Lesion location influences perception of homonymous scotomata during flickering random dot pattern stimulation

Strategies for improving early detection and diagnosis of neovascular age-related macular degeneration

Treatment of the neovascular form of age-related macular degeneration (AMD) has been revolutionized by the introduction of such agents as ranibizumab, bevacizumab, and aflibercept. As a result, the incidence of legal blindness occurring secondary to AMD has fallen dramatically in recent years in many countries. While these agents have undoubtedly been successful in reducing visual impairment and blindness, patients with neovascular AMD typically lose some vision over time, and often lose the ability to read, drive, or perform other important activities of daily living. Efforts are therefore under way to develop strategies that allow for earlier detection and treatment of this disease. In this review, we begin by providing an overview of the rationale for, and the benefits of, early detection and treatment of neovascular AMD. To achieve this, we begin by providing an overview of the pathophysiology and natural history of choroidal neovascularization, before reviewing the evidence from both clinical trials and “real-world” outcome studies. We continue by highlighting an area that is often overlooked: the importance of patient education and awareness for early AMD detection. We conclude the review by reviewing an array of both established and emerging technologies for early detection of choroidal neovascularization, ranging from Amsler chart testing, to hyperacuity testing, to advanced imaging techniques, such as optical coherence tomography.

Recent progress in macular function self-assessment

BACKGROUND

Patients that are deemed to be at risk for the development of choroidal neovascularization are frequently instructed to self-monitor their vision for symptoms that may signal the presence of choroidal neovascularization. Traditionally, the Amsler grid has been used for this purpose, but recent technological innovations have resulted in a number of potential alternatives that offer important advantages, including greater sensitivity, the ability to differentiate exudative from non-exudative disease, and quantitative analysis of test results.

METHODS

The following technologies that could be employed for patient self-assessment of macular function in a home setting are reviewed: computerized Amsler grid, preferential hyperacuity perimetry, macular mapping test and noise-field campimetry.

CONCLUSIONS

A number of technologies are currently available that could significantly improve the ability of patients at risk for the development of choroidal neovascularization to self-monitor their central visual field.

Illusory stimuli can be used to identify retinal blind spots

BACKGROUND

Identification of visual field loss in people with retinal disease is not straightforward as people with eye disease are frequently unaware of substantial deficits in their visual field, as a consequence of perceptual completion ("filling-in") of affected areas.

METHODOLOGY

We attempted to induce a compelling visual illusion known as the induced twinkle after-effect (TwAE) in eight patients with retinal scotomas. Half of these patients experience filling-in of their scotomas such that they are unaware of the presence of their scotoma, and conventional campimetric techniques can not be used to identify their vision loss. The region of the TwAE was compared to microperimetry maps of the retinal lesion.

PRINCIPAL FINDINGS

Six of our eight participants experienced the TwAE. This effect occurred in three of the four people who filled-in their scotoma. The boundary of the TwAE showed good agreement with the boundary of lesion, as determined by microperimetry.

CONCLUSION

For the first time, we have determined vision loss by asking patients to report the presence of an illusory percept in blind areas, rather than the absence of a real stimulus. This illusory technique is quick, accurate and not subject to the effects of filling-in.

Localizing Sites of Activation in Primary Visual Cortex Using Visual-Evoked Potentials and Functional Magnetic Resonance Imaging

This study compared retinotopic map identification in primary visual cortex (V1) using: (i) functional magnetic resonance imaging (fMRI) and (ii) visual evoked potentials (VEPs) coupled with dipole source localization (DSL). A multielectrode array was used to record VEPs while subjects viewed a flickering dartboard pattern modulated by a 16-bit m-sequence. The stimulus preferentially activates V1. Using a common time function DSL algorithm, the primary source of each stimulus patch was found independent of the fMRI. The VEP/DSL and fMRI localization data for each subject were aligned by a rigid translation and rotation. The average distance between VEP and corresponding fMRI sources was 10.8 mm +/- 3.8 mm. To assess the significance of the results, fMRI and DSL solutions were scrambled so the comparisons were no longer for corresponding patches. The average distance between the noncorresponding data sets was 17.2 mm for 50 million scrambles. The probability of the scrambled data yielding a better fit than the real data was p < 10(-7). The combination of multielectrode recording, multiinput visual stimulation and common time function DSL analysis can provide a detailed retinotopic map of visual cortex that has high correspondence with independent fMRI localization analysis on the same subject.

Visual consciousness in health and disease

Conscious experience is an essential part of normal human life and interaction with the environment. Yet the nature of consciousness and conscious perception remains a mystery. Because of its subjective nature, consciousness has been difficult to investigate scientifically, but clues have been gained through studies involving patients with cortical lesions. During the past decade, the development of event-related fMRI has provided insights into aspects of conscious perception in control subjects and patients with cortical lesions by correlating awareness and performance with neural activity during visual tasks. This article reviews how recent research has advanced understanding of conscious perception, its relationship to neural activity and visual performance, and how this relationship can be altered by visual dysfunction. It also presents recent research about how conscious awareness of vision might be represented at a neural level in the central nervous system.

Electrophysiological estimate of human cortical magnification

OBJECTIVE

The cortical magnification factor characterizes the area of human primary visual cortex activated by a stimulus as a function of angular distance from an observer's line of sight. This study estimates human cortical magnification using an electrophysiological method with excellent temporal resolution: visual evoked potential (VEP) dipole source localization.

METHODS

For each of 60 independently modulated checkerboard patches within the central 18 deg of the visual field, location, orientation, magnitude, and time-course of the dipole current source that best described the VEP distribution across a multi-electrode array was obtained. At numerous eccentricities, cortical magnification was determined using two different techniques: (1) the distance between each pair of adjacent stimulus patches was matched to the corresponding distance between adjacent cortical sources; and (2) the area of each stimulus patch was matched to the magnitude of the corresponding cortical source (which was assumed to be proportional to cortical area).

RESULTS

The estimates of human cortical magnification using our electrophysiological method were similar to previous estimates from psychophysics, cortical stimulation, and functional magnetic resonance imaging.

CONCLUSIONS

The concordance of results provided by these disparate technologies, with differing spatial and temporal limitations, supports their combination in studying the spatio-temporal dynamics of human brain function.

Hyperexcitatory activity in visual cortex in homonymous hemianopia after stroke

OBJECTIVES

Damage to and destruction of neural afferents result in a disruption of sensory input, which causes reduced activity in the corresponding cortical areas. Conversely, there is also evidence that lesions in the sensory pathway induce changes in the intracortical connectivity resulting in augmented cortical activity due to disinhibition. As disinhibition is assumed to be involved in the reconfiguration of neural networks, its appearance after brain lesions might be relevant for the restitution of impaired brain functions.

METHODS

The effects of lesions in the visual pathway on the activity in visual cortex were studied using magnetoencephalography. In order to compare the neural activity affected by the lesion with the activity associated with intact visual processing, only patients with unilateral, post-chiasmatic lesions resulting in homonymous hemianopia were examined.

RESULTS

Stimulation within the scotoma resulted in reduced magnetic activity compared to the stimulation of the intact hemifield. Increased activity was observed when the border region of the scotoma was stimulated.

CONCLUSIONS

It is concluded that the magnetic hyperactivity reflects cortical disinhibition induced by lesions in the visual system. Furthermore, the possible role of cortical disinhibition as a basis for cortical reorganization and as a precondition for the recovery of impaired visual functions is discussed.

Using multi-stimulus VEP source localization to obtain a retinotopic map of human primary visual cortex

OBJECTIVE

The goal of this study was to acquire a detailed spatial and temporal map of primary visual cortex using a novel VEP stimulus and analysis technique.

METHODS

A multi-stimulus array spanning the central 18 degrees of the visual field was used where each of 60 checkerboard stimulus 'patches' was simultaneously modulated with an independent binary m-sequence (Sutter, 1992). VEPs corresponding to each patch were recorded from 3 subjects using a dense posterior electrode array. For each stimulus patch, single dipole source localization was conducted to determine the location, magnitude, and time-function of the underlying neural activation. To reduce ambiguity in the solution, a common time-function was assumed for stimulus patches at the same visual eccentricity (defining an annulus). The analysis was conducted independently for each annulus composed of 4-12 patches.

RESULTS

The loci of the dipole solutions followed a smooth retinotopic pattern across annuli consistent with the classical organization of primary visual cortex. Specifically, each dipole was found contralateral to the corresponding stimulus patch and field inversion was observed for all subjects.

CONCLUSIONS

Using this technique, the most detailed spatial and temporal retinotopic map of primary visual cortex to date has been obtained.