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.