Photovoltaic Restoration of Central Vision in Atrophic Age-Related Macular Degeneration

Vertical-junction photodiodes for smaller pixels in retinal prostheses

Objective.To restore central vision in patients with atrophic age-related macular degeneration, we replace the lost photoreceptors with photovoltaic pixels, which convert light into current and stimulate the secondary retinal neurons. Clinical trials demonstrated prosthetic acuity closely matching the sampling limit of the 100 μm pixels, and hence smaller pixels are required for improving visual acuity. However, with smaller flat bipolar pixels, the electric field penetration depth and the photodiode responsivity significantly decrease, making the device inefficient. Smaller pixels may be enabled by (1) increasing the diode responsivity using vertical p-n junctions and (2) directing the electric field in tissue vertically. Here, we demonstrate such novel photodiodes and test the retinal stimulation in a vertical electric field.Approach.Arrays of silicon photodiodes of 55, 40, 30, and 20 μm in width, with vertical p-n junctions, were fabricated. The electric field in the retina was directed vertically using a common return electrode at the edge of the devices. Optical and electronic performance of the diodes was characterized in-vitro, and retinal stimulation threshold measured by recording the visually evoked potentials (VEPs) in rats with retinal degeneration.Main results.The photodiodes exhibited sufficiently low dark current (<10 pA) and responsivity at 880 nm wavelength as high as 0.51 A/W, with 85% internal quantum efficiency, independent of pixel size. Field mapping in saline demonstrated uniformity of the pixel performance in the array. The full-field stimulation threshold was as low as 0.057±0.029 mW/mm²with 10 ms pulses, independent of pixel size.Significance.Photodiodes with vertical p-n junctions demonstrated excellent charge collection efficiency independent of pixel size, down to 20 μm. Vertically-oriented electric field provides a stimulation threshold that is independent of pixel size. These results are the first steps in validation of scaling down the photovoltaic pixels for subretinal stimulation.

Cortical responses to prosthetic retinal stimulation are significantly affected by the light-adaptive state of the surrounding normal retina

Objective Restoration of central vision loss in patients with age-related macular degeneration (AMD) by implanting a retinal prosthesis is associated with an intriguing situation wherein the central prosthetic vision co-exists with natural normal vision. Of major interest are the interactions between the prosthetic and natural vision. Here we studied the effect of the light-adaptive state of the normal retina on the electrical visual evoked potentials arising from the retinal prosthesis. Approach We recorded electrical visual evoked potential elicited by prosthetic retinal stimulation in wild-type rats implanted with a 1-mm photovoltaic subretinal array. Cortical responses were recorded following overnight dark adaption and compared to those recorded following bleaching of the retina by light (520nm) at various intensities and durations. Main Results Compared to dark-adapted responses, bleaching induced a 2-fold decrease in the prosthetic cortical response, which returned to the dark-adapted baseline within 30 min to several hours, depending on the degree of bleaching. This reduction was neither observed in Royal College of Surgeons (RCS) rats with a degenerated photoreceptor layer nor following intravitreal injection of a GABAa receptor blocker (bicuculine), suggesting the involvement of photoreceptors and a GABAa-mediated mechanism. Significance These findings show a robust effect of the retinal light-adaptive state on the obtained prosthetic responses. If a similar effect is found in humans, this will have immediate implications on the design of prosthetic devices, where both natural and prosthetic vision co-exist, such as in AMD patients receiving a photovoltaic retinal implant. Similarly, standardization of the retinal light-adaptive state in prosthetic clinical trials should be considered.

Electric Stimulation Elicits Heterogeneous Responses in ON but Not OFF Retinal Ganglion Cells to Transmit Rich Neural Information

Retinal implants electrically stimulate surviving retinal neurons to restore vision in people blinded by outer retinal degeneration. Although the healthy retina is known to transmit a vast amount of visual information to the brain, it has not been studied whether prosthetic vision contains a similar amount of information. Here, we assessed the neural information transmitted by population responses arising in brisk transient (BT) and brisk sustained (BS) subtypes of ON and OFF retinal ganglion cells (RGCs) in the rabbit retina. To correlate the response heterogeneity and the information transmission, we first quantified the cell-to-cell heterogeneity by calculating the spike time tiling coefficient (STTC) across spiking patterns of RGCs in each type. Then, we computed the neural information encoded by the RGC population in a given type. In responses to light stimulation, spiking activities were more heterogeneous in OFF than ON RGCs (STTC_AVG = 0.36, 0.45, 0.77 and 0.55 for OFF BT, OFF BS, ON BT, and ON BS, respectively). Interestingly, however, in responses to electric stimulation, both BT and BS subtypes of OFF RGCs showed remarkably homogeneous spiking patterns across cells (STTC_AVG = 0.93 and 0.82 for BT and BS, respectively), whereas the two subtypes of ON RGCs showed slightly increased populational heterogeneity compared to light-evoked responses (STTC_AVG = 0.71 and 0.63 for BT and BS, respectively). Consequently, the neural information encoded by the electrically-evoked responses of a population of 15 RGCs was substantially lower in the OFF than the ON pathway: OFF BT and BS cells transmit only ~23% and ~53% of the neural information transmitted by their ON counterparts. Together with previously-reported natural spiking activities in ON RGCs, the higher neural information may make ON responses more recognizable, eliciting the biased percepts of bright phosphenes.

Oculomotor Responses to Dynamic Stimuli in a 44-Channel Suprachoroidal Retinal Prosthesis

Purpose

To investigate oculomotor behavior in response to dynamic stimuli in retinal implant recipients.

Methods

Three suprachoroidal retinal implant recipients performed a four-alternative forced-choice motion discrimination task over six sessions longitudinally. Stimuli were a single white bar (“moving bar”) or a series of white bars (“moving grating”) sweeping left, right, up, or down across a 42″ monitor. Performance was compared with normal video processing and scrambled video processing (randomized image-to-electrode mapping to disrupt spatiotemporal structure). Eye and head movement was monitored throughout the task.

Results

Two subjects had diminished performance with scrambling, suggesting retinotopic discrimination was used in the normal condition and made smooth pursuit eye movements congruent to the moving bar stimulus direction. These two subjects also made stimulus-related eye movements resembling optokinetic reflex (OKR) for moving grating stimuli, but the movement was incongruent with stimulus direction. The third subject was less adept at the task, appeared primarily reliant on head position cues (head movements were congruent to stimulus direction), and did not exhibit retinotopic discrimination and associated eye movements.

Conclusions

Our observation of smooth pursuit indicates residual functionality of cortical direction-selective circuits and implies a more naturalistic perception of motion than expected. A distorted OKR implies improper functionality of retinal direction-selective circuits, possibly due to retinal remodeling or the non-selective nature of the electrical stimulation.

Translational Relevance

Retinal implant users can make naturalistic eye movements in response to moving stimuli, highlighting the potential for eye tracker feedback to improve perceptual localization and image stabilization in camera-based visual prostheses.

Testing Vision Is Not Testing For Vision

Visual prostheses aim to restore, at least to some extent, vision that leads to the type of perception available for sighted patients. Their effectiveness is almost always evaluated using clinical tests of vision. Clinical vision tests are designed to measure the limits of parameters of a functioning visual system. I argue here that these tests are rarely suited to determine the ability of prosthetic devices and other therapies to restore vision. This paper describes and explains many limitations of these evaluations. Prosthetic vision testing often makes use of multiple-alternative forced-choice (MAFC) procedures. Although these paradigms are suitable for many studies, they are frequently problematic in vision restoration evaluation. Two main types of problems are identified: (1) where nuisance variables provide spurious cues that can be learned in repeated training, which is common in prosthetic vision, and thus defeat the purpose of the test; and (2) even though a test is properly designed and performed, it may not actually measure what the researchers believe, and thus the interpretation of results is wrong. Examples for both types of problems are presented. Additional problems arise from confounding factors in the administration of tests are pointed as limitations of current device evaluation. For example, head tracing of magnified objects enlarged to compensate for the system's low resolution, in distinction from the scanning head (camera) movements with which users of prosthetic devices expand the limited field of view. Because of these problems, the ability to perform satisfactorily on the clinical tests is necessary but insufficient to prove vision restoration, therefore, additional tests are needed. I propose some directions to pursue in such testing.

Translational Relevance

Numerous prosthetic devices are being developed and introduced to the market. Proving the utility of these devices is crucial for regulatory and even for post market acceptance, which so far has largely failed, in my opinion. Potential reasons for the failures despite success in regulatory testing and directions for designing improved testing are provided. It is hoped that improved testing will guide improved designs of future prosthetic systems and other vision restoration approaches.

Editorial for the Special Issue on Micro/Nanofabrication for Retinal Implants

The retinal prosthetic community has witnessed tremendous technological advances during the last two decades since the emergence of pioneering work [...].

[Vision restoration: science fiction or reality?]

Visual prostheses aim at restoring useful vision to patients who have become blind. This useful vision should enable them to regain autonomy in society for navigation, face recognition or reading. Two retinal prostheses have already obtained market authorization for patients affected by retinal dystrophies while a new device is in clinical trials for patients affected by age-related macular degeneration. Various prostheses, in particular cortical prostheses, are currently in clinical trials for optic neuropathies (glaucoma). Optogenetic therapy, an alternative strategy, has now reached the stage of clinical trials at the retinal level while moving forward at the cortical level. Other innovating strategies have obtained proofs of concepts in rodents but require a further validation in large animals prior to their evaluation on patients. Restoring vision should therefore become a reality for many patients even if this vision will not be as extensive and perfect as natural vision.

Targeted Stimulation of Retinal Ganglion Cells in Epiretinal Prostheses: A Multiscale Computational Study

Retinal prostheses aim at restoring partial sight to patients that are blind due to retinal degenerative diseases by electrically stimulating the surviving healthy retinal neurons. Ideally, the electrical stimulation of the retina is intended to induce localized, focused, percepts only; however, some epiretinal implant subjects have reported seeing elongated phosphenes in a single electrode stimulation due to the axonal activation of retinal ganglion cells (RGCs). This issue can be addressed by properly devising stimulation waveforms so that the possibility of inducing axonal activation of RGCs is minimized. While strategies to devise electrical stimulation waveforms to achieve a focal RGCs response have been reported in literature, the underlying mechanisms are not well understood. This article intends to address this gap; we developed morphologically and biophysically realistic computational models of two classified RGCs: D1-bistratified and A2-monostratified. Computational results suggest that the sodium channel band (SOCB) is less sensitive to modulations in stimulation parameters than the distal axon (DA), and DA stimulus threshold is less sensitive to physiological differences among RGCs. Therefore, over a range of RGCs distal axon diameters, short-pulse symmetric biphasic waveforms can enhance the stimulation threshold difference between the SOCB and the DA. Appropriately designed waveforms can avoid axonal activation of RGCs, implying a consequential reduction of undesired strikes in the visual field.

Ab-interno surgical technique for the implantation of a wireless subretinal prosthesis in mini-pigs

We sought to describe the surgical techniques required in the ab-interno method to implant subretinal prostheses in mini-pigs and suggest tips to facilitate optimal outcomes. During vitrectomy, the use of valved trocar cannulas was essential to stabilize the detached retina and implanted chip. As a first step in retinal detachment, a 23-gauge cannula with very small amount of viscoelastic material was used to establish the retinal hole and promote retinal detachment. Then, balanced salt solution was applied to increase the retinal detachment and diathermy was used to make opening for subretinal prosthesis. For easy positioning of the subretinal prosthesis, a curved laser probe was adopted when handling the subretinal prosthesis under the retina. After surgery, the sclerotomy sites were tightly sutured to prevent silicone oil leakage. Without special equipment, such as a 41-gauge tip, retinal detachment could be induced easily, while the prosthesis was also successfully inserted and manipulated under the retina without an iatrogenic retinal tear. Two weeks after the operation, the oil fully occupied the intraocular volume without leakage. The subretinal prosthesis remained stable without complication. Understanding the principle of the ab-interno method and considering several tips for improving surgical access may help to enhance surgical success rates of subretinal prostheses implantation.

Decoding network-mediated retinal response to electrical stimulation: implications for fidelity of prosthetic vision

Objective.

Patients with photovoltaic subretinal implant PRIMA demonstrated letter acuity ∼0.1 logMAR worse than sampling limit for 100 μm pixels (1.3 logMAR) and performed slower than healthy subjects tested with equivalently pixelated images. To explore the underlying differences between natural and prosthetic vision, we compare the fidelity of retinal response to visual and subretinal electrical stimulation through single-cell modeling and ensemble decoding.

Approach.

Responses of retinal ganglion cells (RGCs) to optical or electrical white noise stimulation in healthy and degenerate rat retinas were recorded via multi-electrode array. Each RGC was fit with linear–nonlinear and convolutional neural network models. To characterize RGC noise, we compared statistics of spike-triggered averages (STAs) in RGCs responding to electrical or visual stimulation of healthy and degenerate retinas. At the population level, we constructed a linear decoder to determine the accuracy of the ensemble of RGCs on N-way discrimination tasks.

Main results.

Although computational models can match natural visual responses well (correlation ∼0.6), they fit significantly worse to spike timings elicited by electrical stimulation of the healthy retina (correlation ∼0.15). In the degenerate retina, response to electrical stimulation is equally bad. The signal-to-noise ratio of electrical STAs in degenerate retinas matched that of the natural responses when 78 ± 6.5% of the spikes were replaced with random timing. However, the noise in RGC responses contributed minimally to errors in ensemble decoding. The determining factor in accuracy of decoding was the number of responding cells. To compensate for fewer responding cells under electrical stimulation than in natural vision, more presentations of the same stimulus are required to deliver sufficient information for image decoding.

Significance.

Slower-than-natural pattern identification by patients with the PRIMA implant may be explained by the lower number of electrically activated cells than in natural vision, which is compensated by a larger number of the stimulus presentations.

Computational challenges and opportunities for a bi-directional artificial retina

A future artificial retina that can restore high acuity vision in blind people will rely on the capability to both read (observe) and write (control) the spiking activity of neurons using an adaptive, bi-directional and high-resolution device. Although current research is focused on overcoming the technical challenges of building and implanting such a device, exploiting its capabilities to achieve more acute visual perception will also require substantial computational advances. Using high-density large-scale recording and stimulation in the primate retina with an ex vivo multi-electrode array lab prototype, we frame several of the major computational problems, and describe current progress and future opportunities in solving them. First, we identify cell types and locations from spontaneous activity in the blind retina, and then efficiently estimate their visual response properties by using a low-dimensional manifold of inter-retina variability learned from a large experimental dataset. Second, we estimate retinal responses to a large collection of relevant electrical stimuli by passing current patterns through an electrode array, spike sorting the resulting recordings and using the results to develop a model of evoked responses. Third, we reproduce the desired responses for a given visual target by temporally dithering a diverse collection of electrical stimuli within the integration time of the visual system. Together, these novel approaches may substantially enhance artificial vision in a next-generation device.

Ultrasonic Retinal Neuromodulation and Acoustic Retinal Prosthesis

Ultrasound is an emerging method for non-invasive neuromodulation. Studies in the past have demonstrated that ultrasound can reversibly activate and inhibit neural activities in the brain. Recent research shows the possibility of using ultrasound ranging from 0.5 to 43 MHz in acoustic frequency to activate the retinal neurons without causing detectable damages to the cells. This review recapitulates pilot studies that explored retinal responses to the ultrasound exposure, discusses the advantages and limitations of the ultrasonic stimulation, and offers an overview of engineering perspectives in developing an acoustic retinal prosthesis. For comparison, this article also presents studies in the ultrasonic stimulation of the visual cortex. Despite that, the summarized research is still in an early stage; ultrasonic retinal stimulation appears to be a viable technology that exhibits enormous therapeutic potential for non-invasive vision restoration.

Retinal Degeneration Reduces Consistency of Network-Mediated Responses Arising in Ganglion Cells to Electric Stimulation

Retinal prostheses use periodic repetition of electrical stimuli to form artificial vision. To enhance the reliability of evoked visual percepts, repeating stimuli need to evoke consistent spiking activity in individual retinal ganglion cells (RGCs). However, it is not well known whether outer retinal degeneration alters the consistency of RGC responses. Hence, here we systematically investigated the trial-to-trial variability in network-mediated responses as a function of the degeneration level. We patch-clamp recorded spikes in ON and OFF types of alpha RGCs from r d10 mice at four different postnatal days (P15, P19, P31, and P60), representing distinct stages of degeneration. To assess the consistency of responses, we analyzed variances in spike count and timing across repeats of the same stimulus delivered multiple times. We found the trial-to-trial variability of network-mediated responses increased considerably as the disease progressed. Compared to responses taken before degeneration onset, those of degenerate retinas showed up to ~70% higher variability (Fano Factor) in spike counts (p < 0.001) and ~95% lower correlation level in spike timing (p < 0.001). These results indicate consistency weakens significantly in electrically-evoked network-mediated responses and therefore raise concerns about the ability of microelectronic retinal implants to elicit consistent visual percepts at advanced stages of retinal degeneration.

The relationship between morphological properties and thresholds to extracellular electric stimulation in α RGCs

OBJECTIVE

Retinal prostheses strive to restore vison to patients that are blind from retinal degeneration by electrically stimulating surviving retinal ganglion cells (RGCs). The quality of elicited percepts remains limited however and it is desirable to develop improved stimulation strategies. Here, we examine how the anatomical and biophysical properties of RGCs influence activation thresholds, including the effects of variations found naturally.

APPROACH

Detailed reconstructions were made of a large number of mouse α RGCs and were used to create an array of model cells; the models were used to study the effects of individual anatomical features on activation threshold to electric stimulation. Stimulation was delivered epiretinally from a point-source or disk electrode and consisted of monophasic or biphasic rectangular pulses.

MAIN RESULTS

Modeling results show that the region of minimum threshold always is within the axon initial segment (AIS). The properties of this region as well as the absolute value of the minimum threshold are dependent on the length of the AIS as well as on the relative composition of sodium channels within the AIS. Other morphological features, including cell size, dendritic field size and the distance between the AIS and the soma had only a minimal influence on thresholds. Introducing even a small number of low-threshold Na_v1.6 channels into the AIS was sufficient to lower minimum thresholds substantially although further increases in Na_v1.6 had diminishing effects. The distance between the AIS and the electrode affects threshold levels while alignment of the electrode with the axon or dendritic parts of the RGC can result in lower thresholds, even if the distance to the cell remains the same.

SIGNIFICANCE

Intrinsic morphological features can influence activation thresholds with the AIS having the strongest influence. However, the combined influence remains limited and may not be large enough to allow for selective activation between different RGC types.

The effect of waveform asymmetry on perception with epiretinal prostheses

Objective

Retinal prosthetic implants have helped improve vision in patients blinded by photoreceptor degeneration. Retinal implant users report improvements in light perception and performing visual tasks, but their ability to perceive shapes and letters is limited due to the low precision of retinal activation, which is exacerbated by axonal stimulation and high perceptual thresholds. A previous in vitro study in our lab used calcium imaging to measure the spatial activity of mouse retinal ganglion cells (RGCs) in response to electrical stimulation. Based on this study, symmetric anodic-first (SA) stimulation effectively avoided axonal activation and asymmetric anodic-first stimulation (AA) with duration ratios (ratio of the anodic to cathodic phase) greater than 10 reduced RGC activation thresholds significantly. Applying these novel stimulation strategies in clinic may increase perception precision and improve the overall patient outcomes.

Approach

We combined human subject testing and computational modeling to further examine the effect of SA and AA stimuli on perception shapes and thresholds for epiretinal stimulation of RGCs.

Main results

Threshold measurement in three Argus II participants indicated that AA stimulation could increase perception probabilities compared to a standard symmetric cathodic-first (SC) pulse, and this effect can be intensified by addition of an interphae gap (IPG). Our in silico RGC model predicts lower thresholds with AA and asymmetric cathodic-first (AC) stimuli compared to a SC pulse. This effect was more pronounced at shorter pulse widths. The most effective pulse for threshold reduction with short pulse durations (≤0.12 ms) was AA stimulation with small duration ratios (≤5) and long IPGs (≥2 ms). For the 0.5 ms pulse duration, SC stimulation with IPGs longer than 0.5 ms, or asymmetric stimuli with large duration ratios (≥20) were most effective in threshold reduction. Phosphene shape analysis did not reveal a significant change in percept elongation with SA stimulation. However, there was a significant increase in percept size (P < 0.01) with AA stimulation compared to the standard pulse in one participant.

Significane

Including asymmetric waveform capability will provide more flexible options for optimization and personalized fitting of retinal implants.

On optimal coupling of the 'electronic photoreceptors' into the degenerate retina

Objective

To restore sight in atrophic age-related macular degeneration, the lost photoreceptors can be replaced with electronic implants, which replicate their two major functions: (1) converting light into an electric signal, and (2) transferring visual information to the secondary neurons in the retinal neural network—the bipolar cells (BC). We study the selectivity of BC activation by subretinal implants and dynamics of their response to pulsatile waveforms in order to optimize the electrical stimulation scheme such that retinal signal processing with 'electronic photoreceptors' remains as close to natural as possible.

Approach

A multicompartmental model of a BC was implemented to simulate responses of the voltage-gated calcium channels and subsequent synaptic vesicle release under continuous and pulsatile stimuli. We compared the predicted response under various frequencies, pulse durations, and alternating gratings to the corresponding experimental measurements. In addition, electric field was computed for various electrode configurations in a 3-d finite element model to assess the stimulation selectivity via spatial confinement of the field.

Main results

The modeled BC-mediated retinal responses were, in general, in good agreement with previously published experimental results. Kinetics of the calcium pumps and of the neurotransmitter release in ribbon synapses, which underpin the BC's temporal filtering and rectifying functions, allow mimicking the natural BC response with high frequency pulsatile stimulation, thereby preserving features of the retinal signal processing, such as flicker fusion, adaptation to static stimuli and non-linear summation of subunits in receptive field. Selectivity of the BC stimulation while avoiding direct activation of the downstream neurons (amacrine and ganglion cells—RGCs) is improved with local return electrodes.

Significance

If the retinal neural network is preserved to a large extent in age-related macular degeneration, selective stimulation of BCs with proper spatial and temporal modulation of the extracellular electric field may retain many features of the natural retinal signal processing and hence allow highly functional restoration of sight.

Retinal Prosthetic Approaches to Enhance Visual Perception for Blind Patients

Retinal prostheses are implantable devices that aim to restore the vision of blind patients suffering from retinal degeneration, mainly by artificially stimulating the remaining retinal neurons. Some retinal prostheses have successfully reached the stage of clinical trials; however, these devices can only restore vision partially and remain insufficient to enable patients to conduct everyday life independently. The visual acuity of the artificial vision is limited by various factors from both engineering and physiological perspectives. To overcome those issues and further enhance the visual resolution of retinal prostheses, a variety of retinal prosthetic approaches have been proposed, based on optimization of the geometries of electrode arrays and stimulation pulse parameters. Other retinal stimulation modalities such as optics, ultrasound, and magnetics have also been utilized to address the limitations in conventional electrical stimulation. Although none of these approaches have been clinically proven to fully restore the function of a degenerated retina, the extensive efforts made in this field have demonstrated a series of encouraging findings for the next generation of retinal prostheses, and these could potentially enhance the visual acuity of retinal prostheses. In this article, a comprehensive and up-to-date overview of retinal prosthetic strategies is provided, with a specific focus on a quantitative assessment of visual acuity results from various retinal stimulation technologies. The aim is to highlight future directions toward high-resolution retinal prostheses.