Topography of cone dark adaptation deficits in age-related maculopathy

Evaluation of Cone- and Rod-Mediated Parameters in Dark Adaptation Testing as Outcome Measures in Age-Related Macular Degeneration

PURPOSE

To investigate the suitability of 6 rod- or cone-mediated dark adaptation (DA) parameters as outcome measures for clinical trials in age-related macular degeneration (AMD), including their retest reliability, association with age and disease severity, and measurable longitudinal change over time.

DESIGN

Prospective, longitudinal study (Clinicaltrials.gov: NCT01352975).

PARTICIPANTS

A total of 191 patients with AMD and older participants followed longitudinally over 5 years.

METHODS

Dark adaptation testing was performed using the AdaptDx dark adaptometer with a maximum test time of 40 minutes. A 2-part exponential-linear curve was fitted to obtain values for cone decay, cone plateau, time to rod-cone break, rod intercept time (RIT), rod adaptation rate (S2), and area under the curve. Intersession retest reliability was assessed in tests performed within 2 weeks using the Bland-Altman analysis. The relationship of DA parameters with age, AMD severity, and reticular pseudodrusen (RPD) presence was evaluated using linear mixed models.

MAIN OUTCOME MEASURES

Retest reliability, association with disease severity, and longitudinal change of 6 DA parameters.

RESULTS

A total of 1329 DA curves were analyzed. Rod intercept time was the parameter that showed the greatest reliability (intraclass correlation coefficient of 0.88) and greatest association with age, AMD severity, and RPD (marginal R² of 0.38), followed by the rod-mediated parameters area under the curve and rod-cone break. Cone plateau appeared constant at lower RIT values but increased with progressive rod dysfunction (RIT > 22.8 minutes) with a slope of 0.07 log units per 10 minutes RIT prolongation. Therefore, it might provide additional information in the advanced stages of AMD.

CONCLUSIONS

Age-related macular degeneration severity and RPD presence are each associated with large differences in multiple DA curve parameters. In addition, substantial differences in some parameters occur with age, even accounting for AMD severity and RPD status. This supports the 2-hit hypothesis of age and disease status on DA (and perhaps AMD pathophysiology itself). Of the DA parameters, RIT has the highest retest reliability, closest correlation with AMD severity and RPD, and largest longitudinal changes. This underscores the suitability of RIT as an outcome measure in clinical trials. The cone plateau increases only in advanced stages of kinetic rod dysfunction, indicating rod dysfunction preceding cone dysfunction and degeneration in the temporal sequence of pathology in AMD.

The role of dark adaptation in understanding early AMD

The main aim of the paper is to discuss current knowledge on how Age Related Macular Degeneration (AMD) affects Dark Adaptation (DA). The paper is divided into three parts. Firstly, we outline some of the molecular mechanisms that control DA. Secondly, we review the psychophysical issues and the corresponding analytical techniques. Finally, we characterise the link between slowed DA and the morphological abnormalities in early AMD. Historically, DA has been regarded as too cumbersome for widespread clinical application. Yet the technique is extremely useful; it is widely accepted that the psychophysically obtained slope of the second rod-mediated phase of the dark adaptation function is an accurate assay of photoreceptor pigment regeneration kinetics. Technological developments have prompted new ways of generating the DA curve, but analytical problems remain. A simple potential solution to these, based on the application of a novel fast mathematical algorithm, is presented. This allows the calculation of the parameters of the DA curve in real time. Improving current management of AMD will depend on identifying a satisfactory endpoint for evaluating future therapeutic strategies. This must be implemented before the onset of severe disease. Morphological changes progress too slowly to act as a satisfactory endpoint for new therapies whereas functional changes, such as those seen in DA, may have more potential in this regard. It is important to recognise, however, that the functional changes are not confined to rods and that building a mathematical model of the DA curve enables the separation of rod and cone dysfunction and allows more versatility in terms of the range of disease severity that can be monitored. Examples are presented that show how analysing the DA curve into its constituent components can improve our understanding of the morphological changes in early AMD.

Are Current Methods of Measuring Dark Adaptation Effective in Detecting the Onset and Progression of Age-Related Macular Degeneration? A Systematic Literature Review

INTRODUCTION

Dark adaptation (DA) has been proposed as a possible functional biomarker for age-related macular degeneration (AMD). In this systematic review we aim to evaluate current methodology used to assess DA in people with AMD, the evidence of precision in detecting the onset and progression of AMD, and the relationship between DA and other functional and structural measures.

METHODS

MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, PsycARTICLES were searched for studies published between January 2006 and January 2020 that assessed DA in people with AMD. Details of eligible studies including study design, characteristics of study population and outcomes were recorded. All included studies underwent quality appraisal using approved critical appraisal tools. This systematic review follows PRISMA guidelines (PROSPERO registration number: CRD42019129486).

RESULTS

Forty-eight studies were eligible for inclusion, reporting a variety of instruments and protocols to assess different DA parameters. Twenty of these studies used the AdaptDx (MacuLogix, Hummelstown, PA, USA) instrument and assessed rod-intercept time (RIT). Most of these reported that RIT was delayed in people with AMD and this delay worsened with AMD severity. Four studies, involving 533 participants, reported estimates of diagnostic performance of AdaptDx to separate people with AMD from visually healthy controls. DA has been compared to other measures of visual function, patient-reported outcome measures (PROMs) and structural measures. Ten studies specifically considered evidence that the presence of certain structural abnormalities was associated with impaired DA in AMD.

CONCLUSIONS

This systematic review indicates overwhelming evidence of reasonable quality for an association between impaired DA and AMD. Data on the repeatability and reproducibility of DA measurement are sparse. There is evidence that structural abnormalities such as reticular drusen are associated with prolongation of DA time. Fewer studies have explored an association between DA and other measures of visual function or PROMs. We found no studies that had compared DA with performance-based measures.

Abdominal obesity linked to a longer cone-mediated dark-adaptation recovery time in healthy eyes

Obesity has been associated with abnormal lipid metabolism and with tissue hypoxia. Human Bruch's membrane (BrM) lipid deposits have been proposed to create a diffusion barrier to metabolic exchange between the choroid and photoreceptors, delaying the regeneration of photopigments. The speed of retinal dark adaptation (DA) is dependent on the regeneration of these photopigments. While the retina is extremely sensitive to hypoxia, the inner retina, which encodes visual contrast, is more affected by hypoxia than the outer retina. This study examines the association between adiposity measures and the time course of DA measured psychophysically through contrast detection to test the functionality of both the outer and inner retina. Cone-mediated DA recovery of contrast threshold (CT) was measured following near-total photopigment bleach for 6 min in 52 healthy eyes of 52 individuals (42.6 ± 18.3 years). Stimuli were sine-wave gratings of low-spatial frequency (1 cycle-per-degree (cpd)) and low luminance (1 cd/m²) generated at the centre of a CRT monitor. CT recovery functions were fitted to an exponential decay model to determine the time constant (τ, seconds) of cone sensitivity recovery, final cone CT (CT_f) and CT elevation (CT₀). Weight, height and waist circumference (WC) were measured and body mass index (BMI) and waist-to-height ratio (WHtR) calculated. Relationships were examined through Spearman correlation and through multiple linear regression using age, optical and adiposity measures as independent variables. The repeatability of cone time constant measurements was estimated by the Bland-Altman method and reported as the coefficient of repeatability (CoR). Mean ± SD of time constant and CT_f were 57.3 ± 27.7 s and -1.78 ± 0.20 log₁₀ units respectively. Cone time constant showed positive Spearman correlation with WC (p = 0.008) and WHtR (p = 0.023) but not with BMI (p = 0.058). Only WHtR emerged as an independent predictor of time constant (p = 0.001). CT_f was not correlated with any adiposity measures. Mean cone time constant was 41 s slower in subjects (25%, n = 13) with abdominal obesity (WHtR≥0.5). Mean CT_f was not significantly different in subjects with or without abdominal obesity. CoR for cone time constant was ±16 s. In adult subjects, greater abdominal obesity (WHtR) was related to a longer contrast recovery time for cone-mediated DA (time to dark-adapt) suggesting outer retinal dysfunction. Final contrast threshold, preferentially processed by inner retinal cells, was unaffected by abdominal obesity.

Efficient assessment of the time course of perceptual sensitivity change

Perceptual sensitivity is usually estimated over trials and time intervals, which results in imprecise and biased estimates when it changes rapidly over time. We develop a novel procedure, the quick Change-Detection (qCD) method, to accurately, precisely, and efficiently assess the trial-by-trial time course of perceptual sensitivity change. Based on Bayesian adaptive testing, qCD selects the optimal stimulus, and updates, trial by trial, a joint probability distribution of the parameters that quantify perceptual sensitivity change over time. We demonstrate the utility of the method in measuring the time course of dark adaptation. Simulations showed that the accuracy and precision of the estimated dark adaptation curve after one qCD run (root mean squared error (RMSE): 0.002; the half width of the 68.2% credible interval (HWCI): 0.016; standard deviation (SD): 0.020; all in log₁₀ units) was higher than those obtained by ten runs of the quick Forced-Choice (qFC) procedure (RMSE: 0.020; HWCI: 0.032; SD: 0.031) and ten runs of a weighted up-down staircase procedure (RMSE: 0.026; SD: 0.031). Further, the dark adaptation curve obtained from one qCD run in a psychophysics experiment was highly consistent with the average of four qFC runs (RMSE = 0.076 log₁₀ units). Overall, qCD provides a procedure to characterize the detailed time course of perceptual sensitivity change in both basic research and clinical applications.

Optimisation of dark adaptation time required for mesopic microperimetry

Background

Macular Integrity Assessment (MAIA) microperimetry is increasingly used in clinical and research settings to assess point retinal sensitivity and fixation stability. Testing occurs under mesopic conditions, commonly after a period of dark adaptation. Our aim was to identify the minimum length of adaptation required to optimise microperimetry performance.

Methods

MAIA microperimetry using the 10-2 grid was performed on 40 right eyes of 40 healthy participants aged 18–73 with no ocular pathology and vision of at least 0.1 logMAR after ambient light exposure, with 0, 5, 10, 15, 20 and 30 min of adaptation in mesopic settings. Ten right eyes of 10 participants with choroideremia were also tested following 0 and 20 min of adaptation. We further tested 10 right eyes of 10 healthy participants after bright light exposure, with 0, 10 and 20 min of adaptation. We compared changes in threshold sensitivity and fixation stability across time points.

Results

Microperimetry performance did not improve with increasing adaptation time in healthy participants or patients with choroideremia after ambient light exposure. After bright light exposure, we found microperimetry thresholds improved after 10 min of adaptation, but did not improve further at 20 min.

Conclusion

Mesopic adaptation is not required before MAIA microperimetry after exposure to ambient light. Ten minutes of adaptation is sufficient after exposure to a bright light stimulus, such as ophthalmoscopy or retinal imaging. The brief time of dark adaptation required corresponds to cone adaptation curves and provides further evidence for cone-mediated central retinal function under mesopic conditions.

Determining Optimal Test Parameters for Assessing Dark Adaptation in People With Intermediate Age-Related Macular Degeneration

Purpose

The primary aim was to determine optimal test conditions for evaluating dark adaptation in intermediate age-related macular degeneration (iAMD) in order to minimize test time while maintaining diagnostic sensitivity.

Methods

People with AMD and age-similar controls were recruited (aged >55 years). Rod intercept time (RIT) was assessed after a 76%, 70%, and 65% rhodopsin bleach at 5° eccentricity and 76% and 70% bleach at 12°. Test order was randomized and a 30-minute washout period added between tests. Results were compared between control and iAMD groups and receiver operating characteristics (ROC) curves were constructed.

Results

A total of 26 participants with variable grades of macular health attended for two visits. There was a statistically significant difference in average RIT between the control and iAMD groups at 5° (median, IQR controls = 5.8 minutes, 3.8-7.5; iAMD = 20.6 minutes, 11.1-30.0; Mann-Whitney, P = 0.01) and at 12° (mean, controls: 4.54 minutes ± 2.12 SD, iAMD = 7.72 minutes ± 3.37 SD; independent samples t-test, P = 0.03) following a 76% bleach. Area under the ROC curves was 0.83 (confidence interval [CI]: 0.64-1.0) and 0.79 (CI: 0.59-0.99) for these two test conditions, respectively. Five participants (45%) in the iAMD group had RITs >20 minutes for 76% bleach at 5°, but none for any other test condition.

Conclusions

Nearly half of the participants with iAMD produced unacceptably long recovery times (>20 minutes) using a 76% bleach at 5° eccentricity. The 76% bleach at 12° provided almost equivalent separation between AMD and controls but recovery was achieved within 20 minutes.

Recent advances in the dark adaptation investigations

Dark adaptation is a highly sensitive neural function and may be the first symptom of many status including the physiologic and pathologic entity, suggesting that it could be instrumental for diagnose. However, shortcomings such as the lack of standardized parameters, the long duration of examination, and subjective randomness would substantially impede the use of dark adaptation in clinical work. In this review we summarize the recent research about the dark adaptation, including two visual cycles-canonical and cone-specific visual cycle, affecting factors and the methods for measuring dark adaptation. In the opinions of authors, intensive investigations are needed to be done for the widely use of this significant visual function in clinic.

Low-level night-time light therapy for age-related macular degeneration (ALight): study protocol for a randomized controlled trial

Background

Age-related macular degeneration (AMD) is the leading cause of blindness among older adults in the developed world. The only treatments currently available, such as ranibizumab injections, are for neovascular AMD, which accounts for only 10 to 15% of people with the condition. Hypoxia has been implicated as one of the primary causes of AMD, and is most acute at night when the retina is most metabolically active. By increasing light levels at night, the metabolic requirements of the retina and hence the hypoxia will be considerably reduced. This trial seeks to determine whether wearing a light mask that emits a dim, green light during the night can prevent the progression of early AMD.

Methods/design

ALight is a Phase I/IIa, multicentre, randomized controlled trial. Sixty participants (55 to 88 years old) with early AMD in one eye and neovascular AMD (nAMD) in the fellow eye will be recruited from nAMD clinics. They will be randomized (in the ratio 1:1), either to receive the intervention or to be in the untreated control group, stratified according to risk of disease progression. An additional 40 participants with healthy retinal appearance, or early AMD only, will be recruited for a baseline cross-sectional analysis. The intervention is an eye mask that emits a dim green light to illuminate the retina through closed eyelids at night. This is designed to reduce the metabolic activity of the retina, thereby reducing the potential risk of hypoxia. Participants will wear the mask every night for 12 months. Ophthalmologists carrying out monthly assessments will be masked to the treatment group, but participants will be aware of their treatment group. The primary outcome measure is the proportion of people who show disease progression during the trial period in the eye with early AMD. A co-primary outcome measure is the rate of retinal adaptation. As this is a trial of a CE-marked device for an off-label indication, a further main aim of this trial is to assess safety of the mask in the cohort of participants with AMD.

Trial registration

International Standard Randomised Controlled Trials Register: ISRCTN82148651

Measurement of cone dark adaptation: a comparison of four psychophysical methods

PURPOSE

Dark adaptometry is an important clinical tool for the diagnosis of a range of conditions, including age-related macular degeneration. In order to identify the most robust, clinically applicable technique for the measurement of cone dark adaptation, the repeatability and agreement of four psychophysical methods were assessed.

METHODS

Data were obtained from 31 healthy adults on two occasions, using four psychophysical methods. Participants' pupils were dilated, and 96 % of cone photopigment was bleached before threshold was monitored in the dark using one of the techniques, selected at random. This procedure was repeated for each of the remaining methods. An exponential recovery function was fitted to all threshold recovery data. The coefficient of repeatability (CoR) was calculated to assess the repeatability of the methods, and a repeated-measures analysis of variance was used to compare mean recovery parameters.

RESULTS

All four methods demonstrated a similar level of intersession repeatability for measurement of cone recovery, yielding CoRs between 1.18 and 1.56 min. There were no statistically significant differences in estimates of mean time constant of cone recovery (cone τ) between the four methods (p = 0.488); however, significant differences between initial and final cone thresholds were reported (p < 0.005).

CONCLUSIONS

All of the techniques were capable of monitoring the rapid changes in visual threshold that occur during cone dark adaptation, and the repeatability of the techniques was similar. This indicates that despite the respective advantages and disadvantages of these psychophysical techniques, all four methods would be suitable for measuring cone dark adaptation in clinical practice.

The effect of pre-adapting light intensity on dark adaptation in early age-related macular degeneration

BACKGROUND

This study aimed to identify the pre-adapting light intensity that generated the maximum separation in the parameters of dark adaptation between participants with early age-related macular degeneration (AMD) and healthy control participants in the minimum recording time.

METHODS

Cone dark adaptation was monitored in 10 participants with early AMD and 10 age-matched controls after exposure to three pre-adapting light intensities, using an achromatic annulus (12° radius) centred on the fovea. Threshold recovery data were modelled, and the time constant of cone recovery (τ), final cone threshold, and time to rod-cone-break (RCB) were determined. The diagnostic potential of these parameters at all pre-adapting intensities was evaluated by constructing receiver operating characteristic (ROC) curves.

RESULTS

There were significant differences between those with early AMD and healthy controls in cone τ and time to RCB (p < 0.05) at all pre-adapting 'bleaching' intensities. ROC curves showed that the diagnostic potential of dark adaptometry was high following exposure to all three pre-adapting intensities, generating an area under the curve in excess of 0.87 ± 0.08 for cone τ and time to RCB for all conditions.

CONCLUSIONS

Dark adaptation was shown to be highly diagnostic for early AMD across a range of pre-adapting light intensities, and therefore, the lower pre-adapting intensities evaluated in this study may be used to expedite dark adaptation measurement in the clinic without compromising the integrity of the data obtained. This study reinforces the suggestion that cone and rod dark adaptation are good candidate biomarkers for early AMD.

Aging and cone dark adaptation

PURPOSE

Following exposure to a bright light that bleaches a significant portion of photopigment, the eyes take several minutes to regain sensitivity. This slow process, known as dark adaptation, is impaired in patients with age-related macular degeneration and is an important candidate biomarker for this disease. The aim of this study was to evaluate the effect of age on cone dark adaptation.

METHODS

Data were obtained from 41 healthy adults aged between 20 and 83 years. Pupils were dilated and 96% of cone photopigment was "bleached," before threshold was monitored continuously for 5 min in the dark, using a 4° diameter achromatic spot centered on the fovea. Threshold recovery data were modeled, and the time constant of cone recovery (τ), initial cone thresholds, and final cone thresholds were determined. Regression analysis was used to determine the relationship between age and cone dark adaptation parameters.

RESULTS

Cone τ increased by 16.4 s/decade of life, indicating a progressive slowing of dark adaptation with increasing age. This change in cone τ throughout adulthood was significant (p < 0.0005). There was no significant relationship between increasing age and initial cone threshold (p = 0.84) or final cone threshold (p = 0.82).

CONCLUSIONS

Our results provide evidence for age-related slowing of cone dark adaptation after a full bleach in healthy adults, which is likely to contribute to visual difficulties when moving from bright to dim photopic light levels. We propose that the sensitivity and specificity of cone τ as a biomarker for early age-related macular disease could be improved by taking into account the significant age-related decline in this parameter.

Clinical applicability of the Macular Degeneration Detection Device (MDD-2): a novel photostress recovery measurement device

BACKGROUND

Diseases affecting the macula, such as age-related macular degeneration (AMD), diabetic retinopathy and central serous retinopathy can result in impaired photostress recovery time (PSRT) despite normal visual acuity and fundoscopic appearance. The MDD-2 Macular Degeneration Detection Device is a novel flash photostress recovery device. In this study, we examine the repeatability of the MDD-2 in a normal population and its suitability for incorporation into routine clinical practice.

METHODS

One hundred (60 female) subjects (mean age 35 ± 8 years; range 18 to 66 years) were recruited to partake in this study. The photostress recovery time was measured using the MDD-2 on three occasions in the dominant eye and one final occasion in the non-dominant eye to assess measurement repeatability. All subjects were in good ocular health. Visual acuity and iris colour were recorded for each participant.

RESULTS

Repeated measures analysis of variance revealed a statistically significant learning effect on intra-measurement repeatability (p < 0.01). Although paired t-test analysis revealed statistically significant differences between repeated measures both within and between eyes (p < 0.05 for all) the correlation between repeat measurements is statistically significant (p < 0.05 for all), and the coefficient of repeatability reaches clinically acceptable levels once the initial photostress recovery time, which demonstrated increased variability and latency compared to all subsequent measures, is excluded.

CONCLUSION

The MDD-2 provides highly repeatable measurements of photostress recovery time among young naïve subjects, following verbal explanation of the task and only one 'practise' measurement. The measurement is also highly repeatable between eyes, providing a potential immediate clinical biomarker of ocular health.