'Who is the ideal candidate?': decisions and issues relating to visual neuroprosthesis development, patient testing and neuroplasticity

Attitudes of potential recipients toward emerging visual prosthesis technologies

With the advent of multiple visual prosthesis devices to treat blindness, the question of how potential patients view such interventions becomes important in order to understand the levels of expectation and acceptance, and the perceived risk-reward balance across the different device approaches. Building on previous work on single device approaches done with blind individuals in Chicago and Detroit, USA, Melbourne, Australia, and Bejing, China, we investigated attitudes in blind individuals in Athens, Greece with coverage expanded to three of the contemporary approaches, Retinal, Thalamic, and Cortical. We presented an informational lecture on the approaches, had potential participants fill out a preliminary Questionnaire 1, then organized selected subjects into focus groups for guided discussion on visual prostheses, and finally had these subjects fill out a more detailed Questionnaire 2. We report here the first quantitative data that compares multiple prosthesis approaches. Our primary findings are that for these potential patients, perceived risk continues to outweigh perceived benefits, with the Retinal approach having the least negative overall impression and the Cortical approach the most negative. Concerns about the quality of restored vision were primary. Factors that drove the choice of hypothetical participation in a clinical trial were age and years of blindness. Secondary factors focused on positive clinical outcomes. The focus groups served to swing the impressions of each approach from neutrality toward the extremes of a Likert scale, and shifted the overall willingness to participate in a clinical trial from neutral to negative. These results, coupled with informal assessment of audience questions after the informational lecture, suggest that a substantial improvement in performance over currently available devices will be necessary before visual prostheses gain wide acceptance.

Toward a personalized closed-loop stimulation of the visual cortex: Advances and challenges

Current cortical visual prosthesis approaches are primarily unidirectional and do not consider the feed-back circuits that exist in just about every part of the nervous system. Herein, we provide a brief overview of some recent developments for better controlling brain stimulation and present preliminary human data indicating that closed-loop strategies could considerably enhance the effectiveness, safety, and long-term stability of visual cortex stimulation. We propose that the development of improved closed-loop strategies may help to enhance our capacity to communicate with the brain.

Advances in Neuroscience, Not Devices, Will Determine the Effectiveness of Visual Prostheses

Background: Innovations in engineering and neuroscience have enabled the development of sophisticated visual prosthetic devices. In clinical trials, these devices have provided visual acuities as high as 20/460, enabled coarse navigation, and even allowed for reading of short words. However, long-term commercial viability arguably rests on attaining even better vision and more definitive improvements in tasks of daily living and quality of life. Purpose: Here we review technological and biological obstacles in the implementation of visual prosthetics. Conclusions: Research in the visual prosthetic field has tackled significant technical challenges, including biocompatibility, signal spread through neural tissue, and inadvertent activation of passing axons; however, significant gaps in knowledge remain in the realm of neuroscience, including the neural code of vision and visual plasticity. We assert that further optimization of prosthetic devices alone will not provide markedly improved visual outcomes without significant advances in our understanding of neuroscience.

Toward Long-Term Communication With the Brain in the Blind by Intracortical Stimulation: Challenges and Future Prospects

The restoration of a useful visual sense in a profoundly blind person by direct electrical stimulation of the visual cortex has been a subject of study for many years. However, the field of cortically based sight restoration has made few advances in the last few decades, and many problems remain. In this context, the scientific and technological problems associated with safe and effective communication with the brain are very complex, and there are still many unresolved issues delaying its development. In this work, we review some of the biological and technical issues that still remain to be solved, including long-term biotolerability, the number of electrodes required to provide useful vision, and the delivery of information to the implants. Furthermore, we emphasize the possible role of the neuroplastic changes that follow vision loss in the success of this approach. We propose that increased collaborations among clinicians, basic researchers, and neural engineers will enhance our ability to send meaningful information to the brain and restore a limited but useful sense of vision to many blind individuals.

Residual vision activation and the brain-eye-vascular triad: Dysregulation, plasticity and restoration in low vision and blindness - a review

Vision loss due to ocular diseases such as glaucoma, optic neuropathy, macular degeneration, or diabetic retinopathy, are generally considered an exclusive affair of the retina and/or optic nerve. However, the brain, through multiple indirect influences, has also a major impact on functional visual impairment. Such indirect influences include intracerebral pressure, eye movements, top-down modulation (attention, cognition), and emotionally triggered stress hormone release affecting blood vessel dysregulation. Therefore, vision loss should be viewed as the result of multiple interactions within a “brain-eye-vascular triad”, and several eye diseases may also be considered as brain diseases in disguise. While the brain is part of the problem, it can also be part of the solution. Neuronal networks of the brain can “amplify” residual vision through neuroplasticity changes of local and global functional connectivity by activating, modulating and strengthening residual visual signals. The activation of residual vision can be achieved by different means such as vision restoration training, non-invasive brain stimulation, or blood flow enhancing medications. Modulating brain functional networks and improving vascular regulation may offer new opportunities to recover or restore low vision by increasing visual field size, visual acuity and overall functional vision. Hence, neuroscience offers new insights to better understand vision loss, and modulating brain and vascular function is a promising source for new opportunities to activate residual vision to achieve restoration and recovery to improve quality of live in patients suffering from low vision.

Brain Machine Interfaces for Vision Restoration: The Current State of Cortical Visual Prosthetics

Loss of vision alters the day to day life of blind individuals and may impose a significant burden on their family and the economy. Cortical visual prosthetics have been shown to have the potential of restoring a useful degree of vision via stimulation of primary visual cortex. Due to current advances in electrode design and wireless power and data transmission, development of these prosthetics has gained momentum in the past few years and multiple sites around the world are currently developing and testing their designs. In this review, we briefly outline the visual prosthetic approaches and describe the history of cortical visual prosthetics. Next, we focus on the state of the art of cortical visual prosthesis by briefly explaining the design of current devices that are either under development or in the clinical testing phase. Lastly, we shed light on the challenges of each design and provide some potential solutions.

Development of visual Neuroprostheses: trends and challenges

Visual prostheses are implantable medical devices that are able to provide some degree of vision to individuals who are blind. This research field is a challenging subject in both ophthalmology and basic science that has progressed to a point where there are already several commercially available devices. However, at present, these devices are only able to restore a very limited vision, with relatively low spatial resolution. Furthermore, there are still many other open scientific and technical challenges that need to be solved to achieve the therapeutic benefits envisioned by these new technologies. This paper provides a brief overview of significant developments in this field and introduces some of the technical and biological challenges that still need to be overcome to optimize their therapeutic success, including long-term viability and biocompatibility of stimulating electrodes, the selection of appropriate patients for each artificial vision approach, a better understanding of brain plasticity and the development of rehabilitative strategies specifically tailored for each patient.

Preoperative Candidate Evaluations for Retinal Prosthesis Trials

With the development of retinal prostheses, the first clinical trials for these devices are being planned or are already underway. Yet the candidate selection criteria and the preparation of early recipients have received very little attention. As clinical trials grow in scope, the need for such issues will become increasingly important. Especially in preliminary stages of clinical trials, it is absolutely vital to develop the preoperative evaluations of candidates in identifying the suitable candidate for retinal prosthesis implants. This paper addresses the preoperative evaluations of candidates that may provide insight into selecting potential candidates for retinal prosthetic devices. Screening an ideal candidate is complex and, at the minimum, should include medical evaluations, visual function tests, assessments of psychological status, motivation, expectations, as well as rehabilitation capabilities. This will ensure that appropriate candidates are selected, candidate expectations are managed, and success with the retinal prosthetic devices is maximized.

Impact of Early and Late Visual Deprivation on the Structure of the Corpus Callosum: A Study Combining Thickness Profile with Surface Tensor-Based Morphometry

Blindness represents a unique model to study how visual experience may shape the development of brain organization. Exploring how the structure of the corpus callosum (CC) reorganizes ensuing visual deprivation is of particular interest due to its important functional implication in vision (e.g., via the splenium of the CC). Moreover, comparing early versus late visually deprived individuals has the potential to unravel the existence of a sensitive period for reshaping the CC structure. Here, we develop a novel framework to capture a complete set of shape differences in the CC between congenitally blind (CB), late blind (LB) and sighted control (SC) groups. The CCs were manually segmented from T1-weighted brain MRI and modeled by 3D tetrahedral meshes. We statistically compared the combination of local area and thickness at each point between subject groups. Differences in area are found using surface tensor-based morphometry; thickness is estimated by tracing the streamlines in the volumetric harmonic field. Group differences were assessed on this combined measure using Hotelling's T(2) test. Interestingly, we observed that the total callosal volume did not differ between the groups. However, our fine-grained analysis reveals significant differences mostly localized around the splenium areas between both blind groups and the sighted group (general effects of blindness) and, importantly, specific dissimilarities between the LB and CB groups, illustrating the existence of a sensitive period for reorganization. The new multivariate statistics also gave better effect sizes for detecting morphometric differences, relative to other statistics. They may boost statistical power for CC morphometric analyses.

Restoration of vision in blind individuals using bionic devices: a review with a focus on cortical visual prostheses

The field of neurobionics offers hope to patients with sensory and motor impairment. Blindness is a common cause of major sensory loss, with an estimated 39 million people worldwide suffering from total blindness in 2010. Potential treatment options include bionic devices employing electrical stimulation of the visual pathways. Retinal stimulation can restore limited visual perception to patients with retinitis pigmentosa, however loss of retinal ganglion cells precludes this approach. The optic nerve, lateral geniculate nucleus and visual cortex provide alternative stimulation targets, with several research groups actively pursuing a cortically-based device capable of driving several hundred stimulating electrodes. While great progress has been made since the earliest works of Brindley and Dobelle in the 1960s and 1970s, significant clinical, surgical, psychophysical, neurophysiological, and engineering challenges remain to be overcome before a commercially-available cortical implant will be realized. Selection of candidate implant recipients will require assessment of their general, psychological and mental health, and likely responses to visual cortex stimulation. Implant functionality, longevity and safety may be enhanced by careful electrode insertion, optimization of electrical stimulation parameters and modification of immune responses to minimize or prevent the host response to the implanted electrodes. Psychophysical assessment will include mapping the positions of potentially several hundred phosphenes, which may require repetition if electrode performance deteriorates over time. Therefore, techniques for rapid psychophysical assessment are required, as are methods for objectively assessing the quality of life improvements obtained from the implant. These measures must take into account individual differences in image processing, phosphene distribution and rehabilitation programs that may be required to optimize implant functionality. In this review, we detail these and other challenges facing developers of cortical visual prostheses in addition to briefly outlining the epidemiology of blindness, and the history of cortical electrical stimulation in the context of visual prosthetics.

Ethical considerations for volunteer recruitment of visual prosthesis trials

With the development of visual prostheses research from the engineering phase to clinical trials, volunteer recruitment for the early visual prosthesis trials needs to be carefully considered. In this article, we mainly discuss several issues related to volunteer recruitment that had posed serious challenges to the visual prosthesis trials, such as low rates of participants, high expectations and underlying motivations to participate in the visual prosthesis trials as well as the importance of informed consent. When recruiting volunteers for visual prosthesis implants, it is critical that the visual prosthesis researchers should not only take into account the patient's expectations and motivations, but also make the patients fully aware of the possible benefits and risks involved with their participation, and help patients establish realistic expectations for the early phase of visual prosthesis implantation. Based on these considerations to the challenges, eligible volunteers may be recruited in the preliminary stages of visual prosthesis trials.

Retinitis pigmentosa patients' attitudes toward participation in retinal prosthesis trials

PURPOSE

We undertook a questionnaire study to explore the retinitis pigmentosa (RP) patients' attitudes and the main reasons for or against participation in retinal prosthesis trials.

METHODS

Fifty-four patients, who might be potential participants of retinal prosthesis trials, were recruited to complete the questionnaire devised to determine RP patients' willingness, motivations and expectations toward participation in retinal prosthesis trials, identify the concerns of RP patients about participation in retinal prosthesis trials.

RESULTS

Eleven (11/54[21%]) of fifty-four patients were willing to participate in retinal prosthesis trials. Nineteen patients (19/54[35%]) declined participation and twenty-four patients (24/54[44%]) were unsure whether to participate or not. The main reasons cited for willingness to participate in retinal prosthesis trials were high expectations for possible therapeutic benefits (7/11[63.6%]), altruistic desire to help others (3/11[27.3%]), getting better care and closer follow-up (5/11[45.5%]). Conversely, fear of potential risks and side effects (12/19[63.2%]), worry of efficacy of retinal prosthetic devices (11/19[57.9%]), poor logistical supports (8/19[42.1%]), having difficulty in understanding information about retinal prosthesis trials (9/19[47.4%]) were main reasons cited for patients who declined to participate in retinal prosthesis trials.

CONCLUSIONS

The willingness to participate in retinal prosthesis trials is low in RP patients with severe visual impairment. Altruistic motivation should be encouraged and establishing realistic expectations should be an important readiness for retinal prosthesis trials. Sufficient logistical supports and better understanding of the proposed trial may improve the attitudes for participation in retinal prosthesis trials.

Building the bionic eye: an emerging reality and opportunity

Once the topic of folklore and science fiction, the notion of restoring vision to the blind is now approaching a tractable reality. Technological advances have inspired numerous multidisciplinary groups worldwide to develop visual neuroprosthetic devices that could potentially provide useful vision and improve the quality of life of profoundly blind individuals. While a variety of approaches and designs are being pursued, they all share a common principle of creating visual percepts through the stimulation of visual neural elements using appropriate patterns of electrical stimulation. Human clinical trials are now well underway and initial results have been met with a balance of excitement and cautious optimism. As remaining technical and surgical challenges continue to be solved and clinical trials move forward, we now enter a phase of development that requires careful consideration of a new set of issues. Establishing appropriate patient selection criteria, methods of evaluating long-term performance and effectiveness, and strategies to rehabilitate implanted patients will all need to be considered in order to achieve optimal outcomes and establish these devices as viable therapeutic options.

Biocompatibility of intracortical microelectrodes: current status and future prospects

Rehabilitation of sensory and/or motor functions in patients with neurological diseases is more and more dealing with artificial electrical stimulation and recording from populations of neurons using biocompatible chronic implants. As more and more patients have benefited from these approaches, the interest in neural interfaces has grown significantly. However an important problem reported with all available microelectrodes to date is long-term viability and biocompatibility. Therefore it is essential to understand the signals that lead to neuroglial activation and create a targeted intervention to control the response, reduce the adverse nature of the reactions and maintain an ideal environment for the brain-electrode interface. We discuss some of the exciting opportunities and challenges that lie in this intersection of neuroscience research, bioengineering, neurology and biomaterials.

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

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

Toward the development of a cortically based visual neuroprosthesis

Motivated by the success of cochlear implants for deaf patients, we are now facing the goal of creating a visual neuroprosthesis designed to interface with the occipital cortex as a means through which a limited but useful sense of vision could be restored in profoundly blind patients. We review the most important challenges regarding this neuroprosthetic approach and emphasize the need for basic human psychophysical research on the best way of presenting complex stimulating patterns through multiple microelectrodes. Continued research will hopefully lead to the development of and design specifications for the first generation of a cortically based visual prosthesis system.

Proton magnetic resonance spectroscopy (1H-MRS) reveals the presence of elevated myo-inositol in the occipital cortex of blind subjects

This paper is addressed to investigate whether proton magnetic resonance spectroscopy ((1)H-MRS) may provide the means to investigate changes associated to alterations of neural activity and sensory experience in the blind. We examined the relationships between different brain metabolite levels in 10 blind volunteers and 10 sighted subjects matched for age and gender. Adjusted levels of N-acetylaspartate (NAA), creatine (Cr), choline (Cho), glutamate/glutamine (Glx) and myo-inositol (mIno) in the occipital cortex region were quantified in the water-suppressed spectrum using the AMARES estimation algorithms. An unpaired two-tailed t-test was used to determine any significant difference in metabolite ratios. Our results show that none of the blind volunteers presented atrophy or any other MRI detectable degenerative change of the occipital cortex. The main finding was a significant increase of myo-inositol (mIno), a glial marker, in blind subjects compared to sighted controls. This simple sugar-like molecule can be found mainly within astrocytes, and cannot cross the blood-brain barrier. Therefore its increase could reflect glial proliferation or an increase in glial cell size. These results show that (1)H-MRS may help to understand the complex mechanisms involved in brain plasticity and suggest an active role of glial cells in the reorganization of the brain in response to visual deprivation.

Retinal laminar architecture in human retinitis pigmentosa caused by Rhodopsin gene mutations

PURPOSE

To determine the underlying retinal micropathology in subclasses of autosomal dominant retinitis pigmentosa (ADRP) caused by rhodopsin (RHO) mutations.

METHODS

Patients with RHO-ADRP (n = 17, ages 6-73 years), representing class A (R135W and P347L) and class B (P23H, T58R, and G106R) functional phenotypes, were studied with optical coherence tomography (OCT), and colocalized visual thresholds were determined by dark- and light-adapted chromatic perimetry. Autofluorescence imaging was performed with near-infrared light. Retinal histology in hT17M-rhodopsin mice was compared with the human results.

RESULTS

Class A patients had only cone-mediated vision. The outer nuclear layer (ONL) thinned with eccentricity and was not detectable within 3 to 4 mm of the fovea. Scotomatous extracentral retina showed loss of ONL, thickening of the inner retina, and demelanization of RPE. Class B patients had superior-inferior asymmetry in function and structure. The superior retina could have normal rod and cone vision, normal lamination (including ONL) and autofluorescence of the RPE melanin; laminopathy was found in the scotomas. With Fourier-domain-OCT, there was apparent inner nuclear layer (INL) thickening in regions with ONL thinning. Retinal regions without ONL had a thick hyporeflective layer that was continuous with the INL from neighboring regions with normal lamination. Transgenic mice had many of the laminar abnormalities found in patients.

CONCLUSIONS

Retinal laminar abnormalities were present in both classes of RHO-ADRP and were related to the severity of colocalized vision loss. The results in human class B and the transgenic mice support the following disease sequence: ONL diminution with INL thickening; amalgamation of residual ONL with the thickened INL; and progressive retinal remodeling with eventual thinning.