Effect of Age and Refractive Error on the Melanopsin Mediated Post-Illumination Pupil Response (PIPR)

Influencing Factors on Pupillary Light Responses as a Biomarker for Local Retinal Function in a Large Normative Cohort

Purpose

Investigating influencing factors on the pupillary light response (PLR) as a biomarker for local retinal function by providing epidemiological data of a large normative collective and to establish a normative database for the evaluation of chromatic pupil campimetry (CPC).

Methods

Demographic and ophthalmologic characteristics were captured and PLR parameters of 150 healthy participants (94 women) aged 18 to 79 years (median = 46 years) were measured with L-cone- and rod-favoring CPC protocols. Linear-mixed effects models were performed to determine factors influencing the PLR and optical coherence tomography (OCT) data were correlated with the pupillary function volume.

Results

Relative maximal constriction amplitude (relMCA) and latency under L-cone- and rod-favoring stimulation were statistically significantly affected by the stimulus eccentricity (P < 0.0001, respectively). Iris color and gender did not affect relMCA or latency significantly; visual hemifield, season, and daytime showed only minor influence under few stimulus conditions. Age had a statistically significant effect on latency under rod-specific stimulation with a latency prolongation ≥60 years. Under photopic and scotopic conditions, baseline pupil diameter declined significantly with increasing age (P < 0.0001, respectively). Pupillary function volume and OCT data were not correlated relevantly.

Conclusions

Stimulus eccentricity had the most relevant impact on relMCA and latency of the PLR during L-cone- and rod-favoring stimulation. Latency is prolonged ≥60 years under scotopic conditions. Considering the large study collective, a representative normative database for relMCA and latency as valid readout parameters for L-cone- and rod-favoring stimulation could be established. This further validates the usability of the PLR in CPC as a biomarker for local retinal function.

Handheld chromatic pupillometry can reliably detect functional glaucomatous damage in eyes with high myopia

BACKGROUND/AIMS

To assess pupillary light responses (PLRs) in eyes with high myopia (HM) and evaluate the ability of handheld chromatic pupillometry (HCP) to identify glaucomatous functional loss in eyes with HM.

METHODS

This prospective, cross-sectional study included 28 emmetropes (EM), 24 high myopes without glaucoma (HM) and 17 high myopes with confirmed glaucoma (HMG), recruited at the Singapore National Eye Center. Monocular PLRs were evaluated using a custom-built handheld pupillometer that recorded changes in horizontal pupil radius in response to 9 s of exponentially increasing blue (469.1 nm) and red (640.1 nm) lights. Fifteen pupillometric features were compared between groups. A logistic regression model (LRM) was used to distinguish HMG eyes from non-glaucomatous eyes (EM and HM).

RESULTS

All pupillometric features were similar between EM and HM groups. Phasic constriction to blue (p<0.001) and red (p=0.006) lights, and maximum constriction to blue light (p<0.001) were reduced in HMG compared with EM and HM. Pupillometric features of melanopsin function (postillumination pupillary response, PIPR area under the curve (AUC) 0-12 s (p<0.001) and PIPR 6 s (p=0.01) to blue light) were reduced in HMG. Using only three pupillometric features, the LRM could classify glaucomatous from non-glaucomatous eyes with an AUC of 0.89 (95% CI 0.77 to 1.00), sensitivity 94.1% (95% CI 82.4% to 100.0%) and specificity 78.8% (95% CI 67.3% to 90.4%).

CONCLUSION

PLRs to ramping-up light stimuli are unaltered in highly myopic eyes without other diagnosed ocular conditions. Conversely, HCP can distinguish glaucomatous functional loss in eyes with HM and can be a useful tool to detect/confirm the presence of glaucoma in patients with HM.

The association between pupillary responses and axial length in children differs as a function of season

The association between pupillary responses to repeated stimuli and adult refractive error has been previously demonstrated. This study evaluated whether this association exists in children and if it varies by season. Fifty children aged 8-17 years (average: 11.55 ± 2.75 years, 31 females) with refractive error between + 1.51 and - 5.69 diopters (non-cycloplegic) participated (n = 27 in summer, and n = 23 in winter). The RAPDx pupilometer measured pupil sizes while stimuli oscillated between colored light and dark at 0.1 Hz in three sequences: (1) alternating red and blue, (2) red-only, and (3) blue-only. The primary outcome was the difference in pupillary responses between the blue-only and red-only sequences. Pupillary constriction was greater in response to blue light than to red for those with shorter eyes in summer (β = - 9.42, P = 0.034) but not in winter (β = 3.42, P = 0.54). Greater constriction comprised faster pupillary escape following red light onset and slower redilation following stimulus offset of both colors (P = 0.017, 0.036, 0.035 respectively). The association between axial length and children's pupillary responses in summer, but not winter may be explained by greater light-associated release of retinal dopamine in summer. Shorter eyes' more robust responses are consistent with greater light exposure inhibiting axial elongation and reducing myopia risk.

Pupillometry to differentiate idiopathic hypersomnia from narcolepsy type 1

Idiopathic hypersomnia is poorly diagnosed in the absence of biomarkers to distinguish it from other central hypersomnia subtypes. Given that light plays a main role in the regulation of sleep and wake, we explored the retinal melanopsin-based pupil response in patients with idiopathic hypersomnia and narcolepsy type 1, and healthy subjects. Twenty-seven patients with narcolepsy type 1 (women 59%, 36 ± 11.5 years old), 36 patients with idiopathic hypersomnia (women 83%, 27.2 ± 7.2 years old) with long total sleep time (> 11/24 hr), and 43 controls (women 58%, 30.6 ± 9.3 years old) were included in this study. All underwent a pupillometry protocol to assess pupil diameter, and the relative post-illumination pupil response to assess melanopsin-driven pupil responses in the light non-visual input pathway. Differences between groups were assessed using logistic regressions adjusted on age and sex. We found that patients with narcolepsy type 1 had a smaller baseline pupil diameter as compared with idiopathic hypersomnia and controls (p < 0.05). In addition, both narcolepsy type 1 and idiopathic hypersomnia groups had a smaller relative post-illumination pupil response (respectively, 31.6 ± 13.9% and 33.2 ± 9.9%) as compared with controls (38.7 ± 9.7%), suggesting a reduced melanopsin-mediated pupil response in both types of central hypersomnia (p < 0.01). Both narcolepsy type 1 and idiopathic hypersomnia showed a smaller melanopsin-mediated pupil response, and narcolepsy type 1, unlike idiopathic hypersomnia, also displayed a smaller basal pupil diameter. Importantly, we found that the basal pupil size permitted to well discriminate idiopathic hypersomnia from narcolepsy type 1 with a specificity = 66.67% and a sensitivity = 72.22%. Pupillometry may aid to multi-feature differentiation of central hypersomnia subtypes.

Designing artificial circadian environments with multisensory cares for supporting preterm infants' growth in NICUs

Previous studies suggest the importance of stable circadian environments for fetuses to achieve sound physiology and intrauterine development. This idea is also supported by epidemiological and animal studies, in which pregnant females exposed to repeated shifting of light-dark cycles had increased rates of reproductive abnormalities and adverse pregnancy outcomes. In response to such findings, artificial circadian environments with light-dark (LD) cycles have been introduced to NICUs to promote better physical development of preterm infants. Such LD cycles, however, may not be fully effective for preterm infants who are less than 30 weeks gestational age (WGA) since they are too premature to be adequately responsive to light. Instead, circadian rhythmicity of incubated preterm infants less than 30 WGA may be able to be developed through stimulation of the non-visual senses such as touch and sound.

Differences in the Pupillary Responses to Evening Light between Children and Adolescents

Purpose

To assess differences in the pupillary light responses (PLRs) to blue and red evening lights between children and adolescents.

Methods

Forty healthy participants (8-9 years, n=21; 15-16 years, n=19) completed a PLR assessment 1 h before their habitual bedtime. After a 1 h dim-light adaptation period (<1 lux), baseline pupil diameter was measured in darkness for 30 s, followed by a 10 s exposure to 3.0×1013 photons/cm2/s of either red (627 nm) or blue (459 nm) light, and a 40 s recovery in darkness to assess pupillary re-dilation. Subsequently, participants underwent 7 min of dim-light re-adaptation followed by an exposure to the other light condition. Lights were counterbalanced across participants.

Results

Across both age groups, maximum pupil constriction was significantly greater (p< 0.001, ηp2=0.48) and more sustained (p< 0.001, ηp2=0.41) during exposure to blue compared to red light. For adolescents, the post-illumination pupillary response (PIPR), a hallmark of melanopsin function, was larger after blue compared with red light (p= 0.02, d=0.60). This difference was not observed in children. Across light exposures, children had larger phasic (p< 0.01, ηp2=0.20) and maximal (p< 0.01, ηp2=0.22) pupil constrictions compared to adolescents.

Conclusions

Blue light elicited a greater and more sustained pupillary response than red light across participants. However, the overall amplitude of the rod/cone-driven phasic response was greater in children than in adolescents. Our findings using the PLR highlight a higher sensitivity to evening light in children compared to adolescents, and continued maturation of the human non-visual photoreception/system throughout development.

Review on age-related differences in non-visual effects of light: melatonin suppression, circadian phase shift and pupillary light reflex in children to older adults

Physiological effects of light exposure in humans are diverse. Among them, the circadian rhythm phase shift effect in order to maintain a 24-h cycle of the biological clock is referred to as non-visual effects of light collectively with melatonin suppression and pupillary light reflex. The non-visual effects of light may differ depending on age, and clarifying age-related differences in the non-visual effects of light is important for providing appropriate light environments for people of different ages. Therefore, in various research fields, including physiological anthropology, many studies on the effects of age on non-visual functions have been carried out in older people, children and adolescents by comparing the effects with young adults. However, whether the non-visual effects of light vary depending on age and, if so, what factors contribute to the differences have remained unclear. In this review, results of past and recent studies on age-related differences in the non-visual effects of light are presented and discussed in order to provide clues for answering the question of whether non-visual effects of light actually vary depending on age. Some studies, especially studies focusing on older people, have shown age-related differences in non-visual functions including differences in melatonin suppression, circadian phase shift and pupillary light reflex, while other studies have shown no differences. Studies showing age-related differences in the non-visual effects of light have suspected senile constriction and crystalline lens opacity as factors contributing to the differences, while studies showing no age-related differences have suspected the presence of a compensatory mechanism. Some studies in children and adolescents have shown that children's non-visual functions may be highly sensitive to light, but the studies comparing with other age groups seem to have been limited. In order to study age-related differences in non-visual effects in detail, comparative studies should be conducted using subjects having a wide range of ages and with as much control as possible for intensity, wavelength component, duration, circadian timing, illumination method of light exposure, and other factors (mydriasis or non-mydriasis, cataracts or not in the older adults, etc.).

Topical Review: Optometry in Nepal-Clinical Practice, Research Advances, and Challenges

SIGNIFICANCE

This article reviews educational standard, clinical practice, research advances, and challenges associated with optometry in Nepal and provides critical considerations for contemporary and new optometry programs in countries with similar socioeconomic status and health care systems.Optometry education started in Nepal in 1998 with the primary objective of addressing the unmet needs of eye health and vision care in the country. Over the last two decades, this program has made significant contributions to facilitating and improving the delivery of quality eye care and establishing the nation's eye health system as an exemplary model in South Asia. Despite the positive impact in a short time, optometry education and the profession continue to face several challenges, including a shortage of training resources and facilities, poor quality control and regulation of practice standards, lack of professional recognition, limited pathways for entry to governmental jobs via the national public service commission, and limited clinical and academic opportunities in existing eye care programs. This article reviews current education and clinical practice standards, highlights research advances, and discusses present and future challenges in sustaining and improving the quality of education and advancing the scope of practice of optometry in Nepal. Given the limited access to primary eye care services in Nepal, appropriate professional recognition and integration into the national health system, and initiatives targeted at improving the delivery of optometry education in alignment with successful international models may provide a long-sought solution to making eye care services accessible to all and lowering the burden of visual impairment in the country.

Alterations of color vision and pupillary light responses in age-related macular degeneration

Introduction

Age-related macular degeneration (AMD) is the leading cause of irreversible central vision loss in developed countries and one of the leading causes of blindness. In this work, we evaluated color vision and the pupil light reflex (PLR) to assess visual function in patients with early and neovascular AMD (NVAMD) compared with the control group.

Methods

We recruited 34 early patients with dry AMD and classified them into two groups following AREDS: 13 patients with NVAMD and 24 healthy controls. Controls and patients with early dry AMD had visual acuity (VA) best or equal to 20/25 (0.098 logMAR). Color vision was assessed in controls and patients with early dry AMD using the Cambridge Color Test (CCT) 2.0 through the Trivector protocol. The PLR was evaluated using a Ganzfeld, controlled by the RETI-port system. The stimuli consisted of 1s blue (470 nm) and red (631 nm) light flashes presented alternately at 2-min intervals. To assess the cone contribution, we used a red flash at 2.4 log cd.m^-2, with a blue background at 0.78 log cd.m^-2. For rods, we used 470-nm flashes at -3 log cd.m^-2, and for the melanopsin function of ipRGCs, we used 470 nm at 2.4 log cd.m^-2.

Results

Patients with early dry AMD had reduced color discrimination in all three axes: protan (p = 0.0087), deutan (p = 0.0180), and tritan (p = 0.0095) when compared with the control group. The PLR has also been affected in patients with early dry AMD and patients with NVAMD. The amplitude for the melanopsin-driven response was smaller in patients with early dry AMD (p = 0.0485) and NVAMD (p = 0.0035) than in the control group. The melanopsin function was lower in patients with NVAMD (p = 0.0290) than the control group. For the rod-driven response, the latency was lower in the NVAMD group (p = 0.0041) than in the control group. No changes were found in cone-driven responses between the control and AMD groups.

Conclusion

Patients with early dry AMD present diffusely acquired color vision alteration detected by CCT. Rods and melanopsin contributions for PLR are affected in NVAMD. The CCT and the PLR may be considered sensitive tests to evaluate and monitor functional changes in patients with AMD.

The effect of intrinsically photosensitive retinal ganglion cell (ipRGC) stimulation on axial length changes to imposed optical defocus in young adults

PURPOSE

The intrinsically photosensitive retinal ganglion cells (ipRGCs) regulate pupil size and circadian rhythms. Stimulation of the ipRGCs using short-wavelength blue light causes a sustained pupil constriction known as the post-illumination pupil response (PIPR). Here we examined the effects of ipRGC stimulation on axial length changes to imposed optical defocus in young adults.

MATERIALS AND METHODS

Nearly emmetropic young participants were given either myopic (+3 D, n = 16) or hyperopic (-3 D, n = 17) defocus in their right eye for 2 h. Before and after defocus, a series of axial length measurements for up to 180 s were performed in the right eye using the IOL Master following exposure to 5 s red (625 nm, 3.74 × 10¹⁴ photons/cm²/s) and blue (470 nm, 3.29 × 10¹⁴ photons/cm²/s) stimuli. The pupil measurements were collected from the left eye to track the ipRGC activity. The 6 s and 30 s PIPR, early and late area under the curve (AUC), and time to return to baseline were calculated.

RESULTS

The PIPR with blue light was significantly stronger after 2 h of hyperopic defocus as indicated by a lower 6 and 30 s PIPR and a larger early and late AUC (all p<0.05). Short-wavelength ipRGC stimulation also significantly exaggerated the ocular response to hyperopic defocus, causing a significantly greater increase in axial length than that resulting from the hyperopic defocus alone (p = 0.017). Neither wavelength had any effect on axial length with myopic defocus.

CONCLUSIONS

These findings suggest an interaction between myopiagenic hyperopic defocus and ipRGC signaling.

Do static and dynamic pupillary parameters differ according to childhood, adulthood, and old age? A quantitative study in healthy volunteers

Purpose

We aimed to evaluate the normative pupillometry values and mean pupil dilatation speed in healthy individuals in different age groups in our study.

Methods

The study group included 180 eyes of 90 healthy volunteers in different age groups. Group 1 consisted of 30 participants between the ages of 6 and 18, group 2 consisted of 30 participants aged 19-40, and group 3 consisted of 30 participants aged 41-75. Scotopic, mesopic, photopic, and dynamic measurements were taken with automatic pupillometry of Sirius Topographer (CSO, Firenze, Italy). The mean pupil dilation speed at the 18^th second was calculated according to dynamic measurements.

Results

Group 1 had a significantly larger pupil diameter than groups 2 and 3 in all static and dynamic parameters, and the mean pupil dilation speed was the highest among the groups (P < 0.001 for all static and dynamic parameters). In addition, group 2 had a significantly larger pupil diameter than group 3 (P < 0.001 for all static and dynamic parameters) and the mean pupil dilation speed was faster than group 3 (P = 0.027).

Conclusion

We have presented the static and dynamic parameters and the mean speed of pupil dilatation at the 18^th second with automatic pupillometry in healthy individuals in childhood, adulthood, and old age. More studies with higher participants and younger age children are needed.

Keep Your Mask On: The Benefits of Masking for Behavior and the Contributions of Aging and Disease on Dysfunctional Masking Pathways

Environmental cues (e.g., light-dark cycle) have an immediate and direct effect on behavior, but these cues are also capable of “masking” the expression of the circadian pacemaker, depending on the type of cue presented, the time-of-day when they are presented, and the temporal niche of the organism. Masking is capable of complementing entrainment, the process by which an organism is synchronized to environmental cues, if the cues are presented at an expected or predictable time-of-day, but masking can also disrupt entrainment if the cues are presented at an inappropriate time-of-day. Therefore, masking is independent of but complementary to the biological circadian pacemaker that resides within the brain (i.e., suprachiasmatic nucleus) when exogenous stimuli are presented at predictable times of day. Importantly, environmental cues are capable of either inducing sleep or wakefulness depending on the organism’s temporal niche; therefore, the same presentation of a stimulus can affect behavior quite differently in diurnal vs. nocturnal organisms. There is a growing literature examining the neural mechanisms underlying masking behavior based on the temporal niche of the organism. However, the importance of these mechanisms in governing the daily behaviors of mammals and the possible implications on human health have been gravely overlooked even as modern society enables the manipulation of these environmental cues. Recent publications have demonstrated that the effects of masking weakens significantly with old age resulting in deleterious effects on many behaviors, including sleep and wakefulness. This review will clearly outline the history, definition, and importance of masking, the environmental cues that induce the behavior, the neural mechanisms that drive them, and the possible implications for human health and medicine. New insights about how masking is affected by intrinsically photosensitive retinal ganglion cells, temporal niche, and age will be discussed as each relates to human health. The overarching goals of this review include highlighting the importance of masking in the expression of daily rhythms, elucidating the impact of aging, discussing the relationship between dysfunctional masking behavior and the development of sleep-related disorders, and considering the use of masking as a non-invasive treatment to help treat humans suffering from sleep-related disorders.

Light-induced charge generation in polymeric nanoparticles restores vision in advanced-stage retinitis pigmentosa rats

Retinal dystrophies such as Retinitis pigmentosa are among the most prevalent causes of inherited legal blindness, for which treatments are in demand. Retinal prostheses have been developed to stimulate the inner retinal network that, initially spared by degeneration, deteriorates in the late stages of the disease. We recently reported that conjugated polymer nanoparticles persistently rescue visual activities after a single subretinal injection in the Royal College of Surgeons rat model of Retinitis pigmentosa. Here we demonstrate that conjugated polymer nanoparticles can reinstate physiological signals at the cortical level and visually driven activities when microinjected in 10-months-old Royal College of Surgeons rats bearing fully light-insensitive retinas. The extent of visual restoration positively correlates with the nanoparticle density and hybrid contacts with second-order retinal neurons. The results establish the functional role of organic photovoltaic nanoparticles in restoring visual activities in fully degenerate retinas with intense inner retina rewiring, a stage of the disease in which patients are subjected to prosthetic interventions.

Retinal dystrophies such as Retinitis pigmentosa are among the most prevalent causes of inherited incurable legal blindness. Here the authors demonstrate that conjugated polymer nanoparticles reinstate visual functions in aged rats with fully degenerated and rewired retinas.

The intrinsically photosensitive retinal ganglion cell (ipRGC) mediated pupil response in young adult humans with refractive errors

PURPOSE

The intrinsically photosensitive retinal ganglion cells (ipRGCs) signal environmental light, with axons projected to the midbrain that control pupil size and circadian rhythms. Post-illumination pupil response (PIPR), a sustained pupil constriction after short-wavelength light stimulation, is an indirect measure of ipRGC activity. Here, we measured the PIPR in young adults with various refractive errors using a custom-made optical system.

METHODS

PIPR was measured on myopic (-3.50 ± 1.82 D, n = 20) and non-myopic (+0.28 ± 0.23 D, n = 19) participants (mean age, 23.36 ± 3.06 years). The right eye was dilated and presented with long-wavelength (red, 625 nm, 3.68 × 10¹⁴ photons/cm²/s) and short-wavelength (blue, 470 nm, 3.24 × 10¹⁴ photons/cm²/s) 1 s and 5 s pulses of light, and the consensual response was measured in the left eye for 60 s following light offset. The 6 s and 30 s PIPR and early and late area under the curve (AUC) for 1 and 5 s stimuli were calculated.

RESULTS

For most subjects, the 6 s and 30 s PIPR were significantly lower (p < 0.001), and the early and late AUC were significantly larger for 1 s blue light compared to red light (p < 0.001), suggesting a strong ipRGC response. The 5 s blue stimulation induced a slightly stronger melanopsin response, compared to 1 s stimulation with the same wavelength. However, none of the PIPR metrics were different between myopes and non-myopes for either stimulus duration (p > 0.05).

CONCLUSIONS

We confirm previous research that there is no effect of refractive error on the PIPR.

Association Between Postillumination Pupil Response and Glaucoma Severity: A Cross-Sectional Analysis of the LIGHT Study

Purpose

This study determines whether the functional and structural severity of glaucoma is associated with intrinsically photosensitive retinal ganglion cell (ipRGC) function.

Methods

This cross-sectional study assessed 148 eyes from 148 patients with glaucoma (mean age 70.5 years). The ipRGC function was assessed by postillumination pupil response (PIPR) using the pupil diameter after exposure to blue and red light. Main outcome measures were as follows: six-second PIPR amplitude, net PIPR, and net PIPR change. Functional and structural glaucoma severities were evaluated using visual field mean deviation (MD) and the circumpapillary retinal nerve fiber layer (RNFL) thickness, respectively.

Results

Multivariable analysis adjusting for age, sex, body mass index, hypertension, diabetes, oral medication use, cataract surgery, axial length, and topical alpha₂-adrenergic receptor agonist use showed that worsening in visual field MD was significantly associated with higher blue six-second PIPR amplitude (regression coefficient per −1 dB worsening, 0.25; 95% confidence intervals [CI], 0.14, 0.37; P < 0.001). The thinner RNFL thickness was significantly associated with higher blue six-second PIPR amplitude, lower Net PIPR change, and lower net PIPR (blue six-second PIPR amplitude: regression coefficient per 10-µm thinning, 1.29; 95% CI, 0.72, 1.87; P < 0.001; net PIPR change: regression coefficient, −0.70; 95% CI, −1.26, −0.14; P = 0.015; net PIPR: regression coefficient, −0.03; 95% CI, −0.05, −0.001; P = 0.044). No significant association was found between glaucoma severity and red six-second PIPR amplitude.

Conclusions

Our findings revealed a significant association between functional and structural glaucoma severity and impaired ipRGC function independent of potential confounders.

Spectral dependency of the human pupillary light reflex. Influences of pre-adaptation and chronotype

Non-visual photoreceptors (ipRGCs) and rods both exert a strong influence on the human pupil, yet pupil models regularly use cone-derived sensitivity as their basis. This inconsistency is further exacerbated by the fact that circadian effects can modulate the wavelength sensitivity. We assessed the pupillary reaction to narrowband light stimuli in the mesopic range. Pupil size for eighty-three healthy participants with normal color vision was measured in nine experimental protocols with varying series of continuous or discontinuous light stimuli under Ganzfeld conditions, presented after 90 seconds of dark adaptation. One hundred and fifty series of stimulation were conducted across three experiments, and were analyzed for wavelength-dependency on the normalized pupillary constriction (nPC), conditional on experimental settings and individual traits. Traits were surveyed by questionnaire; color vision was tested by Ishihara plates or the Lanthony D15 test. Data were analyzed with generalized additive mixed models (GAMM). The normalized pupillary constriction response is consistent with L+M-cone derived sensitivity when the series of light stimuli is continuous, i.e., is not interrupted by periods of darkness, but not otherwise. The results also show that a mesopic illuminance weighing led to an overall best prediction of pupillary constriction compared to other types of illuminance measures. IpRGC influence on nPC is not readily apparent from the results. When we explored the interaction of chronotype and time of day on the wavelength dependency, differences consistent with ipRGC influence became apparent. The models indicate that subjects of differing chronotype show a heightened or lowered sensitivity to short wavelengths, depending on their time of preference. IpRGC influence is also seen in the post-illumination pupil reflex if the prior light-stimulus duration is one second. However, shorter wavelengths than expected become more important if the light-stimulus duration is fifteen or thirty seconds. The influence of sex on nPC was present, but showed no interaction with wavelength. Our results help to define the conditions, under which the different wavelength sensitivities in the literature hold up for narrowband light settings. The chronotype effect might signify a mechanism for strengthening the individual´s chronotype. It could also be the result of the participant’s prior exposure to light (light history). Our explorative findings for this effect demand replication in a controlled study.

Functional Brain Imaging During Extra-Ocular Light Stimulation in Anophthalmic and Sighted Participants: No Evidence for Extra-Ocular Photosensitive Receptors

Light plays a critical role in regulating physiology and behavior, including both visual and non-visual responses. In mammals, loss of both eyes abolishes all of these responses, demonstrating that the photoreceptors involved are exclusively ocular. By contrast, many non-mammalian species possess extra-ocular photoreceptors located in the pineal complex and deep brain. Whilst there have been suggestions of extra-ocular photoreception in mammals, including man, evidence for these photoreceptors is limited. One approach to objectively determine the presence of such receptors is to measure brain responses to light using functional magnetic resonance imaging (fMRI). Moreover, by using participants who are clinically anophthalmic (congenital and acquired), it is possible to investigate potential light detection in the absence of the retina. Here we scanned participants with anophthalmia and sighted participants in 4 different conditions; the first 3 conditions had a bright light source applied to the following locations: behind the right ear ("ear"), just below the nasal bridge and between the eyes ("head"), and at the right popliteal fossa ("knee"). In the fourth and final scan, the light source was switched off so that there was no light stimulus. All participants were scanned in a completely dark room. No consistent brain activity was detected during any of the light conditions in either sighted controls or anophthalmic participants. Thus, we do not provide any evidence for the presence of extraocular photoreceptors modulating human brain activity, despite recent evidence for gene transcription that may occur as a result of these photoreceptors.

Ambient-task combined lighting to regulate autonomic and psychomotor arousal levels without compromising subjective comfort to lighting

Background

Although evidence of both beneficial and adverse biological effects of lighting has accumulated, biologically favorable lighting often does not match subjectively comfortable lighting. By controlling the correlated color temperature (CCT) of ambient lights, we investigated the feasibility of combined lighting that meets both biological requirements and subjective comfort.

Methods

Two types of combined lightings were compared; one consisted of a high-CCT (12000 K) light-emitting diode (LED) panel as the ambient light and a low-CCT (5000 K) LED stand light as the task light (high-low combined lighting), and the other consisted of a low-CCT (4500 K) LED panel as the ambient light and the same low-CCT (5000 K) stand light as the task light (low-low combined lighting) as control. Ten healthy subjects (5 young and 5 elderly) were exposed to the two types of lighting on separate days. Autonomic function by heart rate variability, psychomotor performances, and subjective comfort were compared.

Results

Both at sitting rest and during psychomotor workload, heart rate was higher and the parasympathetic index of heart rate variability was lower under the high-low combined lighting than the low-low combined lighting in both young and elderly subject groups. Increased psychomotor alertness in the elderly and improved sustainability of concentration work performance in both age groups were also observed under the high-low combined lighting. However, no significant difference was observed in the visual-analog-scale assessment of subjective comfort between the two types of lightings.

Conclusions

High-CCT ambient lighting, even when used in combination with low-CCT task lighting, could increase autonomic and psychomotor arousal levels without compromising subjective comfort. This finding suggests the feasibility of independent control of ambient and task lighting as a way to achieve both biological function regulation and subjective comfort.

Intrinsically photosensitive retinal ganglion cell-driven pupil responses in patients with traumatic brain injury

Previous findings regarding intrinsically photosensitive retinal ganglion cell (ipRGC) function after traumatic brain injury (TBI) are conflicting. We examined ipRGC-driven pupil responses in civilian TBI and control participants using two pupillography protocols that assessed transient and adaptive properties: (1) a one second (s) long wavelength "red" stimulus (651 nm, 133 cd/m²) and 10 increasing intensities of 1 s short wavelength "blue" stimuli (456 nm, 0.167 to 167 cd/m²) with a 60 s interstimulus interval, and (2) two minutes of 0.1 Hz red stimuli (33 cd/m²), followed by two minutes of 0.1 Hz blue stimuli (16 cd/m²). For Protocol 1, constriction amplitude and the 6 s post illumination pupil response (PIPR) were calculated. For Protocol 2, amplitudes and peak velocities of pupil constriction and redilation were calculated. For Protocol 1, constriction amplitude and the 6 s PIPR were not significantly different between TBI patients and control subjects for red or blue stimuli. For Protocol 2, pupil constriction amplitude attenuated over time for red stimuli and potentiated over time for blue stimuli across all subjects. Constriction and redilation velocities were similar between groups. Pupil constriction amplitude was significantly less in TBI patients compared to control subjects for red and blue stimuli, which can be attributed to age-related differences in baseline pupil size. While TBI, in addition to age, may have contributed to decreased baseline pupil diameter and constriction amplitude, responses to blue stimulation suggest no selective damage to ipRGCs.

Pupillary light response after cataract surgery in healthy patients

PURPOSE

To examine the changes in the pupillary light response after phacoemulsification and to compare the difference in the response among patients in different age categories.

STUDY DESIGN

Prospective observational study.

METHODS

Four-hundred twenty-two eyes of 422 patients in 3 age categories (60-69 years, 70-79 years, and 80-89 years) scheduled for phacoemulsification were consecutively enrolled. The eyes underwent examinations with an infrared pupillometer to obtain the parameters of the pupillary light response preoperatively and at 1 day and 1 and 3 months postoperatively. Differences in the parameters of the pupillary response were compared among 4 time intervals and the 3 age categories.

RESULTS

The mean maximum and minimum pupillary diameters significantly decreased at 1 day postoperatively and returned to the preoperative level by 1 month postoperatively (P<.0001). The mean percentage of pupillary constriction was significantly reduced at 1 and 3 months postoperatively compared with preoperatively and at 1 day postoperatively (P<.0001). The average pupillary constriction and dilation velocities were significantly lower at 1 and 3 months postoperatively than they were preoperatively and at 1 day postoperatively (P<.0001). The latency to constriction did not differ significantly among the time intervals. The percentage of pupillary constriction was significantly smaller, and the average constriction and dilation velocities were lower in association with higher age categories at all time intervals (P≤.0185).

CONCLUSION

The pupillary light response was impaired several months after cataract surgery and worsened with increasing patient age, indicating that cataract surgery may compromise the pupillary constriction and dilation functions in association with age.

Impact of age on the circadian visual system and the sleep-wake cycle in mus musculus

Age plays a critical role in disease development and tolerance to cancer treatment, often leading to an increased risk of developing negative symptoms including sleep disturbances. Circadian rhythms and sleep become disrupted as organisms age. In this study, we explored the behavioral alterations in sleep, circadian rhythms, and masking using a novel video system and interrogate the long-term impact of age-based changes in the non-image forming visual pathway on brain anatomy. We demonstrated the feasibility and utility of the novel system and establish that older mice have disruptions in sleep, circadian rhythms, and masking behaviors that were associated with major negative volume alterations in the non-imaging forming visual system, critical for the induction and rhythmic expression of sleep. These results provide important insights into a mechanism, showing brain atrophy is linked to age in distinct non-image forming visual regions, which may predispose older individuals to developing circadian and sleep dysfunction when further challenged by disease or treatment.

Myopia, or near-sightedness, is associated with delayed melatonin circadian timing and lower melatonin output in young adult humans

STUDY OBJECTIVES

Myopia, or near-sightedness, is the most common refractive vision disorder and predisposes the eye to many blinding conditions in adulthood. Recent research has suggested that myopia is associated with increased endogenous melatonin production. Here we investigated the differences in melatonin circadian timing and output in young adult myopes and non-myopes (or emmetropes) as a pathogenesis for myopia.

METHODS

A total of 18 myopic (refractive error [mean ± standard deviation] -4.89 ± 2.16 dioptres) and 14 emmetropic participants (-0.09 ± 0.13 dioptres), aged 22.06 ± 2.35 years were recruited. Circadian timing was assessed using salivary dim light melatonin onset (DLMO), collected half-hourly for 7 h, beginning 5 h before and finishing 2 h after individual average sleep onset in a sleep laboratory. Total melatonin production was assessed via aMT6s levels from urine voids collected from 06:00 pm and until wake-up time the following morning. Objective measures of sleep timing were acquired a week prior to the sleep laboratory visit using an actigraphy device.

RESULTS

Myopes (22:19 ± 1.8 h) exhibited a DLMO phase-delay of 1 hr 12 min compared with emmetropes (21:07 ± 1.4 h), p = 0.026, d = 0.73. Urinary aMT6s melatonin levels were significantly lower among myopes (29.17 ± 18.67) than emmetropes (42.51 ± 23.97, p = 0.04, d = 0.63). Myopes also had a significant delay in sleep onset, greater sleep onset latency, shorter sleep duration, and more evening-type diurnal preference than emmetropes (all p < 0.05).

CONCLUSIONS

These findings suggest a potential association between circadian rhythms and myopia in humans.

Computer Vision for Brain Disorders Based Primarily on Ocular Responses

Real-time ocular responses are tightly associated with emotional and cognitive processing within the central nervous system. Patterns seen in saccades, pupillary responses, and spontaneous blinking, as well as retinal microvasculature and morphology visualized via office-based ophthalmic imaging, are potential biomarkers for the screening and evaluation of cognitive and psychiatric disorders. In this review, we outline multiple techniques in which ocular assessments may serve as a non-invasive approach for the early detections of various brain disorders, such as autism spectrum disorder (ASD), Alzheimer's disease (AD), schizophrenia (SZ), and major depressive disorder (MDD). In addition, rapid advances in artificial intelligence (AI) present a growing opportunity to use machine learning-based AI, especially computer vision (CV) with deep-learning neural networks, to shed new light on the field of cognitive neuroscience, which is most likely to lead to novel evaluations and interventions for brain disorders. Hence, we highlight the potential of using AI to evaluate brain disorders based primarily on ocular features.

Ocular Health of Octodon degus as a Clinical Marker for Age-Related and Age-Independent Neurodegeneration

The aging process and age-related diseases such as Alzheimer’s disease (AD), are very heterogeneous and multifactorial, making it challenging to diagnose the disease based solely on genetic, behavioral tests, or clinical history. It is yet to be explained what ophthalmological tests relate specifically to aging and AD. To this end, we have selected the common degu (Octodon degus) as a model for aging which develops AD-like signs to conduct ophthalmological screening methods that could be clinical markers of aging and AD. We investigated ocular health using ophthalmoscopy, fundus photography, intraocular pressure (IOP), and pupillary light reflex (PLR). The results showed significant presence of cataracts in adult degus and IOP was also found to increase significantly with advancing age. Age had a significant effect on the maximum pupil constriction but other pupil parameters changed in an age-independent manner (PIPR retention index, resting pupil size, constriction velocity, redilation plateau). We concluded that degus have underlying factors at play that regulate PLR and may be connected to sympathetic, parasympathetic, and melanopsin retinal ganglion cell (ipRGC) deterioration. This study provides the basis for the use of ocular tests as screening methods for the aging process and monitoring of neurodegeneration in non-invasive ways.

Intrinsically Photosensitive Retinal Ganglion Cells of the Human Retina

Light profoundly affects our mental and physical health. In particular, light, when not delivered at the appropriate time, may have detrimental effects. In mammals, light is perceived not only by rods and cones but also by a subset of retinal ganglion cells that express the photopigment melanopsin that renders them intrinsically photosensitive (ipRGCs). ipRGCs participate in contrast detection and play critical roles in non-image-forming vision, a set of light responses that include circadian entrainment, pupillary light reflex (PLR), and the modulation of sleep/alertness, and mood. ipRGCs are also found in the human retina, and their response to light has been characterized indirectly through the suppression of nocturnal melatonin and PLR. However, until recently, human ipRGCs had rarely been investigated directly. This gap is progressively being filled as, over the last years, an increasing number of studies provided descriptions of their morphology, responses to light, and gene expression. Here, I review the progress in our knowledge of human ipRGCs, in particular, the different morphological and functional subtypes described so far and how they match the murine subtypes. I also highlight questions that remain to be addressed. Investigating ipRGCs is critical as these few cells play a major role in our well-being. Additionally, as ipRGCs display increased vulnerability or resilience to certain disorders compared to conventional RGCs, a deeper knowledge of their function could help identify therapeutic approaches or develop diagnostic tools. Overall, a better understanding of how light is perceived by the human eye will help deliver precise light usage recommendations and implement light-based therapeutic interventions to improve cognitive performance, mood, and life quality.

Effects of Mydriatics on Rod/Cone- and Melanopsin-driven Pupil Responses

SIGNIFICANCE

Pupillometry protocols evaluating rod/cone- and melanopsin-driven responses often use mydriatics to ensure maximal stimulus exposure; however, retinal effects of mydriatics are not fully understood. We demonstrate that dilation with either atropine or phenylephrine results in similar enhancements of rod/cone- and melanopsin-driven pupil responses.

PURPOSE

The purposes of this study were to compare the effects of atropine, a muscarinic antagonist, and phenylephrine, an adrenergic agonist, on consensual pupil responses and to assess the repeatability of pupil metrics without mydriasis.

METHODS

Right eye pupil responses of 20 adults aged 21 to 42 years were recorded before and 45 minutes after instillation of 0.5% atropine or 2.5% phenylephrine in the left eye. Stimuli were presented to the left eye and included six alternating 1-second 651-nm "red" and 456-nm "blue" flashes. Metrics included baseline pupil diameter, maximal constriction, 6- and 30-second post-illumination pupil responses, and early (0 to 10 seconds) and late (10 to 30 seconds) areas under the curve.

RESULTS

Dilation of the stimulated eye with either mydriatic significantly increased the 6-second post-illumination pupil response and early and late areas under the curve for blue stimuli, and early area under the curve for red stimuli (P < .05 for all). Melanopsin-driven post-illumination pupil responses, achieved with either phenylephrine or atropine, did not significantly differ from each other (P > .05 for all). Without mydriasis, intersession intraclass correlation coefficients for pupil metrics were 0.63 and 0.50 (6- and 30-second post-illumination pupil responses, respectively) and 0.78 and 0.44 (early and late areas under the curve, respectively) for blue stimuli, with no significant difference between sessions (P > .05 for all).

CONCLUSIONS

Dilation with phenylephrine or atropine resulted in similar enhancements of the rod/cone- and melanopsin-driven pupil responses, despite differing mechanisms. Early pupil metrics without mydriasis demonstrated moderate to good intersession repeatability.

Cataract type and pupillary response to blue and white light stimuli

We evaluated the pupil reaction to blue and white light stimulation in 70 eyes with cataract and in 38 eyes with a selective blue-light filtering intra-ocular lens. The diameter of the pupil before stimulation was set as baseline (BPD) and, after a stimulus duration of 1 s, the post-illumination pupillary response (PIPR) was measured using an electronic pupillometer. The BPD showed no significant difference among three grades of nuclear sclerosis (NS). In contrast, the PIPRs differed significantly among the NS grades eyes including with and without subcapsular cataract (SC) and IOL eyes for white light (p < 0.05, Kruskal-Wallis test), but not for blue light. Subcapsular opacity did not affect the BPD or PIPR in all cataract grades for either light stimulus. The tendency of larger PIPR in the pseudophakic eyes than the cataract eyes for both lights, however significant difference was found only for white light (p < 0.05 for white light, p > 0.05 for blue light). Our study demonstrates retention of the PIPR for blue light, but not for white light in cataract eyes. We also confirmed that the pupillary response in pseudohakic eyes with a selective blue light-filtering intra ocular lens was greater than that in cataractous eyes for white light.

Retina and melanopsin neurons

Melanopsin retinal ganglion cells (mRGCs) are the third class of retinal photoreceptors with unique anatomical, electrophysiological, and biological features. There are different mRGC subtypes with differential projections to the brain. These cells contribute to many nonimage-forming functions of the eye, the most relevant being the photoentrainment of circadian rhythms through the projections to the suprachiasmatic nucleus of the hypothalamus. Other relevant biological functions include the regulation of the pupillary light reflex, mood, alertness, and sleep, as well as a possible role in formed vision. The relevance of the mRGC-related pathways in the brain is highlighted by the role that the dysfunction and/or loss of these cells may play in affecting circadian rhythms and sleep in many neurodegenerative disorders including Alzheimer's, Parkinson's and Huntington's disease and in aging. Moreover, the occurrence of circadian dysfunction is a known risk factor for dementia. In this chapter, the anatomy, physiology, and functions of these cells as well as their resistance to neurodegeneration in mitochondrial optic neuropathies or their predilection to be lost in other neurodegenerative disorders will be discussed.

Light and myopia: from epidemiological studies to neurobiological mechanisms

Myopia is far beyond its inconvenience and represents a true, highly prevalent, sight-threatening ocular condition, especially in Asia. Without adequate interventions, the current epidemic of myopia is projected to affect 50% of the world population by 2050, becoming the leading cause of irreversible blindness. Although blurred vision, the predominant symptom of myopia, can be improved by contact lenses, glasses or refractive surgery, corrected myopia, particularly high myopia, still carries the risk of secondary blinding complications such as glaucoma, myopic maculopathy and retinal detachment, prompting the need for prevention. Epidemiological studies have reported an association between outdoor time and myopia prevention in children. The protective effect of time spent outdoors could be due to the unique characteristics (intensity, spectral distribution, temporal pattern, etc.) of sunlight that are lacking in artificial lighting. Concomitantly, studies in animal models have highlighted the efficacy of light and its components in delaying or even stopping the development of myopia and endeavoured to elucidate possible mechanisms involved in this process. In this narrative review, we (1) summarize the current knowledge concerning light modulation of ocular growth and refractive error development based on studies in human and animal models, (2) summarize potential neurobiological mechanisms involved in the effects of light on ocular growth and emmetropization and (3) highlight a potential pathway for the translational development of noninvasive light-therapy strategies for myopia prevention in children.

The Effect of Refractive Error on Melanopsin-Driven Pupillary Responses

Purpose

Human and animal studies suggest that light-mediated dopamine release may underlie the protective effect of time outdoors on myopia development. Melanopsin-containing retinal ganglion cells may be involved in this process by integrating ambient light exposure and regulating retinal dopamine levels. The study evaluates this potential involvement by examining whether melanopsin-driven pupillary responses are associated with adult refractive error.

Methods

Subjects were 45 young adults (73% female, 24.1 ± 1.8 years) with refractive errors ranging from –6.33 D to +1.70 D. The RAPDx (Konan Medical) pupillometer measured normalized pupillary responses to three forms of square-wave light pulses alternating with darkness at 0.1 Hz: alternating long wavelength (red, peak at 608 nm) and short wavelength (blue, peak at 448 nm), followed by red only and then blue only.

Results

Non-myopic subjects displayed greater pupillary constriction in the blue-only condition and slower redilation following blue light offset than subjects with myopia (P = 0.011). Pupillary responses were not significantly different between myopic and non-myopic subjects in the red-only condition (P = 0.15). More hyperopic/less myopic refractive error as a continuous variable was linearly related to larger increases in pupillary constriction in response to blue-only stimuli (r = 0.48, P = 0.001).

Conclusions

Repeated light exposures to blue test stimuli resulted in an adaptation in the pupillary response (more constriction and slower redilation), presumably due to increased melanopsin-mediated input in more hyperopic/less myopic adults. This adaptive property supports a possible role for these ganglion cells in the protective effects of time outdoors on myopia development.

Chromatic Pupillometry Findings in Alzheimer's Disease

Intrinsically photosensitive melanopsin retinal ganglion cells (mRGCs) are crucial for non-image forming functions of the eye, including the photoentrainment of circadian rhythms and the regulation of the pupillary light reflex (PLR). Chromatic pupillometry, using light stimuli at different wavelengths, makes possible the isolation of the contribution of rods, cones, and mRGCs to the PLR. In particular, post-illumination pupil response (PIPR) is the most reliable pupil metric of mRGC function. We have previously described, in post-mortem investigations of AD retinas, a loss of mRGCs, and in the remaining mRGCs, we demonstrated extensive morphological abnormalities. We noted dendrite varicosities, patchy distribution of melanopsin, and reduced dendrite arborization. In this study, we evaluated, with chromatic pupillometry, the PLR in a cohort of mild-moderate AD patients compared to controls. AD and controls also underwent an extensive ophthalmological evaluation. In our AD cohort, PIPR did not significantly differ from controls, even though we observed a higher variability in the AD group and 5/26 showed PIPR values outside the 2 SD from the control mean values. Moreover, we found a significant difference between AD and controls in terms of rod-mediated transient PLR amplitude. These results suggest that in the early stage of AD there are PLR abnormalities that may reflect a pathology affecting mRGC dendrites before involving the mRGC cell body. Further studies, including AD cases with more severe and longer disease duration, are needed to further explore this hypothesis.

The ipRGC-Driven Pupil Response with Light Exposure, Refractive Error, and Sleep

SIGNIFICANCE

We investigated links between the intrinsically photosensitive retinal ganglion cells, light exposure, refractive error, and sleep. Results showed that morning melatonin was associated with light exposure, with modest differences in sleep quality between myopes and emmetropes. Findings suggest a complex relationship between light exposure and these physiological processes.

PURPOSE

Intrinsically photosensitive retinal ganglion cells (ipRGCs) signal environmental light, with pathways to the midbrain to control pupil size and circadian rhythm. Evidence suggests that light exposure plays a role in refractive error development. Our goal was to investigate links between light exposure, ipRGCs, refractive error, and sleep.

METHODS

Fifty subjects, aged 17-40, participated (19 emmetropes and 31 myopes). A subset of subjects (n = 24) wore an Actiwatch Spectrum for 1 week. The Pittsburgh Sleep Quality Index (PSQI) was administered, and saliva samples were collected for melatonin analysis. The post-illumination pupil response (PIPR) to 1 s and 5 s long- and short-wavelength stimuli was measured. Pupil metrics included the 6 s and 30 s PIPR and early and late area under the curve.

RESULTS

Subjects spent 104.8 ± 46.6 min outdoors per day over the previous week. Morning melatonin concentration (6.9 ± 3.5 pg/ml) was significantly associated with time outdoors and objectively measured light exposure (P = .01 and .002, respectively). Pupil metrics were not significantly associated with light exposure or refractive error. PSQI scores indicated good sleep quality for emmetropes (score 4.2 ± 2.3) and poor sleep quality for myopes (5.6 ± 2.2, P = .04).

CONCLUSIONS

We found that light exposure and time outdoors influenced morning melatonin concentration. No differences in melatonin or the ipRGC-driven pupil response were observed between refractive error groups, although myopes exhibited poor sleep quality compared to emmetropes. Findings suggest that a complex relationship between light exposure, ipRGCs, refractive error, and sleep exists.

Light-Induced Pupillary Responses in Alzheimer's Disease

The impact of Alzheimer's disease (AD) on the pupillary light response (PLR) is controversial, being dependent on the stage of the disease and on the experimental pupillometric protocols. The main hypothesis driving pupillometry research in AD is based on the concept that the AD-related neurodegeneration affects both the parasympathetic and the sympathetic arms of the PLR (cholinergic and noradrenergic theory), combined with additional alterations of the afferent limb, involving the melanopsin expressing retinal ganglion cells (mRGCs), subserving the PLR. Only a few studies have evaluated the value of pupillometry as a potential biomarker in AD, providing various results compatible with parasympathetic dysfunction, displaying increased latency of pupillary constriction to light, decreased constriction amplitude, faster redilation after light offset, decreased maximum velocity of constriction (MCV) and maximum constriction acceleration (MCA) compared to controls. Decreased MCV and MCA appeared to be the most accurate of all PLR parameters allowing differentiation between AD and healthy controls while increased post-illumination pupillary response was the most consistent feature, however, these results could not be replicated by more recent studies, focusing on early and pre-clinical stages of the disease. Whether static or dynamic pupillometry yields useful biomarkers for AD screening or diagnosis remains unclear. In this review, we synopsize the current knowledge on pupillometric features in AD and other neurodegenerative diseases, and discuss potential roles of pupillometry in AD detection, diagnosis and monitoring, alone or in combination with additional biomarkers.

Effects of low and moderate refractive errors on chromatic pupillometry

Chromatic pupillometry is an emerging modality in the assessment of retinal and optic nerve disorders. Herein, we evaluate the effect of low and moderate refractive errors on pupillary responses to blue- and red-light stimuli in a healthy older population. This study included 139 participants (≥50 years) grouped by refractive error: moderate myopes (>−6.0D and ≤−3.0D, n = 24), low myopes (>−3.0D and <−0.5D, n = 30), emmetropes (≥−0.5D and ≤0.5D, n = 31) and hyperopes (>0.5D and <6.0D, n = 54). Participants were exposed to logarithmically ramping-up blue (462 nm) and red (638 nm) light stimuli, designed to sequentially activate rods, cones and intrinsically-photosensitive retinal ganglion cells. Pupil size was assessed monocularly using infra-red pupillography. Baseline pupil diameter correlated inversely with spherical equivalent (R = −0.26, P < 0.01), and positively with axial length (R = 0.37, P < 0.01) and anterior chamber depth (R = 0.43, P < 0.01). Baseline-adjusted pupillary constriction amplitudes to blue light did not differ between groups (P = 0.45), while constriction amplitudes to red light were greater in hyperopes compared to emmetropes (P = 0.04) at moderate to bright light intensities (12.25–14.0 Log photons/cm²/s). Our results demonstrate that low and moderate myopia do not alter pupillary responses to ramping-up blue- and red-light stimuli in healthy older individuals. Conversely, pupillary responses to red light should be interpreted cautiously in hyperopic eyes.

Standards in Pupillography

The number of research groups studying the pupil is increasing, as is the number of publications. Consequently, new standards in pupillography are needed to formalize the methodology including recording conditions, stimulus characteristics, as well as suitable parameters of evaluation. Since the description of intrinsically photosensitive retinal ganglion cells (ipRGCs) there has been an increased interest and broader application of pupillography in ophthalmology as well as other fields including psychology and chronobiology. Color pupillography plays an important role not only in research but also in clinical observational and therapy studies like gene therapy of hereditary retinal degenerations and psychopathology. Stimuli can vary in size, brightness, duration, and wavelength. Stimulus paradigms determine whether rhodopsin-driven rod responses, opsin-driven cone responses, or melanopsin-driven ipRGC responses are primarily elicited. Background illumination, adaptation state, and instruction for the participants will furthermore influence the results. This standard recommends a minimum set of variables to be used for pupillography and specified in the publication methodologies. Initiated at the 32nd International Pupil Colloquium 2017 in Morges, Switzerland, the aim of this manuscript is to outline standards in pupillography based on current knowledge and experience of pupil experts in order to achieve greater comparability of pupillographic studies. Such standards will particularly facilitate the proper application of pupillography by researchers new to the field. First we describe general standards, followed by specific suggestions concerning the demands of different targets of pupil research: the afferent and efferent reflex arc, pharmacology, psychology, sleepiness-related research and animal studies.

Chromatic Pupillometry Methods for Assessing Photoreceptor Health in Retinal and Optic Nerve Diseases

The pupillary light reflex is mediated by melanopsin-containing intrinsically-photosensitive retinal ganglion cells (ipRGCs), which also receive input from rods and cones. Melanopsin-dependent pupillary light responses are short-wavelength sensitive, have a higher threshold of activation, and are much slower to activate and de-activate compared with rod/cone-mediated responses. Given that rod/cone photoreceptors and melanopsin differ in their response properties, light stimuli can be designed to stimulate preferentially each of the different photoreceptor types, providing a read-out of their function. This has given rise to chromatic pupillometry methods that aim to assess the health of outer retinal photoreceptors and ipRGCs by measuring pupillary responses to blue or red light stimuli. Here, we review different types of chromatic pupillometry protocols that have been tested in patients with retinal or optic nerve disease, including approaches that use short-duration light exposures or continuous exposure to light. Across different protocols, patients with outer retinal disease (e.g., retinitis pigmentosa or Leber congenital amaurosis) show reduced or absent pupillary responses to dim blue-light stimuli used to assess rod function, and reduced responses to moderately-bright red-light stimuli used to assess cone function. By comparison, patients with optic nerve disease (e.g., glaucoma or ischemic optic neuropathy, but not mitochondrial disease) show impaired pupillary responses during continuous exposure to bright blue-light stimuli, and a reduced post-illumination pupillary response after light offset, used to assess melanopsin function. These proof-of-concept studies demonstrate that chromatic pupillometry methods can be used to assess damage to rod/cone photoreceptors and ipRGCs. In future studies, it will be important to determine whether chromatic pupillometry methods can be used for screening and early detection of retinal and optic nerve diseases. Such methods may also prove useful for objectively evaluating the degree of recovery to ipRGC function in blind patients who undergo gene therapy or other treatments to restore vision.

The ipRGC-driven pupil response with light exposure and refractive error in children

PURPOSE

The intrinsically photosensitive retinal ganglion cells (ipRGCs) signal environmental light, control pupil size and entrain circadian rhythm. There is speculation that ipRGCs may be involved in the protective effects of light exposure in myopia. Here, the ipRGC-driven pupil response was evaluated in children and examined with light exposure and refractive error.

METHODS

Children ages 5-15 years participated. Subjects wore an actigraph device prior to the lab visit for objective measures of light exposure and sleep. For pupillometry, the left eye was dilated and presented with stimuli, and the consensual pupil response was measured in the right eye. Pupil measurements were preceded by 5 min dark adaptation. In Experiment 1 (n = 14), 1 s long wavelength light ('red,' 651 nm, 167 cd m^-2 ) and 10 increasing intensities of 1 s short wavelength light ('blue,' 456 nm, 0.167-167 cd m^-2 ) were presented with a 60 s interstimulus interval. A piecewise two-segment regression was fit to the stimulus response function to determine the functional melanopsin threshold. Pupil responses were analysed with light exposure over the previous 24 h. For Experiment 2 (n = 42), three 1 s red and three 1 s blue alternating stimuli were presented with a 60 s interstimulus interval. Following an additional 5-min dark adaption, the experiment was repeated. Pupil metrics included peak constriction, the 6 s and 30 s post-illumination response (PIPR), early and late area under the curve (AUC). Following pupil measurements, cycloplegic refractive error and axial length were measured.

RESULTS

For Experiment 1, PIPR metrics demonstrated a graded response to increasing intensity blue stimuli, with a mean functional melanopsin threshold of 6.2 ± 4.5 cd m^-2 (range: 0.84-16.7 cd m^-2 ). The 6 s PIPR and early AUC were associated with 24-h light exposure for high intensity stimuli (33.3 and 83.3 cd m^-2 , p < 0.005 for both). For Experiment 2, there were no associations between pupil metrics and refractive error. The 6 s PIPR and early AUC to blue stimuli were significantly increased for Trial 2 compared to Trial 1.

CONCLUSIONS

The ipRGC-driven pupil responses in children were robust and similar to responses previously measured in an adult population. The 6 s PIPR and early AUC to high intensity blue stimuli were associated with previous light exposure. There were no associations between the ipRGC-driven pupil response and refractive status in this cohort.

A Custom-made Pupillometer System for Characterizing Pupillary Light Response

OBJECTIVES

This paper presents the design and construction of a viable pupillometer system and demonstrates its merits with extensive validation tests.

MATERIALS AND METHODS

A web camera was modified by removing its infrared filter and mounted on a chin rest. Light emitting diodes (LEDs) operating at infrared and visible spectra were integrated to provide background and light stimulus, respectively. The LEDs were controlled by a microprocessor board. Stimulation was presented using a periodic paradigm with variable period and duty cycle. Videos of both pupils were recorded at 30 frames/second and processed offline using software developed in-house. The overall system was validated with data gathered from individuals with healthy vision under different stimulation paradigms. Temporal variations in pupil size were determined and analyzed statistically.

RESULTS

The analysis revealed that the pupil sizes were accurately measured from the video frames provided that reflections from both infrared and visible lights remain outside the pupil. The system achieved moderate to excellent repeatability scores (87.8 and 86.8% for short 1 second and long 2 second pulses, respectively), which demonstrated its effectiveness and confirmed that it can be used reliably as a pupillometer.

CONCLUSION

The proposed pupillometer system produces useful, quantitative data characterizing pupillary light response. However, further development and implementation are needed to potentially turn it into a low-cost alternative for other studies involving the autonomic nervous system, cognitive function, drug metabolism, pain response, psychology, fatigue, and sleep disorders.

Circadian rhythms, refractive development, and myopia

PURPOSE

Despite extensive research, mechanisms regulating postnatal eye growth and those responsible for ametropias are poorly understood. With the marked recent increases in myopia prevalence, robust and biologically-based clinical therapies to normalize refractive development in childhood are needed. Here, we review classic and contemporary literature about how circadian biology might provide clues to develop a framework to improve the understanding of myopia etiology, and possibly lead to rational approaches to ameliorate refractive errors developing in children.

RECENT FINDINGS

Increasing evidence implicates diurnal and circadian rhythms in eye growth and refractive error development. In both humans and animals, ocular length and other anatomical and physiological features of the eye undergo diurnal oscillations. Systemically, such rhythms are primarily generated by the 'master clock' in the surpachiasmatic nucleus, which receives input from the intrinsically photosensitive retinal ganglion cells (ipRGCs) through the activation of the photopigment melanopsin. The retina also has an endogenous circadian clock. In laboratory animals developing experimental myopia, oscillations of ocular parameters are perturbed. Retinal signaling is now believed to influence refractive development; dopamine, an important neurotransmitter found in the retina, not only entrains intrinsic retinal rhythms to the light:dark cycle, but it also modulates refractive development. Circadian clocks comprise a transcription/translation feedback control mechanism utilizing so-called clock genes that have now been associated with experimental ametropias. Contemporary clinical research is also reviving ideas first proposed in the nineteenth century that light exposures might impact refraction in children. As a result, properties of ambient lighting are being investigated in refractive development. In other areas of medical science, circadian dysregulation is now thought to impact many non-ocular disorders, likely because the patterns of modern artificial lighting exert adverse physiological effects on circadian pacemakers. How, or if, such modern light exposures and circadian dysregulation contribute to refractive development is not known.

SUMMARY

The premise of this review is that circadian biology could be a productive area worthy of increased investigation, which might lead to the improved understanding of refractive development and improved therapeutic interventions.

Eyeing up the Future of the Pupillary Light Reflex in Neurodiagnostics

The pupillary light reflex (PLR) describes the constriction and subsequent dilation of the pupil in response to light as a result of the antagonistic actions of the iris sphincter and dilator muscles. Since these muscles are innervated by the parasympathetic and sympathetic nervous systems, respectively, different parameters of the PLR can be used as indicators for either sympathetic or parasympathetic modulation. Thus, the PLR provides an important metric of autonomic nervous system function that has been exploited for a wide range of clinical applications. Measurement of the PLR using dynamic pupillometry is now an established quantitative, non-invasive tool in assessment of traumatic head injuries. This review examines the more recent application of dynamic pupillometry as a diagnostic tool for a wide range of clinical conditions, varying from neurodegenerative disease to exposure to toxic chemicals, as well as its potential in the non-invasive diagnosis of infectious disease.

Choroideremia: melanopsin-mediated postillumination pupil relaxation is abnormally slow

PURPOSE

To investigate the rod-cone and melanopsin pupillary light response (PLR) pathways in choroideremia.

METHODS

Eight patients with choroideremia and 18 healthy age-matched controls underwent chromatic pupillometry by applying blue (463 nm) and red light (643 nm) at 100 lux intensity to the right eye while recording pupil diameters. Absolute baseline pupil size (mm), normalized maximal pupil constriction and the early and late postillumination pupillary dilation, from 0 to 10 seconds and 10 to 30 seconds after the end of illumination, respectively, were determined. Postillumination responses to blue light were considered to be primarily driven by melanopsin activation of the intrinsic photosensitive retinal ganglion cells.

RESULTS

Baseline pupil diameters were comparable in patients with choroideremia and control subjects (p = 0.48). The maximum pupil constriction in patients with choroideremia was severely weakened in red light but only mildly weakened in blue light (p < 0.05). Postillumination dilation of the pupil was normal after red illumination but extremely protracted after blue illumination. Also, in contrast to healthy subjects, no abrupt change in the dilation curve was seen in the patients after the end of blue illumination, the early-phase dilation being completely abolished (p < 0.01).

CONCLUSION

Rod-cone-driven pupil responses were decreased as expected in an outer retinal degeneration, and near-normal pupil constriction in blue light supports that the melanopsin system is normal. In contrast, the lack of brisk early-phase dilation after blue illumination in choroideremia is remarkable and may be interpreted to mean that the absence of photoreceptor inhibition promotes a tonic contraction of the pupil.

Understanding the effects of mild traumatic brain injury on the pupillary light reflex

The pupillary light reflex represents an optimal visual system to investigate and exploit in the mild traumatic brain injury (mTBI) population. Static and dynamic aspects of the pupillary light reflex were investigated objectively and quantitatively in the mTBI population. Pupillary responsivity was found to be significantly delayed, slowed and reduced, but symmetrical in nature, and with a smaller baseline diameter, as compared with normals. Several pupillary parameters also discriminated between those with versus without photosensitivity. Thus, dynamic pupillometry provides several objective biomarkers for the presence of mTBI and photosensitivity, gives insight into the global sites of neurological dysfunction and possible related mechanisms, and should result in improved patient care.

Human pupillary light reflex during successive irradiation with 1-ms blue- and green-pulsed light

Background

In the human retina, the contribution of intrinsically photosensitive retinal ganglion cells (ipRGCs) to the regulation of the pupillary response remains poorly understood. The objective of the current study was to determine the response dynamics of the pupillary light reflex to short, successive pulses of light. In order to better assess the roles of ipRGCs and cones, we used pulses of blue and green light.

Methods

Each participant was exposed to 1-ms blue (466 nm) and/or green (527 nm) light pulses simultaneously or separately, with inter-stimulus intervals (ISIs) of 0, 250, 500, 750, or 1000 ms. Pupil diameter was measured using an infrared camera system.

Results

We found that human pupillary light responses during simultaneous irradiation or successive irradiation with ISIs ≤ 250 ms were equivalent, though successive irradiation of blue- and green-pulsed light with ISIs ≥ 500 ms induced markedly increased pupillary constriction.

Conclusions

We propose that this result may be related to cell hyperpolarization that occurs in the retina just after the first light stimulus is turned off, with the threshold for this effect being between 250 and 500 ms in the human retina.

Attenuation of short wavelengths alters sleep and the ipRGC pupil response

PURPOSE

Exposure to increasing amounts of artificial light during the night may contribute to the high prevalence of reported sleep dysfunction. Release of the sleep hormone melatonin is mediated by the intrinsically photosensitive retinal ganglion cells (ipRGCs). This study sought to investigate whether melatonin level and sleep quality can be modulated by decreasing night-time input to the ipRGCs.

METHODS

Subjects (ages 17-42, n = 21) wore short wavelength-blocking glasses prior to bedtime for 2 weeks. The ipRGC-mediated post illumination pupil response was measured before and after the experimental period. Stimulation was presented with a ganzfeld stimulator, including one-second and five-seconds of long and short wavelength light, and the pupil was imaged with an infrared camera. Pupil diameter was measured before, during and for 60 s following stimulation, and the six-second and 30 s post illumination pupil response and area under the curve following light offset were determined. Subjects wore an actigraph device for objective measurements of activity, light exposure, and sleep. Saliva samples were collected to assess melatonin content. The Pittsburgh Sleep Quality Index (PSQI) was administered to assess subjective sleep quality.

RESULTS

Subjects wore the blue-blocking glasses 3:57 ± 1:03 h each night. After the experimental period, the pupil showed a slower redilation phase, resulting in a significantly increased 30 s post illumination pupil response to one-second short wavelength light, and decreased area under the curve for one and five-second short wavelength light, when measured at the same time of day as baseline. Night time melatonin increased from 16.1 ± 7.5 pg mL^-1 to 25.5 ± 10.7 pg mL^-1 (P < 0.01). Objectively measured sleep duration increased 24 min, from 408.7 ± 44.9 to 431.5 ± 42.9 min (P < 0.001). Mean PSQI score improved from 5.6 ± 2.9 to 3.0 ± 2.2.

CONCLUSIONS

The use of short wavelength-blocking glasses at night increased subjectively measured sleep quality and objectively measured melatonin levels and sleep duration, presumably as a result of decreased night-time stimulation of ipRGCs. Alterations in the ipRGC-driven pupil response suggest a shift in circadian phase. Results suggest that minimising short wavelength light following sunset may help in regulating sleep patterns.

Pupillometric evaluation of the melanopsin containing retinal ganglion cells in mitochondrial and non-mitochondrial optic neuropathies

In recent years, chromatic pupillometry is used in humans to evaluate the activity of melanopsin expressing intrinsic photosensitive retinal ganglion cells (ipRGCs). Blue light is used to stimulate the ipRGCs and red light activates the rod/cone photoreceptors. The late re-dilation phase of pupillary light reflex is primarily driven by the ipRGCs. Optic neuropathies i.e. Leber hereditary optic neuropathy (LHON), autosomal dominant optic atrophy (ADOA), nonarteritic anterior ischemic optic neuropathy (NAION), glaucoma, optic neuritis and idiopathic intracranial hypertension (IIH) are among the diseases, which have been subject to pupillometric studies. The ipRGCs are differentially affected in these various optic neuropathies. In mitochondrial optic neuropathies, the ipRGCs are protected against degeneration, whereas in glaucoma, NAION, optic neuritis and IIH the ipRGCs are damaged. Here, we will review the results of pupillometric, histopathological and animal studies evaluating the ipRGCs in mitochondrial and non-mitochondrial optic neuropathies.

Loss of Melanopsin-Expressing Ganglion Cell Subtypes and Dendritic Degeneration in the Aging Human Retina

In mammals, melanopsin-expressing retinal ganglion cells (mRGCs) are, among other things, involved in several non-image-forming visual functions, including light entrainment of circadian rhythms. Considering the profound impact of aging on visual function and ophthalmic diseases, here we evaluate changes in mRGCs throughout the life span in humans. In 24 post-mortem retinas from anonymous human donors aged 10–81 years, we assessed the distribution, number and morphology of mRGCs by immunostaining vertical retinal sections and whole-mount retinas with antibodies against melanopsin. Human retinas showed melanopsin immunoreactivity in the cell body, axon and dendrites of a subset of ganglion cells at all ages tested. Nearly half of the mRGCs (51%) were located within the ganglion cell layer (GCL), and stratified in the outer (M1, 12%) or inner (M2, 16%) margin of the inner plexiform layer (IPL) or in both plexuses (M3, 23%). M1 and M2 cells conformed fairly irregular mosaics, while M3 cell distribution was slightly more regular. The rest of the mRGCs were more regularly arranged in the inner nuclear layer (INL) and stratified in the outer margin of the IPL (M1d, 49%). The quantity of each cell type decrease after age 70, when the total number of mRGCs was 31% lower than in donors aged 30–50 years. Moreover, in retinas with an age greater than 50 years, mRGCs evidenced a decrease in the dendritic area that was both progressive and age-dependent, as well as fewer branch points and terminal neurite tips per cell and a smaller Sholl area. After 70 years of age, the distribution profile of the mRGCs was closer to a random pattern than was observed in younger retinas. We conclude that advanced age is associated with a loss in density and dendritic arborization of the mRGCs in human retinas, possibly accounting for the more frequent occurrence of circadian rhythm disorders in elderly persons.

Quadrant Field Pupillometry Detects Melanopsin Dysfunction in Glaucoma Suspects and Early Glaucoma

It is difficult to detect visual function deficits in patients at risk for glaucoma (glaucoma suspects) and at early disease stages with conventional ophthalmic tests such as perimetry. To this end, we introduce a novel quadrant field measure of the melanopsin retinal ganglion cell mediated pupil light response corresponding with typical glaucomatous arcuate visual field defects. The melanopsin-mediated post-illumination pupil response (PIPR) was measured in 46 patients with different stages of glaucoma including glaucoma suspects and compared to a healthy group of 21 participants with no disease. We demonstrate that the superonasal quadrant PIPR differentiated glaucoma suspects and early glaucoma patients from controls with fair (AUC = 0.74) and excellent (AUC = 0.94) diagnostic accuracy, respectively. The superonasal PIPR provides a linear functional correlate of structural retinal nerve fibre thinning in glaucoma suspects and early glaucoma patients. This first report that quadrant PIPR stimulation detects melanopsin dysfunction in patients with early glaucoma and at pre-perimetric stages may have future implications in treatment decisions of glaucoma suspects.

Rhodopsin and Melanopsin Contributions to the Early Redilation Phase of the Post-Illumination Pupil Response (PIPR)

Melanopsin expressing intrinsically photosensitive Retinal Ganglion Cells (ipRGCs) entirely control the post-illumination pupil response (PIPR) from 6 s post-stimulus to the plateau during redilation after light offset. However, the photoreceptor contributions to the early redilation phase of the PIPR (< 6 s post-stimulus) have not been reported. Here, we evaluated the photoreceptor contributions to the early phase PIPR (0.6 s to 5.0 s) by measuring the spectral sensitivity of the criterion PIPR amplitude in response to 1 s light pulses at five narrowband stimulus wavelengths (409, 464, 508, 531 and 592 nm). The retinal irradiance producing a criterion PIPR was normalised to the peak and fitted by either a single photopigment nomogram or the combined melanopsin and rhodopsin spectral nomograms with the +L+M cone photopic luminous efficiency (Vλ) function. We show that the PIPR spectral sensitivity at times ≥ 1.7 s after light offset is best described by the melanopsin nomogram. At times < 1.7 s, the peak PIPR sensitivity shifts to longer wavelengths (range: 482 to 498 nm) and is best described by the combined photoreceptor nomogram, with major contributions from melanopsin and rhodopsin. This first report of melanopsin and rhodopsin contributions to the early phase PIPR is in line with the electrophysiological findings of ipRGC and rod signalling after the cessation of light stimuli and provides a cut-off time for isolating photoreceptor specific function in healthy and diseased eyes.