The Use of the RETeval Portable Electroretinography Device for Low-Cost Screening: A Mini-Review

Electroretinography (ERG) provides crucial insights into retinal function and the integrity of the visual pathways. However, ERG assessments classically require a complicated technical background with costly equipment. In addition, the placement of corneal or conjunctival electrodes is not always tolerated by the patients, which restricts the measurement for pediatric evaluations. In this short review, we give an overview of the use of the RETeval portable ERG device (LKC Technologies, Inc., Gaithersburg, MD, USA), a modern portable ERG device that can facilitate screening for diseases involving the retina and the optic nerve. We also review its potential to provide ocular biomarkers in systemic pathologies, such as Alzheimer's disease and central nervous system alterations, within the framework of oculomics.

USING RETeval SYSTEM FLICKER ELECTRORETINOGRAPHY FOR EVALUATION OF DENSE VITREOUS HEMORRHAGE

PURPOSE

To determine whether the RETeval electroretinography (ERG) system can be used to evaluate eyes with dense vitreous hemorrhage (VH).

METHODS

This retrospective case series study included 69 eyes of 69 patients with acute dense VH. Flicker ERGs were recorded by the RETeval system, an ERG device with adhesive skin electrodes. We evaluated the flicker ERG amplitudes in eyes with VH and the ratio of the VH eye amplitudes compared with the fellow eye amplitudes for each VH cause.

RESULTS

In patients with rhegmatogenous retinal detachment, the amplitude ratios were extremely low (0.08 ± 0.03). To detect rhegmatogenous retinal detachment, the area under the receiver operating characteristic curve was 0.977 (95% confidence interval, 0.943-1.000) (best rhegmatogenous retinal detachment cutoff value, 0.14; sensitivity, 100.0%; and specificity, 95.4%). The flicker ERG amplitude was not significantly correlated with the initial visual acuity (ρ = -0.189, P = 0.120) but was positively correlated with the postoperative visual acuity in eyes with VH (ρ = -0.328, P = 0.006).

CONCLUSION

The RETeval ERG system was found to be a useful diagnostic option in situations where dense VH precluded fundus examination or posterior vitreous detachment was indistinguishable from rhegmatogenous retinal detachment.

Neuroretinal dysfunction revealed by a flicker electroretinogram correlated with peripheral nerve dysfunction and parameters of atherosclerosis in patients with diabetes

AIMS/INTRODUCTION

Diabetic polyneuropathy (DPN) develops in the early stage of diabetes. However, no common diagnostic protocol has yet been established. Here, to verify that the flicker electroretinogram using a hand-held device can detect the early dysfunction of the peripheral nervous system in patients with diabetes, we investigated the correlation between the progression of DPN and neuroretinal dysfunction.

MATERIALS AND METHODS

In total, 184 participants with type 1 or 2 diabetes underwent a flicker electroretinogram (ERG) using a hand-held device RETeval™ and nerve conduction study. Participants were also evaluated for intima-media thickness, ankle-brachial index, toe brachial index and brachial-ankle pulse wave velocity. Parameters of the nerve conduction study were used to diagnose the severity according to Baba's classification. A multiple regression analysis was used to examine the associations of ERG parameters with the severity of DPN categorized by Baba's classification. Diagnostic properties of the device in DPN were evaluated using a receiver operating characteristic curve.

RESULTS

A multiple regression model to predict the severity of DPN was generated using ERG. In the model, moderate-to-severe DPN was effectively diagnosed (area under the receiver operating characteristic curve 0.692, sensitivity 56.5%, specificity 78.3%, positive predictive value 70.6%, negative predictive value 66.1%, positive likelihood ratio 2.60, negative likelihood ratio 0.56). In the patients without diabetic retinopathy, the implicit time and amplitude in ERG significantly correlated with the parameters of the nerve conduction study, brachial-ankle pulse wave velocity and intima-media thickness.

CONCLUSIONS

Electroretinogram parameters obtained by the hand-held device successfully predict the severity of DPN. The device might be useful to evaluate DPN.

All-printed stretchable corneal sensor on soft contact lenses for noninvasive and painless ocular electrodiagnosis

Electroretinogram examinations serve as routine clinical procedures in ophthalmology for the diagnosis and management of many ocular diseases. However, the rigid form factor of current corneal sensors produces a mismatch with the soft, curvilinear, and exceptionally sensitive human cornea, which typically requires the use of topical anesthesia and a speculum for pain management and safety. Here we report a design of an all-printed stretchable corneal sensor built on commercially-available disposable soft contact lenses that can intimately and non-invasively interface with the corneal surface of human eyes. The corneal sensor is integrated with soft contact lenses via an electrochemical anchoring mechanism in a seamless manner that ensures its mechanical and chemical reliability. Thus, the resulting device enables the high-fidelity recording of full-field electroretinogram signals in human eyes without the need of topical anesthesia or a speculum. The device, superior to clinical standards in terms of signal quality and comfortability, is expected to address unmet clinical needs in the field of ocular electrodiagnosis.

A Diagnostic Model for Screening Diabetic Retinopathy Using the Hand-Held Electroretinogram Device RETeval

PURPOSE

To construct a proper model to screen for diabetic retinopathy (DR) with the RETeval.

METHOD

This was a cross-sectional study. Two hundred thirty-two diabetic patients and seventy controls were recruited. The DR risk assessment protocol was performed to obtain subjects' DR risk score using the RETeval. Afterwards, the receiver operating characteristic (ROC) curve was used to determine the best cutoff for diagnosing DR. Random forest and decision tree models were constructed.

RESULTS

With increasing DR severity, the DR score gradually increased. When the DR score was used to diagnose DR, the ROC curve had an area under the curve of 0.881 (95% confidence interval: 0.836-0.927, P < 0.001), with a best cutoff value of 22.95, a sensitivity of 74.3% (95 CI: 66.0%~82.6%), and a specificity of 90.6% (95 CI: 83.7% ~94.8%). The top four risk factors selected by the random forest were used to construct the decision tree for diagnosing DR, which had a sensitivity of 93.3% (95% CI: 86.3%~97.0%) and a specificity of 80.3% (95% CI: 72.1% ~86.6%).

CONCLUSIONS

The DR risk assessment protocol combined with the decision tree model was innovatively used to evaluate the risk of DR, improving the sensitivity of diagnosis, which makes this method more suitable than the current protocol for DR screening.

Three-Dimensional Model of Electroretinogram Field Potentials in the Rat Eye

OBJECTIVE

The information derived from the electroretinogram (ERG), especially with regard to local areas of retinal dysfunction or therapeutic rescue, can be enhanced by an increased understanding of the relationship between local retinal current sources and local ERG potentials measured at the cornea. A critical step in this direction is the development of a robust bioelectric field model of the ERG.

METHODS

A finite-element model was created to simulate ERG potentials at the cornea resulting from physiologically relevant transretinal currents. A magnetic resonance image of a rat eye was segmented to define all major ocular structures, tissues were assigned conductivity values from the literature. The model was optimized to multi-electrode ERG (meERG) data recorded in healthy rat eyes, and validated with meERG data from eyes with experimental lesions in peripheral retina.

RESULTS

Following optimization, the simulated distribution of corneal potentials was in good agreement with measured values; residual error was comparable to the average difference of individual eyes from the measured mean. The model predicted the corneal potential distribution for eight eyes with experimental lesions with similar accuracy, and a measure of pre- to post-lesion changes in corneal potential distribution was well correlated with the location of the lesion.

CONCLUSION

An eye model with high anatomical accuracy was successfully validated against a robust dataset.

SIGNIFICANCE

This model can now be used for optimization of ERG electrode design, and to support functional mapping of the retina from meERG data via solving the inverse bioelectric source problem.

Assessment of the Absolute Excitatory Level of the Retina by Flicker ERG

Electroretinography (ERG) is important for functional diagnostics of the retina. Types of information about retinal function obtainable by ERG differ depending on recording conditions, e.g., a combination of light stimulus and adaptation. In terms of stimulation, single-flash and flicker stimuli are frequently used because response properties have been well investigated, allowing an assessment of fundamental retinal functionality; for example, how photoreceptors and bipolar cells, including signal transmission between them, are affected under pathological conditions. Usually, ERGs are recorded with a nonzero lower cutoff frequency of amplifiers to avoid certain artifacts, and additionally, responses are averaged over time so that non-event-related signals are cancelled out. However, the improved signal quality is associated with a loss of information. Especially in steady-state flicker ERG, information about the absolute baseline of recordings is missing because the prestimulus baseline is not included on the recording trace as well as because a zero response is obtained in all cases in which the signal baseline stays constant for a sufficient amount of time. In other words, it is impossible to tell from the conventional flicker ERG whether a zero signal is obtained under conditions of maximal or no excitation of the visual system. In this chapter, we describe a direct current ERG protocol (featuring a lower cutoff frequency of zero) with repetitive single flashes mimicking conventional flicker that contains a defined onset. Using this recording protocol, it is possible to assess not only the absolute excitatory level of the retina but also the development of steady-state responses from the single flash response.

Recording and Analysis of the Human Clinical Electroretinogram

The electroretinogram (ERG) represents the biopotential that is produced by the retina in response to a light stimulus. To date, it remains the best diagnostic tool to objectively evaluate the functional integrity of the normal or diseased retina. In the following pages we briefly review the necessary requirements in order to record and analyze the conventional clinical ERG.

Measuring Retinal Function in the Mouse

Electroretinography is a crucial assay for studying the function and the functional integrity of the retina. The mouse is an important animal model for studying the retinal neurons and circuitries. In addition, it is often used as animal model for human retinal disorders. Therefore, a good understanding of the procedures in animal handling, of the methods for data analysis and of the requirements for stimulators and for the data acquisition equipment is of importance. Here, the currently most common methods and materials for in vivo electroretinography in the mouse are discussed.

A portable device for recording evoked potentials, optimized for pattern ERG

Recording evoked potentials in un-anesthetized animals and people is a powerful technique to non-invasively measure the function of neurons. As such, the primary output neurons of the eye can be assessed by the pattern electroretinogram (PERG). Currently, electro-physiologic setups to perform PERG or related recordings are costly, complicated, and non-portable. Here, we design a simple steady-state PERG system, based off an Arduino board. The amplifier is built on a shield that fits over a microcontroller board, an Arduino, which digitizes the signal and sends it to a computer that presents stimuli then records and analyzes the evoked potentials. We used the device to record PERG accurately with a sensitivity as low as half a microvolt. The device has also been designed to implement other evoked potential recordings. This simple device can be quickly constructed and used for experiments in moving systems. Additionally, this device can be used to expose students in underserved areas to research technology that they would otherwise not have access to.

Usefulness of intraoperative monitoring of visual evoked potentials in transsphenoidal surgery

Postoperative visual outcome is a major concern in transsphenoidal surgery (TSS). Intraoperative visual evoked potential (VEP) monitoring has been reported to have little usefulness in predicting postoperative visual outcome. To re-evaluate its usefulness, we adapted a high-power light-stimulating device with electroretinography (ERG) to ascertain retinal light stimulation. Intraoperative VEP monitoring was conducted in TSSs in 33 consecutive patients with sellar and parasellar tumors under total venous anesthesia. The detectability rates of N75, P100, and N135 were 94.0%, 85.0%, and 79.0%, respectively. The mean latencies and amplitudes of N75, P100, and N135 were 76.8 ± 6.4 msec and 4.6 ± 1.8 μV, 98.0 ± 8.6 msec and 5.0 ± 3.4 μV, and 122.1 ± 16.3 msec and 5.7 ± 2.8 μV, respectively. The amplitude was defined as the voltage difference from N75 to P100 or P100 to N135. The criterion for amplitude changes was defined as a > 50% increase or 50% decrease in amplitude compared to the control level. The surgeon was immediately alerted when the VEP changed beyond these thresholds, and the surgical manipulations were stopped until the VEP recovered. Among the 28 cases with evaluable VEP recordings, the VEP amplitudes were stable in 23 cases and transiently decreased in 4 cases. In these 4 cases, no postoperative vision deterioration was observed. One patient, whose VEP amplitude decreased without subsequent recovery, developed vision deterioration. Intraoperative VEP monitoring with ERG to ascertain retinal light stimulation by the new stimulus device was reliable and feasible in preserving visual function in patients undergoing TSS.

Dual electroretinogram/nitric oxide carbon fiber microelectrode for direct measurement of nitric oxide in the in vivo retina

Nitric oxide (NO) plays an important physiological role in normal and pathological retinas. Intraretinal NO concentrations have not been directly measured due to lack of NO electrodes capable of determining their location in the retina. The microelectrodes described here allow recording of the intraretinal electroretinogram (ERG) and NO concentration from the same location, with ERGs used to determine retinal depth. Double-barreled electrodes were constructed with one barrel serving as a reference/voltage recording barrel and the other containing a Nafion-coated carbon fiber used to detect NO amperometrically. Nafion coating imparted a high selectivity for NO versus ascorbic acid (2000:1). In vivo rodent experiments demonstrated that the electrodes could record intraretinal ERGs and NO current with minimal retinal thickness deformation (9%), allowing for retinal NO depth profile measurements. Comparison of NO depth profiles under control conditions and under nitric oxide synthase (NOS) inhibition by 5 mM L-NG-Nitroarginine methyl ester (L-NAME) verified that the recorded current was attributable to NO. NO concentrations from control profiles ( n = 4) were 2.37 ± 0.34 μM at the choroid and 1.12 ± 0.14 μM at the retinal surface. NO concentrations from L-NAME profiles ( n = 4) were significantly lower at 0.83 ± 0.15 μM at the choroid ( p = 0.006) and 0.27 ± 0.04 μM at the retinal surface ( p = 0.001). Localized regions of increased NO (100-400 nM) were seen in the inner retina under control conditions but not after L-NAME. The dual ERG-NO electrode may be a valuable tool in evaluating the role of NO in normal and diseased retinas.

Differential effects of optic media opacities on mfERGs and mfVEPs

OBJECTIVE

To assess different effects of image degradation that could result from optic media opacities on multifocal retinal (mfERG) and cortical responses (mfVEP).

METHODS

Monocular flash-mfERGs and pattern-reversal mfVEPs were recorded. MfERG-P1 amplitudes and implicit times and mfVEP root-mean-square values (RMS) and delays were compared for different filter conditions (none, 8% luminance, 50% luminance, 50% luminance plus blur) in a total of ten participants with normal vision.

RESULTS

Reducing stimulus luminance down to 50% and 8% reduced mfERG amplitudes to 86% and 42%, respectively, with no significant effect on mfVEP amplitude. Implicit times were increased for mfERGs by 0.9 ms and 6.0 ms, respectively, and for mfVEPs by 1.0 ms and 6.3 ms, respectively. For '50% luminance plus blur' mfERG amplitudes were significantly reduced centrally and enhanced peripherally and delayed by 1.3 ms. MfVEPs were reduced close to noise level independent of eccentricity.

CONCLUSIONS

Degradation of the retinal image is a potential source of discrepancies between mfERGs and mfVEPs. Image blur suppresses the mfVEP at all locations and changes mfERG topography, resulting in a selective loss of central responses.

SIGNIFICANCE

Considering optic media opacities is of importance for the correct interpretation of mfERG and mfVEP recordings, particularly in elderly patients.

[Comparison between subtraction skin electrodes and corneal-contact electrodes in flash electroretinograms]

PURPOSE

To compare electroretinogram (ERG) responses measured with a skin electrode with those from a corneal-contact electrode in healthy adults.

METHOD

Sixty two eyes of 31 healthy adults (8 men and 23 women) were enrolled (mean age 34.0 +/- 8.1 years). ERG responses for full-field and single flash stimuli was recorded with skin electrodes and corneal-contact electrodes. Morphology of the ERG waveform, a-wave and b-wave amplitudes, b/a ratios, and a-wave and b-wave implicit times were compared between the two electrode measurements. Correlations between the two measurements were also examined.

RESULTS

All features of the ERG waveform were identifiable using the skin electrodes. In the skin electrode ERGs, a-wave and b-wave amplitudes, and the b/a ratios were smaller (p<0.001) and the a-wave and b-wave implicit times were shorter (p<0.001) than those in the corneal-contact electrode ERGs. The B-wave amplitudes, b/a ratios and the a-wave and b-wave implicit times showed significant correlations between the two electrodes (p<0.01). In 16 eyes the OP4 was detected as the b-wave.

CONCLUSION

The skin electrode ERG had shorter amplitudes and shorter implicit times than the corneal electrode ERGs, but corresponded well in its morphology to the corneal-contact electrode ERGs. Skin electrodes ERG would be useful for the examination of child patients and patients with corneal diseases. Further study is required for clinical application.

Multifocal electroretinograms

A limitation of traditional full-field electroretinograms (ERG) for the diagnosis of retinopathy is lack of sensitivity. Generally, ERG results are normal unless more than approximately 20% of the retina is affected. In practical terms, a patient might be legally blind as a result of macular degeneration or other scotomas and still appear normal, according to traditional full field ERG. An important development in ERGs is the multifocal ERG (mfERG). Erich Sutter adapted the mathematical sequences called binary m-sequences enabling the isolation from a single electrical signal an electroretinogram representing less than each square millimeter of retina in response to a visual stimulus. Results that are generated by mfERG appear similar to those generated by flash ERG. In contrast to flash ERG, which best generates data appropriate for whole-eye disorders. The basic mfERG result is based on the calculated mathematical average of an approximation of the positive deflection component of traditional ERG response, known as the b-wave. Multifocal ERG programs measure electrical activity from more than a hundred retinal areas per eye, in a few minutes. The enhanced spatial resolution enables scotomas and retinal dysfunction to be mapped and quantified. In the protocol below, we describe the recording of mfERGs using a bipolar speculum contact lens. Components of mfERG systems vary between manufacturers. For the presentation of visible stimulus, some suitable CRT monitors are available but most systems have adopted the use of flat-panel liquid crystal displays (LCD). The visual stimuli depicted here, were produced by a LCD microdisplay subtending 35-40 degrees horizontally and 30-35 degrees vertically of visual field, and calibrated to produce multifocal flash intensities of 2.7 cd s m(-2). Amplification was 50K. Lower and upper bandpass limits were 10 and 300 Hz. The software packages used were VERIS versions 5 and 6.

In vivo imaging of intrinsic optical signals in chicken retina with functional optical coherence tomography

Visually evoked intrinsic optical signals (IOSs) were measured in vivo for the first time to our knowledge from all retina layers of the chicken retina with a combined functional optical coherence tomography and electroretinography (ERG) system. IOS traces were recorded from a small volume in the retina with 3.5 μm axial resolution and 7 ms time resolution. Comparison of the IOS and ERG traces shows a correlation between the positive and negative IOS measured from different retinal layers and the timing of the a and b waves in the ERG recording.

Enlarged gold-tipped silicon microprobe arrays and signal compensation for multi-site electroretinogram recordings in the isolated carp retina

In order to record multi-site electroretinogram (ERG) responses in isolated carp retinae, we utilized three-dimensional (3D), extracellular, 3.5-μm-diameter silicon (Si) probe arrays fabricated by the selective vapor-liquid-solid (VLS) growth method. Neural recordings with the Si microprobe exhibit low signal-to-noise (S/N) ratios of recorded responses due to the high-electrical-impedance characteristics of the small recording area at the probe tip. To increase the S/N ratio, we designed and fabricated enlarged gold (Au) tipped Si microprobes (10-μm-diameter Au tip and 3.5-μm-diameter probe body). In addition, we demonstrated that the signal attenuation and phase delay of ERG responses recorded via the Si probe can be compensated by the inverse filtering method. We conclude that the reduction of probe impedance and the compensation of recorded signals are useful approaches to obtain distortion-free recording of neural signals with high-impedance microelectrodes.

Combined optical coherence tomography and electroretinography system for in vivo simultaneous morphological and functional imaging of the rodent retina

A combined ultrahigh resolution optical coherence tomography (UHROCT) and a electroretinography (ERG) system is presented for simultaneous imaging of the retinal structure and physiological response to light stimulation in the rodent eye. The 1060-nm UHROCT system provides approximately 3x5 microm (axialxlateral) resolution in the rat retina and time resolution of 22 micros. A custom-designed light stimulator integrated into the UHROCT imaging probe provides light stimuli with user-selected color, duration, and intensity. The performance of the combined system is demonstrated in vivo in healthy rats, and in a rat model of drug-induced outer retinal degeneration. Experimental results show correlation between the observed structural and physiological changes in the healthy and degenerated retina.

[Optimization of a recording procedure of a multifocal electroretinogram]

The paper presents a procedure and conditions for recording multifocal electroretinogram (mfERG), its origin, and factors influencing small-signal ERG. The optimal conditions of ERG extraction using the existing method are appraised and indications for its use in ophthalmological care defined. The results of comparing the new types of electrodes developed in Russia for ERG recording and a DTL electrode included in the ISCEV guidelines are presented.

[Technical factors that influence multifocal electroretinogram (mfERG) recording]

PURPOSE

To describe the main intervening factors observed during the acquisition and analysis of multifocal electroretinogram (mfERG), that could affect the recorded signal, the obtained responses and their analysis.

METHODS

The error factors observed during the acquisition of 100 sequential multifocal electroretinogram tests, in the period of May to July, 2005 were analyzed. The examinations of multifocal electroretinogram were carried out in agreement with international guideline recommendations, taking into account the established parameters of equipment, with 61 elements, and visual angle of 30 degrees. All patients had been submitted to complete ophthalmologic examination, excluding those with inadequate transparency of ways, flat corneas and those incapable to visualize a central fixation target.

RESULTS

The intervening factors, that could cause artifacts and errors in the interpretation of the obtained results, observed and corrected during the acquisition of multifocal electroretinogram were: eccentric or poor fixation, eye movements, orbicular contraction, cervical muscle contraction, inadequate transparency of the corneal electrode, electrode displacement, lens support decentralization, inadequate viewing distance in patients with high refractive errors, eye height inadequacy in relation to the center of the screen, electrical noise in 60 HZ frequency and electromagnetic field and high impedances. Excessive use of filters in wave processing for noise and artifact removal can interfere with the analysis of the obtained results.

CONCLUSION

Simple observational cares during signal acquisition are of significant importance to ensure accuracy of the topographical electroretinogram information, good waveform morphology and low noise level register. Through their ready correction, the correct and adjusted analysis of the amplitude and of implicit time of peaks N1, P1 and N2 is reliable. Digital smooth system with specific frequency peak removal supply waves with more defined morphology with lower amplitude reduction than other available resources.