Intersubject variability of foveal cone photoreceptor density in relation to eye length

Photoreceptor Degeneration is Correlated With the Deterioration of Macular Retinal Sensitivity in High Myopia

Purpose

To investigate structural changes in the retinal outer layers and choroid using adaptive optics (AO) and optical coherence tomography (OCT) in eyes with myopia, and to correlate the changes with decreased macular light sensitivity (MLS).

Methods

This prospective study included 27 subjects with emmetropia and low myopia (EM/LM), 25 with moderate myopia (MM), and 25 with high myopia (HM). Microperimetry was used to quantify MLS in each subject, while AO and OCT images of fundus were analyzed to quantify cone density and regularity and thickness of outer retinal sublayers and choroid. Differences of MLS, cone distribution, and chorioretinal thicknesses were compared among the three groups, and the associations among photoreceptor morphological alterations, MLS, and other parameters were analyzed.

Results

In HM, the MLS, cone density and regularity, and thicknesses of the myoid and ellipsoid zone (MEZ), Henle fiber layer and outer nuclear layer, interdigitation zone and RPE/Bruch complex, and choroid were lower than in EM/LM. Decreased MLS was correlated with lower cone density and regularity, and thinner MEZ and choroid in the inner region, and with lower cone density, thinner MEZ and choroid, and longer axial length in the outer region. Multivariate regression showed that better MLS was correlated with thicker MEZ in the inner region and with higher cone density in the outer region.

Conclusions

Altered cone distribution and outer retinal thickness, especially cone density and MEZ thickness, were significantly correlated with decline of MLS in HM, which may help to evaluate and monitor visual impairment in HM.

Cellular imaging of inherited retinal diseases using adaptive optics

Adaptive optics (AO) is an insightful tool that has been increasingly applied to existing imaging systems for viewing the retina at a cellular level. By correcting for individual optical aberrations, AO offers an improvement in transverse resolution from 10-15 μm to ~2 μm, enabling assessment of individual retinal cell types. One of the settings in which its utility has been recognised is that of the inherited retinal diseases (IRDs), the genetic and clinical heterogeneity of which warrants better cellular characterisation. In this review, we provide a summary of the basic principles of AO, its integration into multiple retinal imaging modalities and its clinical applications, focusing primarily on IRDs. Furthermore, we present a comprehensive summary of AO-based cellular findings in IRDs according to their associated disease-causing genes.

Changes in macular ultrastructural morphology in unilateral anisometropic amblyopia

It is controversial that retina and photoreceptors are involved in amblyopic development. Lack of imaging devices for quantitative assessment of photoreceptors in vivo impedes further investigation. In this study we investigated the differences of macular thickness, outer nuclear layer (ONL) thickness and cone density among eyes with unilateral anisometropic amblyopia, amblyopic fellow eyes, and normal control eyes using high-definition spectral-domain optical coherence tomography and adaptive optics imaging system. Thicker fovea and parafovea with characteristic quantitative retinal changes in unilateral amblyopic patients indicated that the amblyopic process might involve the retina. Cones tended to be homogeneously distributed at 1.5° from the foveal center in all participants. However, we did not detect any significant differences in cone density and ONL thickness at 1.5° from the foveal center in patients with unilateral amblyopia when compared with the fellow eyes and the normal control eyes. This is the first study to explore whether photoreceptors are involved in amblyopic development in vivo that would help for understanding the underlying mechanisms of amblyopia. Whether macular changes relate to cone photoreceptors migration of the amblyopic eyes remains to be determined.

Photoreceptor evaluation after successful macular hole closure: an adaptive optics study

Objective:

To study photoreceptor changes after a successful macular hole surgery using adaptive optics.

Materials and Methods:

Three patients who underwent a successful macular hole surgery were studied. Cone density, spacing, and number of nearest neighbors were analyzed at 2° and 4° of eccentricity in all four quadrants using adaptive optics.

Results:

All three patients gained a visual acuity better than logMAR 0.477 (Snellen equivalent 6/18) at 6 months following successful macular hole surgery. Following successful closure of the macular hole, photoreceptors were appreciated at 2° and 4° of eccentricity from the center. However, as compared with the fellow normal eye, cell density was reduced significantly in the inferior (12,929.33 ± 2047.50 versus 23,839.67 ± 3711.16 cells/mm² at 2°) and temporal quadrant (13,890 ± 3424.26 versus 22,578.67 ± 5651.34 cells/mm² at 2°), and intercell spacing was increased significantly in inferior (9.6 ± 0.92 versus 7.14 ± 0.545 µm) and nasal quadrant (8.83 ± 0.39 versus 7.49 ± 0.42 µm). Number of nearest neighbors was unaffected after the hole closure.

Conclusion:

Postoperative recovery of vision after successful closure of the hole occurs because of the migration or shifting of cells from parafoveal retina toward the center. Cells nearest to the hole margin (at 2° eccentricity) appear to shift more as compared with cells which are further away.

Human foveal cone photoreceptor topography and its dependence on eye length

We provide the first measures of foveal cone density as a function of axial length in living eyes and discuss the physical and visual implications of our findings. We used a new generation Adaptive Optics Scanning Laser Ophthalmoscope to image cones at and near the fovea in 28 eyes of 16 subjects. Cone density and other metrics were computed in units of visual angle and linear retinal units. The foveal cone mosaic in longer eyes is expanded at the fovea, but not in proportion to eye length. Despite retinal stretching (decrease in cones/mm²), myopes generally have a higher angular sampling density (increase in cones/deg²) in and around the fovea compared to emmetropes, offering the potential for better visual acuity. Reports of deficits in best-corrected foveal vision in myopes compared to emmetropes cannot be explained by increased spacing between photoreceptors caused by retinal stretching during myopic progression.

The human eye has many different parts that enable sight. The retina is the light sensitive tissue at the back of the eye, and it contains the fovea, the region that provides the clearest vision. Light must be focused on the retina to create images, a feat achieved by the transparent parts at the front of the eye called the cornea and lens. These parts of the eye are called the optics.

Between birth and adulthood, significant changes take place in the eye. Most noticeably, the distance between the optics and the fovea grows by about seven millimeters. Cells called cone photoreceptors, which provide light sensitivity, migrate and pack into the fovea. Finally, the eye’s optics adjust to maintain a sharp focus. At the same time, the brain is learning how to process inputs from the eyes to generate mental images that realistically correspond to the physical world around it. The development of the eye is fascinating in its complexity, but for more and more people, the process does not go as expected.

Specifically, a growing proportion of the population has eyes that are too long. This means that, for light reflected by far away objects, the eye’s optics form an image in front of the retina instead of on it. As a result, images of distant objects cannot be seen clearly, a condition known as myopia or nearsightedness. Researchers have also discovered that nearsighted people see less clearly than those who do not use glasses, even when given a sharp image to examine at close range. It has been hypothesized that these deficits result from stretching of the retina as the eye becomes bigger.

Until recently, testing this hypothesis by looking at cone photoreceptors directly in the eye was impossible. This is because the optics of all eyes have small imperfections that distort the light passing through them, including any light used to take high resolution microscopic images of the fovea. This hurdle can be overcome using adaptive optics, which means adding a deformable mirror to the instrument being used to image the eye that can adjust to correct the distortion.

Wang et al. use a new generation Adaptive Optics Scanning Laser Ophthalmoscope to check the density of cones at the fovea in relation to the size of the eye. They show that although the center of the fovea has fewer cones when the eye is bigger, this effect is more than offset because the longer eye increases magnification. So, if a near-sighted person wearing contacts and someone who does not need glasses stood side-by-side admiring the full moon, the near-sighted person would most likely have more cones sampling the image and should therefore have a higher resolution view.

These findings rule out reductions in the density of cone photoreceptors as the cause or effect of visual deficits associated with near-sightedness, adding to the understanding of this common condition.

Loss of Foveal Cone Structure Precedes Loss of Visual Acuity in Patients With Rod-Cone Degeneration

Purpose

To assess the relationship between cone spacing and visual acuity in eyes with rod-cone degeneration (RCD) followed longitudinally.

Methods

High-resolution images of the retina were obtained using adaptive optics scanning laser ophthalmoscopy from 13 eyes of nine RCD patients and 13 eyes of eight healthy subjects at two sessions separated by 10 or more months (mean 765 days, range 311-1935 days). Cone spacing Z-score measured as close as possible (average <0.25°) to the preferred retinal locus was compared with visual acuity (letters read on the Early Treatment of Diabetic Retinopathy Study [ETDRS] chart and logMAR) and foveal sensitivity.

Results

Cone spacing was significantly correlated with ETDRS letters read (ρ = -0.47, 95%CI -0.67 to -0.24), logMAR (ρ = 0.46, 95%CI 0.24 to 0.66), and foveal sensitivity (ρ = -0.30, 95%CI -0.52 to -0.018). There was a small but significant increase in mean cone spacing Z-score during follow-up of +0.97 (95%CI 0.57 to 1.4) in RCD patients, but not in healthy eyes, and there was no significant change in any measure of visual acuity.

Conclusions

Cone spacing was correlated with visual acuity and foveal sensitivity. In RCD patients, cone spacing increased during follow-up, while visual acuity did not change significantly. Cone spacing Z-score may be a more sensitive measure of cone loss at the fovea than visual acuity in patients with RCD.

Residual Cone Structure in Patients With X-Linked Cone Opsin Mutations

Purpose

To assess residual cone structure in subjects with mutations in exon 2, 3, and 4 of the OPN1LW or OPN1MW opsin.

Methods

Thirteen males had their OPN1LW/OPN1MW opsin genes characterized. The cone mosaic was imaged using both confocal and nonconfocal split-detection adaptive optics scanning light ophthalmoscopy (AOSLO), and retinal thickness was evaluated using optical coherence tomography (OCT). Six subjects completed serial imaging over a maximum period of 18 months and cone density was measured across imaging sessions.

Results

Ten subjects had an OPN1LW/OPN1MW "interchange" opsin mutation designated as LIAVA or LVAVA, which both introduce exon 3 splicing defects leading to a lack of functional photopigment in cones expressing LIAVA and greatly reduced functional photopigment in cones expressing LVAVA. Despite disrupted cone reflectivity and reduced numerosity, residual inner segments could be visualized. Similar patterns were observed in individuals with an exon 2 insertion, or an exon 4 splice defect, both of which are also expected to produce cones that are devoid of functional opsin protein. OCT revealed variably reduced retinal thickness. A significant inverse relationship was found between the proportion of waveguiding cones and axial length.

Conclusions

Split-detection imaging revealed that the altered appearance of the cone mosaic in confocal images for subjects with exon 2, 3, and 4 mutations was generally due to disrupted waveguiding, rather than structural loss, making them possible candidates for gene therapy to restore cone function. The relative fraction of waveguiding cones was highly variable across subjects, which appears to influence emmetropization in these subjects.

Task-driven visual exploration at the foveal scale

Humans use saccades to inspect objects of interest with the foveola, the small region of the retina with highest acuity. This process of visual exploration is normally studied over large scenes. However, in everyday tasks, the stimulus within the foveola is complex, and the need for visual exploration may extend to this smaller scale. We have previously shown that fixational eye movements, in particular microsaccades, play an important role in fine spatial vision. Here, we investigate whether task-driven visual exploration occurs during the fixation pauses in between large saccades. Observers judged the expression of faces covering approximately 1°, as if viewed from a distance of many meters. We use a custom system for accurately localizing the line of sight and continually track gaze position at high resolution. Our findings reveal that active spatial exploration, a process driven by the goals of the task, takes place at the foveal scale. The scanning strategies used at this scale resemble those used when examining larger scenes, with idiosyncrasies maintained across spatial scales. These findings suggest that the visual system possesses not only a coarser priority map of the extrafoveal space to guide saccades, but also a finer-grained priority map that is used to guide microsaccades once the region of interest is foveated.

The Longitudinal Danish High Myopia Study, Cohort 1948: at age 66 years visual ability is only occasionally affected by visual field defects

PURPOSE

A descriptive study on visual fields, as part of a 50-year follow-up of high myopia in an unselected cohort-based Danish sample, now aged 66 years.

METHODS

In a Copenhagen 1948 birth cohort (n = 9243), 39 individuals aged 14 years were identified with myopia of at least -6 D, and with regular clinical follow-ups since then. In 2002 (n = 34, age 54 years) and 2008 (n = 32, age 60), the individual ambulatory visual field was outlined by kinetic Goldmann large object perimetry (IV or V,4e). At age 66 years, 28 attended for the 2014-2015 follow-up, at which smaller Goldmann objects (II and I,4e) were added, further to identify relative defects.

RESULTS

Repeated large object perimetry disclosed statistically significant general peripheral narrowing over the 12-13-year test period, though slight and without practical implications. Two new cases showing absolute defects were however added to the three already known. The addition of small Goldmann objects disclosed relative defects in another eight participants, in some to suggest a refraction-related pattern (fundus ectasia; uncorrected high myopia). However, comparing eyes with and without defects, statistical importance could not be attached to the degree of myopia, fundus ectasia or optic disc morphology (χ² , n.s.).

CONCLUSION

(i) Serial large object Goldmann isopters over the 'senior' decade up to age 66 demonstrated a slight general peripheral narrowing by age of visual fields in high myopia. (ii) Overall 42% of the participants had absolute or relative defects (in 5 and 8, respectively), however, without socio-visual consequences when binocular. (iii) Visual field loss by age still appears a minor issue in clinically unselected high myopia.

Distribution of mid-peripheral cones in emmetropic and myopic subjects using adaptive optics flood illumination camera

PURPOSE

We measured in vivo cone photoreceptors up to 24° of eccentricity along the horizontal meridian of healthy human retina. We also investigated the impact on cone densities of axial eye length elongation occurring with myopia.

METHODS

Using a flood illumination device coupled with an adaptive optics system, rtx1™, ( www.imagine-eyes.com), 55 right healthy retinas were imaged along the horizontal (i.e. nasal and temporal) meridian over a 48° field (i.e. from 3° to 24° each 3°). Then, cones were manually detected within 80 × 80 pixel regions of interest. Cone density and packing geometry (i.e. number of neighbours) were calculated (AOdetect software™). Subjects were divided into three groups: a group of 36 emmetropic (i.e. refractive error from -0.25D to +0.50D) subjects; a group of 10 low myopic subjects (i.e. refractive error from -0.50D to -2.50D); and a group of nine high myopic subjects (i.e. >-2.50D).

RESULTS

Cone density decreased with eccentricity in both semi-meridians. The decrease in cone photoreceptors occurred mainly in the first 9°. The difference of cone density between the nasal and temporal semi-meridian increased with eccentricity from 0.6% at 3° to 26% at 24°. Average cone density of emmetropes (850 cones deg^-2 or 11 087 cones mm^-2 ), low myopes (830 cones deg^-2 or 9731 cones mm^-2 ), and high myopes (912 cones deg^-2 or 9744 cones mm^-2 ), suggested that the retinas of the high myopic subjects were more stretched than the low myopic subjects retinas and even more stretched than that of the emmetropes. The axial eyeball elongation (square of the ratio of the axial eye length of 9%) seems to explain the cone density (11%) difference between emmetropes and low myopes. However, while the eyeball elongation between low and high myopes is still important (i.e. 11%), cone density difference between both populations was negligible (i.e. 3%). The ratio of cone density varied from -17% to 22% as a function of eccentricity involving that the retinal stretching is not uniform along the horizontal meridian.

CONCLUSION

The difference of cone density (i.e. cone mm^-2 ) between groups supports the hypothesis that the retina is stretched with the eyeball elongation. However, this elongation does not seem to be uniform along the horizontal meridian favouring the hypothesis of a local elongation of the retina.

Dysflective Cones

Retinal imaging has advanced to enable noninvasive in vivo visualization of macular photoreceptors with cellular resolution. Images of retinal structure are best interpreted in the context of visual function, but clinical measures of visual function lack resolution on the scale of individual cells. Combined with cross-sectional measures of retinal structure acquired with optical coherence tomography (OCT), macular photoreceptor function can be evaluated using visual acuity and fundus-guided microperimetry, but the resolution of these measures is limited to relatively large retinal areas. By incorporating adaptive optics correction of aberrations in light entering and exiting the pupil, individual photoreceptors can be visualized and stimulated to assess structure and function. Discrepancy between structural images and visual function can shed light on the origin of visible features and their relation to visual function. Dysflective cones, cones with abnormal waveguiding properties on confocal adaptive optics scanning laser ophthalmoscopy (AOSLO) images and measurable function, provide insight into the visual significance of features in retinal images and may facilitate identification of patients who could benefit from therapies.

Adaptive optics imaging of the human retina

Adaptive Optics (AO) retinal imaging has provided revolutionary tools to scientists and clinicians for studying retinal structure and function in the living eye. From animal models to clinical patients, AO imaging is changing the way scientists are approaching the study of the retina. By providing cellular and subcellular details without the need for histology, it is now possible to perform large scale studies as well as to understand how an individual retina changes over time. Because AO retinal imaging is non-invasive and when performed with near-IR wavelengths both safe and easily tolerated by patients, it holds promise for being incorporated into clinical trials providing cell specific approaches to monitoring diseases and therapeutic interventions. AO is being used to enhance the ability of OCT, fluorescence imaging, and reflectance imaging. By incorporating imaging that is sensitive to differences in the scattering properties of retinal tissue, it is especially sensitive to disease, which can drastically impact retinal tissue properties. This review examines human AO retinal imaging with a concentration on the use of the Adaptive Optics Scanning Laser Ophthalmoscope (AOSLO). It first covers the background and the overall approaches to human AO retinal imaging, and the technology involved, and then concentrates on using AO retinal imaging to study the structure and function of the retina.

High-resolution imaging of photoreceptors in healthy human eyes using an adaptive optics retinal camera

PURPOSE

To determine the effects of age on perifoveal cone density in healthy subjects using adaptive optics.

METHODS

Healthy subjects of various ages were imaged using an adaptive optics retinal camera (RTX-1^® Imagine Eyes, Orsay, France). All patients underwent a comprehensive ophthalmologic examination and retinal imaging using spectral-domain optical coherence tomography (Spectralis^®, Heidelberg Engineering, Heidelberg, Germany). Cone density together with cone spacing and cone mosaic packing were measured in the nasal and temporal area 450 µm from the fovea. A multivariate analysis was performed to determine which of the following parameters were related to a decrease in cone density: age, axial length, central macular thickness, and retrofoveal choroidal thickness.

RESULTS

One hundred and sixty-seven eyes of 101 subjects aged 6-78 years were studied. Perifoveal cone density significantly decreased with age (R² = 0.17, p<0.01). Inversely, cone spacing increased with age (R²=0.18, p<0.01). There was no change in the cone packing mosaic (p>0.05). The mean coefficient of variation between fellow eyes was 3.9%. Age and axial length were related to a cone density decrease, while choroidal and retinal thicknesses did not affect cone metrics in healthy subjects.

CONCLUSIONS

A moderate perifoveal cone loss occurs with age. The precise consequences of these findings on visual function should be investigated. In addition to a better understanding of normal retinal anatomy, these results could act as a comparative database for further studies on normal and diseased retinas.

Sub-Airy Confocal Adaptive Optics Scanning Ophthalmoscopy

Purpose

To demonstrate the viability of improving transverse image resolution in reflectance scanning adaptive optics ophthalmoscopy using sub-Airy disk confocal detection.

Methods

The foveal cone mosaic was imaged in five human subjects free of known eye disease using two custom adaptive optics scanning light ophthalmoscopes (AOSLOs) in reflectance with 7.75 and 4.30 mm pupil diameters. Confocal pinholes of 0.5, 0.6, 0.8, and 1.0 Airy disk diameters (ADDs) were used in a retinal conjugate plane before the light detector. Average cone photoreceptor intensity profile width and power spectrum were calculated for the resulting images. Detected energy using a model eye was recorded for each pinhole size.

Results

The cone photoreceptor mosaic is better resolved with decreasing confocal pinhole size, with the high spatial frequency content of the images enhanced in both the large- and small-pupil AOSLOs. The average cone intensity profile width was reduced by ∼15% with the use of a 0.5 ADD pinhole when compared to a 1.0 ADD, with an accompanying reduction in signal greater than a factor of four.

Conclusions

The use of sub-Airy disk confocal pinhole detection without increasing retinal light exposure results in a substantial improvement in image resolution at the cost of larger than predicted signal reduction.

Translational Relevance

Improvement in transverse resolution using sub-Airy disk confocal detection is a practical and low-cost approach that is applicable to all point- and line-scanning ophthalmoscopes, including optical coherence tomographers.

Distribution of cone density, spacing and arrangement in adult healthy retinas with adaptive optics flood illumination

The aim of this article is to analyse cone density, spacing and arrangement using an adaptive optics flood illumination retina camera (rtx1^™) on a healthy population. Cone density, cone spacing and packing arrangements were measured on the right retinas of 109 subjects at 2°, 3°, 4°, 5° and 6° of eccentricity along 4 meridians. The effects of eccentricity, meridian, axial length, spherical equivalent, gender and age were evaluated. Cone density decreased on average from 28 884 ± 3 692 cones/mm², at 2° of eccentricity, to 15 843 ± 1 598 cones/mm² at 6°. A strong inter-individual variation, especially at 2°, was observed. No important difference of cone density was observed between the nasal and temporal meridians or between the superior and inferior meridians. However, the horizontal and vertical meridians differed by around 14% (T-test, p<0.0001). Cone density, expressed in units of area, decreased as a function of axial length (r² = 0.60), but remained constant (r² = 0.05) when cone density is expressed in terms of visual angle supporting the hypothesis that the retina is stretched during the elongation of the eyeball. Gender did not modify the cone distribution. Cone density was slightly modified by age but only at 2°. The older group showed a smaller density (7%). Cone spacing increased from 6,49 ± 0,42 μm to 8,72 ± 0,45 μm respectively between 2° and 6° of eccentricity. The mosaic of the retina is mainly triangularly arranged (i.e. cells with 5 to 7 neighbors) from 2° to 6°. Around half of the cells had 6 neighbors.

Agreement in Cone Density Derived from Gaze-Directed Single Images Versus Wide-Field Montage Using Adaptive Optics Flood Illumination Ophthalmoscopy

Purpose

We compared cone density measurements derived from the center of gaze-directed single images with reconstructed wide-field montages using the rtx1 adaptive optics (AO) retinal camera.

Methods

A total of 29 eyes from 29 healthy subjects were imaged with the rtx1 camera. Of 20 overlapping AO images acquired, 12 (at 3.2°, 5°, and 7°) were used for calculating gaze-directed cone densities. Wide-field AO montages were reconstructed and cone densities were measured at the corresponding 12 loci as determined by field projection relative to the foveal center aligned to the foveal dip on optical coherence tomography. Limits of agreement in cone density measurement between single AO images and wide-field AO montages were calculated.

Results

Cone density measurements failed in 1 or more gaze directions or retinal loci in up to 58% and 33% of the subjects using single AO images or wide-field AO montage, respectively. Although there were no significant overall differences between cone densities derived from single AO images and wide-field AO montages at any of the 12 gazes and locations (P = 0.01-0.65), the limits of agreement between the two methods ranged from as narrow as -2200 to +2600, to as wide as -4200 to +3800 cones/mm².

Conclusions

Cone density measurement using the rtx1 AO camera is feasible using both methods. Local variation in image quality and altered visibility of cones after generating montages may contribute to the discrepancies.

Translational Relevance

Cone densities from single AO images are not interchangeable with wide-field montage derived-measurements.

Selective attention within the foveola

Efficient control of attentional resources and high-acuity vision are both fundamental for survival. Shifts in visual attention are known to covertly enhance processing at locations away from the center of gaze, where visual resolution is low. It is unknown, however, whether selective spatial attention operates where the observer already looks, i.e., within the high-acuity foveola, the small, yet disproportionally important rod-free region of the retina. Using new methods for precisely controlling retinal stimulation, here we show that covert attention flexibly improves and speeds-up both detection and discrimination at loci only a fraction of a degree apart within the foveola. These findings reveal a surprisingly precise control of attention and its involvement in fine spatial vision. They show that the commonly studied covert shifts of attention away from the fovea are the expression of a global mechanism that exerts its action across the entire visual field.

Comparing Parafoveal Cone Photoreceptor Mosaic Metrics in Younger and Older Age Groups Using an Adaptive Optics Retinal Camera

BACKGROUND AND OBJECTIVE

To analyze cone mosaic metrics on adaptive optics (AO) images as a function of retinal eccentricity in two different age groups using a commercial flood illumination AO device.

PATIENTS AND METHODS

Fifty-three eyes of 28 healthy subjects divided into two age groups were imaged using an AO flood-illumination camera (rtx1; Imagine Eyes, Orsay, France). A 16° × 4° field was obtained horizontally. Cone-packing metrics were determined in five neighboring 50 µm × 50 µm regions. Both retinal (cones/mm² and µm) and visual (cones/degrees² and arcmin) units were computed.

RESULTS

Results for cone mosaic metrics at 2°, 2.5°, 3°, 4°, and 5° eccentricity were compatible with previous AO scanning laser ophthalmoscopy and histology data. No significant difference was observed between the two age groups.

CONCLUSIONS

The rtx1 camera enabled reproducible measurements of cone-packing metrics across the extrafoveal retina. These findings may contribute to the development of normative data and act as a reference for future research. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:45-50.].

Evaluating Descriptive Metrics of the Human Cone Mosaic

PURPOSE

To evaluate how metrics used to describe the cone mosaic change in response to simulated photoreceptor undersampling (i.e., cell loss or misidentification).

METHODS

Using an adaptive optics ophthalmoscope, we acquired images of the cone mosaic from the center of fixation to 10° along the temporal, superior, inferior, and nasal meridians in 20 healthy subjects. Regions of interest (n = 1780) were extracted at regular intervals along each meridian. Cone mosaic geometry was assessed using a variety of metrics - density, density recovery profile distance (DRPD), nearest neighbor distance (NND), intercell distance (ICD), farthest neighbor distance (FND), percentage of six-sided Voronoi cells, nearest neighbor regularity (NNR), number of neighbors regularity (NoNR), and Voronoi cell area regularity (VCAR). The "performance" of each metric was evaluated by determining the level of simulated loss necessary to obtain 80% statistical power.

RESULTS

Of the metrics assessed, NND and DRPD were the least sensitive to undersampling, classifying mosaics that lost 50% of their coordinates as indistinguishable from normal. The NoNR was the most sensitive, detecting a significant deviation from normal with only a 10% cell loss.

CONCLUSIONS

The robustness of cone spacing metrics makes them unsuitable for reliably detecting small deviations from normal or for tracking small changes in the mosaic over time. In contrast, regularity metrics are more sensitive to diffuse loss and, therefore, better suited for detecting such changes, provided the fraction of misidentified cells is minimal. Combining metrics with a variety of sensitivities may provide a more complete picture of the integrity of the photoreceptor mosaic.

Cone Photoreceptor Structure in Patients With X-Linked Cone Dysfunction and Red-Green Color Vision Deficiency

Purpose

Mutations in the coding sequence of the L and M opsin genes are often associated with X-linked cone dysfunction (such as Bornholm Eye Disease, BED), though the exact color vision phenotype associated with these disorders is variable. We examined individuals with L/M opsin gene mutations to clarify the link between color vision deficiency and cone dysfunction.

Methods

We recruited 17 males for imaging. The thickness and integrity of the photoreceptor layers were evaluated using spectral-domain optical coherence tomography. Cone density was measured using high-resolution images of the cone mosaic obtained with adaptive optics scanning light ophthalmoscopy. The L/M opsin gene array was characterized in 16 subjects, including at least one subject from each family.

Results

There were six subjects with the LVAVA haplotype encoded by exon 3, seven with LIAVA, two with the Cys203Arg mutation encoded by exon 4, and two with a novel insertion in exon 2. Foveal cone structure and retinal thickness was disrupted to a variable degree, even among related individuals with the same L/M array.

Conclusions

Our findings provide a direct link between disruption of the cone mosaic and L/M opsin variants. We hypothesize that, in addition to large phenotypic differences between different L/M opsin variants, the ratio of expression of first versus downstream genes in the L/M array contributes to phenotypic diversity. While the L/M opsin mutations underlie the cone dysfunction in all of the subjects tested, the color vision defect can be caused either by the same mutation or a gene rearrangement at the same locus.

Photoreceptor-Based Biomarkers in AOSLO Retinal Imaging

Improved understanding of the mechanisms underlying inherited retinal degenerations has created the possibility of developing much needed treatments for these relentless, blinding diseases. However, standard clinical indicators of retinal health (such as visual acuity and visual field sensitivity) are insensitive measures of photoreceptor survival. In many retinal degenerations, significant photoreceptor loss must occur before measurable differences in visual function are observed. Thus, there is a recognized need for more sensitive outcome measures to assess therapeutic efficacy as numerous clinical trials are getting underway. Adaptive optics (AO) retinal imaging techniques correct for the monochromatic aberrations of the eye and can be used to provide nearly diffraction-limited images of the retina. Many groups routinely are using AO imaging tools to obtain in vivo images of the rod and cone photoreceptor mosaic, and it now is possible to monitor photoreceptor structure over time with single cell resolution. Highlighting recent work using AO scanning light ophthalmoscopy (AOSLO) across a range of patient populations, we review the development of photoreceptor-based metrics (e.g., density/geometry, reflectivity, and size) as candidate biomarkers. Going forward, there is a need for further development of automated tools and normative databases, with the latter facilitating the comparison of data sets across research groups and devices. Ongoing and future clinical trials for inherited retinal diseases will benefit from the improved resolution and sensitivity that multimodal AO retinal imaging affords to evaluate safety and efficacy of emerging therapies.

Automated measurements of human cone photoreceptor density in healthy and degenerative retina by region-based segmentation

Purpose

The purpose of this study was to develop an algorithm based on region-based segmentation for automated calculations of human cone photoreceptor density of en face images obtained by an adaptive optics scanning laser ophthalmoscope (AOSLO).

Subjects and methods

Cone mosaics of 15 eyes of 15 healthy subjects were photographed by a custom-built AOSLO. The cone density was calculated at 0.5, 1.0, and 1.5 mm temporal from the fovea using a region-based segmentation method (RSM) developed in our laboratory. The cone density was also determined by a manual identification method (MIM) and a conventional spatial filtering method (SFM). The cone densities of three eyes of three patients with retinal degeneration were calculated by the three methods and compared to the results from normal eyes.

Results

The cone densities in healthy retinas determined by the RSM at 0.5, 1.0, and 1.5 mm temporal from the fovea were 28,436, 21,233, and 13,620 cells/mm², respectively. These densities were in good agreement with a histological study and with in vivo AOSLO studies. The cone densities determined by RSM were different from those determined by MIM with a difference of 5% in healthy eyes. In eyes with retinal degeneration, with the appropriate threshold-level settings or spatial frequency bandwidth, the cone density measured by MIM was significantly closer to that measured by RSM than by SFM.

Conclusion

These results suggest that our method is more stable than conventional methods in cases of non-periodical photoreceptor structures such as the affected retinal area. Our method can be used in the longitudinal follow-up of retinal degenerative diseases and to determine the effect of therapy.

Visualization of Photoreceptors in Birdshot Chorioretinopathy Using Adaptive Optics Scanning Laser Ophthalmoscopy: A Pilot Study

PURPOSE

Adaptive optics scanning laser ophthalmoscopy (AOSLO) allows en face visualization of specific layers of the retina. This pilot study evaluated the ability of AOSLO to visualize photoreceptor integrity in patients with birdshot chorioretinopathy (BCR).

METHOD

A total of 16 consecutive patients with HLA-A29+ BCR were imaged using the prototype Apaeros retinal imaging system. Images of high quality were aligned with infrared reflectance photos and correlated with spectral domain optical coherence tomography (SD-OCT).

RESULTS

Images of four eyes of three patients were of sufficient quality to allow posterior pole montage and point-to-point correlation with SD-OCT. Areas of photoreceptor disruption on SD-OCT were seen as patchy areas of loss on AOSLO, whereas areas of intact interdigitation zone and inner segment/outer segment junction correlated with normal appearing photoreceptors on AOSLO.

CONCLUSIONS

Using AOSLO, we found one instance of subclinical photoreceptor disruption not seen on SD-OCT. Ultimately, there are unique challenges associated with imaging BCR patients using AOSLO.

Evaluating outer segment length as a surrogate measure of peak foveal cone density

Adaptive optics (AO) imaging tools enable direct visualization of the cone photoreceptor mosaic, which facilitates quantitative measurements such as cone density. However, in many individuals, low image quality or excessive eye movements precludes making such measures. As foveal cone specialization is associated with both increased density and outer segment (OS) elongation, we sought to examine whether OS length could be used as a surrogate measure of foveal cone density. The retinas of 43 subjects (23 normal and 20 albinism; aged 6-67years) were examined. Peak foveal cone density was measured using confocal adaptive optics scanning light ophthalmoscopy (AOSLO), and OS length was measured using optical coherence tomography (OCT) and longitudinal reflectivity profile-based approach. Peak cone density ranged from 29,200 to 214,000cones/mm² (111,700±46,300cones/mm²); OS length ranged from 26.3 to 54.5μm (40.5±7.7μm). Density was significantly correlated with OS length in albinism (p<0.0001), but not normals (p=0.99). A cubic model of density as a function of OS length was created based on histology and optimized to fit the albinism data. The model includes triangular cone packing, a cylindrical OS with a fixed volume of 136.6μm³, and a ratio of OS to inner segment width that increased linearly with increasing OS length (R²=0.72). Normal subjects showed no apparent relationship between cone density and OS length. In the absence of adequate AOSLO imagery, OS length may be used to estimate cone density in patients with albinism. Whether this relationship exists in other patient populations with foveal hypoplasia (e.g., premature birth, aniridia, isolated foveal hypoplasia) remains to be seen.

Distribution differences of macular cones measured by AOSLO: Variation in slope from fovea to periphery more pronounced than differences in total cones

Large individual differences in cone densities occur even in healthy, young adults with low refractive error. We investigated whether cone density follows a simple model that some individuals have more cones, or whether individuals differ in both number and distribution of cones. We quantified cones in the eyes of 36 healthy young adults with low refractive error using a custom adaptive optics scanning laser ophthalmoscope. The average cone density in the temporal meridian was, for the mean±SD, 43,216±6039, 27,466±3496, 14,996±1563, and 12,207±1278cones/mm² for 270, 630, 1480, and 2070μm from the foveal center. Cone densities at 630μm retinal eccentricity were uncorrelated to those at 2070μm, ruling out models with a constant or proportional relation of cone density to eccentricity. Subjects with high central macula cone densities had low peripheral cone densities. The cone density ratio (2070:630μm) was negatively correlated with cone density at 630μm, consistent with variations in the proportion of peripheral cones migrating towards the center. We modelled the total cones within a central radius of 7deg, using the temporal data and our published cone densities for temporal, nasal, superior, and inferior meridians. We computed an average of 221,000 cones. The coefficient of variation was 0.0767 for total cones, but higher for samples near the fovea. Individual differences occur both in total cones and other developmental factors related to cone distribution.

Noninvasive imaging of the thirteen-lined ground squirrel photoreceptor mosaic

Ground squirrels are an increasingly important model for studying visual processing, retinal circuitry, and cone photoreceptor function. Here, we demonstrate that the photoreceptor mosaic can be longitudinally imaged noninvasively in the 13-lined ground squirrel (Ictidomys tridecemlineatus) using confocal and nonconfocal split-detection adaptive optics scanning ophthalmoscopy using 790 nm light. Photoreceptor density, spacing, and Voronoi analysis are consistent with that of the human cone mosaic. The high imaging success rate and consistent image quality in this study reinforce the ground squirrel as a practical model to aid drug discovery and testing through longitudinal imaging on the cellular scale.

MULTIMODAL IMAGING OF POSTERIOR POLAR ANNULAR CHOROIDAL DYSTROPHY

BACKGROUND

Posterior polar annular choroidal dystrophy (PPACD) is a rare disease. Patients with PPACD show loss of retinal pigment epithelium and choriocapillaries surrounding the vascular arcades and optic nerve.

METHODS

Two patients with PPACD were evaluated with multimodal imaging, including fundus autofluorescence (FAF) and adaptive optics (AO).

REPORT OF CASES

One patient (32 year old, one eye) with PPACD was followed up for 3 years. Best-corrected visual acuity (BCVA) was stable at 20/40, whereas a slight enlargement of paravascular atrophy of pigment epithelium was observed at fundus autofluorescence (FAF). Adaptive optics obtained at last examination showed reduced density of foveal cone photoreceptors. The second patient (30 year old, two eyes) with PPACD showed bilateral normal BCVA, associated with reduction in the density of foveal cone photoreceptors.

CONCLUSION

At FAF, longitudinal follow-up of PPACD showed progression of the paravascular atrophy of the pigment epithelium. Foveal cone photoreceptors can be reduced even in the presence of preserved visual acuity.

The organization of the cone photoreceptor mosaic measured in the living human retina

The cone photoreceptors represent the initial fundamental sampling step in the acquisition of visual information. While recent advances in adaptive optics have provided increasingly precise estimates of the packing density and spacing of the cone photoreceptors in the living human retina, little is known about the local cone geometric arrangement beyond a tendency towards hexagonal packing. We analyzed the cone mosaic in data from 10 normal subjects. A technique was applied to calculate the local average cone mosaic structure which allowed us to determine the hexagonality, spacing and orientation of local regions. Using cone spacing estimates, we find the expected decrease in cone density with retinal eccentricity and higher densities along the horizontal as opposed to the vertical meridians. Orientation analysis reveals an asymmetry in the local cone spacing of the hexagonal packing, with cones having a larger local spacing along the horizontal direction. This horizontal/vertical asymmetry is altered at eccentricities larger than 2 degrees in the superior meridian and 2.5 degrees in the inferior meridian. Analysis of hexagon orientations in the central 1.4° of the retina shows a tendency for orientation to be locally coherent, with orientation patches consisting of between 35 and 240 cones.

Individual neurons in the caudal fastigial oculomotor region convey information on both macro- and microsaccades

Recent studies have suggested that microsaccades, the small amplitude saccades made during fixation, are precisely controlled. Two lines of evidence suggest that the cerebellum plays a key role not only in improving the accuracy of macrosaccades but also of microsaccades. First, lesions of the fastigial oculomotor regions (FOR) cause horizontal dysmetria of both micro- and macrosaccades. Secondly, our previous work on Purkinje cell simple spikes in the oculomotor vermis (OV) has established qualitatively similar response preferences for these two groups of saccades. In this work, we investigated the control signals for micro- and macrosaccades in the FOR, the target of OV Purkinje cell axons. We found that the same FOR neurons discharged for micro- and macrosaccades. For both groups of saccades, FOR neurons exhibited very similar dependencies of their discharge strength on direction and amplitude and very similar burst onset time differences for ipsi- and contraversive saccades and, in both, response duration reflected saccade duration, at least at the population level. An intriguing characteristic of microsaccade-related responses is that immediate pre-saccadic firing rates decreased with distance to the target center, a pattern that strikingly parallels the eye position dependency of both microsaccade metrics and frequency, which may suggest a potential neural mechanism underlying the role of FOR in fixation. Irrespective of this specific consideration, our study supports the view that microsaccades and macrosaccades share the same cerebellar circuitry and, in general, further strengthens the notion of a microsaccade-macrosaccade continuum.

Extrafoveal Cone Packing in Eyes With a History of Retinopathy of Prematurity

Purpose

To study the density and packing geometry of the extrafoveal cone photoreceptors in eyes with a history of retinopathy of prematurity (ROP). We used a multimodal combination of adaptive optics (AO) scanning light ophthalmoscopy (SLO) and optical coherence tomography (OCT).

Methods

Cones were identified in subjects (aged 14–26 years) with a history of ROP that was either severe and treated by laser ablation of avascular peripheral retina (TROP; n = 5) or mild and spontaneously resolved, untreated (UROP; n = 5), and in term-born controls (CT; n = 8). The AO-SLO images were obtained at temporal eccentricities 4.5°, 9°, 13.5°, and 18° using both confocal and offset apertures with simultaneous, colocal OCT images. Effects of group, eccentricity, and aperture were evaluated and the modalities compared.

Results

In the SLO images, cone density was lower and the packing pattern less regular in TROP, relative to CT and UROP retinae. Although SLO image quality appeared lower in TROP, root mean square (RMS) wavefront error did not differ among the groups. In TROP eyes, cone discrimination was easier in offset aperture images. There was no evidence of cone loss in the TROP OCT images.

Conclusions

Low cone density in TROP confocal SLO images may have resulted from lower image quality. Since AO correction in these eyes was equivalent to that of the control group, and OCT imaging showed no significant cone loss, the optical properties of the inner retina or properties of the cones themselves are likely altered in a way that affects photoreceptor imaging.

Assessing the spatial relationship between fixation and foveal specializations

Increased cone photoreceptor density, an avascular zone (FAZ), and the displacement of inner retinal neurons to form a pit are distinct features of the human fovea. As the fovea provides the majority of our vision, appreciating how these anatomical specializations are related is important for understanding foveal development, normal visual function, and retinal disease. Here we evaluated the relationship between these specializations and their location relative to the preferred retinal locus of fixation (PRL). We measured foveal pit volume, FAZ area, peak cone density, and location of the PRL in 22 subjects with normal vision using optical coherence tomography and adaptive optics scanning light ophthalmoscopy. Foveal pit volume was positively correlated with FAZ area; however, peak cone density was not correlated with pit volume. In addition, there was no systematic offset of the location of any of these specializations relative to PRL, and there was no correlation between the magnitude of the offset from PRL and the corresponding foveal specialization measurements (pit volume, FAZ area, peak cone density). The standard deviation of our PRL measurements was consistent with previous measurements of fixational stability. These data provide insight into the sequence of events during foveal development and may have implications for visual function and retinal disease.

High-Resolution Imaging of Parafoveal Cones in Different Stages of Diabetic Retinopathy Using Adaptive Optics Fundus Camera

PURPOSE

To assess cone density as a marker of early signs of retinopathy in patients with type II diabetes mellitus.

METHODS

An adaptive optics (AO) retinal camera (rtx1™; Imagine Eyes, Orsay, France) was used to acquire images of parafoveal cones from patients with type II diabetes mellitus with or without retinopathy and from healthy controls with no known systemic or ocular disease. Cone mosaic was captured at 0° and 2°eccentricities along the horizontal and vertical meridians. The density of the parafoveal cones was calculated within 100×100-μm squares located at 500-μm from the foveal center along the orthogonal meridians. Manual corrections of the automated counting were then performed by 2 masked graders. Cone density measurements were evaluated with ANOVA that consisted of one between-subjects factor, stage of retinopathy and the within-subject factors. The ANOVA model included a complex covariance structure to account for correlations between the levels of the within-subject factors.

RESULTS

Ten healthy participants (20 eyes) and 25 patients (29 eyes) with type II diabetes mellitus were recruited in the study. The mean (± standard deviation [SD]) age of the healthy participants (Control group), patients with diabetes without retinopathy (No DR group), and patients with diabetic retinopathy (DR group) was 55 ± 8, 53 ± 8, and 52 ± 9 years, respectively. The cone density was significantly lower in the moderate nonproliferative diabetic retinopathy (NPDR) and severe NPDR/proliferative DR groups compared to the Control, No DR, and mild NPDR groups (P < 0.05). No correlation was found between cone density and the level of hemoglobin A1c (HbA1c) or the duration of diabetes.

CONCLUSIONS

The extent of photoreceptor loss on AO imaging may correlate positively with severity of DR in patients with type II diabetes mellitus. Photoreceptor loss may be more pronounced among patients with advanced stages of DR due to higher risk of macular edema and its sequelae.

[Adaptive optics for ophthalmology]

Adaptive optics is a technology enhancing the visual performance of an optical system by correcting its optical aberrations. Adaptive optics have already enabled several breakthroughs in the field of visual sciences, such as improvement of visual acuity in normal and diseased eyes beyond physiologic limits, and the correction of presbyopia. Adaptive optics technology also provides high-resolution, in vivo imaging of the retina that may eventually help to detect the onset of retinal conditions at an early stage and provide better assessment of treatment efficacy.

Multifocal electroretinogram in non-pathological myopic subjects: correlation with optical coherence tomography

AIM

To investigate the changes of retinal function in non-pathological myopic subjects using multifocal electroretinography (mfERG) and to correlate the data with the central macular thickness obtained using optical coherence tomography (OCT).

METHODS

One hundred and thirteen subjects (113 eyes) with age range from 18 to 35y were enrolled in the study. The subjects were divided into four groups according to spherical equivalent (SE) and axial length (AL): emmetropia group (EG, n=31; SE: +0.75 to -0.50 D; AL: 22 to 24 mm), low and medium myopia group (LMMG, n=26; SE: >-0.50 to -6.00 D; AL: >24 to 26 mm), high myopia group (HMG, n=34; SE: >-6.00 to -10.00 D; AL: >26 to 28 mm) and super high myopia group (SHMG, n=22; SE: >-10.00 D; AL:>28 mm). The P1 amplitude density, P1 amplitude, and P1 implicit time of the first-order kernel mfERG responses were obtained and grouped into five rings. The central subfield macular thickness (CST) was obtained using macular cube 512×218 scan of Cirrus HD-OCT.

RESULTS

With the increasing of eccentricity, the first positive peak (P1) amplitude density (P=0.0000, 0.0001, 0.0021 in ring 1-3 respectively) and P1 amplitude (all P=0.0000 in ring 1-5) of each group decreased. With the increasing of myopia, P1 implicit time gradually extended (all P=0.0000 in ring 1-3). The average CST in four diagnostic groups was 241.56±12.72 µm, 244.56±12.19 µm, 254.33±11.61 µm, 261.75±11.83 µm respectively. With the increasing of myopia, CST increased (P<0.001). There was negative relationship between CST and P1 amplitude, P1 amplitude density (r=-0.402, P<0.001; r=-0.261, P=0.003). There was positive relationship between CST and P1 implicit time (r=0.34, P<0.001).

CONCLUSION

With the increasing of myopia, P1 amplitude density and P1 amplitude of the first-order reaction gradually reduced. This showed potential decline in retinal function in myopia. To some extent it may reflect the functional disorder or depression of the visual cells. The exact mechanism needs further study.

Methods for investigating the local spatial anisotropy and the preferred orientation of cones in adaptive optics retinal images

The ability to noninvasively image the cone photoreceptor mosaic holds significant potential as a diagnostic for retinal disease. Central to the realization of this potential is the development of sensitive metrics for characterizing the organization of the mosaic. Here we evaluated previously-described and newly-developed (Fourier- and Radon-based) methods of measuring cone orientation in simulated and real images of the parafoveal cone mosaic. The proposed algorithms correlated well across both simulated and real mosaics, suggesting that each algorithm provides an accurate description of photoreceptor orientation. Despite high agreement between algorithms, each performed differently in response to image intensity variation and cone coordinate jitter. The integration property of the Fourier transform allowed the Fourier-based method to be resistant to cone coordinate jitter and perform the most robustly of all three algorithms. Conversely, when there is good image quality but unreliable cone identification, the Radon algorithm performed best. Finally, in cases where the cone coordinate reliability was excellent, the method previously described by Pum and colleagues performed best. These descriptors are complementary to conventional descriptive metrics of the cone mosaic, such as cell density and spacing, and have the potential to aid in the detection of photoreceptor pathology.

Hessian-LoG filtering for enhancement and detection of photoreceptor cells in adaptive optics retinal images

Automated analysis of retinal images plays a vital role in the examination, diagnosis, and prognosis of healthy and pathological retinas. Retinal disorders and the associated visual loss can be interpreted via quantitative correlations, based on measurements of photoreceptor loss. Therefore, it is important to develop reliable tools for identification of photoreceptor cells. In this paper, an automated algorithm is proposed, based on the use of the Hessian-Laplacian of Gaussian filter, which allows enhancement and detection of photoreceptor cells. The performance of the proposed technique is evaluated on both synthetic and high-resolution retinal images, in terms of packing density. The results on the synthetic data were compared against ground truth as well as cone counts obtained by the Li and Roorda algorithm. For the synthetic datasets, our method showed an average detection accuracy of 98.8%, compared to 93.9% for the Li and Roorda approach. The packing density estimates calculated on the retinal datasets were validated against manual counts and the results obtained by a proprietary software from Imagine Eyes and the Li and Roorda algorithm. Among the tested methods, the proposed approach showed the closest agreement with manual counting.

Retinal Architecture in ​RGS9- and ​R9AP-Associated Retinal Dysfunction (Bradyopsia)

PURPOSE

To characterize photoreceptor structure and mosaic integrity in subjects with ​RGS9- and R9AP-associated retinal dysfunction (bradyopsia) and compare to previous observations in other cone dysfunction disorders such as oligocone trichromacy.

DESIGN

Observational case series.

METHODS

setting: Moorfields Eye Hospital (United Kingdom) and Medical College Wisconsin (USA).

STUDY POPULATION

Six eyes of 3 subjects with disease-causing variants in ​RGS9 or R9AP.

MAIN OUTCOME MEASURES

Detailed retinal imaging using spectral-domain optical coherence tomography and confocal adaptive-optics scanning light ophthalmoscopy.

RESULTS

Cone density at 100 μm from foveal center ranged from 123 132 cones/mm(2) to 140 013 cones/mm(2). Cone density ranged from 30 573 to 34 876 cones/mm(2) by 600 μm from center and from 15 987 to 16,253 cones/mm(2) by 1400 μm from center, in keeping with data from normal subjects. Adaptive-optics imaging identified a small, focal hyporeflective lesion at the foveal center in both eyes of the subject with RGS9-associated disease, corresponding to a discrete outer retinal defect also observed on spectral-domain optical coherence tomography; however, the photoreceptor mosaic remained intact at all other observed eccentricities.

CONCLUSIONS

Bradyopsia and oligocone trichromacy share common clinical symptoms and cannot be discerned on standard clinical findings alone. Adaptive-optics imaging previously demonstrated a sparse mosaic of normal wave-guiding cones remaining at the fovea, with no visible structure outside the central fovea in oligocone trichromacy. In contrast, the subjects presented in this study with molecularly confirmed bradyopsia had a relatively intact and structurally normal photoreceptor mosaic, allowing the distinction between these disorders based on the cellular phenotype and suggesting different pathomechanisms.

Macular Bruch's Membrane Length and Axial Length. The Beijing Eye Study

PURPOSE

To assess whether macular Bruch´s membrane gets lengthened in axial myopia.

METHODS

Using the enhanced depth imaging mode of spectral-domain optical coherence tomography and examining a subgroup of participants of the population-based cross-sectional Beijing Eye Study, we measured the length of Bruch´s membrane ("MacBMLength") from the fovea to the temporal edge of parapapillary gamma zone, and the distance between the fovea and the temporal optic disc border. Parapapillary gamma zone was defined as the parapapillary region without Bruch's membrane. We additionally measured ocular biometric parameters and assessed non-ophthalmologic variables.

RESULTS

Measurements of MacBMLength were performed on 322 individuals. MacBMLength (mean: 3.99 ± 0.33 mm; range: 3.17-4.93 mm) was not significantly associated with any systemic parameter or ocular biometric parameter. Gamma zone width (mean: 0.18 ± 0.30 mm; range: 0.00-2.61 mm) was associated (multivariate analysis; correlation coefficient r:0.80) with longer axial length (P<0.001; standardized correlation coefficient beta: 0.60; non-standardized correlation coefficient B:0.11; 95%CI: 0.09,0.14) and with longer fovea-optic disc border distance (P<0.001; beta:0.28; B:0.19; 95%CI:0.14,0.25), but not with MacBMLength (P = 0.42). Fovea-temporal disc border distance (mean: 4.16 ± 0.44 mm; range: 3.17-5.86 mm) was associated (overall correlation coefficient: 0.68) with longer axial length (P<0.001; beta: 0.36; B: 0.10; 95%CI: 0.06, 0.13), after adjusting for flatter anterior chamber depth (P = 0.003; beta:-0.14; B:-0.14; 95%CI: -0.23,-0.05) and wider parapapillary gamma zone (P<0.001; beta:0.42; B:0.62; 95%CI:0.44,0.81).

CONCLUSIONS

In contrast to parapapillary gamma zone width and fovea-disc border distance, MacBMLength was not significantly associated with axial length. Axial elongation associated increase in fovea-disc distance may predominantly occur through development or elongation of parapapillary gamma zone, while macular Bruch´s membrane may mostly be independent of axial elongation.

Variability in Human Cone Topography Assessed by Adaptive Optics Scanning Laser Ophthalmoscopy

PURPOSE

To assess between- and within-individual variability of macular cone topography in the eyes of young adults.

DESIGN

Observational case series.

METHODS

Cone photoreceptors in 40 eyes of 20 subjects aged 19-29 years with normal maculae were imaged using a research adaptive optics scanning laser ophthalmoscope. Refractive errors ranged from -3.0 diopters (D) to 0.63 D and differed by <0.50 D in fellow eyes. Cone density was assessed on a 2-dimensional sampling grid over the central 2.4 mm × 2.4 mm. Between-individual variability was evaluated by coefficient of variation (COV). Within-individual variability was quantified by maximum difference and root mean square (RMS). Cones were cumulated over increasing eccentricity.

RESULTS

Peak densities of foveal cones are 168 162 ± 23 529 cones/mm(2) (mean ± SD) (COV = 0.14). The number of cones within the cone-dominated foveola (0.8-0.9 mm diameter) is 38 311 ± 2319 (COV = 0.06). The RMS cone density difference between fellow eyes is 6.78%, and the maximum difference is 23.6%. Mixed-model statistical analysis found no difference in the association between eccentricity and cone density in the superior/nasal (P = .8503), superior/temporal (P = .1551), inferior/nasal (P = .8609), and inferior/temporal (P = .6662) quadrants of fellow eyes.

CONCLUSIONS

New instrumentation imaged the smallest foveal cones, thus allowing accurate assignment of foveal centers and assessment of variability in macular cone density in a large sample of eyes. Though cone densities vary significantly in the fovea, the total numbers of foveolar cones are very similar both between and within subjects. Thus, the total number of foveolar cones may be an important measure of cone degeneration and loss.

Refractive error and ocular parameters: comparison of two SD-OCT systems

PURPOSE

Spectral domain optical coherence tomography (OCT) was used to examine the influence of refractive error (RE) on foveal retinal and choroidal thicknesses and scleral canal width (SCW). The performance of the Cirrus and Bioptigen spectral domain OCT instruments was compared in the same eyes.

METHODS

Both eyes of 40 healthy human subjects, aged 22 to 38 years, were dilated and imaged, with the Cirrus OCT, using 6-mm five-line rasters collapsed into one line, one centered on the fovea and one bisecting the optic nerve head. Seventy-two of the same eyes were imaged with the Bioptigen OCT, using 6- by 6-mm scans, one centered on the fovea and one on the optic nerve head. Subfoveal retinal and choroidal thicknesses and SCW were measured. Axial lengths (ALs) and REs were obtained using an IOLMaster and a Grand Seiko autorefractor, respectively.

RESULTS

Only right eyes were included in analyses. Spherical equivalent REs ranged from -12.18 to +8.12 diopters (mean [±SD], -3.44 [±4.06] diopters), and ALs ranged from 20.56 to 29.17 mm (mean [±SD], 24.86 [±1.91] mm). Myopia was associated with relatively thin choroids at the fovea (p < 0.05) but normal retinal thickness. Scleral canal width was significantly correlated with AL as measured with the Bioptigen OCT (p < 0.05). Retinal and choroidal thicknesses recorded with the Bioptigen OCT tended to be smaller than values obtained with the Cirrus OCT (mean difference, 5.63 and 24.76 μm, respectively), whereas the converse was true for the SCW (mean difference, 25.45 μm).

CONCLUSIONS

The finding that high myopes tend to have a thinner subfoveal choroid is consistent with previous studies. That high myopia was linked to enlarged scleral canals may help to explain the increased risk of glaucoma in myopia. Observed differences obtained with the Cirrus and Bioptigen instruments urge caution in comparing results collected with different instruments.

Multimodal imaging of a case of peripheral cone dystrophy

Purpose

To characterize the peripheral cones in the images obtained by spectral-domain optical coherence tomography (OCT), swept source OCT, and adaptive optics fundus camera in a patient with peripheral cone dystrophy.

Methods

A 28-year-old Japanese man underwent detailed ophthalmic evaluations including high-resolution imaging of the fundus of both eyes.

Results

The decimal best-corrected visual acuity was 1.2 in both eyes. The results of slit-lamp biomicroscopy and ophthalmoscopy were essentially normal. Fluorescein and indocyanine green angiographies did not show any hyper- or hypofluorescent areas of the retina. Goldmann perimetry showed full peripheral visual fields but relative central scotomas within the central 20°. The results of the Humphrey Visual Field Analyzer showed a limited preservation of the central sensitivity. Color vision tests showed no errors in both eyes. Spectral-domain OCT showed attenuation of both the ellipsoid and interdigitation zones throughout the macular region except the center of the fovea. The scotopic full-field ERGs were normal, but the photopic ERGs were markedly reduced. Regular cone mosaics were not observed especially more than 450 μm radius from the fovea in the adaptive optics retinal images. The parafoveal cone densities were severely decreased in both eyes.

Conclusions

Our findings indicate that the peripheral cone dystrophy diagnosed by full-field ERGs and perimetry is due to a reduction in the density of parafoveal and peripheral cones.

HTRA1 (high temperature requirement A serine peptidase 1) gene is transcriptionally regulated by insertion/deletion nucleotides located at the 3' end of the ARMS2 (age-related maculopathy susceptibility 2) gene in patients with age-related macular degeneration

Dry age-related macular degeneration (AMD) accounts for over 85% of AMD cases in the United States, whereas Japanese AMD patients predominantly progress to wet AMD or polypoidal choroidal vasculopathy. Recent genome-wide association studies have revealed a strong association between AMD and an insertion/deletion sequence between the ARMS2 (age-related maculopathy susceptibility 2) and HTRA1 (high temperature requirement A serine peptidase 1) genes. Transcription regulator activity was localized in mouse retinas using heterozygous HtrA1 knock-out mice in which HtrA1 exon 1 was replaced with β-galactosidase cDNA, thereby resulting in dominant expression of the photoreceptors. The insertion/deletion sequence significantly induced HTRA1 transcription regulator activity in photoreceptor cell lines but not in retinal pigmented epithelium or other cell types. A deletion construct of the HTRA1 regulatory region indicated that potential transcriptional suppressors and activators surround the insertion/deletion sequence. Ten double-stranded DNA probes for this region were designed, three of which interacted with nuclear extracts from 661W cells in EMSA. Liquid chromatography-mass spectrometry (LC-MS/MS) of these EMSA bands subsequently identified a protein that bound the insertion/deletion sequence, LYRIC (lysine-rich CEACAM1 co-isolated) protein. In addition, induced pluripotent stem cells from wet AMD patients carrying the insertion/deletion sequence showed significant up-regulation of the HTRA1 transcript compared with controls. These data suggest that the insertion/deletion sequence alters the suppressor and activator cis-elements of HTRA1 and triggers sustained up-regulation of HTRA1. These results are consistent with a transgenic mouse model that ubiquitously overexpresses HtrA1 and exhibits characteristics similar to those of wet AMD patients.

Cone dystrophy in patient with homozygous RP1L1 mutation

The purpose of this study was to determine whether an autosomal recessive cone dystrophy was caused by a homozygous RP1L1 mutation. A family including one subject affected with cone dystrophy and four unaffected members without evidence of consanguinity underwent detailed ophthalmic evaluations. The ellipsoid and interdigitation zones on the spectral-domain optical coherence tomography images were disorganized in the proband. The proband had a reduced amplitude of cone and flicker full-field electroretinograms (ERGs). Focal macular ERGs and multifocal ERGs were severely reduced in the proband. A homozygous RP1L1 mutation (c.3628T>C, p.S1210P) was identified in the proband. Family members who were heterozygous for the p.S1210P mutation had normal visual acuity and normal results of clinical evaluations. To investigate other putative pathogenic variant(s), a next-generation sequencing (NGS) approach was applied to the proband. NGS identified missense changes in the heterozygous state of the PCDH15, RPGRIP1, and GPR98 genes. None of these variants cosegregated with the phenotype and were predicted to be benign reinforcing the putative pathogenicity of the RP1L1 homozygous mutation. The AO images showed a severe reduction of the cone density in the proband. Our findings indicate that a homozygous p.S1210P exchange in the RP1L1 gene can cause cone dystrophy.

Henle fiber layer phase retardation changes associated with age-related macular degeneration

PURPOSE

To quantify and compare phase retardation amplitude and regularity associated with the Henle fiber layer (HFL) between nonexudative AMD patients and age-matched controls using scanning laser polarimetry (SLP) imaging.

METHODS

A scanning laser polarimeter was used to collect 15 × 15° macular-centered images in 25 patients with nonexudative AMD and 25 age-matched controls. Raw image data were used to compute macular phase retardation maps associated with the HFL. Consecutive, annular regions of interest from 0.5 to 3.0° eccentricity, centered on the fovea, were used to generate intensity profiles from phase retardation data and analyzed with two complementary techniques: a normalized second harmonic frequency (2f) of the fast Fourier Transform (FFT) analysis and a curve fitting analysis using a 2f sine function. Paired t-tests were used to compare the normalized 2f FFT magnitude at each eccentricity between the two groups, the eccentricity that yielded the maximum normalized 2f FFT between paired individuals across the two groups, and curve fitting RMS error at each eccentricity between the two groups.

RESULTS

Normalized 2f FFT components were lower in the AMD group at each eccentricity, with no difference between the two groups in the maximum normalized 2f FFT component eccentricity. The root-mean-square (RMS) error from curve fitting was significantly higher in the AMD group.

CONCLUSIONS

Phase retardation changes in the central macula indicate loss and/or structural alterations to central cone photoreceptors in nonexudative AMD patients. Scanning laser polarimetry imaging is a noninvasive method for quantifying cone photoreceptor changes associated with central macular disease.

Correlation of outer nuclear layer thickness with cone density values in patients with retinitis pigmentosa and healthy subjects

PURPOSE

We studied the correlation between outer nuclear layer (ONL) thickness and cone density in normal eyes and eyes with retinitis pigmentosa (RP).

METHODS

Spectral-domain optical coherence tomography (SD-OCT) scans were acquired using a displaced pupil entry position of the scanning beam to distinguish Henle's fiber layer from the ONL in 20 normal eyes (10 subjects) and 12 eyes with RP (7 patients). Cone photoreceptors were imaged using adaptive optics scanning laser ophthalmoscopy. The ONL thickness and cone density were measured at 0.5° intervals along the horizontal meridian through the fovea nasally and temporally. The ONL thickness and cone density were correlated using Spearman's rank correlation coefficient r.

RESULTS

Cone densities averaged over the central 6° were lower in eyes with RP than normal, but showed high variability in both groups. The ONL thickness and cone density were significantly correlated when all retinal eccentricities were combined (r = 0.74); the correlation for regions within 0.5° to 1.5° eccentricity was stronger (r = 0.67) than between 1.5° and 3.0° eccentricity (r = 0.23). Although cone densities were lower between 0.5° and 1.5° in eyes with RP, ONL thickness measures at identical retinal locations were similar in the two groups (P = 0.31), and interindividual variation was high for ONL and cone density measures. Although ONL thickness and retinal eccentricity were important predictors of cone density, eccentricity was over 3 times more important.

CONCLUSIONS

The ONL thickness and cone density were correlated in normal eyes and eyes with RP, but both were strongly correlated with retinal eccentricity, precluding estimation of cone density from ONL thickness. (ClinicalTrials.gov number, NCT00254605.).

Individual variation in cone photoreceptor density in house sparrows: implications for between-individual differences in visual resolution and chromatic contrast

Between-individual variation has been documented in a wide variety of taxa, especially for behavioral characteristics; however, intra-population variation in sensory systems has not received similar attention in wild animals. We measured a key trait of the visual system, the density of retinal cone photoreceptors, in a wild population of house sparrows (Passer domesticus). We tested whether individuals differed from each other in cone densities given within-individual variation across the retina and across eyes. We further tested whether the existing variation could lead to individual differences in two aspects of perception: visual resolution and chromatic contrast. We found consistent between-individual variation in the densities of all five types of avian cones, involved in chromatic and achromatic vision. Using perceptual modeling, we found that this degree of variation translated into significant between-individual differences in visual resolution and the chromatic contrast of a plumage signal that has been associated with mate choice and agonistic interactions. However, there was no evidence for a relationship between individual visual resolution and chromatic contrast. The implication is that some birds may have the sensory potential to perform "better" in certain visual tasks, but not necessarily in both resolution and contrast simultaneously. Overall, our findings (a) highlight the need to consider multiple individuals when characterizing sensory traits of a species, and (b) provide some mechanistic basis for between-individual variation in different behaviors (i.e., animal personalities) and for testing the predictions of several widely accepted hypotheses (e.g., honest signaling).

Adaptive optics imaging of parafoveal cones in type 1 diabetes

PURPOSE

To evaluate the parafoveal cone density in patients with Type 1 diabetes mellitus (DM1).

METHODS

Adaptive optics retinal images of the photoreceptor mosaic were acquired from 11 DM1 patients (study group) and 11 age-matched healthy subjects (control group). Cone density was analyzed, along the horizontal and vertical meridian, at 230-µm, 350-µm, and 460-µm eccentricity from the fovea. Central retinal thickness was measured using a Spectralis spectral-domain optical coherence tomography. A multiple regression model was performed to determine the relationships between the explanatory variables (age, glycohemoglobin level, presence of diabetic retinopathy, duration of diabetes, and central retinal thickness) and cone density.

RESULTS

Patients had a diagnosis of DM1 in the past 9 years to 21 years. Of these, five patients had a diagnosis of no diabetic retinopathy and six had mild nonproliferative diabetic retinopathy. On average, cone density was 10% lower in the study than in the control group at each retinal eccentricity along the horizontal and vertical meridians (analysis of variance, P < 0.001). The central retinal thickness was thicker in DM1 eyes than in the control eyes (278 ± 20 µm and 260 ± 13 µm; P < 0.05). The model explained 61% (P < 0.01) of the variance of cone density in the population, with the variables representing an abnormal glucose metabolism, that is, a higher glycohemoglobin level, the presence of diabetic retinopathy, and a chronic diabetes, having the highest influence on cone density decline.

CONCLUSION

A subtle decrease of parafoveal cone density was found in DM1 patients in comparison with age-matched control subjects via high-resolution adaptive optics retinal imaging. The cone density decline was moderately associated with a disturbance in the glucose metabolism.

Technical factors influencing cone packing density estimates in adaptive optics flood illuminated retinal images

PURPOSE

To investigate the influence of various technical factors on the variation of cone packing density estimates in adaptive optics flood illuminated retinal images.

METHODS

Adaptive optics images of the photoreceptor mosaic were obtained in fifteen healthy subjects. The cone density and Voronoi diagrams were assessed in sampling windows of 320×320 µm, 160×160 µm and 64×64 µm at 1.5 degree temporal and superior eccentricity from the preferred locus of fixation (PRL). The technical factors that have been analyzed included the sampling window size, the corrected retinal magnification factor (RMFcorr), the conversion from radial to linear distance from the PRL, the displacement between the PRL and foveal center and the manual checking of cone identification algorithm. Bland-Altman analysis was used to assess the agreement between cone density estimated within the different sampling window conditions.

RESULTS

The cone density declined with decreasing sampling area and data between areas of different size showed low agreement. A high agreement was found between sampling areas of the same size when comparing density calculated with or without using individual RMFcorr. The agreement between cone density measured at radial and linear distances from the PRL and between data referred to the PRL or the foveal center was moderate. The percentage of Voronoi tiles with hexagonal packing arrangement was comparable between sampling areas of different size. The boundary effect, presence of any retinal vessels, and the manual selection of cones missed by the automated identification algorithm were identified as the factors influencing variation of cone packing arrangements in Voronoi diagrams.

CONCLUSIONS

The sampling window size is the main technical factor that influences variation of cone density. Clear identification of each cone in the image and the use of a large buffer zone are necessary to minimize factors influencing variation of Voronoi diagrams of the cone mosaic.