Visual evoked responses in the assessment of field defects in glaucoma

Objective detection of visual field defects with multifrequency VEPs

PURPOSE

To correlate multifrequency pattern reversal VEPs in quadrants (QmfrVEPs) with perimetric field losses for objective detection of visual field losses.

METHODS

QmfrVEP measurements were performed using four LED-based checkerboard stimulators to stimulate the four quadrants of the visual field. QmfrVEPs were measured monocularly in 5 normal subjects and in 5 glaucoma patients who showed losses in conventional Octopus perimetry. The pattern reversal frequency varied slightly between the stimulators: (11.92, 12.00, 12.08 and 12.16 reversals/sec). The responses to the different stimuli were identified by discrete Fourier analysis. VEPs were recorded using different electrode configurations, and the recording with the highest signal-to-noise ratio (SNR) was used for further analysis.

RESULTS

QmfrVEP responses from the different quadrants can be reliably measured and separated using the 0.08 reversals/sec interstimulus reversal frequency differences. The signal-to-noise ratio in the four quadrants was significantly correlated with the equivalent visual field losses obtained with perimetry (Spearman rank correlation: P < 0.001). In the five glaucoma patients, the SNR was reduced in 15 out of the 16 quadrants with a perimetric defect, in comparison to the results in quadrants of healthy subjects. This confirms the sensitivity of the procedure.

CONCLUSION

QmfrVEP responses can be measured reliably. This pilot study suggests that high SNR values exclude visual field defects and that focal defects can be identified in glaucoma patients.

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Steady-State Visually Evoked Potentials Elicited by Multifrequency Pattern-Reversal Stimulation

Purpose

It has been shown that multifrequency stimulation with multifocal electroretinography can reduce recording time without a loss in signal-to-noise ratio. Here, we studied the applicability of multifrequency stimulations for steady-state visually evoked potential (VEP) recordings.

Methods

Multifrequency VEPs were recorded monocularly from 10 healthy subjects using pattern-reversal stimuli. The reversal frequency varied between 5 and 30 Hz. Pattern-reversal checkerboard stimuli were generated using four square arrays, each containing 100 light-emitting diodes (LEDs), positioned in four quadrants. Each array had a temporal frequency that differed slightly from the nominal frequency. The long duration of the data acquisition ensured that the slightly different stimulus frequencies in the four LED arrays can be resolved and that the responses to the stimulus in each array can be distinguished (e.g., with a frequency resolution: 0.011 Hz at 12 Hz). The best response from the four recording electrode configuration, defined as the recording with the maximal signal-to-noise ratio, was used for further analysis. Algorithmic latencies were calculated from the ratio of phase data and frequencies in a range of 4 and 20 Hz.

Results

Quadrant-VEPs with simultaneous pattern-reversal stimulation yielded a significant dependency on temporal frequency and stimulus location. The frequency range leading to the maximal response amplitude was between 10 and 12 Hz. Response phases decreased approximately linearly, with increasing temporal frequency suggesting a mean algorithmic latency between 112 and 126 ms.

Conclusions

Multifrequency stimulation using LED arrays is an efficient method for recording pattern-reversal VEPs while all stimuli are presented at the same time.

Translational Relevance

Simultaneously recorded VEPs as performed by the multi-frequency method can be used for objective measurements of visual field defects.

Correlation of pattern reversal visual evoked potential parameters with the pattern standard deviation in primary open angle glaucoma

AIM

To evaluate whether glaucomatous visual field defect particularly the pattern standard deviation (PSD) of Humphrey visual field could be associated with visual evoked potential (VEP) parameters of patients having primary open angle glaucoma (POAG).

METHODS

Visual field by Humphrey perimetry and simultaneous recordings of pattern reversal visual evoked potential (PRVEP) were assessed in 100 patients with POAG. The stimulus configuration for VEP recordings consisted of the transient pattern reversal method in which a black and white checker board pattern was generated (full field) and displayed on VEP monitor (colour 14″) by an electronic pattern regenerator inbuilt in an evoked potential recorder (RMS EMG EP MARK II).

RESULTS

The results of our study indicate that there is a highly significant (P<0.001) negative correlation of P100 amplitude and a statistically significant (P<0.05) positive correlation of N70 latency, P100 latency and N155 latency with the PSD of Humphrey visual field in the subjects of POAG in various age groups as evaluated by Student's t-test.

CONCLUSION

Prolongation of VEP latencies were mirrored by a corresponding increase of PSD values. Conversely, as PSD increases the magnitude of VEP excursions were found to be diminished.

Dichoptic multifocal visual evoked potentials identify local retinal dysfunction in age-related macular degeneration

PURPOSE

To evaluate the ability of multifocal visual evoked potentials (mfVEPs) to identify functional loss in patients with early and exudative age-related macular degeneration (AMD). A dichoptic multifocal stimulus presentation was employed to investigate the regional effects of AMD and the potential diagnostic utility in macular disease.

METHODS

MfVEP responses were recorded from 19 unilateral exudative AMD patients with non-exudative (n = 15) or normal (n = 4) presentations in the fellow eye and 28 age-matched controls. Root mean square (RMS) waveforms were pooled across selected EEG channels to produce global field RMS (gfRMS) waveforms. GfRMS amplitudes and response delays were analysed by multivariate linear models, and diagnostic capacity was measured using areas under the curve (AUC) of receiver operator characteristic plots.

RESULTS

The mean gfRMS amplitude of the exudative eye of AMD patients was significantly reduced compared with the controls (-2.03 ± 0.08 dB, t = -12.9). Fellow non-exudative AMD eyes were less effected but still significantly reduced (-0.84 ± 0.07 dB, t = -11.5). No significant difference in mean gfRMS delay of AMD eyes across the central 46° was observed. AUC values of 100 ± 0.0% (mean ± SE) for exudative and 79.7 ± 6.5% for non-exudative eyes were obtained for response amplitudes.

CONCLUSION

The study demonstrated that mfVEP identified retinal dysfunction in both exudative AMD and fellow non-exudative AMD eyes, but mostly affecting the macular field. The reduced testing duration and good diagnostic accuracy suggest that dichoptic mfVEPs may be a sensitive tool for monitoring progression in AMD.

Significance of Visual Evoked Potentials in the Assessment of Visual Field Defects in Primary Open-Angle Glaucoma: A Review

Visual evoked potentials is an important visual electrophysiological tool which has been used for the evaluation of visual field defects in primary open-angle glaucoma and is an appropriate objective measure of optic nerve function. Significant correlations between the magnitude of the VEP parameters and MD of Humphrey static perimetry suggest that the impaired visual cortical responses observed in glaucoma patients can be revealed by both electrophysiological and psychophysical methods. In addition, the severity of global glaucomatous damage evidenced by reduction in MD could depend on the delay in neural conduction from retina to the visual cortex as revealed by the significant correlation between VEP latencies and MD which also supports the validity of the VEP testing in progression of glaucoma.

Effect of different stimulus configurations on the visual evoked potential (VEP)

The purpose of this study was to assess changes in the response profile of the pattern visual evoked potential (VEP) using three stimulus configurations simulating visual-field scotomas: central circular and central blank fields increasing incrementally in diameter from 1° to 15°, hemi-field, and quadrant patterns. Five visually normal adult subjects (ages 22-68 years) were tested binocularly at 1 m for each stimulus configuration on 5 separate days. A checkerboard test pattern (64 × 64 black-and-white checks, 85% contrast, 64 cd/m(2) luminance, 20 s of stimulus duration, 2-Hz temporal frequency) was used. The group mean VEP amplitude increased in a linear manner with increase in the central circular diameter (y = 0.805x + 2.00; r = 0.986) and decrease in central blank field diameter (y = -0.769x + 16.22; r = 0.987). There was no significant change in latency in nearly all cases. The group mean coefficient of variability results indicated that the VEP amplitude was repeatable for the different stimulus configurations. The finding of VEP response linearity for the circular stimulus fields, and repeatability for all stimulus configurations, suggests that the clinician may be able to use the VEP technique with the suggested test patterns as a rapid and simple tool for objective assessment for several types of visual-field defects for a range of abnormal visual conditions and special populations.

Electrophysiological Evaluation of Cranial Neuropathies

BACKGROUND

Cranial nerve abnormalities occur frequently in both focal and diffuse neurologic disorders and can be evaluated by electrophysiological techniques available in most clinical neurophysiology laboratories.

REVIEW SUMMARY

The optic nerve is evaluated by visual evoked potentials. Measurements of latency, amplitude, and waveform morphology are especially useful in detecting demyelinating lesions. Brain stem auditory evoked potentials evaluate the auditory portion of the eighth cranial nerve. Using an auditory stimulus, a number of waveforms are generated, and changes in the normal patterns of response can detect abnormalities. Assessment of the trigeminal and facial nerves is done using a series of electrical stimulation techniques including the blink, masseter, and masseter inhibitory reflexes and facial motor nerve conduction studies. The blink reflex detects lesions of the first division of the trigeminal nerve and the facial nerve. The masseter reflex evaluates the third division of the trigeminal nerve. Changes in responses are measured and, using a combination of these techniques, localization of lesions at specific sites can be made. Accessory motor nerve conduction is useful not only in focal nerve injury, but repetitive stimulation on the accessory and facial nerves is used in diagnosing neuromuscular junction disorders. In addition, many of the voluntary muscles innervated by the cranial nerves are accessible to needle electrode examination, and evaluation can aid in identification of focal nerve lesions, as well as diagnosis in diffuse nerve and muscle disorders.

CONCLUSION

Electrophysiological techniques offer reliable means of measuring the integrity of the cranial nerves and their central pathways.

Evaluation of VEP perimetry in normal subjects and glaucoma patients

PURPOSE

To estimate sensitivity to glaucomatous visual field loss using multifocal visual evoked potential (VEP) perimetry, to compare these findings to those of conventional achromatic perimetry and to determine specificity of VEP perimetry in normal subjects.

METHODS

A total of 33 glaucoma patients with known visual field defects in at least one eye on standard computerized perimetry and 33 healthy subjects were tested with VEP perimetry. The glaucoma patients were also tested with standard computerized perimetry using the 30-2 SITA Fast program of the Humphrey Field Analyzer (HFA). Visual evoked potential perimetry classification and VEP probability maps were used to determine the sensitivity and specificity of the technique.

RESULTS

Visual evoked potential perimetry classified 68% of all eyes in the glaucoma group (45/66) as pathological; sensitivity increased to 81% (38/47) when considering only those eyes with HFA field defects. It also identified more test locations with significant loss at the p < 5% level in both groups (48% and 37%, respectively) than did HFA, while HFA identified more loss at the higher significance levels p < 2%, and p < 1%. Visual evoked potential perimetry showed more significant loss in eyes with almost normal or slightly damaged standard fields, while HFA identified more significant field loss in eyes with severe conventional field damage. The mean VEP amplitude of the 66 glaucoma eyes was 1.46e(-7) V; it was 1.676e(-7) V for the 66 control eyes. This difference was significant (p = 0.0033), but the overlap between groups was large. Visual evoked potential perimetry classified 42% of the control eyes as 'outside normal limits', and VEP probability maps showed 30.0% of test segments as significantly depressed at the p < 5% level, 10.8% of sites at p < 2%, and 4.6% at the p < 1% level.

CONCLUSION

Mean VEP amplitude differed significantly between normal and glaucoma eyes, but the overlap was considerable. Visual evoked potential perimetry falsely classified a large number of normal eyes as pathological and showed many more significantly depressed test locations than expected. Agreement between VEP and standard perimetry was relatively poor for the glaucoma group. Further refinements are needed before VEP perimetry can be regarded as a reliable clinical method of mapping glaucomatous visual fields.

Impaired visual function in glaucoma

OBJECTIVE

This work aims to evaluate whether glaucomatous visual field defects could be related to an impaired retinal function, to a delayed neural conduction in postretinal visual pathways, or both.

METHODS

Visual field by Humphrey perimeter (central 24-2 threshold test) and simultaneous recordings of visual evoked potential (VEP) and pattern electroretinogram (PERG) were assessed in 21 subjects with open angle glaucoma (POAG) and in 15 age-matched controls (C).

RESULTS

VEP: in POAG eyes we found P100 latency significantly (P<0.01) delayed when compared with controls and correlated with mean deviation (index of global visual field damage, MD) of 24-2 Humphrey perimetry (P<0.001); the P100 amplitudes were significantly (P<0.01) lower in POAG eyes than in control eyes and correlated with MD (P<0.001). PERG: POAG eyes showed P50 latency significantly (P<0.01) delayed when compared with controls and correlated with MD (P=0.002); the P50 and N95 amplitudes were significantly (P<0.01) lower in POAG than in control eyes and correlated with MD (P50: P=0.006; N95: P=0.002). Retinocortical time (RCT: difference between VEP P100 and PERG P50 latencies) and latency window (LW: difference between VEP N75 and PERG P50 latencies) were significantly (P<0.01) longer in POAG eyes than in control eyes and correlated with MD (RCT: P<0.001; LW: P<0.001). No significant correlations (P>0.05) were found between electrophysiological parameters and the corrected pattern standard deviation (index of localized visual field damage) of 24-2 Humphrey perimetry.

CONCLUSION

In patients with open angle glaucoma the reduction of the index of global visual field damage (MD) could be ascribed to two sources of functional impairment: one retinal (impaired PERG) and one postretinal (delayed RCT and LW). In the postretinal impairment, a postsynaptic degeneration at the level of the lateral geniculate nucleus could be suggested.

Multifocal pattern VEP perimetry: analysis of sectoral waveforms

PURPOSE

The objective detection of local visual field defects using multi-focal pattern visual evoked potentials (VEP) has recently been described. The individual waveforms show variable polarity in different parts of the visual field due to underlying cortical convolutions. Normal trace arrays were examined to determine if certain areas of similar waveform could be grouped for analysis, while minimising cancellation of data.

METHOD

The VEP was assessed using multi-focal pseudo-randomly alternated pattern stimuli which were cortically scaled in size. Bipolar occipital electrodes were used for recording. Waveforms were compared for different locations within the field up to 25 degrees of eccentricity. Analysis of sectors showing similarly shaped waveforms was performed. Twelve normal subjects were studied.

RESULT

Grouping waveforms by sectors of similar waveform increased the total calculated upper hemifield amplitude by 60%, compared with simple summations of responses for the whole hemifield. The inferior hemifield showed more consistent waveforms throughout, with the amplitude only increasing by 11% with sectoral summation. Intra-subject variability (10.6%) is less for sectors than for individual points (17.3%). Inter-subject amplitude differences are high, calculated at 56% for individual points and 45% for sectors.

CONCLUSIONS

Due to differences in waveform as a result of underlying cortical anatomy, individual VEP responses from multifocal recordings should be grouped as sectors along the vertical meridian and above and below the horizontal, rather than by hemifields or quadrants. This finding is significant if one is considering within-field grouping strategies similar to the glaucoma hemifield test used in conventional perimetry, or reporting derived overall VEP amplitudes and latencies from a multifocal recording. Large amplitude variations between individuals and small signals from horizontal and upper field seen in single channel recording, still limit the application of this technique as a form of objective perimetry.

Objective perimetry in glaucoma: recent advances with multifocal stimuli

The introduction of multifocal stimulus recording has enhanced our ability to examine the human visual field with electrophysiologic techniques. We have adapted the multifocal pattern visual evoked potential (PVEP) to detect visual field loss. In glaucoma patients we sought to determine the extent to which the PVEP amplitudes correlate with perimetric thresholds. Multifocal pseudorandomly alternated pattern stimuli, which were cortically scaled in size, were presented with use of the VERIS-Scientific system. Bipolar occipital straddle electrode positions were used. The visual field up to 25 degrees of eccentricity was investigated. Forty-three glaucoma patients with reproducible visual field defects were tested. The bipolar PVEP corresponded well with Humphrey visual field defects, showing loss of signal in the scotoma area. For Humphrey quadrant threshold totals and PVEP quadrant amplitudes, the correlation coefficient was strong (r = 0.49, P < 0.0001). The multifocal PVEP demonstrates good correspondence with the topography of the visual field. This technique represents the first practical application of the multifocal PVEP to objective detection of visual field defects in glaucoma.

The diagnostic significance of the multifocal pattern visual evoked potential in glaucoma

The concept of objective perimetry is an exciting one because it strives to assess glaucoma damage without relying on psychophysical testing. The recent introduction of multifocal stimulus recording has enhanced our ability to examine the human visual field using electrophysiology. A multifocal pattern visual evoked potential can now be recorded, testing up to 60 sites within the central 25 degrees. The test requires only that the subject fixate on a target, while a cortically scaled dartboard pattern stimulus undergoes pseudorandom alternation within each of the test segments. In its present configuration the test requires at least 8 minutes recording time per eye. Modified bipolar electrode positions are required to ensure that adequate signals are detected from all parts of the visual field. In glaucoma patients, pattern visual evoked potential amplitudes have been shown to reflect visual field loss with reduction of signal amplitude in the affected areas. This technique represents the first major step toward objective detection of visual field defects in glaucoma.

Objective detection of hemifield and quadrantic field defects by visual evoked cortical potentials

AIMS/BACKGROUND

An objective method for detecting hemifield and quadrantic visual field defects has been developed using steady state visual evoked cortical potentials (VECPs), an adaptive noise canceller (ANC), and Hotelling's t2 statistic. The purpose of this study was to determine the sensitivity and specificity of the technique.

METHODS

Nine subjects (mean age 44 years) were investigated with field loss due to a variety of causes including both anterior and posterior visual pathway lesions. Dynamic perimetry was performed by means of a Goldmann or Tübingen perimeter. VECP recordings were made from each visual field quadrant (23 degrees X 23 degrees) by means of a steady state reversing checkerboard (7.7 rev/s). The central 5 degrees of the visual field and the vertical and horizontal meridians were masked during these measurements. Recordings were made from three electrode sites, positioned over the visual cortex, relative to a mid frontal electrode. Each recording lasted 2 minutes, during which time fixation was monitored. The data from each recording were divided into 4 second segments, and the amplitude and phase of the VECP signal measured using the ANC. Hotelling's t2 statistic was applied to determine the probability of signal detection. Receiver operating characteristic curves were used to find the optimum signal detection threshold for identification of the visual field defects.

RESULTS

The results of the study confirmed patterns of subjective visual field loss. The technique had a sensitivity and a specificity of 81% and 85%, respectively, for detecting 'non-seeing' areas in the inferior visual field, and 82% and 89%, respectively, for detecting 'non-seeing' areas in the superior visual field.

CONCLUSION

These results demonstrate that the technique is of potential clinical value to ophthalmologists and neurologists when subjective perimetry is not possible.

The measurement of steady-state visual evoked cortical potentials using an adaptive noise canceller

A new software method for measuring steady-state visual evoked cortical potentials (VECPs) has been developed using the principle of adaptive noise cancelling. The steady-state VECP is composed of narrow-band frequency components at harmonics of the stimulus frequency. In clinical recordings, these signal components are masked by wide-band noise, predominantly electroencephalographic activity and muscle noise. The stimulus frequency is exactly known and by using a reference sinusoid at the stimulus frequency (or its harmonics) the adaptive noise canceller (ANC) is able to cancel uncorrelated noise components from the recording. In effect, the ANC functions as an adaptive narrow-band-pass filter at the reference frequency. The performance of the ANC has been evaluated using both simulated and physiological signals. The output of the ANC provides temporal information on the signal amplitude and phase, and can be used to calculate the reliability of signal detection. For this application, the ANC has a number of advantages over the fast Fourier transform: it is a more sensitive detector, it requires fewer calculations, it is less computationally intensive, it requires less memory and it can be implemented in real time.

Steady-state visual evoked cortical potentials from stimulation of visual field quadrants. Optimizing pattern variables for the size of the field to be investigated

The effects of check size and stimulus size were investigated to optimize the steady-state visual evoked cortical potentials from pattern-reversal stimulation of the visual field quadrants. Check sizes of 15', 30', 60', 90', 120' and 180' were investigated at a pattern reversal rate of 11.6 per second for field sizes varying from 2 degrees x 2 degrees to 24 degrees x 24 degrees. The visual evoked cortical potentials were recorded from mid occipital, right occipital and left occipital positions. In the inferonasal quadrant, the largest amplitudes were obtained with 30' and 60' check sizes; however, for these check sizes, the visual evoked cortical potential yielded limited additional information for field sizes greater than 4 degrees x 4 degrees and 6 degrees x 6 degrees, respectively. When a field size of 12 degrees x 12 degrees was investigated, a 90' check size was optimal. The results indicated that, with the above recording positions and check sizes of 15' to 120', there is an optimal number of pattern elements, 40 to 100, for stimulation of the inferonasal quadrant. This should be taken into account when a check size is selected to investigate a field quadrant of a particular size. Digital signal processing techniques were applied to analyze the visual evoked cortical potential, and the system shows promise for objective examination of the visual field.

Prognostic significance of the pattern visual evoked potential in ocular hypertension

This paper reports a prospective study on 49 ocular hypertensive patients to evaluate the prognostic significance of transient abnormalities in the pattern visual evoked potential (VEP) in the development of glaucoma. Seven of 24 patients with VEP abnormalities at diagnosis of ocular hypertension developed glaucomatous field defects in the follow-up period as compared with none of 25 patients with normal VEPs at diagnosis. We conclude that appropriately designed pattern VEP testing is a valuable complement to careful (preferably computerised, static) perimetry. In addition, our findings support the contention that, in glaucomatous disease of the optic nerve, rudimentary pattern processing mechanisms--that is 'Y'-type units of the magnocellular pathways--may be affected earlier than luminance processing mechanisms.

The flash stimulated VEP in the diagnosis of glaucoma

The Visual Evoked Potential using pattern stimulation has been used in recent years as an attempt to make an early diagnosis of glaucoma. However because of the macular dominance of responses obtained by this method, only diseases involving the papillomacular bundle reveal abnormality; such conditions do not occur in glaucoma. In this study we report the use of the early component (P1) of the flash stimulated visual evoked potential in the diagnosis of primary open angle glaucoma. It appears to provide an objective, accurate and repeatable screening technique. The size of P1 correlates well with the size of optic disc cupping, and field loss. The relationships between systemic vascular disease, P1 reductions, and glaucoma, lend support to the ischaemic origins of the disease.

The visual evoked potential in acute primary angle closure glaucoma

Visual evoked potentials (VEPs) were elicited from 29 patients who had experienced a previous attack of acute primary angle closure glaucoma. The VEPs were shown to be abnormal in at least one of the measures (latency, amplitude, contrast threshold, or slope) in 72.4% of affected eyes, whereas only 41.4% indicated obvious optic nerve damage. It is notable that 48.1% of fellow eyes with no (known) history of acute pressure rise also showed some form of VEP abnormality. The possible pathophysiological mechanisms operating in both affected and fellow eyes are discussed. It is concluded that, despite the presence of possible artefactual influences, the results probably reflect the presence of primary angle closure glaucoma.

Interindividual variation and additivity of the visual evoked potentials to the local checkerboard stimulation of the central and paracentral retina

Visually evoked cortical potentials to reversing checkerboard stimulation were recorded from normal subjects. Different locations of the central visual field of maximally 8 degrees radius were stimulated. Stimulation of various parts of the central visual field changed the waveform and the amplitude of the responses of different subjects very individually. This makes it impossible to make a universal decision, how large field or which part of the central field contributes most to pattern evoked cortical potentials. The responses to the upper half field stimulation showed greatest variation making the VEP recording worthless in detecting altitudinal visual field defects. The computed sum of the half field responses was of similar waveform and amplitude to the response to the full field stimulation. The good additivity of the responses applied to all parts of the central visual field tested.

Visual evoked cortical potential to paracentral retinal stimulation in chronic glaucoma, ocular hypertension, and an age-matched group of normals

Visual evoked cortical potentials (VECPs) to midperipheral stimulation of the visual field were elicited in age-matched groups of patients with unilateral chronic simple glaucoma or ocular hypertension and normal subjects. With a multimodal stimulus approach comprising transient and steady-state pattern reversal and transient onset-offset VECPs, 82.1% of the glaucoma group and 50.9% of the ocular hypertensives revealed significant abnormalities (p less than 0.01) in one or more of the electrophysiological features measured, i.e., latency, phase, amplitude, and contrast threshold.

How might demyelinating disorders and glaucoma modify synaptic function?

Latencies of visually evoked potentials (VEPs) tend to be abnormally long in multiple sclerosis (MS). Similar VEP delays are seen in glaucoma. Such delays could result in part from reduced intensities of synaptic inputs at post-retinal synaptic relays, and defects of axoplasmic transport might be one cause for this. The effective rate of synaptic activation of a given postsynaptic neuron can be decreased either by reducing the arrival-rate of presynaptic action potentials (e.g., by complete or partial blockage of conduction in some presynaptic axons), or by reducing the quantity of neurotransmitter released per action potential (e.g., as a consequence of presynaptic neurotransmitter depletion). It is proposed that in both glaucoma and MS, delayed VEPs may result from either or both of these mechanisms. Firstly, loss and functional impairment of optic nerve axons occurs in each disorder. Secondly, in glaucoma the increased intraocular pressure tends to block the rapid anterograde axoplasmic transport (RAAT) which brings neurotransmitter supplies to the axon terminals. This could result in neurotransmitter depletion in the lateral geniculate relay, decreased synaptic effectiveness of remaining normally-conducting optic nerve axons, and thereby increased VEP latencies. RAAT is also blocked by demyelinated lesions that have been produced experimentally by injection of diphtheria toxin. If it is impaired by the demyelinated plaques of multiple sclerosis, then VEP slowing by a similar presynaptic depletion mechanism could ensue.

Variable effects of pathologic scotomata on wave form of pattern-reversal visual evoked response

Further experiments in healthy subjects have confirmed the characteristic but variable differential effect of experimental scotomata on the pattern evoked potentials. While the waveform changes associated with different pathological scotomata also showed considerable variability, certain features common to healthy and abnormal responses could be identified. These non-specific effects of scotomata on component amplitudes and distributions frequently result in spurious delays of wide-field responses and thus have important implications for the pathophysiological interpretation of abnormal responses.

Visual evoked response in transient monocular visual loss

The pattern-reversal visual evoked response (VER) was recorded in 2 patients during transient monocular visual reduction. In both cases the VER was initially abolished. With recovery of vision there was gradual return of amplitude over a 3- to 8-minute period, while latencies remained unchanged from preattack values. These findings are discussed with regard to current understanding of the origins of the VER and relevant aspects of retinal electrophysiology.

[Clinical applications of visual evoked potentials for detection of chiasmal and postchiasmal lesions (author's transl)]

Visual evoked potentials (VEP) were recorded in 18 patients with pathologic processes confirmed by computerized tomography in the chiasmal (n = 9) and parietooccipital region (n = 9). Reactions from the right and left hemisphere could be recorded separately in spite of using a simple one-channel apparatus and electrodes only at Oz and Cz. In 17 cases changes of the VEP provided information concerning the localization and extension of the lesion. In chiasmal processes we found a prolongation of monocular latencies, and a delayed or extinguished reaction to half-field stimulation from temporal retinal areas. However, the VEP was often pathologic for half-field stimulation of the nasal hemiretina. Pathologic VEPs were not always accompanied by visual field defects. In contrary to patients with chiasmal processes no pathologic reaction could be found to full-field stimulation in parieto-occipital lesions. Only when the affected hemisphere was stimulated selectively were diminution of amplitudes, prolongation of latencies, or extinguished responses observed. The VEP changes were uniform despite the cause of the lesion (tumor, ischemia). In chiasmal and parieto-occipital processes the VEP supplements computerized tomography by detecting deficits in function. This method appears suitable for monitoring the course of disease before and after neurosurgery.

VER in intraocular hypertension. Short communication

Transient and steady state VER's before and after artificial IOP elevation were recorded from 16 eyes (9 persons) with untreated intraocular hypertension observed for several years without signs of functional loss or optic disc changes. Four eyes (two patients) demonstrated a pathological transient VER amplitude drop after pressure increase. One eye with an ophthalmoscopically atypical disc presented a grossly deformed transient VER at the habitual pressure level; the fellow eye was lost from trauma. Another eye presented an abnormal VER pattern and showed as yet normal function and ophthalmoscopy, the fellow eye had developed open angle glaucoma and showed identical VER changes. The prognostic and diagnostic implications are briefly discussed.

Electroretinogram (ERG) and visual evoked response (VER) studies in patients with optic disc drusen

Non-corneal ERGs, recorded from infraorbital skin electrodes to flash stimulation and mid-occipital and parasagittal VERs to both flash stimulation and pattern reversal were performed in 26 patients with optic disc drusen. ERGs were normal in all patients. The mean VER amplitude was lower in the eyes with optic disc drusen than the mean amplitude of VERs in the normals but the interindividual variation was also so great in normals that the difference was not significant. The waveform of the major positive peak was quite often broad or split. VER latencies were usually in normal range although the visual field defects could be rather severe. Some other cause was present when the major positive peak was delayed.

Investigation and management of symptomatic hyperprolactinaemia

Fifteen patients with infertility and hyperprolactinaemia have been investigated using tests of prolactin and LH secretion, and treated by prolactin suppression. In addition, 4 patients with hyperprolactinaemia not desiring fertility were also investigated. Of the total group, 16 had galactorrhoea and 15 had amenorrhoea. Pituitary tumours were present in 6 patients and 4 had pituitary microadenomas. Prolactin levels measured by both radioimmunoassay and radioreceptor assay were elevated before treatment and fell during therapy with bromoergocryptine (7.5 mg daily). Tests of prolactin release with TRH and chlorpromazine before treatment did not distinguish patients with functional hyperprolactinaemia from those with pituitary tumours. Basal plasma gonadotrophin concentrations were not elevated despite subnormal urinary oestrogen levels. The serum LH response to LRH was normal during hyperprolactinaemia, but LH release in response to oestrogen provocation was impaired in 14 of 17 patients. During prolactin suppression, mean oestrogen excretion rose significantly and the oestrogen provocation test became normal in all except 2 patients. Pregnancy occurred in all of the 15 patients desiring fertility. Abortion has occurred in 4 patients, all of whom are currently pregnant again. Nine pregnancies have reached term, with no complications from pituitary expansion. It appears that during hyperprolactinaemia there are defects in both positive and negative feedback of oestrogen on LH secretion, and that prolactin suppression in such patients is highly effective in restoring fertility.

Effects of luminance on the pattern visual evoked potential in multiple sclerosis

Pattern visual evoked potentials (PVEPs) were recorded at 5 levels of luminance from 26 patients with multiple sclerosis and from age-matched normal subjects. In normal subjects, the latency of both the major positive peak (P100) and the early positive peak (P60) was an inverse logarithmic function of pattern luminance. The increase in latency per unit log decrease in luminance was 12.1 msec for P100 and 5.7 msec for P60. Only 2 patients had entirely normal results. In 9 patients, the increase in latency of P100 per unit log decrease in luminance was abnormal. Of the 18 luminance-latency functions obtained from testing both eyes, 10 were abnormal, 6 showing a greater than normal increase in latency with decreasing luminance and 4 a less than normal increase. The 6 luminance-latency functions with a greater than normal increase in latency with decreasing luminance were all from patients without other evidence of optic nerve involvement. Pattern luminance, therefore, as well as patient selection, can significantly affect the proportion of abnormal PVEP latencies in any group of patients with possible, probable or definite multiple sclerosis. The abnormal response of the PVEP to changes in luminance and the different effects upon P100 and P60 indicate that the delayed PVEPs in patients with multiple sclerosis cannot be attributed solely to slowing of conduction in the optic nerve.

[The electroretinogram and the visual evoked potential in normal and glaucomatous eyes (author's transl)]

The functional changes of the intraocular nerve structures caused by glaucoma were examined electro-ophthalmologically. The OPs, the photopic and scotopic ERG to examine the receptor and bipolar layers, as well as the EPs, elicited by luminance and pattern-reversal stimuli, for evaluation of the signal conduction in the optic nerve, were recorded. The problem was approached by way of three investigations: first was the question of which nerve structures are affected by glaucoma and exactly how the loss of visual field due to glaucoma can be determined. For this reason, 55 glaucomatous eyes with regulated intraocular pressure and different visual field losses were examined. The results show a functional diminution of all intraocular nerve structures in which the prelaminary part of the optic nerve is most affected. Differences in the visual field loss of both eyes can be well determined by the EPs. Second, the electro-ophthalmologic behavior in seven normal and eight pressure-regulated glaucomatous eyes was studied by gradually elevated intraocular pressure in order to obtain better insight into the functional pathology of glaucoma. The elevation of intraocular pressure was performed with a Müller spring dynamometer in five steps, depending on the ophthalmic blood pressure. The pressure behavior of the ERG components and the EPs is different. The amplitudes of the ERG components show a gradual decrease in normal as well as in glaucomatous eyes when intraocular pressure is increased, and are maintained when intraocular pressure reaches ophthalmic blood pressure. On the other hand, the EPs show a strong decrease in amplitude when intraocular pressure exceeds the mean ophthalmic blood pressure, particularly in the case of glaucomatous eyes. This behavior can be explained by a high pressure sensitivity of the preliminary part of the optic nerve, even greater in glaucomatous eyes. Third, the influence of pressure decrease on the electrical response was examined in glaucomatous eyes with chronic and acute pressure increase before and after pressure regulation. A mean pressure decrease of 37-13.6 mm Hg in ten eyes with chronic pressure increase led to no change in electrical responses other than a phase shift on the pattern-reversal EPs. In five cases with acute pressure increase, an amplitude increase on the luminance EPs was noticed after pressure regulation, with unchanged systemic blood pressure and almost unchanged ERG components. However, in one case an amplitude decrease on luminance EPs and ERG components was found with simultaneous blood pressure decrease. The increase of the amplitudes of the luminance EPs and the phase shifts of the pattern-reversal EPs can be explained as the functional improvement of the prelaminary part of the optic nerve caused by pressure decrease due to improved blood circulation in the prelaminary part of the optic nerve...

Latency of luminance and contrast evoked potentials in multiple sclerosis patients

Luminance and contrast visual evoked potentials (VEPs), were studied in 18 multiple sclerosis (MS) patients and 11 healthy subjects. Luminance EPs were recorded to stimulation with noise modulated light (0--60 Hz); contrast EPs were obtained to appearance-disappearance or reversal of a checkerboard pattern with various check sizes and repetition periods. Our results indicate that the apparent latency of luminance EPs to noise modulated light can hardly be used for diagnosis of MS, since the range of normal values scatters widely and greatly overlaps the range of latency values in MS patients (detection rate of 3/13). Our data confirm, on the other hand, that the latency of contrast EPs can be used to discriminate between MS patients and healthy subjects (detection rate of 12/18). We recommend for diagnostic purposes to determine the apparent latency from the phase spectrum of the responses to checkerboard reversal at repetition rates between 5 and 20 Hz, since in this frequency range the failure rate was found to be minimal. The specificity of the apparent latency data can be improved if the wave form of the transient reversal EP at a lower repetition rate (around 2 Hz) is also inspected. We suggest that an increased latency can be ascribed to several causes, only one of these being an increased conduction time due to demyelination. Indirectly this confirms that an increased EP latency is not specific for MS.

Effect of body temperature on visual evoked potential delay and visual perception in multiple sclerosis

Seven multiple sclerosis patients were cooled and four heated, but evoked potential delay changed in only five out 11 experiments. Control limits were set by cooling eight and heating four control subjects. One patient gave anomalous results in that although heating degraded perceptual delay and visual acuity, and depressed the sine wave grating MTF, double-flash resolution was improved. An explanation is proposed in terms of the pattern of axonal demyelination. The medium frequency flicker evoked potential test seems to be a less reliable means of monitoring the progress of demyelination in multiple sclerosis patients than is double-flash campimetry or perceptual delay campimetry, although in some situations the objectivity of the evoked potential test would be advantageous.

Steady-state evoked potentials

The advantages of steady-state EP recording include (1) speed in assessing sensory function in normal and sick infants (e.g., in amblyopia) and in sick adults (e.g., in multiple sclerosis); (2) monitoring certain activities of sensory pathways that do not intrude into conscious perception; (3) rapidly assessing sensory function when a large number of subjects must be tested (e.g., in refraction); (4) objective measurement at very high suprathreshold levels where psychophysical methods are difficult or ineffective; (5) rapidly assessing sensory function in normal subjects when EP variability and nonstationarity preculde lengthy experiments; and (6) proving a speedy objective equivalent to behavioral test in animals.

Average multichannel EEG potential fields evoked from upper and lower hemi-retina: latency differences

Checkerboard reversals shown to the upper hemiretina evoke EEG potentials which in anterior-posterior derivations are approximately inverted in polarity compared with potentials evoked by lower hemiretinal stimulation. Using a 48-channel system, EEG scalp field distributions of such responses were mapped. Examination of the map sequences shows that occipital positive maximal field values start to develop at about the same time in the two stimulus conditions, but peak much earlier and somewhat more anteriorly for upper than for lower hemiretinal stimulation. Thus, there is a difference of response latency in the two conditions, which accounts for the approximate inversion of polarity. Possible correlations with reports of higher receptor cell density, higher visual acuity, and shorter motor reaction time of the upper hemiretinal system are noted.

Visual pattern evoked responses and blink reflexes in assessment of MS diagnosis. A clinical study of 135 multiple sclerosis/pathol

VEPs were measured after pattern reversal in 135 MS patients and 30 control subjects. Neurological findings were documented in a standard manner. An extensive ophthalmological examination of all subjects was part of the study. The latency of P2 was abnormally delayed in 82% of the "definite", in 60% of the "probable" and in 65% of the "possible" MS groups respectively. The VEP was more often delayed in relation to ophthalmological disturbances. Changes in the MS classification had to be made in more than 10% of the patients, due to delay of VEP latency. These were patients with a "spinal" form of MS, which is known to create diagnostic problems. Optically and electrically evoked blink reflexes were recorded in 107 MS patients. All patients with mesencephalic lesions had delayed responses of the optically evoked reflex. 74% of the patients with caudal brainstem lesions had delayed latencies of the components of the electrically evoked blink reflex. The blink reflex was delayed in 18 additional patients without brainstem signs. The possibility of delineating clinically silent brainstem lesions by investigating blink reflexes is discussed.

Visually evoked potentials: theory, techniques and clinical applications

The visually evoked potential (VEP), the recording of which has recently been made possible by the development of computer averaging techniques, is a gross electrical signal generated by the occipital region of the cortex in response to visual stimulation. It is more specific than the electroencephalogram (EEG) and more sensitive to changes in the visual stimulus; thus, it can provide ophthalmologists and vision researchers with information about the human visual system that is unavailable by other methods. Clinically, the VEP is of special value in the areas of refraction, infant acuity, diseases of the optic nerve, color blindness, amblyopia and field defects. Theory, techniques and instrumentation are described, and applications of the VEP to clinical situations and to vision research are discussed.

The Pulfrich stereo-illusion as an index of optic nerve dysfunction

A simple test based on the Pulfrich phenomenon may provide an indication of optic nerve dysfunction. When a small object swinging pendulum fashion is viewed binocularly by a person with one eye covered by a neutral density filter, the object appears to swing in an elliptical path. The patient with optic nerve dysfunction may see it this way without use of a filter. The Pulfrich theory is explained, clinical applications are discussed, and instructions for constructing a Pulfrich apparatus are given.