvasculature according to treatment were examined, and the correlation between changes in microvasculature and improvement in best-corrected visual acuity (BCVA) was evaluated. There were 57, 35, and 41 patients in the patch occlusion, optical correction, and control groups, respectively (mean age, 6.4 ± 2.0 years). Both amblyopic groups showed changes in the foveal and parafoveal deep capillary plexus vessel density (DCPD), choroidal thickness, and choroidal vascularity index (CVI) following short-term treatment (mean, 4.5 months). In the patch occlusion group, BCVA improved as the foveal DCPD increased (P = 0.013) and the CVI decreased (P = 0.037). In the optical correction group, BCVA improved as the foveal and parafoveal DCPD increased (P = 0.009). Increased foveal DCPD following amblyopia treatment and decreased CVI by patch occlusion were associated with improved BCVA.

IMI-The Dynamic Choroid: New Insights, Challenges, and Potential Significance for Human Myopia

The choroid is the richly vascular layer of the eye located between the sclera and Bruch's membrane. Early studies in animals, as well as more recent studies in humans, have demonstrated that the choroid is a dynamic, multifunctional structure, with its thickness directly and indirectly subject to modulation by a variety of physiologic and visual stimuli. In this review, the anatomy and function of the choroid are summarized and links between the choroid, eye growth regulation, and myopia, as demonstrated in animal models, discussed. Methods for quantifying choroidal thickness in the human eye and associated challenges are described, the literature examining choroidal changes in response to various visual stimuli and refractive error-related differences are summarized, and the potential implications of the latter for myopia are considered. This review also allowed for the reexamination of the hypothesis that short-term changes in choroidal thickness induced by pharmacologic, optical, or environmental stimuli are predictive of future long-term changes in axial elongation, and the speculation that short-term choroidal thickening can be used as a biomarker of treatment efficacy for myopia control therapies, with the general conclusion that current evidence is not sufficient.

Acute hyperglycemia compromises the responses of choroidal vessels using swept-source optical coherence tomography during dark and light adaptations

PURPOSE

To clarify the effects of acute hyperglycemia on the responses of choroidal structural components and vascularity index during light modulation in healthy participants using techniques including image binarization and artificial intelligence (AI) segmentation based on swept-source optical coherence tomography (SS-OCT).

METHODS

Twenty-four eyes of 24 healthy participants were imaged at different stages after ambient light, 40 min of dark adaptation, and 5 min of light adaptation in two imaging sessions: control and after receiving 75 g of oral glucose solution. The choroidal structural parameters, including luminal volume (LV), stromal volume (SV), total choroidal volume (TCV), and choroidal vascularity index (CVI) within a 6 mm area were determined using a custom algorithm based on image binarization and AI segmentation of SS-OCT. These measurements were compared among the conditions after adjusting for axial length, age to identify the differences.

RESULTS

In the dark, CVI decreased (-0.36 ± 0.09%) significantly in acute hyperglycemia compared to the control condition. During the transition to ambient light, there was an increasing trend in the choroidal parameters compared with the control experiment. However, only TCV (0.38 ± 0.17 mm³) and LV (0.27 ± 0.10 mm³) showed a significant increase at the time point of 5 min after ambient light.

CONCLUSION

Analysis of choroidal structural parameters and CVI based on SS-OCT images is a potentially powerful method to objectively reflect subtle changes in neurovascular coupling between the choroid and photoreceptor during dark adaptation.

Retinal Physiology and Circulation: Effect of Diabetes

In this article, we present a discussion of diabetes and its complications, including the macrovascular and microvascular effects, with the latter of consequence to the retina. We will discuss the anatomy and physiology of the retina, including aspects of metabolism and mechanisms of oxygenation, with the latter accomplished via a combination of the retinal and choroidal blood circulations. Both of these vasculatures are altered in diabetes, with the retinal circulation intimately involved in the pathology of diabetic retinopathy. The later stages of diabetic retinopathy involve poorly controlled angiogenesis that is of great concern, but in our discussion, we will focus more on several alterations in the retinal circulation occurring earlier in the progression of disease, including reductions in blood flow and a possible redistribution of perfusion that may leave some areas of the retina ischemic and hypoxic. Finally, we include in this article a more recent area of investigation regarding the diabetic retinal vasculature, that is, the alterations to the endothelial surface layer that normally plays a vital role in maintaining physiological functions. © 2020 American Physiological Society. Compr Physiol 10:933-974, 2020.

Choroidal changes in human myopia: insights from optical coherence tomography imaging

The choroid is a vascular tissue which plays a range of critical roles in the normal physiology of the eye, such as supplying the outer retina with oxygen and nutrients and the regulation of intraocular pressure. There is also substantial evidence, particularly from animal studies, that the choroid plays an important role in the regulation of eye growth and the development of common refractive errors like myopia. In recent years, advances in optical coherence tomography technology have improved our ability to image and measure the choroid in the human eye. Research using this technology over the past decade has dramatically improved our knowledge of the normal choroid, and its potential role in the regulation of eye growth and refractive error development. This review aims to provide an overview of recent work examining the normal human choroid, its changes with myopia and the possible role of the choroid in the mechanism regulating eye growth. Studies have demonstrated that choroidal thinning accompanies the development and progression of myopia, and have established a close link between eye growth and choroidal thickness changes. Dramatic thinning of the choroid is seen with high myopia, and associations are also observed between choroidal thinning and reduced vision, and the development of retinal pathology associated with high myopia. In the short-term, environmental factors known to be associated with myopia development and more rapid eye growth typically lead to a thinning of the choroid, whereas factors linked to a slowing of eye growth are typically associated with short-term choroidal thickening. Collectively, these findings suggest that the choroid is an important biomarker of eye growth in the human eye, and additional research to better understand the human choroid is likely to further our knowledge of the signals and pathways regulating eye growth, myopia development and progression.

Daily morning light therapy is associated with an increase in choroidal thickness in healthy young adults

Ambient light exposure is one environmental factor thought to play a role in the regulation of eye growth and refractive error development, and choroidal thickness changes have also been linked to longer term changes in eye growth. Therefore in this study we aimed to examine the influence of a 1-week period of morning light therapy upon choroidal thickness. Twenty two healthy young adult subjects had a series of macular choroidal thickness measurements collected with spectral domain optical coherence tomography before, and then following a 7-day period of increased daily light exposure. Increased light exposure was delivered through the use of commercially available light therapy glasses, worn for 30 minutes in the morning each day. A significant increase in subfoveal choroidal thickness (mean increase of +5.4 ± 10.3 µm) was found following 7-days of increased daily light exposure (p = 0.02). An increase in choroidal thickness was also observed associated with light therapy across the central 5 mm macular region. This study provides the first evidence in the human eye that daily morning light therapy results in small magnitude but statistically significant increases in choroidal thickness. These changes may have implications for our understanding of the impact of environmental factors upon eye growth.

Neural control of choroidal blood flow

The choroid is richly innervated by parasympathetic, sympathetic and trigeminal sensory nerve fibers that regulate choroidal blood flow in birds and mammals, and presumably other vertebrate classes as well. The parasympathetic innervation has been shown to vasodilate and increase choroidal blood flow, the sympathetic input has been shown to vasoconstrict and decrease choroidal blood flow, and the sensory input has been shown to both convey pain and thermal information centrally and act locally to vasodilate and increase choroidal blood flow. As the choroid lies behind the retina and cannot respond readily to retinal metabolic signals, its innervation is important for adjustments in flow required by either retinal activity, by fluctuations in the systemic blood pressure driving choroidal perfusion, and possibly by retinal temperature. The former two appear to be mediated by the sympathetic and parasympathetic nervous systems, via central circuits responsive to retinal activity and systemic blood pressure, but adjustments for ocular perfusion pressure also appear to be influenced by local autoregulatory myogenic mechanisms. Adaptive choroidal responses to temperature may be mediated by trigeminal sensory fibers. Impairments in the neural control of choroidal blood flow occur with aging, and various ocular or systemic diseases such as glaucoma, age-related macular degeneration (AMD), hypertension, and diabetes, and may contribute to retinal pathology and dysfunction in these conditions, or in the case of AMD be a precondition. The present manuscript reviews findings in birds and mammals that contribute to the above-summarized understanding of the roles of the autonomic and sensory innervation of the choroid in controlling choroidal blood flow, and in the importance of such regulation for maintaining retinal health.

Effects of a high level of illumination before sleep at night on chorioretinal thickness and ocular biometry

The choroid is affected by many factors. One of the factors, change in illumination has been suggested to influence choroidal thickness. However, the effects of bright light before sleep at night on the human eye are not well established. The purpose of this study was to investigate the effects of a high level of illumination in the evening on ocular measurements. Twenty-seven men with myopia spent seven consecutive nights in the sleep laboratory. During the first two nights, subjects were exposed to light at 150 lux between 20:00 and midnight. Then, for five consecutive nights, they were exposed to ambient light at 1000 lux between 20:00 and midnight. Ocular parameters and their diurnal variations were compared between the two periods and the effects of a high level of illumination were analyzed. After subjects were exposed to 1000 lux of illumination, axial length increased with borderline significance (p = 0.064). Macular volume and retinal thickness did not change. However, subfoveal choroidal thickness after exposure to 1000 lux of illumination (245.37 ± 52.84 μm) was significantly lower than that after 150 lux of illumination (268.00 ± 57.10 μm), (p < 0.001). Significant diurnal variations were found in mean keratometry (p = 0.039), intraocular pressure (IOP, p = 0.003), ocular perfusion pressure (OPP, p < 0.0001), macular volume (p = 0.019), and subfoveal choroidal thickness (p < 0.0001). A high level of illumination had significant effects on only IOP and OPP (p = 0.027 and 0.017, respectively). Bright light exposure before sleep at an intensity as high as 1000 lux reduced subfoveal choroidal thickness in healthy young men. In conclusion, diurnal variation in choroidal thickness can be affected by bright light exposure before sleep.

Melanopsin Phototransduction Contributes to Light-Evoked Choroidal Expansion and Rod L-Type Calcium Channel Function In Vivo

Purpose

In humans, rodents, and pigeons, the dark → light transition signals nonretinal brain tissue to increase choroidal thickness, a major control element of choroidal blood flow, and thus of photoreceptor and retinal pigment epithelium function. However, it is unclear which photopigments in the retina relay the light signal to the brain. Here, we test the hypothesis that melanopsin (Opn4)-regulated phototransduction modulates light-evoked choroidal thickness expansion in mice.

Methods

Two-month-old C57Bl/6 wild-type (B6), 4- to 5-month-old C57Bl/6/129S6 wild-type (B6 + S6), and 2-month-old melanopsin knockout (Opn4^−/−) on a B6 + S6 background were studied. Retinal anatomy was evaluated in vivo by optical coherence tomography and MRI. Choroidal thickness in dark and light were measured by diffusion-weighted MRI. Rod cell L-type calcium channel (LTCC) function in dark and light (manganese-enhanced MRI [MEMRI]) was also measured.

Results

Opn4^−/− mice did not show the light-evoked expansion of choroidal thickness observed in B6 and B6 + S6 controls. Additionally, Opn4^−/− mice had lower than normal rod cell and inner retinal LTCC function in the dark but not in the light. These deficits were not due to structural abnormalities because retinal laminar architecture and thickness, and choroidal thickness in the Opn4^−/− mice were similar to controls.

Conclusions

First time evidence is provided that melanopsin phototransduction contributes to dark → light control of murine choroidal thickness. The data also highlight a contribution in vivo of melanopsin phototransduction to rod cell and inner retinal depolarization in the dark.

MRI of Retinal Free Radical Production With Laminar Resolution In Vivo

Purpose

Recent studies have suggested the hypothesis that quench-assisted 1/T1 magnetic resonance imaging (MRI) measures free radical production with laminar resolution in vivo without the need of a contrast agent. Here, we test this hypothesis further by examining the spatial and detection sensitivity of quench-assisted 1/T1 MRI to strain, age, or retinal cell layer-specific genetic manipulations.

Methods

We studied: adult wild-type mice; mice at postnatal day 7 (P7); cre dependent retinal pigment epithelium (RPE)-specific MnSOD knockout mice; doxycycline-treated Sod2^flox/flox mice lacking the cre transgene; and α-transducin knockout (Gnat1^−/−) mice on a C57Bl/6 background. Transretinal 1/T1 profiles were mapped in vivo in the dark without or with antioxidant treatment, or followed by light exposure. We calibrated profiles spatially using optical coherence tomography.

Results

Dark-adapted RPE-specific MnSOD knockout mice had greater than normal 1/T1 in the RPE and outer nuclear layers that was corrected to wild-type levels by antioxidant treatment. Dark and light Gnat1^−/− mice also had greater than normal outer retinal 1/T1 values. In adult wild-type mice, dark values of 1/T1 in the ellipsoid region and in the outer segment were suppressed by 13 minutes of light. By 29 minutes of light, 1/T1 reduction extended to the outer nuclear layer. Gnat1^−/− mice demonstrated a faster light-evoked suppression of 1/T1 values in the outer retina. In P7 mice, transretinal 1/T1 profiles were the same in dark and light.

Conclusions

Quench-assisted MRI has the laminar resolution and detection sensitivity to evaluate normal and pathologic production of free radicals in vivo.

Choroidal Thickness, Photoreceptor Thickness, and Retinal Vascular Caliber Alterations in Dark Adaptation

PURPOSE

Our aim was to evaluate the alterations of subfoveal choroidal thickness (SFCT), photoreceptor layer thickness (PRT), and retinal vessel diameter in the dark and light adaptation.

METHODS

Twenty-four eyes of 24 healthy volunteers (12 males, 12 females) were included in this cross-sectional and observational study. The SFCT, PRT, retinal arteriole, and venule caliber measurements were performed with spectral domain optical coherence tomography in the dark (0.0 cd/m²) and under light (80 cd/m²) adapted conditions.

RESULTS

The mean age of the participants was 30.4 ± 4.4 years (range: 22-42). The SFCT increased statistically significantly in dark adaptation (p < 0.001), then returned to baseline values following light adaptation. The PRT, retinal arteriole, and venule caliber measurements were similar in the dark and light (p > 0.05).

CONCLUSIONS

While SFCT increased, PRT, and retinal vessel diameter did not change following transition from light to dark.

Measuring In Vivo Free Radical Production by the Outer Retina

PURPOSE

Excessive and continuously produced free radicals in the outer retina are implicated in retinal aging and the pathogenesis of sight-threatening retinopathies, yet measuring outer retinal oxidative stress in vivo remains a challenge. Here, we test the hypothesis that continuously produced paramagnetic free radicals from the outer retina can be measured in vivo using high-resolution (22-μm axial resolution) 1/T1magnetic resonance imaging (MRI) without and with a confirmatory quench (quench-assisted MRI).

METHODS

Low-dose sodium iodate-treated and diabetic C57Bl6/J mice (and their controls), and rod-dominated (129S6) or cone-only R91W;Nrl-/- mice were studied. In dark-adapted groups, 1/T1 was mapped transretinally in vivo without or with (1) the antioxidant combination of methylene blue (MB) and α-lipoic acid (LPA), or (2) light exposure; in subgroups, retinal superoxide production was measured ex vivo (lucigenin).

RESULTS

In the sodium iodate model, retinal superoxide production and outer retina-specific 1/T1 values were both significantly greater than normal and corrected to baseline with MB+LPA therapy. Nondiabetic mice at two ages and 1.2-month diabetic mice (before the appearance of oxidative stress) had similar transretinal 1/T1 profiles. By 2.3 months of diabetes, only outer retinal 1/T1 values were significantly greater than normal and were corrected to baseline with MB+LPA therapy. In mice with healthy photoreceptors, a light quench caused 1/T1 of rods, but not cones, to significantly decrease from their values in the dark.

CONCLUSIONS

Quench-assisted MRI is a feasible method for noninvasively measuring normal and pathologic production of free radicals in photoreceptors/RPE in vivo.

Application of Arterial Spin Labelling in the Assessment of Ocular Tissues

Arterial spin labelling (ASL) is a noninvasive magnetic resonance imaging (MRI) modality, capable of measuring blood perfusion without the use of a contrast agent. While ASL implementation for imaging the brain and monitoring cerebral blood flow has been reviewed in depth, the technique is yet to be widely used for ocular tissue imaging. The human retina is a very thin but highly stratified structure and it is also situated close to the surface of the body which is not ideal for MR imaging. Hence, the application of MR imaging and ASL in particular has been very challenging for ocular tissues and retina. That is despite the fact that almost all of retinal pathologies are accompanied by blood perfusion irregularities. In this review article, we have focused on the technical aspects of the ASL and their implications for its optimum adaptation for retinal blood perfusion monitoring. Retinal blood perfusion has been assessed through qualitative or invasive quantitative methods but the prospect of imaging flow using ASL would increase monitoring and assessment of retinal pathologies. The review provides details of ASL application in human ocular blood flow assessment.

MRI of rod cell compartment-specific function in disease and treatment in vivo

Rod cell oxidative stress is a major pathogenic factor in retinal disease, such as diabetic retinopathy (DR) and retinitis pigmentosa (RP). Personalized, non-destructive, and targeted treatment for these diseases remains elusive since current imaging methods cannot analytically measure treatment efficacy against rod cell compartment-specific oxidative stress in vivo. Over the last decade, novel MRI-based approaches that address this technology gap have been developed. This review summarizes progress in the development of MRI since 2006 that enables earlier evaluation of the impact of disease on rod cell compartment-specific function and the efficacy of anti-oxidant treatment than is currently possible with other methods. Most of the new assays of rod cell compartment-specific function are based on endogenous contrast mechanisms, and this is expected to facilitate their translation into patients with DR and RP, and other oxidative stress-based retinal diseases.

Autonomic control of the eye

The autonomic nervous system influences numerous ocular functions. It does this by way of parasympathetic innervation from postganglionic fibers that originate from neurons in the ciliary and pterygopalatine ganglia, and by way of sympathetic innervation from postganglionic fibers that originate from neurons in the superior cervical ganglion. Ciliary ganglion neurons project to the ciliary body and the sphincter pupillae muscle of the iris to control ocular accommodation and pupil constriction, respectively. Superior cervical ganglion neurons project to the dilator pupillae muscle of the iris to control pupil dilation. Ocular blood flow is controlled both via direct autonomic influences on the vasculature of the optic nerve, choroid, ciliary body, and iris, as well as via indirect influences on retinal blood flow. In mammals, this vasculature is innervated by vasodilatory fibers from the pterygopalatine ganglion, and by vasoconstrictive fibers from the superior cervical ganglion. Intraocular pressure is regulated primarily through the balance of aqueous humor formation and outflow. Autonomic regulation of ciliary body blood vessels and the ciliary epithelium is an important determinant of aqueous humor formation; autonomic regulation of the trabecular meshwork and episcleral blood vessels is an important determinant of aqueous humor outflow. These tissues are all innervated by fibers from the pterygopalatine and superior cervical ganglia. In addition to these classical autonomic pathways, trigeminal sensory fibers exert local, intrinsic influences on many of these regions of the eye, as well as on some neurons within the ciliary and pterygopalatine ganglia.

Oxidative stress and light-evoked responses of the posterior segment in a mouse model of diabetic retinopathy

PURPOSE

To test the hypothesis that in a mouse model of diabetic retinopathy, oxidative stress is linked with impaired light-evoked expansion of choroidal thickness and subretinal space (SRS).

METHODS

We examined nondiabetic mice (wild-type, wt) with and without administration of manganese, nondiabetic mice deficient in rod phototransduction (transducin alpha knockout; GNAT1(-/-)), and diabetic mice (untreated or treated with the antioxidant α-lipoic acid [LPA]). Magnetic resonance imaging (MRI) was used to measure light-evoked increases in choroidal thickness and the apparent diffusion coefficient (ADC) at 88% to 100% depth into the retina (i.e., the SRS layer).

RESULTS

Choroidal thickness values were similar (P > 0.05) between all untreated nondiabetic dark-adapted groups and increased significantly (P < 0.05) with light; this expansion was subnormal (P < 0.05) in both diabetic groups. Apparent diffusion coefficient values in the SRS layer robustly increased (P < 0.05) in a light duration-dependent manner, and this effect was independent of the presence of Mn(2+). The light-stimulated increase in ADC at the location of the SRS was absent in GNAT1(-/-) and diabetic mice (P > 0.05). In diabetic mice, the light-dependent increase in SRS ADC was significantly (P < 0.05) restored with LPA.

CONCLUSIONS

Apparent diffusion coefficient MRI is a sensitive method for evaluating choroid thickness and its light-evoked expansion together with phototransduction-dependent changes in the SRS layer in mice in vivo. Because ADC MRI exploits an endogenous contrast mechanism, its translational potential is promising; it can also be performed in concert with manganese-enhanced MRI (MEMRI). Our data support a link between diabetes-related oxidative stress and rod, but not choroidal, pathophysiology.

Bright light induces choroidal thickening in chickens

PURPOSE

Bright light is a potent inhibitor of myopia development in animal models. Because development of refractive errors has been linked to changes in choroidal thickness, we have studied in chickens whether bright light may exert its effects on myopia also through changes in choroidal thickness.

METHODS

Three-day-old chickens were exposed to "bright light" (15,000 lux; n = 14) from 10 AM to 4 PM but kept under "normal light" (500 lux) during the remaining time of the light phase for 5 days (total duration of light phase 8 AM to 6 PM). A control group (n = 14) was kept under normal light during the entire light phase. Choroidal thickness was measured in alert, hand-held animals with optical coherence tomography at 10 AM, 4 PM, and 8 PM every day.

RESULTS

Complete data sets were available for 12 chicks in bright light group and nine in normal light group. The striking inter-individual variability in choroidal thickness (coefficient of variance: 23%) made it necessary to normalize changes to the individual baseline thickness of the choroid. During the 6 hours of exposure to bright light, choroidal thickness decreased by -5.2 ± 4.0% (mean ± SEM). By contrast, in the group kept under normal light, choroidal thickness increased by +15.4 ± 4.7% (difference between both groups p = 0.003). After an additional 4 hours, choroidal thickness increased also in the "bright light group" by +17.8 ± 3.5%, while there was little further change (+0.6 ± 4.0%) in the "normal light group" (difference p = 0.004). Finally, the choroid was thicker in the "bright light group" (+7.6 ± 26.0%) than in the "normal light group" (day 5: -18.6 ± 26.9%; difference p = 0.036).

CONCLUSIONS

Bright light stimulates choroidal thickening in chickens, although the response is smaller than with experimentally imposed myopic defocus, and it occurs with some time delay. It nevertheless suggests that choroidal thickening is also involved in myopia inhibition by bright light.

Functional hyperemia and mechanisms of neurovascular coupling in the retinal vasculature

The retinal vasculature supplies cells of the inner and middle layers of the retina with oxygen and nutrients. Photic stimulation dilates retinal arterioles producing blood flow increases, a response termed functional hyperemia. Despite recent advances, the neurovascular coupling mechanisms mediating the functional hyperemia response in the retina remain unclear. In this review, the retinal functional hyperemia response is described, and the cellular mechanisms that may mediate the response are assessed. These neurovascular coupling mechanisms include neuronal stimulation of glial cells, leading to the release of vasoactive arachidonic acid metabolites onto blood vessels, release of potassium from glial cells onto vessels, and production and release of nitric oxide (NO), lactate, and adenosine from neurons and glia. The modulation of neurovascular coupling by oxygen and NO are described, and changes in functional hyperemia that occur with aging and in diabetic retinopathy, glaucoma, and other pathologies, are reviewed. Finally, outstanding questions concerning retinal blood flow in health and disease are discussed.

Retinal oximetry

ABSTRACT.:

PURPOSE

Malfunction of retinal blood flow or oxygenation is believed to be involved in various diseases. Among them are retinal vessel occlusions, diabetic retinopathy and glaucoma. Reliable, non-invasive technology for retinal oxygen measurements has been scarce and most of the knowledge on retinal oxygenation comes from animal studies. This thesis describes human retinal oximetry, performed with novel retinal oximetry technology. The thesis describes studies on retinal vessel oxygen saturation in (1) light and dark in healthy volunteers, (2) central retinal vein occlusion, (3) branch retinal vein occlusion, (4) central retinal artery occlusion, (5) diabetic retinopathy, (6) patients undergoing glaucoma surgery and (7) patients taking glaucoma medication.

METHODS

The retinal oximeter (Oxymap ehf., Reykjavik, Iceland) is based on a fundus camera. An attached image splitter allows the simultaneous capture of four images of the same area of the fundus. Two images are used for further analysis, one acquired with 586 nm light and one with 605 nm light. Light absorbance of retinal vessels is sensitive to oxygen saturation at 605 nm but not at 586 nm. Measurement of reflected light at these wavelengths allows estimation of oxygen saturation in the main retinal vessels. This is performed with custom-made analysis software.

RESULTS

LIGHT AND DARK: After 30 min in the dark, oxygen saturation in retinal arterioles of healthy volunteers was 92 ± 4% (mean ± SD, n = 15). After 5 min in 80 cd/m(2) light, the arteriolar saturation was 89 ± 5%. The decrease was statistically significant (p = 0.008). The corresponding values for retinal venules were 60 ± 5% in the dark and 55 ± 10% in the light (p = 0.020). Similar results were found after alternating 5 min periods of darkness and light. In a second experiment (n = 19), a significant decrease in retinal vessel oxygen saturation was found in 100 cd/m(2) light compared with darkness but 1 and 10 cd/m(2) light had no significant effect. CENTRAL RETINAL VEIN OCCLUSION: In patients with central retinal vein occlusion, the mean saturation in affected retinal venules was 49 ± 12%, while the mean value for venules in the fellow eye was 65 ± 6% (mean ± SD, p = 0.003, n = 8). The retinal arteriolar saturation was the same in affected (99 ± 3%) and the unaffected (99 ± 6%) eyes. The venous oxygen saturation showed much variation between affected eyes. BRANCH RETINAL VEIN OCCLUSION: Median oxygen saturation in venules affected by branch retinal vein occlusion was 59% (range, 12-93%, n = 22), while it was 63% (23-80%) in unaffected venules in the affected eye and 55% (39-80%) in venules in the fellow eye. The difference was not statistically significant (p > 0.05). There was a significant difference between affected arterioles (median 101%; range, 89-115%) and unaffected arterioles (95%, 85-104%) in the affected eye (p < 0.05, n = 18). CENTRAL RETINAL ARTERY OCCLUSION: In a patient with a day's history of central retinal artery occlusion due to temporal arteritis, the mean arteriolar saturation was 71 ± 9% and 63 ± 9% in the venules. One month later, after treatment with prednisolone, the mean arteriolar saturation was 100 ± 4% and the venous saturation 54 ± 5%. DIABETIC RETINOPATHY: When compared with healthy volunteers (n = 31), patients with all categories of diabetic retinopathy had on average 7-10 percentage points higher saturation in retinal arterioles (p < 0.05 for all categories, n = 6-8 in each category). In venules, the saturation was 8-12 percentage points higher (p < 0.05 for all categories). GLAUCOMA SURGERY: Oxygen saturation in retinal arterioles increased by 2 percentage points on average (p = 0.046, n = 19) with surgery, which lowered intraocular pressure from 23 ± 7 mmHg (mean ± SD) to 10 ± 4 mmHg (p < 0.0001). No other significant changes were found (p ≥ 0.35). DORZOLAMIDE: A significant reduction of 3 percentage points was found in arterioles (p < 0.01) and venules (p < 0.05) when patients with glaucoma or ocular hypertension changed from dorzolamide-timolol combination eye drops to timolol alone (n = 6). No change was found in patients, who started on timolol and switched to the combination therapy (p > 0.05, n = 7).

CONCLUSIONS

Dual wavelength oximetry can be used to non-invasively measure retinal vessel oxygen saturation in health and disease. The results indicate that retinal vessel oxygen saturation is (1) increased in the dark, (2) lower in venules affected by central retinal vein occlusions, (3) variable in branch retinal vein occlusion, (4) lower in retinal arterioles in central retinal artery occlusion, (5) increased in diabetic retinopathy, (6-7) mildly affected by glaucoma surgery or dorzolamide.

Trigeminal interpolaris/caudalis transition neurons mediate reflex lacrimation evoked by bright light in the rat

Abnormal sensitivity to bright light can cause discomfort or pain and evoke protective reflexes such as lacrimation. Although the trigeminal nerve is probably involved, the mechanism linking luminance to somatic sensory nerve activity remains uncertain. This study determined the effect of bright light on second-order ocular neurons at the ventral trigeminal interpolaris/caudalis transition (Vi/Vc) region, a major termination zone for trigeminal sensory fibers that innervate the eye. Most Vi/Vc neurons (80.9%) identified by responses to mechanical stimulation of the ocular surface also encoded bright light intensity. Light-evoked neural activity displayed a long latency to activation (> 10 s) and required transmission through the trigeminal root ganglion. Light-evoked neural activity was inhibited by intravitreal injection of phenylephrine or l-N(G) -nitro-arginine methyl ester (L-NAME), suggesting a mechanism coupled to vascular events within the eye. Laser Doppler flowmetry revealed rapid light-evoked increases in ocular blood flow that occurred prior to the increase in Vi/Vc neural activity. Synaptic blockade of the Vi/Vc region by cobalt chloride prevented light-evoked increases in tear volume, whereas blockade at the more caudal spinomedullary junction (Vc/C1) had no effect. In summary, Vi/Vc neurons encoded bright light intensity and were inhibited by drugs that alter blood flow to the eye. These results support the hypothesis that light-responsive neurons at the Vi/Vc transition region are critical for ocular-specific functions such as reflex lacrimation, whereas neurons at the caudal Vc/C1 junction region probably serve other aspects of ocular nociception.

Cellular and physiological mechanisms underlying blood flow regulation in the retina and choroid in health and disease

We review the cellular and physiological mechanisms responsible for the regulation of blood flow in the retina and choroid in health and disease. Due to the intrinsic light sensitivity of the retina and the direct visual accessibility of fundus blood vessels, the eye offers unique opportunities for the non-invasive investigation of mechanisms of blood flow regulation. The ability of the retinal vasculature to regulate its blood flow is contrasted with the far more restricted ability of the choroidal circulation to regulate its blood flow by virtue of the absence of glial cells, the markedly reduced pericyte ensheathment of the choroidal vasculature, and the lack of intermediate filaments in choroidal pericytes. We review the cellular and molecular components of the neurovascular unit in the retina and choroid, techniques for monitoring retinal and choroidal blood flow, responses of the retinal and choroidal circulation to light stimulation, the role of capillaries, astrocytes and pericytes in regulating blood flow, putative signaling mechanisms mediating neurovascular coupling in the retina, and changes that occur in the retinal and choroidal circulation during diabetic retinopathy, age-related macular degeneration, glaucoma, and Alzheimer's disease. We close by discussing issues that remain to be explored.

Light-induced trigeminal sensitization without central visual pathways: another mechanism for photophobia

PURPOSE

The authors investigated whether trigeminal sensitization occurs in response to bright light with the retina disconnected from the rest of the central nervous system by optic nerve section.

METHODS

In urethane-anesthetized rats, trigeminal reflex blinks were evoked with air puff stimuli directed at the cornea in darkness and at three different light intensities. After normative data were collected, the optic nerve was lesioned and the rats were retested. In an alert rat, reflex blinks were evoked by stimulation of the supraorbital branch of the trigeminal nerve in the dark and in the light.

RESULTS

A 9.1 × 10(3) μW/cm(2) and a 15.1 × 10(3) μW/cm(2) light significantly enhanced the magnitude of reflex blinks relative to blinks evoked by the same trigeminal stimulus when the rats were in the dark. In addition, rats exhibited a significant increase in spontaneous blinking in the light relative to the blink rate in darkness. After lesioning of the optic nerve, the 15.1 × 10(3) μW/cm(2) light still significantly increased the magnitude of trigeminal reflex blinks.

CONCLUSIONS

Bright lights increase trigeminal reflex blink amplitude and the rate of spontaneous blinking in rodents. Light can modify trigeminal activity without involving the central visual system.

The short-term influence of exercise on axial length and intraocular pressure

PURPOSE

The aim of this study is to investigate the short-term influence of a period of dynamic exercise on axial length (AXL) and intraocular pressure (IOP) in young adult subjects.

PATIENTS AND METHODS

In all, 20 young adult subjects (10 myopes and 10 emmetropes) participated. Baseline measures of ocular biometrics, IOP and ocular pulse amplitude (OPA) were taken following a 20-min rest period. Subjects then performed 10 min of moderate intensity, low impact dynamic exercise (bicycle ergometry). Measures of ocular biometrics, IOP and OPA were repeated immediately after, and then 5 and 10 min after this exercise task. Systemic blood pressure and pulse rate were also monitored. A repeated measures analysis of variance was used to investigate the changes in the measured parameters.

RESULTS

Exercise resulted in significant changes in a range of ocular parameters. A small but significant decrease in AXL was observed following exercise (P<0.0001). The largest change in AXL was noted immediately following exercise (mean decrease -17±10 μm). IOP and OPA also decreased significantly following exercise (P<0.0001). A moderate but significant positive association was found between the changes in AXL and the changes in IOP (r(2)=0.36, P<0.0001). There were no significant differences found between the myopic and emmetropic subjects in the magnitude of changes observed in ocular parameters following exercise.

CONCLUSION

The physiological effects of dynamic exercise lead to changes in a range of ocular parameters, including significant reductions in IOP, OPA and decreases in AXL.

Ocular blood flow assessment using continuous laser Doppler flowmetry

This article describes the technique of continuous laser Doppler flowmetry (LDF) as applied to the measurement of the flux of red blood cells in the optic nerve head, iris and subfoveal choroid. Starting with the exposition of the physical principles underlying LDF, we first describe the various devices developed to perform LDF in these vascular beds. We then discuss the clinical protocols, blood flow parameters, calibration procedures, reproducibility and limitations of the LDF technique. Various problems still need to be solved in order to bring to light the full potential of LDF in the assessment of microcirculatory haemodynamics.

Bright light produces Fos-positive neurons in caudal trigeminal brainstem

Excessive discomfort after exposure to bright light often occurs after ocular injury and during headache. Although the trigeminal nerve is necessary for light-evoked discomfort, the mechanisms underlying this phenomenon, often referred to generally as photophobia, are not well defined. Quantitative Fos-like immunoreactivity (Fos-LI) was used to determine the pattern of neuronal activation in the caudal brainstem after bright light stimulation and, secondly, whether a neurovascular mechanism within the eye contributes to this response. Under barbiturate anesthesia, male rats were exposed to low (1 x 10(4) lx) or high intensity (2 x 10(4) lx) light delivered from a thermal neutral source for 30 min (30 s ON, 30 s OFF) and allowed to survive for 90 min. Intensity-dependent increases in Fos-LI were seen in laminae I-II at the trigeminal caudalis/cervical cord junction region (Vc/C1) and nucleus tractus solitarius (NTS). Fos-LI also increased at the trigeminal interpolaris/caudalis transition (Vi/Vc(vl)) and dorsal paratrigeminal (dPa5) regions independent of intensity. Intravitreal injection of norepinephrine greatly reduced light-evoked Fos-LI at the Vc/C1, dPa5 and NTS, but not at the Vi/Vc transition. Lidocaine applied to the ocular surface had no effect on Fos-LI produced in trigeminal brainstem regions. These results suggested that multiple regions of the caudal trigeminal brainstem complex integrate light-related sensory information. Fos-LI produced at the dPa5 and NTS, coupled with norepinephrine-induced inhibition, was consistent with the hypothesis that light-evoked activation of trigeminal brainstem neurons involves an intraocular neurovascular mechanism with little contribution from neurons that supply the ocular surface.

Experimentally reduced perfusion of one eye impairs retinal function in both eyes

PURPOSE

The oscillatory potential index of scotopic white flash electroretinograms is reversibly enhanced in the contralateral eye when the ocular perfusion pressure (OPP) to the test eye is transiently reduced. A transient increase in the intraocular pressure (IOP) and decrease in the OPP in the test eye induced quantifiable vascular changes in the optic nerve head of the contralateral eye. We explored this contralateral phenomenon looking at ganglion cell function in both eyes during elevated IOP and decreased OPP in the test eye only. Our specific objective was to characterize the effects that transient hypoperfusion had on the neural generators of the pattern-reversal electroretinograms (pERGs), the ganglion cells, and preganglion neurons.

METHODS

A transient elevation in the IOP was sustained in 10 healthy subjects by scleral suction to reduce the baseline OPP by 15, 30, 45, and 60% for 2-min intervals. For each level of OPP, pERGs were evoked by a checkerboard with 75 minarc high-contrast black-white checks reversing at 5 Hz and recorded bilaterally using DTL fiber electrodes. The pERGs were also recorded immediately after removal of scleral suction and at 2-min intervals thereafter for an 8-min recovery interval.

RESULTS

The unilateral decrease in OPP differentially reduced the pERG in the test and contralateral eyes. The pERG for the test eye returned to baseline amplitude within 2 min of removing the suction cup. In contrast, the pERG in the contralateral eye remained below baseline throughout the entire 8-min recovery interval.

CONCLUSIONS

The observation of a bilateral decrease in the pERGs while the OPP was decreased in the test eye only suggested that these neuronal changes were modified at more central visual centers for retinal function to be compromised bilaterally. This latter effect may have been mediated by the transiently altered OPP or yet unknown neurohormonal mechanisms.

Anatomical and functional evidence for progressive age-related decline in parasympathetic control of choroidal blood flow in pigeons

The choroid receives extensive parasympathetic innervation, which in birds arises largely from the ciliary ganglion (CG). Since age-related changes in parasympathetic regulation of choroidal blood flow (ChBF) could contribute to age-related retinal decline, we used anatomical and functional methods to determine if ChBF control by the CG shows age-related decline in pigeons. The efficacy of the choroidal vasodilatory response to activation of the CG preganglionic input from the medial subdivision of the nucleus of Edinger-Westphal (EWM) was assessed using laser Doppler flowmetry (LDF). The EWM receives bisynaptic retinal input, and electrical stimulation of EWM or light stimulation of the retina in young animals produces dramatic choroidal vasodilation. Transcleral LDF was therefore used to measure both basal ChBF and the increases in ChBF elicited by electrical stimulation of EWM or by retinal illumination in 0.5-18 year old pigeons. Fixed cryostat sections of the eye from 0.5 to 22 year old pigeons were immunolabeled for the 3A10 neurofilament-associated antigen to determine if intrachoroidal nerve fibers arising from CG exhibited age-related loss. We focused on superior choroid, since it is the primary target for CG nerve fibers. There was a marked age-related loss in the ChBF vasodilatory response elicited by either EWM stimulation or retinal illumination, as was also true for basal ChBF. A progressive decrease in choroidal nerve fibers of CG origin, to 17% of youthful abundance by 22 years of age, was also observed. The evoked ChBF increase, and basal ChBF, achieved 50% of their age-related decline between the ages of 3 and 4 years, while half the loss in CG innervation of choroid was later, occurring by 10 years. Age-related loss of choroidal nerve fibers occurs in parallel with but more slowly than the reduction in basal ChBF and the choroidal vasodilation that can be elicited via natural (light) or electrical activation of the central neural input to CG choroidal neurons. The prominent age-related decline in parasympathetic control of ChBF early in the pigeon life span could contribute to the age-related retinal decline observed in pigeons.

Blue flicker modifies the subfoveal choroidal blood flow in the human eye

The objective of the present study was to reveal an interaction between choroidal blood flow (ChBF) and light-induced photoreceptor activity, a physiological coupling that has been already demonstrated for retinal blood flow but rejected for ChBF. Ten healthy adults volunteered for this study. A real-time recording near-infrared laser-Doppler flowmeter was used to quantify the subfoveal ChBF while the luminance of blue flicker between 1 and 64 Hz was first increased and then decreased by 4.0 log units in 1.0-log unit steps between 0.0375 and 375 cd/m2. In separate testing, flash electroretinograms (ERGs) provided electrophysiological indexes of the relative response of short-wave cones (s-cones) and rods to blue light stimulation. Group-averaged, normalized ChBF measurements revealed that it was modulated by approximately 9% by flicker frequency. Increasing the blue flicker luminance from low to high attenuated the subfoveal ChBF, volume, and velocity by approximately 32%, approximately 30%, and approximately 5%, respectively. Decreasing the luminance from high to low over the same range had no effect on the subfoveal choroidal hemodynamics. The markedly different effects of reversed directions of change in blue flicker luminance on the subfoveal ChBF were linked to transitions between rod-dominated and s-cone-dominated retinal responses. Collectively, these findings indicate that the blue light-induced photoreceptor response is associated with a differential distribution of the ChBF across the ocular fundus according to the degree and type of retinal photoreceptor stimulated.

Changes in choroidal blood flow during light/dark transitions are not altered by atropine or propranolol in healthy subjects

It has recently been reported that light/dark transitions lead to changes in choroidal blood flow. Several observations indicate that these changes in choroidal perfusion are triggered at least in part by neural mechanisms. In the present study we hypothesised that the choroidal blood flow response to changes in retinal illumination may be modified by either the muscarinic receptor antagonist atropine or by the beta-receptor antagonist propranolol. In 15 healthy subjects the response of choroidal perfusion was studied in a randomised placebo-controlled three way cross-over study using laser Doppler flowmetry and laser interferometric measurement of fundus pulsation amplitude. Before drug administration a transition from light to dark reduced both choroidal haemodynamic parameters by 8%-12%. Neither propranolol nor atropine altered basal choroidal blood flow or choroidal blood flow responses to light/dark transitions. Our data indicate that neither muscarinic nor beta-receptors are involved in the choroidal blood flow response to changes in retinal illumination. Further studies are required to elucidate which mechanisms contribute to this blood flow behaviour of the choroid.