Two cases of retinal degeneration with an unusual form of electroretinogram

Brain trauma impacts retinal processing: photoreceptor pathway interactions in traumatic light sensitivity

BACKGROUND

Concussion-induced light sensitivity, or traumatic photalgia, is a lifelong debilitating problem for upwards of 50% of mild traumatic brain injury (mTBI) cases, though of unknown etiology. We employed spectral analysis of electroretinographic (ERG) responses to assess retinal changes in mTBI as a function of the degree of photalgia.

METHODS

The design was a case-control study of the changes in the ERG waveform as a function of level of light sensitivity in individuals who had suffered incidents of mild traumatic brain injury. The mTBI participants were categorized into non-, mild-, and severe-photalgic groups based on their spectral nociophysical settings. Light-adapted ERG responses were recorded from each eye for 200 ms on-off stimulation of three spectral colors (R:red, G:green, and B:blue) and their sum (W:white) at the highest pain-free intensity level for each participant. The requirement of controls for testing hypersensitive individuals at lower light levels was addressed by recording a full light intensity series in the control group.

RESULTS

Both the b-wave and the photopic negative response (PhNR) were significantly reduced in the non-photalgic mTBI group relative to controls. In the photalgic groups, the main b-wave peak shifted to the timing of the rod b-wave, with reduced amplitude at the timing of the cone response.

CONCLUSION

These results suggest the interpretation that the primary etiology of the painful light sensitivity in mTBI is release of the rod pathway from cone-mediated inhibition at high light levels, causing overactivation of the rod pathway.

Clinical vision and molecular loss: Integrating visual psychophysics with molecular genetics reveals key details of normal and abnormal visual processing

Over the past two decades we have developed techniques and models to investigate the ways in which known molecular defects affect visual performance. Because molecular defects in retinal signalling invariably alter the speed of visual processing, our strategy has been to measure the resulting changes in flicker sensitivity. Flicker measurements provide not only straightforward clinical assessments of visual performance but also reveal fundamental details about the functioning of both abnormal and normal visual systems. Here, we bring together our past measurements of patients with pathogenic variants in the GNAT2, RGS9, GUCA1A, RPE65, OPA1, KCNV2 and NR2E3 genes and analyse the results using a standard model of visual processing. The model treats flicker sensitivity as the result of the actions of a sequence of simple processing steps, one or more of which is altered by the genetic defect. Our analyses show that most defects slow down the visual response directly, but some speed it up. Crucially, however, other steps in the processing sequence can make compensatory adjustments to offset the abnormality. For example, if the abnormal step slows down the visual response, another step is likely to speed up or attenuate the response to rebalance system performance. Such compensatory adjustments are probably made by steps in the sequence that usually adapt to changing light levels. Our techniques and modelling also allow us to tease apart stationary and progressive effects, and the localised molecular losses help us to unravel and characterise individual steps in the normal and abnormal processing sequences.

ISCEV extended protocol for the stimulus-response series for the dark-adapted full-field ERG b-wave

The International Society for Clinical Electrophysiology of Vision (ISCEV) standard for full-field electroretinography (ERG) describes a minimum protocol for clinical testing but encourages more extensive testing where appropriate. This ISCEV extended protocol describes an extension of the ISCEV full-field ERG standard, in which methods to record and evaluate the growth of the dark-adapted (DA) ERG b-wave with increasing stimulus energy are described. The flashes span a range that includes the weakest flash required to generate a reliable DA ERG b-wave and that required to generate a maximal b-wave amplitude. The DA ERG b-wave stimulus-response series (also known historically as the "intensity-response" or "luminance-response" series) can more comprehensively characterize generalized rod system function than the ISCEV standard ERG protocol and may be of diagnostic or prognostic value in disorders that cause generalized rod system dysfunction.

Rod and cone function in patients with KCNV2 retinopathy

BACKGROUND

To investigate rod and cone function and disease mechanisms in patients with KCNV2 retinopathy.

METHODOLOGY/PRINCIPAL FINDINGS

Psychophysical examinations as well as detailed electrophysiological examinations with Ganzfeld and multifocal electroretinogram (ERG) were performed to study response dynamics. Additionally, fundus photography, autofluorescence imaging and spectral domain OCTs were carried out for morphological characterization. Molecular genetic analysis revealed compound heterozygosity in five patients and homozygosity for the KCNV2 gene in one patient. The mutations resulted in complete absence of Kv8.2 subunits in three patients (no protein group, NOP), while the other three patients expressed mutant Kv8.2 subunits resulting in altered Kv2.1/Kv8.2 heteromeric or residual Kv2.1 homomeric potassium channel function (altered protein group, ALP). Although more advanced morphological changes were visible in the NOP group, a clear functional difference between the two groups could not be observed. All patients showed characteristic dynamics of the b-wave intensity-response function, however, scotopic b-wave response amplitudes were within normal limits. We also observed severely reduced oscillatory potentials.

CONCLUSIONS/SIGNIFICANCE

A specific genotype-phenotype correlation in retinal function could not be demonstrated. KCNV2 mutations cause a unique form of retinal disorder illustrating the importance of K(+)-channels for the resting potential, activation and deactivation of photoreceptors, while phototransduction remains unchanged. The reduced oscillatory potentials further suggest an altered function of the inner retina. Besides the characteristically steep amplitude-versus-intensity relationship, flicker responses at intermediate frequencies (5-15 Hz) are significantly reduced and shifted in phase.

Retinal function and structure in Ant1-deficient mice

PURPOSE

Mutations in ANT, a mitochondrial ATP transporter, are typically associated with myopathy. Because of the high metabolic demands of the retina, the authors examined whether elimination of the Ant1 isoform in a transgenic mouse affects retinal function or morphology.

METHODS

RT-PCR was used to confirm Ant1 expression in retinas of wild-type (WT) or Ant1(-/-) mice. Full-field ERGs were used to test retinal function under dark- and light-adapted conditions and the recovery of the photoresponse to a bright flash. Using histologic methods, the authors assessed the retinal location of ANT and ANT1-β-gal reporter protein, mitochondrial activity with cytochrome c oxidase (COX) and succinate dehydrogenase (SDH) staining, retinal layer thickness, and bipolar cell types using Chx10 and recoverin.

RESULTS

Ant1(-/-) mice had supernormal ERG b-waves under both dark- and light-adapted conditions. X-Gal staining was detected in a subset of cells within the inner retina. The following characteristics were normal in Ant1(-/-) mice compared with age-matched WT mice: recovery of the photoresponse, COX and SDH activity, retinal morphology, and bipolar cell morphology.

CONCLUSIONS

The presence of ANT1 in a subset of inner retinal cells accompanied by supernormal ERG responses suggests that ANT1 may be localized to hyperpolarizing bipolar cells. However, the immunohistochemical techniques used here did not show any differences in bipolar cells. Moderate functional changes coupled with a lack of detectable morphologic changes suggest that ANT1 is not essential for ATP transport in the retina.

"Cone dystrophy with supernormal rod electroretinogram": a comprehensive genotype/phenotype study including fundus autofluorescence and extensive electrophysiology

PURPOSE

The purpose of this study was to characterize the clinical, electrophysiologic, and genetic features in "cone dystrophy with supernormal rod electroretinogram (ERG)."

METHODS

Twenty-four cases between 5 and 59 years of age were ascertained. Full-field ERGs, incorporating the international standards, were used to derive intensity-ERG response functions. ON-OFF ERGs were performed. Fundus autofluorescence imaging was performed on 15 subjects. Deoxyribonucleic acid was available in 18 cases and was screened for a mutation in KCNV2.

RESULTS

Photophobia and nyctalopia were common. Autofluorescence was variable but often showed a ring-like area of high density that in middle-aged individuals, usually surrounded by an area of macular retinal pigment epithelial atrophy. Scotopic ERG amplitudes overlapped with the normal range but had characteristic a- and b-wave intensity-response functions; all had a broadened a-wave to the brightest flash. Photopic ERGs were abnormal; there was a delay in some ON and most OFF responses. Mutations in KCNV2 were detected in 18 cases, including 4 with novel mutations.

CONCLUSION

Individuals with mutations in KCNV2 manifest a wide range of macular and autofluorescence abnormalities. A ring-like area of parafoveal high density autofluorescence is common. ERG amplitudes are variable, but the intensity-ERG response functions and bright flash ERG waveforms are pathognomonic.

PIII and Derived PII Analysis in a Patient with Retinal Dysfunction with Supernormal Scotopic ERG

PURPOSE

To present electroretinographic (ERG) findings in a patient with retinal dysfunction with supernormal scotopic ERG, and to analyze rod and cone PIII components and rod inner nuclear layer (derived PII) responses.

PATIENT

A Japanese 11-year-old girl complained of poor visual acuity. There was no parental consanguinity in her family. The corrected visual acuity was 0.7 in both eyes. No abnormal finding was observed in both fundi.

METHODS

The patient underwent full-field ERGs. Rod and cone a-waves were analyzed using photoreceptor models. The derived PII responses were analyzed using a technique described by Hood and Birch.

RESULTS

In the photopic ERG, responses to single flash and 30-Hz flicker were attenuated. In the scotopic ERG, b-wave was supernormal in amplitude in response to intense flashes, but smaller than normal and markedly delayed over a lower range of flash intensities. By the PIII analysis, phototransductions (values of S) of both rod and cone were remarkably decreased. The derived PII responses for this patient were larger than the responses for normal subjects, and the onset of the PII responses in this patient are significantly delayed compared to those in normal subjects.

CONCLUSIONS

The ophthalmological findings in this patient are consistent with previous publications of this disease. Although it has been reported that the sites of disease action were beyond the outer segment (values of S were within the normal range), our results suggest that photoreceptors could be involved in sites of disease action in at least some patients with this disease.

Evidence supportive of a functional discrimination between photopic oscillatory potentials as revealed with cone and rod mediated retinopathies

We report on a family where four of the eleven children presented with reduced visual acuities, a red-green deficit at the Farnsworth-Munsel FM 100-hue test, normal appearing fundi and unexpected electroretinographic findings. Light- (photopic) and dark- (scotopic) adapted electroretinograms (ERG) and oscillatory potentials (OPs) were obtained following an accepted standard protocol. The b-wave of their photopic ERG was significantly more attenuated than the a-wave due to the specific abolition of OP4, while the amplitudes of OP2 and OP3 were within the normal range, giving to the b-wave a truncated appearance reminiscent of that seen in congenital stationary night blindness (CSNB) with myopia. Interestingly in the latter condition, which is believed to result from an ON-retinal pathway anomaly, it is OP2 and OP3 which are specifically abolished while OP4 is of normal amplitude thus resulting in an OP response pattern which complements that seen with our patients. Also of interest is the fact that, in our patients, the amplitude of the dark-adapted OP2 was, on average, 240% larger than that measured in light-adaptation while, in normal, a non-significant 14% increase is noted; a finding which is in keeping with other studies reporting supernormal scotopic ERGs in some forms of cone dystrophies. Based on the photopic OP response pattern, our patients represent the electrophysiological complement of patients affected with CSNB. Interestingly their symptoms are also complementary, a finding which could support a functional discrimination between the photopic OPs.

Assessing abnormal rod photoreceptor activity with the a-wave of the electroretinogram: applications and methods

The impact of a disease on phototransduction can be assessed by fitting the leading edge of the rod a-wave to high-energy flashes with a quantitative expression. Two parameters of rod receptor activity are obtained, S (sensitivity) and Rm (maximum response). In this study, the meaning of these parameters and examples of conditions that change them were examined. In addition, a new protocol was developed for obtaining these parameters. A set of three to five white flashes were first presented in the dark and then on an adapting field (30 cd/m2). Subtracting the light-adapted responses from the dark-adapted responses yielded isolated rod a-wave responses. A clinical protocol was developed based on a single white flash energy. It is possible to determine whether a disease is producing a change in S and/or Rm with this single flash energy without the use of any equations.

Sites of disease action in a retinal dystrophy with supernormal and delayed rod electroretinogram b-waves

Delayed rod ERG b-waves in patients with an unusual retinal dystrophy have been attributed by some to an abnormality in receptor cGMP activity. Here the sites of disease action are studied by analyzing rod and cone ERGs using new analytical methods and a wide range of stimulus intensities. Consistent with previous reports, the five patients studied showed rod b-waves that were normal or supernormal in amplitude in response to intense flashes, but smaller than normal and markedly delayed in response to weaker flashes. The cone ERGs, recorded to 29 Hz flicker and to flashes upon a background, were smaller than normal and also showed delays. Models of phototransduction fitted to rod and cone a-waves indicated that the delays in the rod and cone b-waves were not due to the speed or amplification of the transduction process. An analysis of the derived inner nuclear layer (INL) response suggests that the sites of disease action are beyond the outer segment and involve a delay in the activation of INL activity.

Retinal cone dysfunction of supernormal rod ERG type. Five new cases

Five patients, not related to each other, showed clinical signs, including electroretinograms, of a retinal dysfunction which mainly affected the cone system, but also involved the rod responses in a peculiar way. ERG b-wave threshold under dark adapted conditions was elevated. In contrast, rod b-wave sensitivity was enhanced with medium to high intensity flash stimulation. Furthermore, all patients had a severe reduction of the oscillatory potentials. The findings are discussed with special emphasis on a hypothetical disturbance in the cyclic guanosine monophosphate metabolism, involving both photoreceptors and cells of the inner plexiform layer responsible for retinal feedback mechanisms.

Cone dysfunction and supernormal scotopic electroretinogram with a high-intensity stimulus. A report of three cases

An unusual form of scotopic electroretinogram with a bright white stimulus, which consisted of a rectangular a-wave of normal amplitude and a b-wave of supernormal amplitude, was recorded in three patients with cone dysfunction. In addition to poor visual acuity, abnormal color vision and reduced amplitude of the photopic electroretinogram, these patients showed a 2-log unit elevation of the dark-adaptation threshold. Funduscopic examination and fluorescein angiography revealed fine granular pigment disturbances at the macula. The relationship between the response of the dark-adapted electroretinogram versus stimulus intensity was unique to these patients. The b-wave thresholds were elevated by 1 log unit. The b-waves were reduced in amplitude and markedly delayed in implicit time to dim stimuli, but supernormal in amplitude and normal in implicit time to bright stimuli.

Effects of IBMX on the rod ERG of the isolated perfused cat eye: antagonism with light, calcium or L-cis-diltiazem

Full-field electroretinograms (ERGs) were recorded from isolated cat eyes perfused through the ophthalmociliary artery with the cGMP-PDE inhibitor, 3-isobutylmethylxanthine (IBMX). Under dark-adapted conditions perfusion with IBMX resulted in reduced ERG b-wave amplitudes at low stimulus luminances and supernormal b-wave amplitudes at high stimulus luminances with reduced b-wave sensitivity; b-wave implicit times were more delayed at low than at high stimulus luminances. Presentation of a steady white background or high calcium fully reversed the supernormal amplitudes and partially reversed the delayed implicit times produced by IBMX. Rod ERG b-wave sensitivity, reduced with IBMX alone, was partially reversed with calcium but further reduced with background light. Perfusion with the cation channel blocker, L-cis-diltiazem, also reversed the supernormal amplitudes produced by IBMX but had no effect on implicit times or b-wave sensitivity. Possible mechanisms of action of these antagonists and clinical implications of these findings are considered.

Cone dystrophy and supernormal dark-adapted b-waves in the electroretinogram

A male patient suffering from cone dystrophy was followed over 9 years. In addition to the typical clinical and electrophysiologic signs, supernormal b-waves were found in the dark-adapted electroretinogram. Our case is compared with 12 similar patients described in the literature. Our patient differed from the other patients in the following aspects: he was male and had a congenital stationary disease with a small pigment epithelial scar in the left eye only and no other fundus changes up to the age of 22 years. He did not complain of night blindness. The dark-adapted electroretinogram of our patient showed a normal b-wave threshold with increased b-wave amplitudes and markedly prolonged b-wave latencies and implicit times. This combination of signs has not been reported to date in any other patient and points towards a postreceptoral defect of the interneuronal connection.

Effects of IBMX on the ERG of the isolated perfused cat eye

Full-field electroretinograms (ERGs) were recorded from isolated cat eyes perfused through the ophthalmociliary artery with isobutylmethylxanthine (IBMX), an inhibitor of cyclic guanosine monophosphate (cyclic GMP) phosphodiesterase. Low doses of IBMX (0.1-0.3 mM) produced decreased rod ERG amplitudes at low stimulus luminances and increased rod ERG amplitudes at high stimulus luminances. A high dose of IBMX (1.0 mM) initially produced the same effect as the low doses and then led to decreased rod ERG amplitudes at all stimulus luminances. Perfusion with IBMX also resulted in elevations in the semi-saturation luminance (sigma), delayed rod a-wave latencies, delayed rod a-wave and b-wave implicit times, and reduced rod a-wave slopes. Eyes perfused with IBMX (1.0 mM) were also found to have elevated levels of retinal cyclic GMP. These effects of IBMX on the rod ERG are considered in the context of previously described ERGs in selected cases of human retinal degeneration.