Electrophysiological signs of retinal dopamine deficiency in recently diagnosed Parkinson's disease and a follow up study

The retina in Parkinson's disease

As a more complete picture of the clinical phenotype of Parkinson's disease emerges, non-motor symptoms have become increasingly studied. Prominent among these non-motor phenomena are mood disturbance, cognitive decline and dementia, sleep disorders, hyposmia and autonomic failure. In addition, visual symptoms are common, ranging from complaints of dry eyes and reading difficulties, through to perceptual disturbances (feelings of presence and passage) and complex visual hallucinations. Such visual symptoms are a considerable cause of morbidity in Parkinson's disease and, with respect to visual hallucinations, are an important predictor of cognitive decline as well as institutional care and mortality. Evidence exists of visual dysfunction at several levels of the visual pathway in Parkinson's disease. This includes psychophysical, electrophysiological and morphological evidence of disruption of retinal structure and function, in addition to disorders of 'higher' (cortical) visual processing. In this review, we will draw together work from animal and human studies in an attempt to provide an insight into how Parkinson's disease affects the retina and how these changes might contribute to the visual symptoms experienced by patients.

Low-level human equivalent gestational lead exposure produces supernormal scotopic electroretinograms, increased retinal neurogenesis, and decreased retinal dopamine utilization in rats

BACKGROUND

Postnatal lead exposure in children and animals produces alterations in the visual system primarily characterized by decreases in the rod-mediated (scotopic) electroretinogram (ERG) amplitude (subnormality). In contrast, low-level gestational Pb exposure (GLE) increases the amplitude of scotopic ERGs in children (supernormality).

OBJECTIVES

The goal of this study was to establish a rat model of human equivalent GLE and to determine dose-response effects on scotopic ERGs and on retinal morphology, biochemistry, and dopamine metabolism in adult offspring.

METHODS

We exposed female Long-Evans hooded rats to water containing 0, 27 (low), 55 (moderate), or 109 (high) ppm of Pb beginning 2 weeks before mating, throughout gestation, and until postnatal day (PND) 10. We measured maternal and litter indices, blood Pb concentrations (BPb), retinal Pb concentrations, zinc concentrations, and body weights. On PND90, we performed the retinal experiments.

RESULTS

Peak BPb concentrations were < 1, 12, 24, and 46 microg/dL in control, low-, moderate- and high-level GLE groups, respectively, at PNDs 0-10. ERG supernormality and an increased rod photoreceptor and rod bipolar cell neurogenesis occurred with low- and moderate-level GLE. In contrast, high-level GLE produced ERG subnormality, rod cell loss, and decreased retinal Zn levels. GLE produced dose-dependent decreases in dopamine and its utilization.

CONCLUSIONS

Low- and moderate-level GLE produced persistent scotopic ERG supernormality due to an increased neurogenesis of cells in the rod signaling pathway and/or decreased dopamine utilization, whereas high-level GLE produced rod-selective toxicity characterized by ERG subnormality. The ERG is a differential and noninvasive biomarker of GLE. The inverted U-shaped dose-response curves reveal the sensitivity and vulnerability of the developing retina to GLE.

Influence of Dopamine Deficiency in Early Parkinson’s Disease on the Slow Stimulation Multifocal-ERG

PURPOSE

In animal studies intravitreal injection of tetrodotoxin (TTX) results in mfERG waveform changes similar to those observed in glaucoma. As TTX blocks amacrine as well as ganglion cells, there is still a question regarding the underlying cell population responsible for these changes in waveform. In an attempt to assess the contribution of the amacrine cells to these changes, a mfERG was obtained from patients with Parkinson's disease as some amacrine cells are mediated by dopamine, a substance lacking in Parkinson's.

METHODS

Eight patients with early Parkinson's disease underwent ophthalmologic examination, testing of contrast sensitivity and electrophysiological examination according to ISCEV standard at least 12 h following their last medication with Dopamine. A slow stimulation mfERG was obtained with a stimulus base interval of 53.3 ms and with a stimulus base interval of 106.6 ms. During MF-ERG recordings 103 hexagons stimulated the central 50 deg of the retina simultaneously and independently (m-sequence 2(13), L(max): 200 cd/m(2), approximately 100% contrast).

RESULTS

Contrast sensitivity and ISCEV standard electrophysiological testing was unremarkable. When the mfERG was analyzed, only four patients had an adequate signal-to-noise ratio to allow further data analysis - one of whom was diagnosed with a multi system atrophy in retrospect. The first order response component was analyzed at a filter setting of 10-300 Hz and at 100-300 Hz (OPs) and compared to mfERGs of a control group. On average, in patients, the amplitude of N1P1 was slightly lower in the central and nasal response averages. When the three OPs at a latency of 72-89 ms were analyzed in the 53.3 ms base interval recording, the most marked difference in amplitude was observed in the superior nasal response average of the first OP. Here a mean amplitude of 1.3 nV/deg(2) in patients compared to a mean amplitude of 1.9 nV/deg(2) in the control group (P: 0.08).

DISCUSSION

In contrast to our previous findings in NTG, there was a consistent presence of three OPs. Under the stimulus conditions applied, we did not find an influence of dopaminergic amacrine cells on the mfERG in our patients with moderate stages of Parkinsion's. The difficulties in obtaining an adequate signal-to noise ratio due to e.g. muscle artifacts even in Parkinson patients of moderate disease stages render a success of mfERG recording in patients with more advanced stages unlikely. The question of the influence of dopaminergic amacrine cells on the mfERG could possibly be addressed using MPDT in animal research.

The relation between visual hallucinations and visual evoked potential in Parkinson disease

OBJECTIVE

The pathophysiology of hallucinations in Parkinson disease is poorly understood. This study investigated the relation between visual hallucination and visual evoked potentials (VEPs) in Parkinson disease.

METHODS

Nineteen patients with Parkinson disease were studied. The authors divided patients into 2 groups: patients with visual hallucinations (VH group) and those without visual hallucinations (no-VH group). VEPs using a checkerboard stimulus were recorded under a drug-free state.

RESULTS

On multivariate regression analysis, only the average P100 latency was selected and remained significant after the backward elimination method.

CONCLUSION

The authors demonstrated a close association between visual hallucinations and elongated VEP latency in Parkinson disease. VEPs may become one of the predictors for visual hallucination.

Independent patterns of damage within magno-, parvo- and koniocellular pathways in Parkinson's disease

Sensory deficits have been documented in Parkinson's disease, in particular within the visual domain. However, ageing factors related to the brain and to neural and non-neural ocular structures could explain some of the previously reported results, in particular the claimed impairment within the koniocellular pathway. This study addressed visual impairment attributable to the magno- (luminance), parvo- (red-green) and koniocellular (blue-yellow) pathways in a population of Parkinson's disease patients. To avoid potentially confounding factors, all subjects underwent a full neurophthalmological assessment which led to exclusion of subjects with increased intraocular pressure, diabetes even in the absence of retinopathy, and ocular abnormalities (from a total of 72 patients' eyes, 12 were excluded). Both parvo- and koniocellular pathways were studied by means of contrast sensitivity (CS) measurements along protan, tritan and deutan axes and also by fitting chromatic discrimination ellipses using eight measured contrast axes. Magnocellular function was assessed, using stimuli that induce a frequency doubling illusion, in 17 locations in the fovea and periphery. Achromatic (luminance modulation) thresholds were significantly higher in Parkinson's disease both in foveal and peripheral locations. A significant impairment was observed along protan and deutan axes, but only marginally along the tritan axis. These results were corroborated by a significant elongation of chromatic discrimination ellipses in our Parkinson's disease group. Correlation analysis showed that achromatic and chromatic CS measures were independent, which implies that multiple visual pathways are affected independently in Parkinson's disease. Magnocellular impairment was significantly correlated with age and disease stage, in contrast to the measured chromatic deficits. We conclude that in Parkinson's disease, independent damage occurs in the early magno- and parvocellular pathways. Furthermore, traditional koniocellular probing strategies in Parkinson's disease may be confounded by ageing factors, which may reconcile the previously reported controversial findings concerning chromatic impairment in Parkinson's disease.

Morphological impairments in retinal neurons of the scotopic visual pathway in a monkey model of Parkinson's disease

Physiological abnormalities resulting from death of dopaminergic neurons of the central nervous system in Parkinson's disease also extend to the retina, resulting in impaired visual functions. In both parkinsonian patients and animal models, low levels of dopamine and loss of dopaminergic cells in the retina have been reported. However, the morphology and connectivity of their postsynaptic neurons, the amacrine cells, have not been analyzed. Here we report, with macaques chronically treated with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) as a model of Parkinson's disease, that morphological impairments in dopaminergic retinal neurons and their plexus in the inner retina are accompanied by an immunoreactivity decrease in gamma-aminobutyric acidergic and glycinergic amacrine cells. Especially deteriorated were AII amacrine cells, the main neuronal subtype postsynaptic to dopaminergic cells, which exhibited a marked loss of lobular appendages and dendritic processes. Concomitantly, electrical synapses among AII cells, as well as chemical synapses between these and rod bipolar cells, were highly deteriorated in parkinsonian monkeys. These results highlight that the scotopic visual pathway is severely impaired in the parkinsonian condition and provide a morphological basis for a number of abnormalities found in electrophysiological and psychophysical trials in Parkinson's disease patients and animal models.

Changes in Pattern Electroretinograms to Equiluminant Red-Green and Blue-Yellow Gratings in Patients with Early Parkinson’s Disease

In Parkinson's disease (PD), the luminance pattern electroretinogram (PERG) is reported to be abnormal, indicating dysfunction of retinal ganglion cells (RGCs). To determine the vulnerability of different subpopulations of RGCs in PD patients, the authors recorded the PERG to stimuli of chromatic (red-green [R-G] and blue-yellow [B-Y]) and achromatic (yellow-black [Y-Bk]) contrast, known to emphasize the contribution of parvocellular, koniocellular, and magnocellular RGCs, respectively. Subjects were early PD patients (n = 12; mean age, 60.1 +/- 8.3 years; range, 46 to 74 years) not undergoing treatment with levodopa and age-sex-matched controls (n = 12). Pattern electroretinograms were recorded monocularly in response to equiluminant R-G, B-Y, and Y-Bk horizontal gratings of 0.3 c/deg and 90% contrast, reversed at 1Hz, and presented at a viewing distance of 24 cm (59.2 x 59 degree field). In PD patients, the PERG amplitude was significantly reduced (by 40 to 50% on average) for both chromatic and luminance stimuli. Pattern electroretinogram latency was significantly delayed (by about 15 ms) for B-Y stimuli only. Data indicate that, in addition to achromatic PERGs, chromatic PERGs are altered in PD before levodopa therapy. Overall, chromatic PERGs to B-Y equiluminant stimuli exhibited the largest changes. Data are consistent with previous findings in PD, showing that visual evoked potentials (VEP) to B-Y chromatic stimuli are more delayed than VEPs to R-G and achromatic stimuli. The results suggest that the koniocellular subpopulation of RGCs may be particularly vulnerable in early stages of Parkinson's disease.

Neuroimaging in dementia with Lewy bodies: metabolism, neurochemistry, and morphology

Dementia with Lewy bodies (DLB) is recognized as one of the most common forms of neurodegenerative dementia. Neuroimaging contributes to a better understanding of the pathophysiology of DLB by examining alterations in brain metabolism, neurochemisty, and morphology in living patients. Neuroimaging can provide objective and quantifiable antemortem markers for the presence of and the progression of DLB and permits differentiation from other dementias. This article reviews current neuroimaging findings in DLB with particular attention to occipital hypometabolism, dopaminergic and cholinergic deficits, and medial temporal lobe atrophy as measured by positron emission tomography, single-photon emission computed tomography, and magnetic resonance imaging.

Occipital hypoperfusion in Parkinson's disease without dementia: correlation to impaired cortical visual processing

OBJECTIVE

The purpose of this study was to analyse changes in regional cerebral blood flow (rCBF) in Parkinson's disease (PD) without dementia.

METHODS

Twenty eight non-demented patients with PD and 17 age matched normal subjects underwent single photon emission computed tomography with N-isopropyl-p-[(123)I]iodoamphetamine to measure rCBF. The statistical parametric mapping 96 programme was used for statistical analysis.

RESULTS

The PD patients showed significantly reduced rCBF in the bilateral occipital and posterior parietal cortices (p<0.01, corrected for multiple comparison p<0.05), when compared with the control subjects. There was a strong positive correlation between the score of Raven's coloured progressive matrices (RCPM) and the rCBF in the right visual association area (p<0.01, corrected for multiple comparison p<0.05) among the PD patients.

CONCLUSIONS

This study showed occipital and posterior parietal hypoperfusion in PD patients without dementia. Furthermore, it was demonstrated that occipital hypoperfusion is likely to underlie impairment of visual cognition according to the RCPM test, which is not related to motor impairment.

Diurnal metabolism of dopamine in dystrophic retinas of homozygous and heterozygous retinal degeneration slow (rds) mice

Dopamine metabolism was studied in dystrophic retinal degeneration slow (rds) mice which carry a mutation in the rds/peripherin gene. RDS mutations in humans cause several forms of retinal degeneration. Dopamine synthesis and utilization were analyzed at various time points in the diurnal cycle in homozygous rds/rds retinas which lack photoreceptor outer segments and heterozygous rds/+ retinas which have short malformed outer segments. Homozygous retinas exhibited depressed dopamine synthesis and utilization while the heterozygous retina retained a considerable level of activity which was, nevertheless, significantly lower than that of normal retinas. By one year, heterozygous rds/+ retinas which had lost half of the photoreceptors still maintained significant levels of dopamine metabolism. Normal characteristics of dopamine metabolism such as a spike in dopamine utilization at light onset were observed in mutant retinas. However, light intensity-dependent changes in dopamine utilization were observed in normal but not rds/+ retinas. The findings of this study suggest that human patients with peripherin/rds mutations, or other mutations that result in abnormal outer segments that can still capture light, might maintain light-evoked dopamine metabolism and dopamine-dependent retinal functions during the progression of the disease, proportional to remaining levels of light capture capabilities. However, visual deficits due to reduced light-evoked dopamine metabolism and abnormal patterns of dopamine utilization could be expected in such diseased retinas.

Levodopa may improve vision loss in recent-onset, nonarteritic anterior ischemic optic neuropathy

OBJECTIVE

To study the effect of levodopa in improving visual function in patients treated within 45 days of onset of nonarteritic anterior ischemic optic neuropathy (NAION).

DESIGN

Nonrandomized, retrospective, comparative trial.

PARTICIPANTS

The study involved 37 patients with NAION of less than 45 days duration.

METHODS

Eighteen patients who had been treated with levodopa were assigned to the case group, and 19 untreated patients were assigned to the control group. Snellen visual acuity converted to logMAR and mean deviation on Humphrey automated perimetry (Program 24-2, Humphrey Instruments, San Leardro, CA) were evaluated at the initial and 6-month visits.

INTERVENTION

The 18 patients in the case group were administered a capsule of 100 mg levodopa/25 mg carbidopa (Sinemet 25-100) three times daily for 3 weeks.

MAIN OUTCOME MEASURES

The primary outcome measures were changes in visual acuity and visual field at 6 months from baseline. Improvement in visual acuity was defined as a difference of -0.3 logMAR or less between the 6-month and initial visual acuities, whereas worsened visual acuity was a difference of +0.3 logMAR or more. Each 0.3 LogMar represented a doubling of the visual angle, i.e., a change by three lines on the eye chart. Improvement in visual field was defined as a difference in mean deviation of +3.0 dB or more between the 6-month and initial visual field tests, whereas worsened visual field was a difference in mean deviation of -3.0 dB or less.

RESULTS

The proportions of patients with worsened, unchanged, and improved visual acuity at 6 months were compared for the levodopa and control groups. There was a significant difference (P = 0.012) between the groups. Examination of the proportions showed that a higher proportion of patients who received levodopa had improved visual acuity with a corresponding lower proportion having worsened visual acuity as compared with the control patients. Ten of 13 patients (76.9%) in the levodopa group with 20/40 visual acuity or worse at baseline had improved visual acuity at 6 months, and none of the 18 patients had worsened visual acuity. In contrast, 3 of 10 control patients (30%) with 20/40 visual acuity or worse at baseline had improved visual acuity at 6 months, and 3 of 19 control patients (16.3%) had worsened visual acuity. The proportions of patients with worsened, unchanged, and improved visual fields at 6 months were compared for the levodopa and control groups. There was no significant difference between the groups (P = 0.25).

CONCLUSIONS

Patients treated with levodopa within 45 days of onset of NAION were more likely to experience improvement and less likely to have worsened visual acuity than untreated patients. Levodopa appears to be beneficial in the treatment of recent-onset NAION.

Visual contrast response functions in Parkinson's disease: evidence from electroretinograms, visually evoked potentials and psychophysics

OBJECTIVES

Visual contrast detection thresholds and suprathreshold contrast discrimination thresholds were compared to luminance and flash/pattern electroretinograms (ERG) and visually evoked potentials (VEP) in patients with Parkinson's disease (n = 31), patients with multiple system atrophy (n = 6), patients with progressive supranuclear palsy (n = 6) and control patients without central nervous disease (n = 33).

METHODS

The stimuli were luminance modulated full-field (flash) or horizontally oriented sinewave gratings (pattern), the latter having either a low (0.5 cycles/deg) or medium (4.0 cycles/deg) spatial frequency. Stimulus contrast ranged from 10 to 80% so that contrast response functions could be derived.

RESULTS

Contrast thresholds were higher in the patients with Parkinson's disease than in the control patients. Contrast discrimination thresholds were also somewhat elevated in patients with Parkinson's disease. Pattern ERG amplitudes were significantly reduced in patients with Parkinson's disease for the medium spatial frequency stimulus, but less for the low spatial frequency and flash stimuli.

CONCLUSIONS

Our results suggest that Parkinson's disease impairs contrast processing in the retina. VEP amplitudes did not significantly differ between the groups for the conditions tested. Patients with progressive supranuclear palsy also showed impaired contrast perception and reduced ERG amplitudes, whereas patients with multiple system atrophy were less impaired.

Clinical manifestations of Parkinson's disease

Although the clinical manifestations of PD remain similar to those described by Parkinson in the nineteenth century, knowledge of associated findings has increased dramatically. The ability to characterize the myriad of findings associated with PD enables clinicians to care better for patients with PD. Knowledge of the associated symptoms as well as the cardinal manifestations allows clinicians to target treatment to specific symptoms and thereby improve the quality of life of those affected with PD.

Impairment in preattentive visual processing in patients with Parkinson's disease

We explored the possibility of whether preattentive visual processing is impaired in Parkinson's disease. With this aim, visual discrimination thresholds for orientation texture stimuli were determined in two separate measurement sessions in 16 patients with idiopathic Parkinson's disease. The results were compared with those of 16 control subjects age-matched and 16 young healthy volunteers. Discrimination thresholds were measured in a four-alternative spatial forced-choice paradigm, in which subjects judged the location of a target embedded in a background of distractors. Four different stimulus configurations were employed: (i) a group of vertical targets among horizontal distractors ('vertical line targets'); (ii) targets with varying levels of orientation difference on a background of spatially filtered vertically oriented noise ('Gaussian filtered noise'); (iii) one 'L' among 43 '+' signs ('texton'), all of which assess preattentive visual processing; and (iv) control condition, of one 'L' among 43 'T' distractors ('non-texton' search target), which reflects attentive visual processing. In two of the preattentive tasks (filtered noise and texton), patients with Parkinson's disease required significantly greater orientation differences and longer stimulus durations, respectively. In contrast, their performance in the vertical line target and non-texton search target was comparable to that of the matched control subjects. These differences were more pronounced in the first compared with the second session. Duration of illness and age within the patient group correlated significantly with test performance. In all conditions tested, the young control subjects performed significantly better than the more elderly control group, further indicating an effect of age on this form of visual processing. The results suggest that, in addition to the well documented impairment in retinal processing, idiopathic Parkinson's disease is associated with a deficit in preattentive cortical visual processing.

Does pattern electroretinogram spatial tuning alteration in Parkinson's disease depend on motor disturbances or retinal dopaminergic loss?

Systemic decrease of dopaminergic cells, such as in Parkinson's disease may produce visual alterations in humans. In order to show possible pattern electroretinogram (PERG) spatial tuning function (STF) alterations due to impaired dopaminergic transmission in humans, we studied a group of Parkinson's disease patients before and during treatment with the dopamine precursor, levodopa, and compared their performances with those of an age-matched control group. Moreover, in order to exclude the possible involvement of motor disabilities to produce PERG alterations, we also investigated PERG responses in post-traumatic parkinsonian patients who exhibited motor abnormalities as a consequence of focal lesions of basal ganglia, in the absence of systemic dopaminergic degeneration. Our results showed a clear decrease of PERG responses in Parkinson's disease patients particularly at medium spatial frequency range (2.7-4.0 cycles/degree) with a substantial preservation of responses at low frequencies. Levodopa therapy reversed these alterations in Parkinson's disease patients, resulting in the recovery of a normal tuning function shape. In contrast to Parkinson's disease, the tuning function appeared to be preserved in post-traumatic parkinsonian patients. Our results clearly establish a relationship between retinal alteration in PD patients and dopaminergic retinal function.

Neurobiology of retinal dopamine in relation to degenerative states of the tissue

Neurobiology of retinal dopamine is reviewed and discussed in relation to degenerative states of the tissue. The Introduction deals with the basic physiological actions of dopamine on the different neurons in vertebrate retinae with an emphasis upon mammals. The intimate relationship between the dopamine and melatonin systems is also covered. Recent advances in the molecular biology of dopamine receptors is reviewed in some detail. As degenerative states of the retina, three examples are highlighted: Parkinson's disease; ageing; and retinal dystrophy (retinitis pigmentosa). As visual functions controlled, at least in part, by dopamine, absolute sensitivity, spatial contrast sensitivity, temporal (including flicker) sensitivity and colour vision are reviewed. Possible cellular and synaptic bases of the visual dysfunctions observed during retinal degenerations are discussed in relation to dopaminergic control. It is concluded that impairment of the dopamine system during retinal degenerations could give rise to many of the visual abnormalities observed. In particular, the involvement of dopamine in controlling the coupling of horizontal and amacrine cell lateral systems appears to be central to the visual defects seen.

Ozone produces functional deficits in the rat visual pathway

The effects of ozone (O3) have been studied mainly in reference to the respiratory pathways, though some reports have shown that this gas produces noxious effects in brain. The aim of the present work was to study the O3 effects on the central nervous system, focusing on the visual pathway by means of visual evoked potentials technique recording in the visual cortex and the lateral geniculate nucleus of rats exposed to three different concentrations of O3 (0.75, 1.5 and 3.0 ppm). Our results showed that P1, N1 and P2 components were significantly delayed in the visual cortex and lateral geniculate nucleus in those rats exposed to 3.0 ppm of O3. Moreover, the N1 component in the visual cortex was also affected even under exposure to 1.5 ppm of O3. Results suggest that O3 exposure affects the conduction mechanisms and synaptic excitability of the visual pathway. It is known that inhalation of O3 produce a cascade of ozonation products capable of producing lipid peroxidation in the brain. Unevenness of some neurotransmitters has also been referred in animals exposed to this gas. Thus we consider that the delay found in the primary components of the visual evoked potentials could obey to a neurochemical disorder produced by O3 inhalation.