[Subretinal visual implants]

Morphometric evaluation of cerebellar structures in late monocular blindness

BACKGROUND

Only a few studies have investigated structural and functional changes in monocular blind individuals. Our aim in this study was to segmentally investigate the cerebellar structures of subjects with late-onset monocular blindness (LMB) using a Voxel-based volumetric analysis system.

METHODS

The segmental volumetric values, cortical thickness, gray matter volumes and percentage ratios of the cerebellar lobules of individuals with LMB due to trauma and in healthy individuals with bilateral sight as the control group were calculated at the volBrain CERES 1.0 website ( https://volbrain.upv.es/ ) by using brain 3D fast spoiled gradient recall acquisition in steady-state (3D T1 FSPGR) MRI sequence images in our prospective study.

RESULTS

We studied 11 subjects with LMB (8 males/3 females) and 11 healthy control subjects (8 males/3 females). The mean age was 41.45 ± 14.15 and 40 ± 11.11 years, respectively (p > 0.05). The mean duration of the LMB status was 20.8 ± 11.2 years. Cerebellar lobule crus II volume and cerebellar lobule VIIB/VIIIA volume/percentage were higher in the LMB group, and mean cerebellar cortical thickness, cerebellar lobule VI-cerebellar lobule crus I-II cortical thickness, and cerebellar lobule VI gray matter volume values were lower in the LMB group (p < 0.05).

CONCLUSION

In this study, cerebellar lobule VIIB/VIIIA volume/total percent ratio, cerebellar cortical thickness and cerebellar gray matter volume in the LMB group were found to be different from the control group. To our knowledge, this is the first study to report cerebellar anatomical changes in patients with LMB.

Changes in microchip position after implantation of a subretinal vision prosthesis in humans

PURPOSE

Retinal prosthetic devices have been developed to partially restore very low vision in legally blind patients with end-stage hereditary retinal dystrophies. Subretinal implants, unlike epiretinal implants, are not fixated by a tack. The aim of this study was to assess and analyse possible changes over time in the subretinal position of the RETINA IMPLANT Alpha IMS and Alpha AMS (ClinicalTrials.gov NCT01024803).

METHODS

Imaging studies were performed on fundus photographs using GIMP (Version 2.8.14). Postoperative photographs of the implanted eye were scaled and aligned. Landmarks were chosen and distances between landmarks were measured to then calculate the displacement of the microchip using a transformation matrix for rotational and translational movements. Analyses were performed using MATLAB 8.6 (The MathWorks Inc., Natick, MA).

RESULTS

Of the 27 datasets with the Alpha IMS device, 12 (44%) remained stable without displacement of the microchip relative to the optic disc and the major blood vessels, whereas in 15 (56%), displacement occurred. The mean ± SD displacement in those 15 eyes was 0.66 ± 0.35 mm (range, 0.24-1.67 mm). Of the eight datasets with the Alpha AMS device, 1 (13%) remained stable without displacement of the microchip relative to the optic disc and the major blood vessels, whereas in 7 (87%), displacement occurred. The mean ± SD displacement in those seven eyes was 0.66 ± 0.26 mm (range, 0.32-0.97 mm). Calculated from all eyes (including those in which no displacement occurred), the mean displacement was 0.36 mm in the IMS cohort, and 0.58 mm in the AMS cohort, however, the difference was not statistically significant (p = 0.17).

CONCLUSIONS

We have shown that the position of the subretinal implant changes in the majority of the cases after implantation. While the overall mean displacement of the chip was not significantly different in either of the cohorts, the maximum displacement was smaller in the Alpha AMS cohort.

Optical Coherence Tomography in Patients With the Subretinal Implant Retina Implant Alpha IMS

BACKGROUND AND OBJECTIVE

The aim of this study was to assess changes in retinal structure and thickness after subretinal implantation of the Retina Implant Alpha IMS (Retina Implant AG, Reutlingen, Germany).

PATIENTS AND METHODS

Spectral-domain optical coherence tomography (SD-OCT) imaging was performed to assess the structure and thickness of the retina anterior to the microphotodiode array preoperatively, within 6 weeks and 6 months ± 1 month after implantation. Thickness measurements were performed using the distance tool of the built-in software. Three thickness measurements were performed in each of the four quadrants of the retina on the microchip within 6 weeks and 6 months ± 1 month after implantation.

RESULTS

The mean ± standard deviation change in retinal thickness from within 6 weeks to 6 months ± 1 month after implantation in all four quadrants combined was 24 μm ± 68 μm. None of the tested variables (location, time, or their interaction) had a statistically significant effect on the mean retinal thickness (P = .961, P = .131, and P = .182, respectively; n = 19).

CONCLUSION

The authors report on qualitative and quantitative findings in retinal structure in 27 patients after subretinal implantation of the Retina Implant Alpha IMS using OCT technology. No significant changes of retinal thickness could be observed in a period of 6 months after surgery. With more patients receiving subretinal implants and with advanced OCT technology, the data set will be extended to study possible changes in retinal structure in finer detail. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:993-999.].

[Visual prostheses]

Sensory neuroprostheses for restoration of vision are a technical approach for treatment of previously untreatable blindness. These systems consist of a technical sensor such as a camera and an implanted multi-electrode array within the visual system. The image information from the sensor is processed with specially designed integrated circuits in such a way that the stimulation pulses can be determined and presented to the implanted multi-electrode matrix. Energy supply and the transfer of the stimulus pulse information is realized either via direct cable connections within the site of the implant or by telemetric inductive links. Currently, two retinal implant systems are approved in the European Union (EU) to be used in blind patients with retinitis pigmentosa. With both systems basic visual functions can be restored. The complication rate is relatively low given the complexity of the surgical procedure. Other systems are still under development but approval studies by several manufacturers and consortia are already in preparation.

Structural brain MRI studies in eye diseases: are they clinically relevant? A review of current findings

Many eye diseases reduce visual acuity or are associated with visual field defects. Because of the well-defined retinotopic organization of the connections of the visual pathways, this may affect specific parts of the visual pathways and cortex, as a result of either deprivation or transsynaptic degeneration. For this reason, over the past several years, numerous structural magnetic resonance imaging (MRI) studies have examined the association of eye diseases with pathway and brain changes. Here, we review structural MRI studies performed in human patients with the eye diseases albinism, amblyopia, hereditary retinal dystrophies, age-related macular degeneration (AMD) and glaucoma. We focus on two main questions. First, what have these studies revealed? Second, what is the potential clinical relevance of their findings? We find that all the aforementioned eye diseases are indeed associated with structural changes in the visual pathways and brain. As such changes have been described in very different eye diseases, in our view the most parsimonious explanation is that these are caused by the loss of visual input and the subsequent deprivation of the visual pathways and brain regions, rather than by transsynaptic degeneration. Moreover, and of clinical relevance, for some of the diseases - in particular glaucoma and AMD - present results are compatible with the view that the eye disease is part of a more general neurological or neurodegenerative disorder that also affects the brain. Finally, establishing structural changes of the visual pathways has been relevant in the context of new therapeutic strategies to restore retinal function: it implies that restoring retinal function may not suffice to also effectively restore vision. Future structural MRI studies can contribute to (i) further establish relationships between ocular and neurological neurodegenerative disorders, (ii) investigate whether brain degeneration in eye diseases is reversible, (iii) evaluate the use of neuroprotective medication in ocular disease, (iv) determine optimal timing for retinal implant insertion and (v) establish structural MRI examination as a diagnostic tool in ophthalmology.

The influence of axial length on confocal scanning laser ophthalmoscopy and spectral-domain optical coherence tomography size measurements: a pilot study

PURPOSE

To investigate the influence of axial length on SD-OCT and cSLO size measurements from the Heidelberg Spectralis.

METHODS

In this pilot study, eight emmetropic pseudophakic eyes with subretinal visual implant were selected. The axial length was measured in three short (<22.5 mm), three medium (22.51-25.50 mm) and two long (>25.52 mm) eyes. The known size of subretinal implant sensor field (2800 × 2800 μm) was measured on 15 images per eye with cSLO and SD-OCT.

RESULTS

The mean axial length was 20.8 ± 0.8 mm in short eyes, 23.3 ± 0.4 mm in medium eyes, and 26.3 ± 0.5 mm in long eyes respectively. We found in short eyes, in medium eyes and in long eyes a mean value of sensor field size measurements from cSLO of 3327 ± 9 μm, 2800 ± 9 μm and 2589 ± 12 μm and from SD-OCT of 3328 ± 9 μm, 2800 ± 12 μm and 2585 ± 19 μm respectively. The size measurements decreased in SD-OCT and cSLO measurements with longer axial lengths significantly (p < 0.0001).

CONCLUSION

The present findings demonstrate accuracy of the scaling in cSLO and SD-OCT measurements of the Heidelberg Spectralis for emmetropic medium eyes. The size measurements from SD-OCT to those from cSLO were approximately equal. Caution is recommended when comparing the measured values of short and long eyes with the normative database of the instrument. Further studies with larger sample sizes are needed to confirm findings.

Artificial vision with wirelessly powered subretinal electronic implant alpha-IMS

This study aims at substituting the essential functions of photoreceptors in patients who are blind owing to untreatable forms of hereditary retinal degenerations. A microelectronic neuroprosthetic device, powered via transdermal inductive transmission, carrying 1500 independent microphotodiode-amplifier-electrode elements on a 9 mm² chip, was subretinally implanted in nine blind patients. Light perception (8/9), light localization (7/9), motion detection (5/9, angular speed up to 35 deg s⁻¹), grating acuity measurement (6/9, up to 3.3 cycles per degree) and visual acuity measurement with Landolt C-rings (2/9) up to Snellen visual acuity of 20/546 (corresponding to decimal 0.037 or corresponding to 1.43 logMAR (minimum angle of resolution)) were restored via the subretinal implant. Additionally, the identification, localization and discrimination of objects improved significantly (n = 8; p < 0.05 for each subtest) in repeated tests over a nine-month period. Three subjects were able to read letters spontaneously and one subject was able to read letters after training in an alternative-force choice test. Five subjects reported implant-mediated visual perceptions in daily life within a field of 15° of visual angle. Control tests were performed each time with the implant's power source switched off. These data show that subretinal implants can restore visual functions that are useful for daily life.

Use of the Argus II retinal prosthesis to improve visual guidance of fine hand movements

PURPOSE

We studied the capabilities of the Argus II retinal prosthesis for guiding fine hand movement, and demonstrated and quantified guidance improvement when using the device over when not using the device for progressively less predictable trajectories.

METHODS

A total of 21 patients with retinitis pigmentosa (RP), remaining vision no more than bare light perception, and an implanted Argus II epiretinal prostheses used a touchscreen to trace white paths on black backgrounds. Sets of paths were divided into three categories: right-angle/single-turn, mixed-angle/single-turn, and mixed-angle/two-turn. Subjects trained on paths by using prosthetic vision and auditory feedback, and then were tested without auditory feedback, with and without prosthetic vision. Custom software recorded position and timing information for any contact that subjects made with the screen. The area between the correct path and the trace, and the elapsed time to trace a path were used to evaluate subject performance.

RESULTS

For right-angle/single-turn sets, average tracing error was reduced by 63% and tracing time increased by 156% when using the prosthesis, relative to residual vision. With mixed-angle/single-turn sets, error was reduced by 53% and time to complete tracing increased by 184%. Prosthesis use decreased error by 38% and increased tracing time by 252% for paths that incorporated two turns.

CONCLUSIONS

Use of an epiretinal visual prosthesis can allow RP patients with no more than bare light perception to guide fine hand movement visually. Further, prosthetic input tends to make subjects slower when performing tracing tasks, presumably reflecting greater effort. (ClinicalTrials.gov number, NCT01123928.)

[What can blind patients see in daily life with the subretinal Alpha IMS implant? Current overview from the clinical trial in Tübingen]

The subretinal visual implant is a scientific research approach to restore partial vision in end-stage hereditary retinal diseases by replacing the function of the degenerated photoreceptors by microelectronic chips. In a clinical trial in Tübingen these implants were tested on voluntary blind patients. By using the implants in daily living the patients reported valuable visual information. The subretinal microchip mediates subjectively useful visual information in near as well as in distant vision.

Acute electrical stimulation of the human retina with an epiretinal electrode array

PURPOSE

To determine the threshold charges needed for eliciting visual perceptions through acute electrical stimulation of the human retina in patients suffering from retinitis pigmentosa, using an epiretinal microelectrode array.

METHODS

In a multicentre study, 20 patients (average age 55 years) with visual acuities ranging from 4/200 to no light perception were included. The stimulation procedure was performed during a pars plana vitrectomy, for a maximum of 45 min, by using a microcontact film with IrO(x) electrodes connected by cable to a current generator. After repeated stimulation and threshold charge determination, the microelectrode array was removed.

RESULTS

Nineteen of 20 patients stated in the postoperative interviews that they experienced one or more visual perceptions with close time correlation to single stimulation events. Minimum threshold charges needed to generate visual perceptions could be measured and verified in 15 patients. The charge level ranged from 20 to 768 nC with single or multiple electrodes. One patient suffered a retinal detachment during the procedure; this patient's retina was successfully reattached. There were no further adverse reactions observed during the 3-month follow-up.

CONCLUSION

Acute epiretinal stimulation of the human retina, using a microelectrode array, can elicit visual perceptions in blind patients with retinitis pigmentosa.

[Use of nanoparticles in ophthalomology]

Nanotechnology, the manufacture and use of structures and implements of around a few 100 nm in size, is becoming a key technology of the twenty-first century. An important element for the manufacture of nanoparticles is gold. Gold nanoparticles can be custom made and chemically modified in their size and form. Initial investigations have shown that they are physiologically non-hazardous. A potential application is in neovascular age-related macular degeneration. Gold nanoparticles of suitable dimensions introduced into newly forming blood vessels can be targeted and heated which selectively destroys these blood vessels. This principle has already been demonstrated in cultivated endothelial cells.