Selective activation of neuronal targets with sinusoidal electric stimulation

Electric stimulation of the CNS is being evaluated as a treatment modality for a variety of neurological, psychiatric, and sensory disorders. Despite considerable success in some applications, existing stimulation techniques offer little control over which cell types or neuronal substructures are activated by stimulation. The ability to more precisely control neuronal activation would likely improve the clinical outcomes associated with these applications. Here, we show that specific frequencies of sinusoidal stimulation can be used to preferentially activate certain retinal cell types: photoreceptors are activated at 5 Hz, bipolar cells at 25 Hz, and ganglion cells at 100 Hz. In addition, low-frequency stimulation (≤25 Hz) did not activate passing axons but still elicited robust synaptically mediated responses in ganglion cells; therefore, elicited neural activity is confined to within a focal region around the stimulating electrode. Our results suggest that sinusoidal stimulation provides significantly improved control over elicited neural activity relative to conventional pulsatile stimulation.

The use of onabotulinum toxin A in the treatment of see-saw nystagmus

See-saw nystagmus (SSN) is an uncommon disorder that consists of cycles in which one eye rises and intorts while the other depresses and extorts, followed by reversal of the pattern. It typically causes debilitating symptoms including oscillopsia that interfere with activities of daily living. There are myriad etiologies, including stroke, tumors, trauma, and multiple sclerosis. Treatment options are limited and are often unsatisfactory. The authors report a case in which targeted injections of onabotulinum toxin A were used to decrease the torsional component of SSN and thus significantly improve the subjective symptoms of oscillopsia in a patient with acquired SSN.

Eye and visual function in traumatic brain injury

Combat blast is an important cause of traumatic brain injury (TBI) in the Department of Veterans Affairs polytrauma population, whereas common causes of TBI in the civilian sector include motor vehicle accidents and falls. Known visual consequences of civilian TBI include compromised visual acuity, visual fields, and oculomotor function. The visual consequences of TBI related to blast remain largely unknown. Blast injury may include open globe (eye) injury, which is usually detected and managed early in the rehabilitation journey. The incidence, locations, and types of ocular damage in eyes without open globe injury after exposure to powerful blast have not been systematically studied. Initial reports and preliminary data suggest that binocular function, visual fields, and other aspects of visual function may be impaired after blast-related TBI, despite relatively normal visual acuity. Damage to the ocular tissues may occur from blunt trauma without rupture or penetration (closed globe injury). Possible areas for research are development of common taxonomy and assessment tools across services, surgical management, and outcomes for blast-related eye injury; the incidence, locations, and natural history of closed globe injury; binocular and visual function impairment; quality of life in affected service members; pharmacological and visual therapies; and practice patterns for screening, management, and rehabilitation.

Subjectively quantified Maddox rod testing improves diagnostic yield over alternate cover testing alone in patients with diplopia

We aimed to assess the added diagnostic value of subjectively-quantified red Maddox rod testing in patients with diplopia or suspected strabismus. Over 9 months we compared measures of ocular alignment (inspection; alternate cover; Maddox rod) with final anatomic and etiologic diagnoses using clinical records in a cross-sectional study in an academic neuro-ophthalmology unit. Seventy-seven consecutive patients (98 visits) met study criteria. Mean age was 54 years (range 11-100 years). Most visits (73%) were for symptomatic diplopia and all three measures of alignment were generally available (92%). Maddox findings prompted additional diagnostic tests for 13 patients, leading to an important new diagnosis (systemic vasculitis; posterior fossa arachnoid cyst with mass effect; cavernous sinus mass) in three patients (4%). Maddox rod testing may add clinically relevant diagnostic information to that obtained by alternate cover testing alone. Its use might help prevent missed diagnoses in the evaluation of patients with diplopia or suspected strabismus.

Realization of a 15-channel, hermetically-encased wireless subretinal prosthesis for the blind

A miniaturized, hermetically-encased, wirelessly-operated retinal prosthesis has been developed for implantation and pre-clinical studies in Yucatan mini-pig animal models. The prosthesis conforms to the eye and drives a microfabricated polyimide stimulating electrode array with sputtered iridium oxide electrodes. This array is implanted in the subretinal space using a specially-designed ab externo surgical technique that affixes the bulk of the prosthesis to the surface of the sclera. The implanted device includes a hermetic titanium case containing a 15-channel stimulator chip and discrete power supply components. Feedthroughs from the case connect to secondary power- and data-receiving coils. In addition, long-term in vitro pulse testing was performed on the electrodes to ensure their stability for the long lifetime of the hermetic case. The final assembly was tested in vitro to verify wireless operation of the system in biological saline using a custom RF transmitter circuit and primary coils. Stimulation pulse strength, duration and frequency were programmed wirelessly using a custom graphical user interface. Operation of the retinal implant has been verified in vivo in one pig for more than three months by measuring stimulus artifacts on the eye surface using a contact lens electrode.

Electric stimulation with sinusoids and white noise for neural prostheses

We are investigating the use of novel stimulus waveforms in neural prostheses to determine whether they can provide more precise control over the temporal and spatial pattern of elicited activity as compared to conventional pulsatile stimulation. To study this, we measured the response of retinal ganglion cells to both sinusoidal and white noise waveforms. The use of cell-attached and whole cell patch clamp recordings allowed the responses to be observed without significant obstruction from the stimulus artifact. Electric stimulation with sinusoids elicited robust responses. White noise analysis was used to derive the linear kernel for the ganglion cell's spiking response as well as for the underlying excitatory currents. These results suggest that in response to electric stimulation, presynaptic retinal neurons exhibit bandpass filtering characteristics with a peak response that occurs 25 ms after onset. The experimental approach demonstrated here may be useful for studying the temporal response properties of other neurons in the CNS.

Adhesion molecules promote chronic neural interfaces following neurotrophin withdrawal

Neural prostheses and recording devices have been successfully interfaced with the nervous system; however, substantial integration issues exist at the biomaterial-tissue interface. In particular, the loss of neurons at the implantation site and the formation of a gliotic scar capsule diminish device performance. We have investigated the potential of a tissue-engineered coating, consisting of adhesion molecule-modified surfaces (i.e., polylysine and collagen) in combination with neurotrophin application (i.e., brain derived neurotrophic factor, BDNF), to enhance the electrode-host interface. Neurite length and density were examined in a retinal explant model. In the presence of BDNF for 7 days, we found no synergistic effect of BDNF and adhesion molecule-modified surfaces on neurite length, although there was a possible increase in neurite density for collagen-coated surfaces. After BDNF withdrawal (7 days BDNF+/7 days BDNF- medium), we found that both polylysine and collagen treated surfaces displayed increases in neurite length and density over negative, untreated control surfaces. These results suggest that adhesion molecules may be used to support chronic neuron-electrode interfaces induced by neurotrophin exposure.

Spatiotemporal aspects of pulsed electrical stimuli on the responses of rabbit retinal ganglion cells

Implanted intraocular microelectrode arrays are being used to provide sight to individuals who are blind due to photoreceptor degeneration. It is envisioned that this retinal prosthesis will create the illusion of motion by stimulating focal areas of the retina in a sequential fashion through neighboring electrodes, much like the rapid succession of still images in movies and computer animation gives rise to apparent motion. Using a high-density microelectrode array, we examined the extracellularly recorded responses of rabbit retinal ganglion cells to a bar-shaped electrode array that was stepped at 50 microm increments at different rates across the retina and compared these responses to the responses generated to a similarly shaped light stimulus that was stepped across the retina. When the retina was stimulated at 1 step/s, retinal ganglion cells gave robust bursts of action potentials to both the electrode array and the light stimulus. The responses to the 'moving' electrode array decreased progressively with increasing stepping frequency. At 16 steps/s (highest frequency tested), the number of spikes per sweep and the number of bursts per sweep were reduced 75% and 67% respectively. In contrast, when the retina was stimulated at 16 steps/s with the 'moving' light stimulus, the number of spikes per sweep and the number of bursts per sweep were reduced only 43% and 25% respectively. These findings suggest that simple translation of object motion to sequential stimulation through neighboring electrodes may not be the best way to convey the perception of object motion in a patient with a retinal prosthesis.

Extraction of a chronically implanted, microfabricated, subretinal electrode array

PURPOSE

To assess the feasibility of extraction of a chronically implanted subretinal electrode array.

METHODS

Inactive, polyimide strips (10 mm x 1.5 mm x 15 microm) were surgically implanted into the subretinal space of 8 rabbits using a mostly ab externo approach. Pre- and postoperative clinical examinations, electroretinography and in some cases optical coherence tomography were performed to follow the course of the eyes. Two months after implantation, the polyimide strips were extracted from 5 eyes; 2 animals kept the implants and served as controls. All animals were then sacrificed and eyes enucleated for histological examination.

RESULTS

All 8 surgeries yielded successful placement of the arrays into the subretinal space. All 5 extraction surgeries were performed without obvious complications. Clinical examinations and electroretinography did not reveal any significant abnormalities. The histological examinations showed alterations from normal anatomy in all animals; the anatomical changes in the explanted animals were relatively mild and confined to the area of the surgery.

CONCLUSIONS

Successful extraction of electrode arrays from the subretinal space of rabbits can be reliably performed 2 months after implantation, which is beyond the time period when postoperative scarring would be most intense.

Sputtered iridium oxide films for neural stimulation electrodes

Sputtered iridium oxide films (SIROFs) deposited by DC reactive sputtering from an iridium metal target have been characterized in vitro for their potential as neural recording and stimulation electrodes. SIROFs were deposited over gold metallization on flexible multielectrode arrays fabricated on thin (15 microm) polyimide substrates. SIROF thickness and electrode areas of 200-1300 nm and 1960-125,600 microm(2), respectively, were investigated. The charge-injection capacities of the SIROFs were evaluated in an inorganic interstitial fluid model in response to charge-balanced, cathodal-first current pulses. Charge injection capacities were measured as a function of cathodal pulse width (0.2-1 ms) and potential bias in the interpulse period (0.0 to 0.7 V vs. Ag|AgCl). Depending on the pulse parameters and electrode area, charge-injection capacities ranged from 1-9 mC/cm(2), comparable with activated iridium oxide films (AIROFs) pulsed under similar conditions. Other parameters relevant to the use of SIROF on nerve electrodes, including the thickness dependence of impedance (0.05-10(5) Hz) and the current necessary to maintain a bias in the interpulse region were also determined.

Activation of ganglion cells in wild-type and rd1 mouse retinas with monophasic and biphasic current pulses

We and other research groups are designing an electronic retinal prosthesis to provide vision for patients who are blind due to photoreceptor degeneration. In this study, we examined the effect of stimulus waveform on the amount of current needed to activate retinal ganglion cells (RGCs) when the retinal neural network is stimulated. Isolated retinas of wild-type and rd1 mice were stimulated with cathodal and anodal monophasic current pulses of 1 ms duration and symmetric biphasic current pulses (1 ms per phase) delivered through an electrode that was located subretinally. For both wild-type and rd1 mouse retinas, cathodal current pulses were least effective in activating most RGCs. The median threshold current for a cathodal current pulse was 2.0-4.4 fold higher than the median threshold current for either an anodal or a biphasic current pulse. In wild-type mouse retinas, the median threshold current for activating RGCs with anodal current pulses was 23% lower than that with biphasic current pulses. In rd1 mouse retinas, the median threshold currents for anodal and biphasic current pulses were about the same. However, the variance in thresholds of rd1 RGCs for biphasic pulse stimulation was much smaller than for anodal pulse stimulation. Thus, a symmetric biphasic current pulse may be the best stimulus for activating the greatest number of RGCs in retinas devoid of photoreceptors.

Development and implantation of a minimally invasive wireless subretinal neurostimulator

A wirelessly operated, minimally invasive retinal prosthesis was developed for preclinical chronic implantation studies in Yucatan minipig models. The implant conforms to the outer wall of the eye and drives a microfabricated polyimide stimulating electrode array with sputtered iridium oxide electrodes. This array is implanted in the subretinal space using a specially designed ab externo surgical technique that fixes the bulk of the prosthesis to the outer surface of the sclera. The implanted device is fabricated on a host polyimide flexible circuit. It consists of a 15-channel stimulator chip, secondary power and data receiving coils, and discrete power supply components. The completed device is encapsulated in poly(dimethylsiloxane) except for the reference/counter electrode and the thin electrode array. In vitro testing was performed to verify the performance of the system in biological saline using a custom RF transmitter circuit and primary coils. Stimulation patterns as well as pulse strength, duration, and frequency were programmed wirelessly using custom software and a graphical user interface. Wireless operation of the retinal implant has been verified both in vitro and in vivo in three pigs for more than seven months, the latter by measuring stimulus artifacts on the eye surface using contact lens electrodes.

Axonal sodium-channel bands shape the response to electric stimulation in retinal ganglion cells

Electric stimulation of the retina reliably elicits light percepts in patients blinded by outer retinal diseases. However, individual percepts are highly variable and do not readily assemble into more complex visual images. As a result, the quality of visual information conveyed to patients has been quite limited. To develop more effective stimulation methods that will lead to improved psychophysical outcomes, we are studying how retinal neurons respond to electric stimulation. The situation in the retina is analogous to other neural prosthetic applications in which a better understanding of the underlying neural response may lead to improved clinical outcomes. Here, we determined which element in retinal ganglion cells has the lowest threshold for initiating action potentials. Previous studies suggest multiple possibilities, although all were within the soma/proximal axon region. To determine the actual site, we measured thresholds in a dense two-dimensional grid around the soma/proximal axon region of rabbit ganglion cells in the flat mount preparation. In directionally selective (DS) ganglion cells, the lowest thresholds were found along a small section of the axon, about 40 microm from the soma. Immunochemical staining revealed a dense band of voltage-gated sodium channels centered at the same location, suggesting that thresholds are lowest when the stimulating electrode is closest to the sodium-channel band. The size and location of the low-threshold region was consistent within DS cells, but varied for other ganglion cell types. Analogously, the length and location of sodium channel bands also varied by cell type. Consistent with the differences in band properties, we found that the absolute (lowest) thresholds were also different for different cell types. Taken together, our results suggest that the sodium-channel band is the site that is most responsive to electric stimulation and that differences in the bands underlie the threshold differences we observed.

Short-wavelength light sensitivity of circadian, pupillary, and visual awareness in humans lacking an outer retina

As the ear has dual functions for audition and balance, the eye has a dual role in detecting light for a wide range of behavioral and physiological functions separate from sight. These responses are driven primarily by stimulation of photosensitive retinal ganglion cells (pRGCs) that are most sensitive to short-wavelength ( approximately 480 nm) blue light and remain functional in the absence of rods and cones. We examined the spectral sensitivity of non-image-forming responses in two profoundly blind subjects lacking functional rods and cones (one male, 56 yr old; one female, 87 yr old). In the male subject, we found that short-wavelength light preferentially suppressed melatonin, reset the circadian pacemaker, and directly enhanced alertness compared to 555 nm exposure, which is the peak sensitivity of the photopic visual system. In an action spectrum for pupillary constriction, the female subject exhibited a peak spectral sensitivity (lambda(max)) of 480 nm, matching that of the pRGCs but not that of the rods and cones. This subject was also able to correctly report a threshold short-wavelength stimulus ( approximately 480 nm) but not other wavelengths. Collectively these data show that pRGCs contribute to both circadian physiology and rudimentary visual awareness in humans and challenge the assumption that rod- and cone-based photoreception mediate all "visual" responses to light.

Tissue Engineering Applied to the Retinal Prosthesis: Neurotrophin-Eluting Polymeric Hydrogel Coatings

Several groups are developing visual prostheses to aid patients with vision loss. While these devices have shown some success in the clinic, they are severely limited by poor resolution, and in many cases have as few as 15 electrodes. Pixel density is poor because high stimulation thresholds require large electrodes to minimize charge density that would otherwise damage the electrode and tissue. A significant contributor to high stimulation threshold requirements is poor biocompatibility. We investigated the application of one system popular in tissue engineering, drug-releasing hydrogels, as a mechanism to improve the tissue-electrode interface. Hydrogels studied (i.e., PEGPLA photocrosslinkable polymers) released neurotrophic factors (i.e., BDNF) known to promote neuron survival and neurite extension in the retina. Hydrogels were examined in co-culture with retinal explants for 7 and 14 days, at which time neurite extension and neurite density was measured. Neurite extension was enhanced in samples exposed to BDNF-releasing hydrogels at 7 days; however, these increases were absent by day 14 suggesting declining drug release. Thus, PEGPLA hydrogels are excellent candidates for short-term (< 14 day) acute release of therapeutic factors in the retina, but will require additional modifications for application with neural prostheses. Additionally, these results suggest that the effects of neurotrophic factors are short-lived in the absence of additional support cues, and tissue engineering systems employing such factors may only produce transient benefits to the patient.

Retinal prostheses: current challenges and future outlook

Blindness from retinal diseases, including age-related macular degeneration (AMD) and retinitis pigmentosa (RP), usually causes a significant decline in quality of life for affected patients. Currently there is no cure for these conditions. However, over the last decade, several groups have been developing retinal prostheses which hopefully will provide some degree of improved visual function to these patients. Several such devices are now in clinical trials. Unfortunately, the possibility of electrode or tissue damage limits excitation schemes to those that may be employed with electrodes that have relatively low charge densities. Further, the excitation thresholds that have been required to achieve vision to date, in general, are relatively high. This may result in part from poor apposition between neurons and the stimulating electrodes and is confounded by the effects of the photoreceptor loss, which initiates other pathology in the surviving retinal tissue. The combination of these and other factors imposes a restriction on the pixel density that can be used for devices that actively deliver electrical stimulation to the retina. The resultant use of devices with relatively low pixel densities presumably will limit the degree of visual resolution that can be obtained with these devices. Further increases in pixel density, and therefore increased visual acuity, will necessitate either improved electrode-tissue biocompatibility or lower stimulation thresholds. To meet this challenge, innovations in materials and devices have been proposed. Here, we review the types of retinal prostheses investigated, the extent of their current biocompatibility and future improvements designed to surmount these limitations.

Optokinetic nystagmus as a measure of visual function in severely visually impaired patients

PURPOSE

To evaluate the efficacy of using optokinetic nystagmus (OKN) as an objective measurement of vision in severely visually impaired patients, in whom it is difficult to measure visual function reliably. Objective visual acuity (VA) measurements would be useful in the pre-and postoperative assessment of severely visually impaired patients who are potential candidates for visual rehabilitation strategies, such as retinal prostheses, neural and stem cell transplantation, and molecular approaches.

METHODS

Full-field visual stimuli were used to evoke horizontal OKN responses in 17 subjects. Eye movements were recorded and analyzed to determine the maximum stimulus velocity (V(max)) at which subjects could maintain an OKN response. This endpoint was compared to logMAR VA and Goldmann visual field (VF) test

RESULTS

results. V(max) was dependent on VA, VF, and the spatial frequency (SF) of the stimulus, yielding the equation V(max) = 14.2 . log(VA) - 6.20 . log(SF) + 0.22 . VF + 25.0. The findings suggest that V(max) in the presence of full-field OKN stimuli may provide an objective measure of VA and peripheral vision.

CONCLUSIONS

OKN testing may be useful as an additional, more objective means of assessing visual function in a select group of severely visually impaired patients who are being considered as candidates for new visual rehabilitative strategies.

Neurotrophin-eluting hydrogel coatings for neural stimulating electrodes

Improved sensory and motor prostheses for the central nervous system will require large numbers of electrodes with low electrical thresholds for neural excitation. With the eventual goal of reducing stimulation thresholds, we have investigated the use of biodegradable, neurotrophin-eluting hydrogels (i.e., poly(ethylene glycol)-poly(lactic acid), PEGPLA) as a means of attracting neurites to the surface of stimulating electrodes. PEGPLA hydrogels with release rates ranging from 1.5 to 3 weeks were synthesized. These hydrogels were applied to multielectrode arrays with sputtered iridium oxide charge-injection sites. The coatings had little impact on the iridium oxide electrochemical properties, including charge storage capacity, impedance, and voltage transients during current pulsing. Additionally, we quantitatively examined the ability of neurotrophin-eluting, PEGPLA hydrogels to promote neurite extension in vitro using a PC12 cell culture model. Hydrogels released neurotrophin (nerve growth factor, NGF) for at least 1 week, with neurite extension near that of an NGF positive control and much higher than extension seen from sham, bovine serum albumin-releasing boluses, and a negative control. These results show that neurotrophin-eluting hydrogels can be applied to multielectrode arrays, and suggest a method to improve neuron-electrode proximity, which could result in lowered electrical stimulation thresholds. Reduced thresholds support the creation of smaller electrode structures and high density electrode prostheses, greatly enhancing prosthesis control and function.

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

Appropriate delivery of electrical stimulation to intact visual structures can evoke patterned sensations of light in individuals who have been blind for many years. This pivotal finding has lent credibility to the concept of restoring functional vision by artificial means. As numerous groups worldwide pursue human clinical testing with visual prosthetic devices, it is becoming increasingly clear that there remains a considerable gap between the challenges of prosthetic device development and the rehabilitative strategies needed to implement this new technology in patients. An important area of future work will be the development of appropriate pre- and post-implantation measures of performance and establishing candidate selection criteria in order to quantify technical advances, guide future device design and optimize therapeutic success. We propose that the selection of an 'ideal' candidate should also be considered within the context of the variable neuroplastic changes that follow vision loss. Specifically, an understanding of the adaptive and compensatory changes that occur within the brain could assist in guiding the development of post-implantation rehabilitative strategies and optimize behavioral outcomes.

Responses of ganglion cells to repetitive electrical stimulation of the retina

Retinal ganglion cells (RGCs) can be activated electrically either directly or indirectly (via the retinal neural network). Previous studies have shown that RGCs can follow high stimulus rates (> or = 200 pulses s(-1)) when directly activated. In the present study, we investigated how well RGCs can follow repetitive stimulation of the neural network. We studied the responses (spike activity) of RGCs in isolated rabbit retina to stimulation with paired pulses applied at different interpulse intervals and trains of pulses applied at different frequencies. We found that the response amplitude of a RGC to a current pulse applied soon (< or = 400 ms) after a preceding current pulse is diminished. This depression in response amplitude became greater as the interval between pulses became shorter. At an interpulse interval of 15 ms (shortest tested), the response amplitude to the second current pulse was reduced on average 94%. When a train of ten stimulus pulses was applied, further depression was observed, particularly at high stimulation frequencies. The depression with each successive pulse was relatively moderate compared to the depression to the second pulse. The results of this study have implications for the design of electrical stimulation strategies in a retinal prosthesis.

Neurotrophin-eluting hydrogel coatings for neural stimulating electrodes

Improved sensory and motor prostheses for the central nervous system will require large numbers of electrodes with low electrical thresholds for neural excitation. With the eventual goal of reducing stimulation thresholds, we have investigated the use of biodegradable, neurotrophin-eluting hydrogels (i.e., poly(ethylene glycol)-poly(lactic acid), PEGPLA) as a means of attracting neurites to the surface of stimulating electrodes. PEGPLA hydrogels with release rates ranging from 1.5 to 3 weeks were synthesized. These hydrogels were applied to multielectrode arrays with sputtered iridium oxide charge-injection sites. The coatings had little impact on the iridium oxide electrochemical properties, including charge storage capacity, impedance, and voltage transients during current pulsing. Additionally, we quantitatively examined the ability of neurotrophin-eluting, PEGPLA hydrogels to promote neurite extension in vitro using a PC12 cell culture model. Hydrogels released neurotrophin (nerve growth factor, NGF) for at least 1 week, with neurite extension near that of an NGF positive control and much higher than extension seen from sham, bovine serum albumin-releasing boluses, and a negative control. These results show that neurotrophin-eluting hydrogels can be applied to multielectrode arrays, and suggest a method to improve neuron-electrode proximity, which could result in lowered electrical stimulation thresholds. Reduced thresholds support the creation of smaller electrode structures and high density electrode prostheses, greatly enhancing prosthesis control and function.

Biocompatibility of materials implanted into the subretinal space of Yucatan pigs

PURPOSE

To assess the biocompatibility of materials for possible use in subretinal prostheses.

METHODS

Strips (0.5 x 5 mm; 10-microm thick) of either plain poly(imide) or poly(imide) coated with amorphous aluminum oxide (AAO), amorphous carbon (AC), parylene, poly(vinyl pyrrolidone) (PVP), or poly(ethylene glycol) (PEG) were each implanted into the subretinal space of four Yucatan miniature pigs. Two types of control surgery without implantation were performed in four other animals. Electroretinograms (ERGs) were performed before and after surgery. All animals were euthanatized 3 months after surgery, and histologic slides of the retina were assessed for 15 criteria. Paired, two-tailed Student's t-tests were used for statistical analyses.

RESULTS

Across all animals, the mean amplitude of the ERG b-wave did not differ from baseline after 3 months. In implanted animals, the histologic analyses revealed that (1) all the implanted materials produced abnormalities that were significantly greater than in the control subjects; (2) overall, PEG, parylene, and PVP produced less histologic disruption than the other three materials; (3) parylene and PEG did not differ significantly from the control in disturbing retinal anatomy; (4) only PI and AAO produced RPE alterations that were significantly greater than in control subjects; and (5) AAO and PI produced a significantly greater degree of peri-implant cellular responses than did the other materials.

CONCLUSIONS

All implants produced some alteration of the retina, but there were clear differences among the materials in the degree to which their presence disturbed the normal anatomy of the retina or RPE or incited tissue reactions around the implant.

In vivo electrical stimulation of rabbit retina: effect of stimulus duration and electrical field orientation

Information that defines the depth of activation of retinal neurons is useful in considering strategies for stimulation with a retinal prosthesis, or interpreting the results from human studies that have previously been performed. The purpose of this study was to test the assertion that electrical pulse durations >0.5 msec preferentially stimulate retinal neurons deep to the ganglion cell layer. Thirteen Dutch-belted rabbits (1.2-2.0 kg) were used in this study. A Goldmann-like dome was used to deliver photic stimuli to the retina to measure the electroretinogram (ERG) and the light-induced cortical potential (VECP). Then, a micromanipulator was used to position a 500 microm inner diameter bipolar electrode near the visual streak on the epi-retinal surface. Symmetric biphasic pulses (7-1600 microA; 0.25 msec and 2.0 msec pulses per phase; biphasic pulses delivered at 2 Hz) were delivered to the retina with a current source. Extra-dural electrodes were used to record electrical evoked cortical potentials (EECPs) over the occipital cortex by performing 50 consecutive computer-averaged stimulations. The effect on the EECP of sequential epi-retinal (i.e. return electrode on epi-retinal surface) vs. trans-retinal (i.e. return electrode behind sclera) stimulation was compared. The effect upon the ERG, VECP and EECP was then assessed after 2,3,dihydroxy-6-nitro-7-sulfamoyl-benzo-f-quinoxaline (NBQX) at 112 microM concentration, d-2-amino-7-phosphonoheptanoic acid (D-AP7) at 1200 microM concentration, and l-amino-4-phosphonobutyrate (APB) at 300 microM concentration were delivered into the vitreous cavity to selectively block neuronal input to the retinal ganglion cells. Median values were reported. The amplitudes of the light-induced ERG and VECP were markedly reduced by instillation of the intra-vitreal synaptic blocking drugs. By comparison, pharmacological blockade of input to the retinal ganglion cells did not significantly alter the threshold charge or amplitude of the electrically-induced cortical responses (P>0.05). For the electrical stimuli, there was no significant difference in threshold charge for the EECP for epi-retinal vs. trans-retinal stimulation (P>0.05). The amplitude of the EECP increased linearly with increasing charge using both 0.25 msec and 2.0 msec pulses, even after synaptic blockade of input to the ganglion cells. The lack of obvious degradation of cortical amplitudes after drug instillation indicates that neurons of the middle retina are not being preferentially driven with epi-retinal stimulation, at least not with stimulus pulses up to 2.0 msec in duration. This conclusion is in contrast to prior evidence that 2.0 msec pulses would preferentially stimulate deeper retinal neurons, specifically the bipolar cells. Based upon our own observations in other studies, we believe that preferential stimulation of the middle retina in fact can be achieved by epi-retinal stimulation, by using pulse durations at least 5 times longer than those used in this study.

Thresholds for activation of rabbit retinal ganglion cells with a subretinal electrode

The ultimate success of a retinal prosthesis to create vision will likely depend upon developing a base of knowledge of how best to electrically stimulate the retina. Previously, we studied the responses of rabbit retinal ganglion cells (RGCs) to current pulses applied with an electrode placed on the epiretinal surface. In the present study, we examined the responses of rabbit RGCs to current pulses applied with a subretinal electrode. Single-unit extracellular recordings were made from OFF RGCs and ON RGCs in isolated retinas, which were stimulated with monophasic current pulses (0.1-50ms in duration), delivered through a 500-mum diameter electrode. All RGCs elicited one or more bursts of action potentials upon electrical stimulation of the retina. The timing of the bursts depended upon both the polarity of the electrical stimulus and the RGC type. With near-threshold current pulses, the response latencies of OFF RGCs to anodal stimulation were comparable to those of ON RGCs to cathodal stimulation, whereas the response latencies of OFF RGCs to cathodal stimulation were comparable to those of ON RGCs to anodal stimulation. Threshold currents for activation of RGCs decreased with increased pulse duration. For OFF RGCs, threshold currents for cathodal current pulses were, on average, 2-7.5 times higher (depending upon pulse duration) than the threshold currents for anodal current pulses. For ON RGCs, threshold currents for cathodal and anodal current pulses were, on average, nearly identical for all pulse durations and were equivalent to threshold currents of OFF RGCs to anodal stimulation. With respect to a subretinal prosthesis, our findings suggest the possibility that cathodal current pulses may bias activation of ON RGCs in blind patients.

Ischemic Optic Neuropathy Following Spine Surgery in a 16-Year-Old Patient and a Ten-Year-Old Patient

Peri-operative ischemic optic neuropathy typically occurs in middle-aged or older patients. We report this condition in two patients aged 16 and 10 years. Only six other cases of peri-operative ischemic optic neuropathy have been reported in patients aged less than 30 years, all but one occurring after spinal surgery. Although the visual prognosis appears to be more favorable in younger patients, the pathogenesis of this rare complication of surgery is likely to be the same as that affecting older individuals.

Delayed Visual Decline in Patients With “Stable” Optic Neuropathy

BACKGROUND

Histological studies on the human optic nerve have documented decreasing axonal nerve fiber counts with age. In patients with optic atrophy, a nonpathological dropout of ganglion cell axons as part of the normal aging process may become clinically significant.

OBJECTIVE

To describe the occurrence of delayed visual loss in patients with presumably "stable" optic neuropathy.

METHODS

We reviewed the medical records of 3 patients who experienced slowly progressive visual loss in adulthood after suffering childhood optic nerve injury.

RESULTS

All 3 patients had a monophasic illness in childhood that caused bilateral optic atrophy and visual impairment. Following decades of stability, each suffered a gradual, symptomatic visual decline that extended over years. No new ophthalmologic, systemic, or neurologic disorder was found that explained the visual decline in any of these patients.

CONCLUSION

We hypothesize that the late visual decline in these 3 patients resulted from deleterious effects of age-related axonal loss on an already depleted population of neurons.

Thresholds for Activation of Rabbit Retinal Ganglion Cells with Relatively Large, Extracellular Microelectrodes

PURPOSE

To investigate the responses of retinal ganglion cells (RGCs) to electrical stimulation, using electrodes comparable in size to those used in human studies investigating the feasibility of an electronic retinal prosthesis.

METHODS

Rabbit retinas were stimulated in vitro with current pulses applied to the inner surface with 125- and 500-mum diameter electrodes while the responses of RGCs were recorded extracellularly.

RESULTS

Both short-latency (SL; 3-5 ms) and long-latency (LL; >/=9 ms) responses were observed after electrical stimulation within the receptive field of an RGC. With short, 0.1-ms current pulses, the threshold current for the SL cell response was significantly lower than that for the LL cell response. With long (10- to 20-ms) pulses, the threshold currents for the SL and LL cell responses were very similar. The threshold current for the SL cell response increased more steeply than did the LL cell response when the electrode was displaced from the point of lowest electrical threshold, either above or along the surface of the retina. Stimulation of an RGC axon outside of the cell's receptive field produced only an SL response. For 0.1-ms duration pulses, the threshold current for the axonal response was significantly higher than the threshold current for the SL cell response. At pulse durations > 1 ms, the thresholds were very similar.

CONCLUSIONS

RGC responses to electrical stimulation depend on the current pulse duration and location of the stimulating electrode. For an epiretinal prosthesis, short-duration current pulses may be preferable since they result in a more localized activation of the retina.

Comparison of electrically evoked cortical potential thresholds generated with subretinal or suprachoroidal placement of a microelectrode array in the rabbit

The aim of the study was to directly compare the threshold electrical charge density of the retina (retinal threshold) in rabbits for the generation of electrical evoked potentials (EEP) by delivering electrical stimulation with a custom-made microelectrode array (MEA) implanted into either the subretinal or suprachoroidal space. Nine eyes of seven Dutch-belted rabbits were studied. The electroretinogram (ERG), visual evoked potentials (VEP) and EEP were recorded. Electrodes for the VEP and EEP were placed on the dura mater overlying the visual cortex. The EEP was recorded following electrical stimulation of the MEA placed either subretinally beneath the visual streak of the retina or in the suprachoroidal space in the rabbit eye. An ab externo approach was used for placement of the MEA. Liquid perfluorodecaline (PFCL; 0.4 ml) was placed within the vitreous cavity to flatten the neurosensory retina on the MEA after subretinal implantation. The retinal threshold for generation of an EEP was determined for each MEA placement by three consecutive measurements consisting of 100 computer-averaged recordings. Animals were sacrificed at the conclusion of the experiment and the eyes were enucleated for histological examination. The retinal threshold to generate an EEP was 9 +/- 7 nC (0.023 +/- 0.016 mC cm(-2)) within the subretinal space and 150 +/- 122 nC (0.375 +/- 0.306 mC cm(-2)) within the suprachoroidal space. Histology showed disruption of the outer retina with subretinal but not suprachoroidal placement. The retinal threshold to elicit an EEP is significantly lower with subretinal placement of the MEA compared to suprachoroidal placement (P < 0.05). The retinal threshold charge density with a subretinal MEA is well below the published charge limit of 1 mC cm(-2), which is the level below which chronic stimulation of the retina is considered necessary to avoid tissue damage (Shannon 1992 IEEE Trans. Biomed. Eng. 39 424-6).

In vitroactivation of retinal cells: estimating location of stimulated cell by using a mathematical model

Activation of neurons at different depths within the retina and at various eccentricities from the stimulating electrode will presumably influence the visual percepts created by a retinal prosthesis. With an electrical prosthesis, neurons will be activated in relation to the stimulating charge that impacts their cell membranes. The common model used to predict charge density is Coulomb's law, also known as the square law. We propose a modified model that can be used to predict neuronal depth that takes into account: (1) finite dimensions related to the position and size of the stimulating and return electrodes and (2) two-dimensional displacements of neurons with respect to the electrodes, two factors that are not considered in the square law model. We tested our model by using in vitro physiological threshold data that we had obtained previously for eight OFF-center brisk-transient rabbit retinal ganglion cells. For our most spatially dense threshold data (25 microm increments up to 100 microm from the cell body), our model estimated the depth of one RGC to be 76 +/- 76 microm versus 87 +/- 62 microm (median: SD) for the square law model, respectively. This difference was not statistically significant. For the seven other RGCs for which we had obtained threshold data up to 800 microm from the cell body, the estimate of the RGC depth (using data obtained along the X axis) was 96 +/- 74 versus 20 +/- 20 microm for the square law and our modified model, respectively. Although this difference was not statistically significant (Student t-test: p = 0.12), our model provided median values much closer to the estimated depth of these RGCs (>>25 microm). This more realistic estimate of cell depth predicted by our model is not unexpected in this latter data set because of the more spatially distributed threshold data points that were evaluated. Our model has theoretical advantages over the traditional square law model under certain conditions, especially when considering neurons that are horizontally displaced from the stimulating electrode. Our model would have to be tested with a larger threshold data pool to permit more conclusive statements about the relative value of our model versus the traditional square law model under special circumstances.

Responses of rabbit retinal ganglion cells to electrical stimulation with an epiretinal electrode

Rational selection of electrical stimulus parameters for an electronic retinal prosthesis requires knowledge of the electrophysiological responses of retinal neurons to electrical stimuli. In this study, we examined the effects of cathodal and anodal current pulses on the extracellularly recorded responses of OFF and ON rabbit retinal ganglion cells (RGCs) in an in vitro preparation. Current pulses (1 msec duration), delivered by a 125 microm electrode placed on the inner retinal surface within the receptive field of a RGC, produced both short-latency (< or =5 msec) and long-latency (8-60 msec) responses. The long-latency responses, but not the short-latency responses, were abolished upon application of the glutamate receptor antagonists CNQX and NBQX, thus indicating that the long-latency responses of RGCs are due to activation of presynaptic neurons in the retina. The latency of the long-latency response depended upon the polarity of the stimulus. For OFF RGCs, the average latency was 11 msec for a cathodal stimulus and 24 msec for an anodal stimulus. For ON RGCs, the average latency was 25 msec for a cathodal stimulus and 16 msec for an anodal stimulus. The threshold current also depended upon the polarity of the stimulus, at least for OFF RGCs. The average threshold current for evoking a long-latency response in OFF RGCs was 10 microA for a cathodal stimulus and 21 microA for an anodal stimulus. In ON RGCs, the average threshold current was 13 microA for a cathodal stimulus and 15 microA for an anodal stimulus.

What blindness can tell us about seeing again: merging neuroplasticity and neuroprostheses

Significant progress has been made in the development of visual neuroprostheses to restore vision in blind individuals. Appropriate delivery of electrical stimulation to intact visual structures can evoke patterned sensations of light in those who have been blind for many years. However, success in developing functional visual prostheses requires an understanding of how to communicate effectively with the visually deprived brain in order to merge what is perceived visually with what is generated electrically.

Optic nerve head circulation in nonarteritic anterior ischemic optic neuropathy and optic neuritis

PURPOSE

To quantify optic nerve head circulatory abnormalities in patients with unilateral nonarteritic anterior ischemic optic neuropathy (NAION) or optic neuritis (ON), and to assess the potential of such measurements to differentiate NAION from ON.

DESIGN

Prospective, cross-sectional, observational study.

PARTICIPANTS

Thirty consecutive patients with unilateral NAION, 22 consecutive patients with unilateral ON, and 50 healthy control subjects.

METHODS

All subjects underwent a complete neuro-ophthalmologic evaluation. The widths of Doppler-broadened frequency spectra, which are directly proportional to the speed of blood cells flowing through the capillaries of the optic nerve head, were measured at multiple sites in both eyes of each subject. The variation of Doppler broadening (DB) with age was determined in the control subjects. Doppler broadening values in the patients were compared between similar sites in affected and contralateral eyes, and between both affected and contralateral eyes and the age-adjusted values determined in the control subjects.

MAIN OUTCOME MEASURES

The differences in DB between (1) the affected and contralateral eyes of the patients, (2) the patients and the control subjects, and (3) the patients with NAION and those with ON.

RESULTS

In NAION, DB was decreased at both temporal (-20.2% and -18.5%) and nasal (-12.8% and -12.4%) sites of the nerve head in affected eyes compared with contralateral eyes or eyes of control subjects. In ON, DB was also decreased at temporal sites (-11.3% and -9.2%) in affected eyes compared with contralateral or control eyes. At nasal sites, there were no significant differences in DB in affected eyes of ON patients compared with contralateral or control eyes. The DB decreases were significantly greater in NAION patients than in ON patients.

CONCLUSIONS

Optic nerve head circulatory abnormalities are present in patients with NAION or ON. This is the first demonstration of such abnormalities in ON, a finding consistent with the recent attention given to the phenomenon of axonal loss in this disease. Although there are differences in the circulatory abnormalities between the 2 diseases that provide insights into the pathophysiological mechanisms at play, they are not large enough to enable the clinician to distinguish between ON and NAION in an individual patient.

Identification ofKIF21AMutations as a Rare Cause of Congenital Fibrosis of the Extraocular Muscles Type 3 (CFEOM3)

PURPOSE

Three congenital fibrosis of the extraocular muscles phenotypes (CFEOM1-3) have been identified. Each represents a specific form of paralytic strabismus characterized by congenital restrictive ophthalmoplegia, often with accompanying ptosis. It has been demonstrated that CFEOM1 results from mutations in KIF21A and CFEOM2 from mutations in PHOX2A. This study was conducted to determine the incidence of KIF21A and PHOX2A mutations among individuals with the third CFEOM phenotype, CFEOM3.

METHODS

All pedigrees and sporadic individuals with CFEOM3 in the authors' database were identified, whether the pedigrees were linked or consistent with linkage to the FEOM1, FEOM2, and/or FEOM3 loci was determined, and the appropriate pedigrees and the sporadic individuals were screened for mutations in KIF21A and PHOX2A.

RESULTS

Twelve CFEOM3 pedigrees and 10 CFEOM3 sporadic individuals were identified in the database. The structures of eight of the pedigrees permitted the generation of meaningful linkage data. KIF21A was screened in 17 probands, and mutations were identified in two CFEOM3 pedigrees. One pedigree harbored a novel mutation (2841G-->A, M947I) and one harbored the most common and recurrent of the CFEOM1 mutations identified previously (2860C-->T, R954W). None of CFEOM3 pedigrees or sporadic individuals harbored mutations in PHOX2A.

CONCLUSIONS

The results demonstrate that KIF21A mutations are a rare cause of CFEOM3 and that KIF21A mutations can be nonpenetrant. Although KIF21A is the first gene to be associated with CFEOM3, the results imply that mutations in the unidentified FEOM3 gene are the more common cause of this phenotype.

Outer retinal degeneration: an electronic retinal prosthesis as a treatment strategy

OBJECTIVE

To review progress toward an electronic retinal prosthesis for outer retinal degeneration.

METHOD

Literature review.

RESULTS

Retinal degenerations such as retinitis pigmentosa result in a loss of photoreceptors. There is a secondary loss of inner retinal cells, but significant numbers of bipolar and ganglion cells remain for many years. Electrical stimulation can produce phosphenes in the eyes of individuals who are blind as a result of retinitis pigmentosa. Several research groups are trying to exploit this phenomenon to produce artificial vision with electronic retinal prostheses. Two groups, with private company sponsorship, have recently implanted first-generation devices in subjects with advanced retinitis pigmentosa. They have reported limited preliminary results. This article seeks to put these results in a broader context and review potential obstacles to successful prosthesis development. These include inner retinal cell viability, high thresholds, signal encoding, power requirements, biocompatibility, and device encapsulation.

CONCLUSION

There has been substantial progress toward an electronic retinal prosthesis, but fully functional, long-lasting devices are not on the immediate horizon.

Sputtered iridium oxide films (SIROFs) for low-impedance neural stimulation and recording electrodes

Iridium oxide films formed by electrochemical activation of iridium metal (AIROF) or by electrochemical deposition (EIROF) are being evaluated as low-impedance charge-injection coatings for neural stimulation and recording. Iridium oxide may also be deposited by reactive sputtering from iridium metal in an oxidizing plasma. The characterization of sputtered iridium oxide films (SIROFs) as coatings for nerve electrodes is reported. SIROFs were characterized by cyclic voltammetry, electrochemical impedance spectroscopy, and potential transient measurements during charge-injection. The surface morphology of the SIROF transitions from smooth to highly nodular with increasing film thickness from 80 nm to 4600 nm. Charge-injection capacities exceed 0.75 mC/cm(2) with 0.75 ms current pulses in thicker films. The SIROF was deposited on both planar and non-planar substrates and photolithographically patterned by lift-off.

Differential recovery of the electroretinogram, visually evoked cortical potential, and electrically evoked cortical potential following vitrectomy: Implications for acute testing of an implanted retinal prosthesis

To determine the extent to which electrophysiologic tests of the afferent visual pathway are affected by vitrectomy, the procedure was performed in 15 eyes of 11 adult Dutch-belted rabbits. An electroretinogram (ERG), visually evoked cortical potential (VECP), and electrically evoked cortical potential (EECP) were obtained preoperatively and sequentially after surgery. For electrical stimulations, biphasic impulses were delivered to the retina. Post-vitrectomy declines of 49, 25, and 41% from the median baseline amplitudes and increases of 13, 18, and 17% from the median baseline latency values were found for ERG, VECP, and EECP, respectively. At 90 min, 13 to 30% of eyes still had an amplitude more than 10% below baseline on at least one of the three tests, whereas 10 to 47% of eyes had an abnormal latency more than 10% above baseline on at least one of the three tests. Amplitudes were more likely than latencies to return to near baseline, but for eyes that remained subnormal, the decline was greater for amplitudes than latencies. Significant alterations in retinal function, manifested by declines in amplitudes and increases in latencies of the ERG, VECP, and EECP, persist in a large proportion of eyes up to 90 min post-vitrectomy.

In vivo electrical stimulation of rabbit retina with a microfabricated array: strategies to maximize responses for prospective assessment of stimulus efficacy and biocompatibility

PURPOSE

Our primary goal was to assess the effects of varying stimulus parameters on the electrically evoked cortical potentials (EECPs) in rabbits, which we intend to use as one measure of biocompatibility of implanted retinal prosthetic devices. We also sought to exclude contamination of waveforms recorded over the occipital cortex from electrical activity from the retina and the degree of reproducibility of EECP recordings.

METHODS

A concentric bipolar platinum electrode or microfabricated 5x5 electrode array delivered current to the retina of 43 Dutch-belted rabbits while the EECP was recorded from extradural electrodes over the occipital cortex. Electroretinogram (ERG) and visual evoked cortical potential (VECP) recordings were routinely obtained. Verification that occipital cortical recordings were not heavily contaminated by electrical potentials from the retina (i.e. the "validity" of the cortical recordings) was made by recording retinal and brain responses before and after intravitreal injection of tetrodotoxin. Electrical stimulation of the retina was performed with monopolar (with distant return) or bipolar electrode configurations. Cortical responses were computer-averaged over 100-500 stimulations. The effect of variation in stimulus current, charge, duration, frequency, polarity and spatial orientation of stimulating electrodes on cortical responses was studied.

RESULTS

Progressive reduction of responses toward the anterior skull and abolition of posterior recordings by tetrodotoxin indicated that retinal activity did not significantly contaminate EECP recordings. Reproducibility testing revealed that inter-animal variability within the first hour of testing across all animals was not significantly greater than that found during prolonged testing of a single animal. The lowest current that yielded a reproducible EECP with monopolar stimulation was 75 microA (total current through 21 electrodes) using 200 microsec pulses, which yielded a 45 microV cortical response. Strength-duration curves were generally flat for fixed charge stimulation and linear for fixed current stimulation, at least up to a saturation point, which occurred at very high charge. Over 0.5-16 Hz stimulus frequencies, ERGs varied little but evoked potential responses showed a monotonic decline in amplitude at higher frequencies. Large negative-going initial pulses of a biphasic pair yielded the largest cortical amplitudes. EECP amplitudes varied significantly with the orientation of stimulating electrodes on the retina.

CONCLUSIONS

This study provides novel data on the reproducibility of EECP recordings, and insight into stimulation parameters that affect retinal and cortical responses. This information can be used to improve the yield of retinal and evoked potential recordings, which will enhance the prospective assessment of the efficacy of stimulation and health of the stimulated tissues following.

Methods and Perceptual Thresholds for Short-Term Electrical Stimulation of Human Retina with Microelectrode Arrays

PURPOSE

To report methods for performing epiretinal electrical stimulation with microfabricated electrode arrays and determining perceptual thresholds on awake human volunteers during acute surgical trials.

METHODS

Four hypotheses were tested: (1) epiretinal stimulation can be performed during acute experiments without obviously damaging the retina or degrading vision or the health of the eye; (2) perception can be obtained 50% of the time in blind patients with charge densities below published safety limits; (3) the minimal charge needed to induce perception would be higher in patients with more severe retinal degeneration; and (4) threshold charge would be lower at shorter stimulus durations. Five subjects with severe blindness from retinitis pigmentosa and one with normal vision (who underwent enucleation of the eye because of orbital cancer) were studied. Electrical stimulation of the retina was performed on awake volunteers by placing a single 250-microm diameter handheld needle electrode or a 10-microm thick microfabricated array of iridium oxide electrodes (400-, 100-, or 50-microm diameter) on the retina. Current sources outside the eye delivered charge to the electrodes. Assessment of damage was made by observing the clinical appearance of the eyes, comparing pre- and postoperative visual acuity, obtaining retinal histology in one case, and comparing perceptual thresholds with published safety limits.

RESULTS

No clinically visible damage to the eye or loss of vision occurred. Even at sites removed from stimulation, histology revealed swollen photoreceptor inner and outer segments, which were believed to be nonspecific findings. Percepts could not be reliably elicited with 50-microm diameter electrodes using safe charges in one blind patient. With the two larger electrodes, only the normal-sighted patient had thresholds at charge densities below 0.25 and 1.0 millicoulombs (mC)/cm(2) for 400- and 100-microm diameter electrodes, respectively, which is one seemingly reasonable estimate of safety derived from the product of charge per phase and charge density per phase. In blind patients, thresholds always exceeded these levels, although most were close to these limits in patient 6. The range of charge density thresholds with the 400- microm electrode in blind patients was 0.28 to 2.8 mC/cm(2). The normal-sighted patient had a threshold of 0.08 mC/cm(2) with a 400-microm electrode, roughly one quarter of the lowest threshold in the blind patients. Strength-duration curves obtained in two blind patients revealed the lowest threshold charge at the 0.25- or 1.0-ms stimulus duration.

CONCLUSIONS

Threshold charge densities in severely blind patients were substantially higher than that in a normal-sighted patient. Charge densities in blind patients always exceeded one seemingly reasonable estimate of safe stimulation. The potential adversity of long-term stimulation of the retina by a prosthesis has yet to be determined.