A comparison of oscillatory potential and pattern electroretinogram measures in diabetic retinopathy

Electrophysiological assessment of visual function in newly-diagnosed IDDM patients

Electrophysiological tests (electroretinogram, oscillatory potentials, visual evoked potentials, in the basal condition and after photostress) reveal an abnormal function of the visual system in insulin-dependent diabetic (IDDM) patients. The aim of our work was to assess whether electrophysiological abnormalities in visual function exist in newly-diagnosed diabetic patients free of any fluorangiographic signs of retinopathy. Ten control subjects (age 28.7 +/- 2.44 years) and then IDDM patients (age 25.2 +/- 6.78 years; disease duration 5.3 +/- 3.5 months) in stable metabolic control (HbA1C 7.5 +/- 1.1%) were evaluated. Flash-electroretinograms and oscillatory potentials were similar in both groups. Visual evoked potentials (VEP) recorded under basal conditions showed that P100 latency was significantly increased in the diabetic patients compared to control subjects (p < 0.01), while N75-P100 amplitude was similar in both groups. The recovery time of VEP after photostress was equivalent in diabetic patients and control subjects. The impaired basal VEPs suggest an early involvement of the nervous conduction in the optic nerve. However, the preserved flash-electroretinogram and the normal recovery time after photostress indicate that a short disease duration does not induce physiopathological changes in the outer retinal layers or in the macular function.

Effect of pharmacologically induced mydriasis on the normal variability of retinal oscillatory potentials in man

In this study we describe certain aspects of normal variability of oscillatory potentials, with particular reference to interaction between pupil size and stimulus intensity. The mean latencies of the earlier oscillatory potentials, O1 and O2, were significantly shorter when adopting the dilated pupil condition than when stimulating with a normal pupil. This occurred at various light intensities, although the difference was more significant at the highest intensity. O1 and O2 latencies became significantly longer as the stimulus intensity was progressively reduced. The latencies of the later components O3 and O4 were unaffected. The O1 and O2 amplitudes were not influenced by pupil size, but a significant reduction occurred with the progressive decrease in stimulus intensity. The later components O3 and O4 are greatly reduced in amplitude after pupil dilatation using higher stimulus intensities; the O4 potential may even disappear in 10% of the cases. These data provide further support for the existence of two distinct behavior patterns for earlier and later oscillatory potentials. Although light adaptation may affect oscillatory potentials, we suggest that in our experimental conditions, oscillatory potential changes may occur as a result of the activity of the neural modulating system, not only as a result of photoreceptor interaction.

Comparison of colour discrimination and electroretinography in evaluation of visual pathway dysfunction in aretinopathic IDDM patients

The slow progression of diabetic retinopathy makes it difficult to assess the effects of intervention therapy. There is thus a need for surrogate markers of visual change in diabetes. Colour vision tests and electroretinography (ERG) may be useful in this regard; yet little is known of their relative performance in the assessment of visual dysfunction in diabetes. The aim of the present study was to compare colour discrimination (100 hue test) and ERG indices (oscillatory potentials (OP) and pattern ERG (PERG)) in the evaluation of aretinopathic IDDM patients. Colour discrimination was abnormal in 10 aretinopathic IDDM patients when compared with nine age matched controls; mean square root 100 hue error scores were 10.38 (SD 2.89) versus 4.77 (1.87) respectively, p < 0.01. OP implicit times of the ERG were also abnormal; for example, for right eye, mean OP1 implicit time for diabetics versus OP1 implicit time for controls was 20.1 (2.0) versus 18.6 (1.4) ms, p = 0.03. Comparison of the two techniques suggested that the 100 hue test was more sensitive and more specific than ERG OP implicit times in the detection of diabetic visual dysfunction in these patients.

Presence and further development of retinal dysfunction after 3-year follow up in IDDM patients without angiographically documented vasculopathy

Abnormalities in neuroretinal function may play a role in the development of diabetic retinopathy. The natural course of diabetic retinal dysfunction in a group of subjects with insulin-dependent diabetes mellitus and with no apparent microvascular alterations in the retina was followed-up with fluorescein angiography and a sensitive electrophysiological technique, i.e., steady-state focal electroretinogram at the macula, for 3 years. Before the beginning and throughout our study, strict glycaemic control was maintained by three or four daily insulin injections under careful monitoring. Analysis of macular electroretinogram provided information from different neural layers. At the first examination, functional activities of postreceptoral neurons were significantly decreased with respect to those of age-matched control subjects. Diabetic patients showed a functional loss of both ganglion cell (0.53 +/- 0.09 vs 0.42 +/- 0.11 microV; t = 5; p = 0.0001) and preganglion cell (0.51 +/- 0.13 vs 0.42 +/- 0.14 microV; t = 2.8; p = 0.007) layers. Diabetes did not alter photoreceptor activity. After 3 years, dysfunction was significantly greater in the preganglion cell layer (0.28 +/- 0.11 microV; t = 6.3; p = 0.0001). Although in some patients further impairment of ganglion cell function was shown, no significant difference was found in 3 years. Photoreceptor function remained unaltered. No vascular abnormalities in the retina were noted after 3 years in this group of patients. Metabolic control was not correlated to functional changes. Our findings suggest that the middle retinal layer is the most sensitive physiological locus of progressive diabetes-induced dysfunction in the absence of angiographically documented abnormalities.

The electroretinogram during orbital compression following intraorbital regional block for cataract surgery

The electroretinogram (ERG) is a transient biopotential that reflects the electrical response of the distal retina to photostimulation. Disturbances in retinal circulation produce characteristic abnormalities in the ERG wave form. The objective of this study was to investigate the changes in the ERG produced by combined retrobulbar and peribulbar injections of a large volume (8 ml) of local anaesthetic, followed by ocular compression. Electroretinogram recordings were obtained from skin electrodes placed on the infero orbital ridge in response to stroboscopic flash stimulation in 34 adult patients undergoing cataract surgery: (a) prior to regional anaesthesia (baseline condition); (b) within one minute after regional anaesthesia of the orbit (block condition); (c) after ten minutes of orbital compression with a Honan's device at 30 mmHg. (compression condition); (d) and five minutes after removal of orbital compression (recovery condition). The ERG implicit times of both a- and b-wave increased (P < 0.001) after anaesthetic block. The amplitude of the a- and b-waves also decreased (P < 0.001) immediately following anaesthetic block and continued to decrease following application of the compression device (P < 0.01). Following removal of ocular compression the amplitude of the b-wave increased (P < 0.01). Only the a-wave implicit time (P < 0.005) decreased with release of ocular compression. These findings are compatible with the ERG changes of transient retinal ischaemia produced by ocular compression.

Early selective neuroretinal disorder in prepubertal type 1 (insulin-dependent) diabetic children without microvascular abnormalities

The duration of diabetes before puberty is not considered relevant to the future development of complications. To evaluate the effects of diabetes on the neural retina, we analysed macular function by steady-state focal electroretinography in 20 prepubescent diabetic children without vascular retinopathy and in 39 sex- and age-matched normal children. The mean (+/- SD) response related to retinal cellular elements between the photoreceptors and ganglion cells was significantly lower in diabetic children than in the control group (0.38 +/- 0.12 vs. 0.51 +/- 0.13 microV; unpaired t-test = 3; P = 0.005). Similarly, ganglion cell function showed a significant impairment in diabetic children with respect to the control group (0.4 +/- 0.13 vs. 0.53 +/- 0.09 microV; unpaired t-test = 5.4; P = 0.0001), whereas the photoreceptors appeared unaffected. Metabolic control and disease duration were not correlated with functional deficits. Our results suggest that before puberty, early diabetes may have a selective effect on the neural retina prior to the appearance of microvascular changes. A focal electroretinogram could identify diabetic children with neurosensory disorders who may have a higher risk of developing microvascular retinopathy.

Comparison of the second and third oscillatory potentials with oscillatory potential power in early diabetic retinopathy

We used an oscillatory potential power method (a measure of the summed oscillatory potential activity) based on fast-Fourier transform analysis to study the oscillatory potentials in early diabetic retinopathy. The method was used in 29 diabetic patients with no ophthalmoscopically visible diabetic retinopathy, 29 diabetic patients with early signs only and 27 control subjects. The reduction in oscillatory potential power was compared with the reduction in the second and third oscillatory potential amplitudes and increase in implicit time in the diabetic patients. The amplitude of the second oscillatory potential was slightly more resistant to diabetic retinopathy than was the amplitude of the third oscillatory potential. Because the oscillatory potentials were detected by means of a high-resolution technique, their implicit times seem to be as discriminating as the oscillatory potential power in the detection of early diabetic retinopathy.

Oscillatory potentials, retinopathy, and long-term glucose control in insulin-dependent diabetes

The main objective of the study was to assess effects of long-term lowering of glucosylated hemoglobin (HbA1%) on neurosensory function in insulin-dependent diabetes. Individual (OP-1, OP-2, OP-3) and summed (OP-sum) amplitudes of oscillatory potentials (OPs) of electroretinography were recorded at study start and 7-years later in 45 patients (the Oslo study). As an overall 7-year change, amplitudes of OP-2, OP-3 and OP-sum were reduced (p < 0.0001-0.01), retinopathy worsened (p = 0.005), intraocular pressure decreased (p < 0.001), systolic blood pressure increased (p < 0.0002), and glycemic control improved from HbA1 of 11.2 +/- 2.2% at study start to a 7-year cumulative mean of 9.5 +/- 1.5% (p < 0.0001). Multiple regression analysis did not identify any independent relations between change in OP-1, OP-2, OP-3, OP-sum and change in glycemic control or background variables, including change in age and duration of diabetes. However, cross-sectional observations at 7 years showed negative correlations between all OPs and age (p < 0.0001-0.003), and between OP-3 and duration (p = 0.003) and counts of microaneurysms (p = 0.02). The data suggest that various clinical background variables may influence individual and summed amplitudes of OPs differently. Reduced neurosensory retinal function (OPs) seemed to appear after 7-years, independently of vascular defects of retinopathy and long-term improvement in glucose control.

Retinal oscillatory potential abnormalities in patients with chronic renal failure, before and after dialytic treatment

Nineteen patients with chronic renal failure were studied, oscillatory potentials (OPs) being recorded shortly before and after dialytic treatment. Mean values of either onset latency (O1 latency) and duration of the complex (O1-N4 inter-peak latency) were found to be significantly longer in patients than in controls (p < 0.001). Most of the patients (12) showed a pathological prolongation of latency (> 2.5 SD). Amplitude changes also affected OPs, but earlier components were reduced to a lesser degree than the later ones, as shown by statistical analysis. Moreover, seven patients showed an almost complete loss of O3 and O4 peaks. Latency changes may be transiently reversed by dialysis, suggesting a functional impairment of the retinal response; the loss of later components is a more persistent abnormality probably related with a structural damage.

Electroretinographic oscillatory potentials in diabetic retinopathy. An analysis in the domains of time and frequency

The oscillatory potentials of the electroretinogram in dark and light adaptation were evaluated by Fourier transform in 87 diabetics and 74 age-matched controls. The study consisted of four groups: normal control, no observable diabetic retinopathy, background diabetic retinopathy and proliferative diabetic retinopathy. A reduction in the amplitude of each oscillatory potential, the summed amplitudes, the area and the total power of the oscillatory potentials as well as delayed implicit time of each oscillatory potential peak in dark and light adaptation could be found in patients with background diabetic retinopathy and proliferative diabetic retinopathy. The amplitude of oscillatory potential 4 in dark adaptation and the total power of the oscillatory potentials in light adaptation seemed to be affected in patients with no observable diabetic retinopathy. The implicit time of oscillatory potential 2 in dark adaptation was valuable to distinguish between patients with no observable diabetic retinopathy and background diabetic retinopathy.

High correlation between absolute psychophysical threshold and the scotopic threshold response to the same stimulus

The scotopic threshold response (STR) is a negative potential to low intensity light recorded from the dark-adapted retina. It reflects inner retinal function. The STR is now recorded routinely as part of our electroretinography protocol. The projected absolute threshold calculated from the amplitude versus intensity function for the STR has been found to correlate well (r = 0.59) with the absolute subjective threshold to the same stimulus. The correlation holds for about 1.5 log units above normal. With further elevation the STR is usually abnormal or absent as b wave threshold is approached. The correlation would have been much greater were it not for this truncated range over which both are recordable. This report includes our findings in 127 patients and examines several disease groups. When the STR had a reduced and abnormal intensity series or was absent, the subjective threshold was elevated in almost all cases (92.2%). The converse relationship also held. When there was a discrepancy, recording problems were usually identified. Since the STR requires difficult, time consuming signal averaging for reliable recording, it may be adequate to record the subjective threshold alone to provide a relatively easily recordable indicator of inner retinal function. Additional STR recording will seldom be warranted.

The pattern electroretinogram in retinal and optic nerve disease. A quantitative comparison of the pattern of visual dysfunction

A retrospective analysis was performed on the transient and steady-state pattern electroretinograms recorded from 42 patients with glaucoma, 13 patients with senile dementia of the Alzheimer's type, 58 patients with diabetes mellitus, and 92 control subjects to evaluate the pattern of electroretinographic changes associated with retinal and optic nerve disease. The amplitudes of both the initial positive component (N1 to P1) and the subsequent negative component (P1 to N2) of the transient (4 rps) responses were measured. From these measurements the (P1 to N2)/(N1 to P1) was derived. The N1 to P1 amplitude of the steady-state pattern electroretinogram also was measured. In the glaucoma patients all three amplitude measures, as well as the amplitude ratio of the components of the transient response, were reduced significantly compared with age-matched controls (p less than 0.05). A similar pattern was detected in the patients with Alzheimer's disease, but in this case the only statistically significant amplitude reduction was in the steady-state pattern electroretinogram. A different pattern was observed among the diabetic patients (both with and without retinopathy). Only minor reductions in the amplitude of the transient pattern electroretinogram, which were not statistically significant, were noted. In addition, the ratio of the amplitudes of the components of the transient response did not differ from age-matched controls. The amplitude of the steady-state pattern electroretinogram was reduced in diabetics, but this was significant only for those patients with retinopathy (p less than 0.01). These findings support the suggestion that an analysis of both the positive and negative components of the pattern electroretinogram may be useful for differentiating the contributions of retinal and optic nerve dysfunction to visual impairment. The results also indicate that in both retinal and optic nerve disease the steady-state pattern electroretinogram can be an earlier sign of dysfunction than the transient pattern electroretinogram.

Spatial frequency-selective losses with pattern electroretinogram in type 1 (insulin-dependent) diabetic patients without retinopathy

Neurosensory abnormalities have been implicated in the first stages of diabetic retinopathy. The activity of retinal ganglion cells in 24 Type 1 (insulin-dependent) diabetic patients with short disease duration without retinopathy on fluorescein angiography was investigated by using a pattern electroretinogram in response to sinusoidal gratings of different spatial frequencies (0.6, 1.0, 1.4, 2.2 4.8 cycles/deg), counterphase modulated at 8 Hz. The pattern electroretinogram reflects, at least in part, the activity of subsets of generators (i.e. ganglion cells) which show spatial selectivity. Mean pattern electroretinogram amplitude was significantly reduced in patients at lower and intermediate, but not at higher spatial frequencies compared with 40 age-matched control subjects. At 1.4 cycles/deg the pattern electroretinogram amplitude was significantly correlated (r = 0.59) with age at onset (p = 0.002) and duration of disease (p = 0.002). Our results suggest that in Type 1 diabetic patients without retinopathy, there is an early sensory deficit of specific inner retina neurons which respond preferentially to gratings of medium and large size.

The electroretinogram in minimal diabetic retinopathy

The pattern and diffuse flash electroretinograms were measured in 20 normal subjects and 40 diabetic patients who had either normal fundi or microaneurysms only. The amplitudes of the pattern electroretinogram were found to be similar in both normals and diabetics. In the case of the flash electroretinogram the diabetic patients showed a division into two main groups. One group was not dissimilar to the group of normal subjects, while the second group showed hypernormal amplitudes. No explanation could be given, from the data collected, for this subdivision, though it is suggested it might reflect the degree of metabolic disturbance.

The effects of altered retinal vascular perfusion pressure on the white flash scotopic ERG and oscillatory potentials in man

The oscillatory potentials (OPs) of the flash-elicited electroretinogram b-wave have been identified as sensitive indices of abnormalities within the retinal circulation. A recent study by Lovasik and Kothe has identified the rod system as being more vulnerable than the cone system to transient alterations of the retinal vascular perfusion pressure (RVPP). In view of these previous findings, we investigated the susceptibility of the scotopic OPs to altered retinal perfusion, in 10 normotensive paid volunteers between 21 and 31 years of age. A transient increase in RVPP was effected by body inversion, while a transient decrease in RVPP was obtained by suction ophthalmodynamometry. Group averaged data showed that OP-1 to OP-4 decreased in amplitude with either an increase or a decrease in RVPP. In contrast to all other OPs, OP-5 was reduced to a greater degree when RVPP was decreased and showed a pronounced gain in amplitude as RVPP was increased. Our study has isolated a component-specific vulnerability to altered retinal perfusion. This finding may be interpreted as indicating a different retinal site of origin for the generators of OP-5. The heightened sensitivity of OP-5 to alteration of the RVPP may offer diagnostic advantage for investigating chronic diseases causing retinal ischemia.

The pattern electroretinogram in diabetes

In 27 normal subjects and 64 insulin-dependent diabetic patients, we evaluated the pattern electroretinogram, which may reflect the neural activity of the spatially sensitive retinal ganglion cells. The amplitude of the pattern electroretinogram was reduced in diabetic patients who had no observable retinal changes. The amplitude was further reduced with increasing retinopathy. The pattern electroretinogram amplitude change was a more sensitive indicator of retinal change among the diabetic subpopulations than the statistically significant changes in latency. A significant correlation between pattern electroretinogram amplitude and the duration of diabetes were found in diabetic patients with either no observable retinopathy or minimal background retinopathy. The pattern electroretinogram may be useful as a quantitative, dependent variable to establish and monitor short-term metabolic and physiologic changes in diabetic patients.

The wide-angle pattern electroretinogram. Relation between pattern electroretinogram amplitude and stimulus area using large stimuli

Pattern electroretinograms (PERGs) were recorded from two normal human subjects in response to various spatial frequencies and stimulus areas. The maximum stimulus area was 75 degrees x 86 degrees which was achieved by using a standard TV monitor and a reduced viewing distance. The amplitude of the PERG increased with area in an approximately logarithmic fashion over the range investigated. The explanation relates to non-linearities of the stimulus, the retinal image and neural processing. The wide-angle PERG may be useful in the assessment of retinal diseases affecting the mid-peripheral inner retina, such as diabetic retinopathy.

Steady-state pattern electroretinogram in insulin-dependent diabetics with no or minimal retinopathy

Steady-state pattern electroretinogram (PERG) in response to sinusoidal gratings (1.7 c/deg spatial frequency; 9 x 9 deg field size) temporally modulated (sinusoidally) at 8 Hz were recorded in 40 insulin-dependent diabetics and 28 age-matched normal subjects. Visual acuity was greater than or equal to 20/20 in all 40 patients; 31 (62 eyes) showed no sign of retinopathy and nine (18 eyes) showed a few microaneurysms on fluorescein angiography. Insulin-dependent diabetics showed a significant reduction in the PERG mean amplitude as compared with age-matched control subjects (one-way analysis of variance: p less than 0.0001). Significant differences were observed between normals and diabetics without retinopathy (Scheffé test: p less than 0.0001), normals and diabetics with early retinopathy (Scheffé test: p less than 0.0001), no retinopathy and early retinopathy patients (Scheffé test: p less than 0.05). In diabetics without retinopathy multifactorial analysis of variance revealed a significant effect of age of onset of the disease (p less than 0.01) and an interaction effect between age of onset and duration (p less than 0.001) on PERG amplitude. These results suggest a possible use of the steady-state PERG to detect early macular dysfunction in insulin-dependent diabetics.

The scotopic threshold response in diabetic retinopathy

The scotopic threshold response (STR) is a recently discovered component of the electroretinogram. It is a corneal negative deflection elicited in the fully dark adapted eye to dim stimuli, and appears to originate in the inner retina. The STR was recorded in a group of 50 insulin dependent diabetics with various degrees of diabetic retinopathy, who had not undergone laser photocoagulation. In addition, the scotopic b-wave, oscillatory potentials (OPs) and a pattern electroretinogram (PERG) were recorded. Retinopathy was assessed with stereo colour photographs of the seven standard fields as defined in the Diabetic Retinopathy Study. Retinopathy level was assigned to each eye using a modification of the Airlie House Classification System. Fluorescein angiograms were taken using a 60 degree fundus camera and graded for the presence of leakage and capillary non-perfusion. There was a significant correlation between the severity of retinopathy and the amplitude and latency of the STR. There was a similar correlation with the amplitude and latency of the OPs, a weaker correlation with the amplitude of the PERG, but no significant correlation with the latency of the PERG. These results support an inner retinal origin for the STR and suggest a role for STR in the electroretinographic assessment of diabetic retinopathy.

Variability in clinically measured photopic oscillatory potentials

Oscillatory potentials found on the ascending phase of the electroretinogram b-wave probably originate in some element(s) of the inner plexiform layer. As oscillatory potentials are particularly sensitive to changes in retinal, and possibly choroidal, blood flow, they have been used extensively to provide clinical measures of the degree of retinal ischemia during the progression of diabetic retinopathy. Recent studies in our laboratories have disclosed previously unreported significant variability in the photopic oscillatory potentials on repeated measures even in tightly controlled conditions. The amplitude of five recordable light-adapted wavelets exhibited considerable intra- and inter-subject variability. Until further investigation can determine factors affecting standardization of testing, it appears that changes in oscillatory potential implicit times rather than in amplitudes are a better measurement in clinical neurophysiology.

Psychophysical and electrophysiological testing of retinal function. Macular recovery time and oscillatory potentials in normal subjects

We evaluated different aspects of 1) psychophysical and 2) electrophysiological testing procedures of retinal function, represented by macular recovery time (nyctometry) and oscillatory potentials (electroretinography), respectively. Ninety healthy males, aged 18-28 years, were used in the study. We registered two different phases of macular recovery time, IRT: initial recovery time (less than 40 sec) and AUC: area under the curve (less than 120 sec) and both individual and summed nodes of oscillatory potentials (OPs). A significant effect of training was observed in monocular registration of IRT and AUC (P less than 0.01), and the superiority of binocular recovery was numerically compared to monocular recovery (P less than 0.01). The inter-variability (coefficient of variation) of IRT was high (40%) in both monocular and binocular registrations, while AUC had a smaller variability binocularily than monocularily (33% vs 21%). The inter-variability of OPs was low (16%). Intra-variability, between first and second eye tested, showed highly correlated values in IRT, AUC and OPs (r = 0.51-0.82; P less than 0.004), while IRT/AUC was not correlated to amplitudes of OPs. The results emphasize that selecting one eye, mean of two eyes or both eyes are critical for accuracy and validity in psychophysical testing of visual performance.

A review of the clinical applications of the pattern electroretinogram

The pattern electroretinogram (PERG) has recently been introduced as a clinical procedure. It has been thought by many to represent activity of the retinal ganglion cells, although this is still a matter of contention. The exciting prospect of a selective test of ganglion cell function led to the application of the PERG in a variety of ophthalmological conditions. In the course of these investigations the PERG was found to be diminished in cases of maculopathy, optic atrophy, optic neuritis, toxic optic neuropathy, neurotransmitter disorders, glaucoma and ocular hypertension and in retinal vascular disorders such as diabetes. It was also affected in some cases of amblyopia. This paper briefly describes the techniques used to record the PERG and reviews current literature pertaining to its clinical application.

Neural effects of body inversion: photopic oscillatory potentials

The effect of alterations in retinal and choroidal circulation resulting from changes in body orientation were examined in 10 subjects with normal systemic and intraocular pressures. Body inversion resulted in an increase in the intraocular pressure with a concomitant increase in the ocular perfusion pressure. The effect of these pressure elevations was assessed by photopic oscillatory potentials (OPs). The trends in the change in OP amplitude with experimentally elevated ocular perfusion pressure varied across OP wavelets. OP-1 and the OP index exhibited a statistically significant decrease with an increase in ocular perfusion pressure, with OP-2 to OP-5 showing statistically insignificant reductions. Only OP-5 showed a significant decrease in implicit time with increased perfusion pressure. The magnitude of these changes were quite small despite a greater than 70% increase in the ocular perfusion pressure. Vascular autoregulatory mechanisms are hypothesized to be responsible for maintaining the OPs to within clinically normal levels.

Oscillatory potentials, macular recovery time, and diabetic retinopathy through 3 years of intensified insulin treatment

Forty-five diabetic patients, 18 to 45 years of age, with mild or no retinopathy, were randomly assigned to continuous subcutaneous insulin infusion (CSII), multiple injections (Mls), and conventional insulin treatment (CIT). The effects of near-normoglycemia (CSII and MI) on oscillatory potentials (electroretinography [ERG]) and macular recovery time (nyctometry) were studied prospectively for 41 months. Before randomization, the amplitudes of oscillatory potentials were negatively correlated to age (P = 0.002) and positively correlated to the diameter of retinal veins (P less than 0.05). Men had shorter macular recovery time than women (P = 0.03). Nyctometry and oscillatory potentials were not related to mean blood glucose values, glycosylated hemoglobin (HbA1), retinopathy, blood pressure levels, or duration of diabetes. Changes in metabolic control (MI and CSII; P less than 0.01) and in microaneurysms and hemorrhages (CSII and CIT) during the study did not affect oscillatory potentials or nyctometry. Soft exudates (15 patients) and proliferative retinopathy (1 patient) transiently developed with MI and CSII regimens. No changes in oscillatory potentials or nyctometry were observed and no pretreatment characteristics of these parameters predicted the occurrence of these ischemic lesions. At the stage of proliferation, however, lowered amplitudes of oscillatory potentials and lengthened macular recovery time were observed.

The pattern electroretinogram

Physiological experiments and the exploitation of clinical conditions have provided compelling evidence that retinal ganglion cells and other inner retinal structures generate the pattern ERG (PERG). As an increasing number of clinical reports have been published some contradictory findings have been reported. These may be ascribed to variation in recording and measuring techniques. The PERG consists of two major portions, the early positive and the following negative component which can be investigated separately if the stimulus conditions allow isolated (or "transient") responses to be recorded. Care has to be taken in positioning the reference electrode, maintaining accurate refraction, and the influence of pupil size must be considered. Furthermore the PERG is contaminated by a luminance component which may be generated in the outer retina. The size of this increases with low spatial frequency (large check-sizes) and high mean luminance. The PERG permits the examination of an additional level of the retina and helps the understanding of pathophysiology of various eye diseases, and is of clinical importance in routine diagnosis and assessment. In glaucoma the PERG amplitude is often reduced before it is possible to detect a scotoma and it is therefore an important prognostic indicator in patients with ocular hypertension. In diabetic retinopathy, retinal ischaemia sufficient to lead to the pre-proliferative state can be demonstrated. The PERG also has a major clinical role in examining localised retinal pathology. If combined with VECP recording, it greatly extends the interpretations possible, since not only can damage to the optic nerve be detected by both tests, but the normal PERG in the presence of an abnormal PVECP implies that the losses are confined to the central pathway.