Reappraisal of a short-wavelength-sensitive (S-cone) recording technique in routine clinical electroretinography

ISCEV extended protocol for the S-cone ERG

The International Society for Clinical Electrophysiology of Vision (ISCEV) standard for full-field electroretinography (ERG) describes a minimum procedure for testing generalized retinal function but encourages more extensive testing. This extended protocol describes a method of assessing the function of the short-wavelength-sensitive cone (S-cone) retinal pathway, using a short-wavelength flash superimposed on a background that saturates the rods and adapts the L/M-cones to elicit a response, known as the S-cone ERG. Stimulus parameters such as the strength and luminance of the flash and background, respectively, and their spectral and temporal characteristics are specified. As a complement to the ISCEV standard, testing the S-cone ERG enables further characterization of light-adapted retinal function and may refine diagnosis of some retinal disorders. Typical applications are described including use in the diagnosis of rod monochromacy and S-cone monochromacy, identification and investigation of cone On-bipolar cell dysfunction and use of the technique to confirm the diagnosis of enhanced S-cone syndrome.

Human S-cone electroretinograms obtained by silent substitution stimulation

We used triple silent substitution stimuli to characterize human S-cone electroretinograms (ERGs) in normal trichromats. Short-wavelength-cone (S-cone) ERGs were found to have different morphological features and temporal frequency response characteristics compared to ERGs derived from L-cones, M-cones, and rod photoreceptors in normal participants. Furthermore, in two cases of retinal pathology, blue cone monochromatism (BCM) and enhanced S-cone syndrome (ESCS), S-cone ERGs elicited by our stimuli were preserved and enhanced, respectively. The results from both normal and pathological retinae demonstrate that triple silent substitution stimuli can be used to generate ERGs that provide an assay of human S-cone function.

Blue flash ERG PhNR changes associated with poor long-term glycemic control in adolescents with type 1 diabetes

PURPOSE

To investigate the relationship between long-term glycemic control and photopic negative response (PhNR) changes in the blue flash ERG in adolescents with type 1 diabetes (T1D) without diabetic retinopathy (DR).

METHODS

After light adaptation, ERG responses to 1.60 cd·s/m(2) blue (420 nm) flashes (blue flash ERG) and 3.0 cd·s/m(2) white flashes (LA 3.0 ERG) were recorded in 22 patients (age range, 12 to 19 years) and 28 age-similar control subjects. The primary outcome measure was the amplitude of the PhNR. Secondary outcome measures were the amplitude and implicit time of the a-wave and b-wave. Multiple regression analyses were conducted with glycated hemoglobin (HbA(1c)) values and the time since diagnosis of T1D as covariates.

RESULTS

Blue flash ERG PhNR amplitudes were reduced (P = 0.005) in patients compared with control subjects. Multiple regression analysis demonstrated that a 1-unit increase in HbA(1c) was associated with a 15% decrease in the blue flash ERG PhNR amplitude (r = 0.61, P = 0.003). Compared with controls blue flash ERG a-waves (P = 0.03) and b-waves (P = 0.02) were delayed in patients but were not significantly associated with HbA(1c) or time since diagnosis of T1D. None of the ERG measures in the LA 3.0 ERG were significantly different in patients compared with controls.

CONCLUSIONS

Poorer long-term glycemic control is associated with worsening inner retinal dysfunction involving short-wavelength cone pathways of adolescents with T1D and no clinically visible DR. Future studies are warranted to determine whether changes in the blue flash ERG PhNR are a predictive marker of subclinical DR.

Silent substitution S-cone electroretinogram in subjects with diabetes mellitus

A defect in the blue sensitive mechanism has been reported in certain ocular and systemic diseases. For example, tritanopic colour vision defects and changes to the S-cone electroretinogram (ERG) have been demonstrated in glaucoma and diabetes mellitus. Electrophysiological methods of eliciting the S-cone ERG, however, often result in considerable L- and M-cone intrusion. We report the findings of a study employing the silent substitution S-cone ERG technique, which is thought to represent an almost pure S-cone signal, and the L'Anthony desaturated D15 colour vision test in subjects with Type 1 or 2 diabetes mellitus with no or minimal background retinopathy. The results of this study show a significantly increased S-cone ERG b-wave implicit time and significantly worse colour vision in those with background retinopathy compared with those with no diabetic retinopathy. This suggests that S-cone pathway dysfunction may be responsible for the deterioration in colour vision found in diabetes mellitus.

Modulation of the human photopic ERG luminance-response function with the use of chromatic stimuli

In response to progressively brighter flashes, the amplitude of the photopic b-wave of the human electroretinogram (ERG) first increases, then saturates at a maximal value (V(max)) to finally decrease with the brightest flashes. The purpose of this study was to investigate if this "photopic hill" could be modulated with the use of stimuli of different wavelengths. ERGs were evoked to flashes of white, blue, green and red light presented against a white background in 30 normal subjects. Each chromatic stimulus produced a photopic hill. Findings indicate that the amplitude of V(max) was essentially identical except for that measured in response to the red stimuli, where it was 20% smaller than the others.

Clinical S-cone ERG recording with a commercial hand-held full-field stimulator

Our purpose was to explore S-cone ERG protocols for a commercial full-field hand-held stimulator that contains colored LEDs, and to see whether the test would be useful as a part of routine ERG testing. S-cone responses were elicited by blue flashes over a longer-wavelength background. With the standard stimulator containing blue (461 nm), green (513 nm) and red (652 nm) LEDs, we were unable to obtain satisfactory responses. Reproducible S-cone ERGs were obtained with a stimulator that had been custom-fitted with shorter-wavelength blue (440 nm) LEDs for stimulation, and orange (590 nm) LEDs for background adaptation. S-cone responses took only a few minutes to record, and the typical waveform showed a slow peak at 45-50 ms with amplitude 3-9 microV, but ranging from 0 microV to more than 10 microV. Larger waves appeared in a patient with enhanced S-cone syndrome. S-cone responses could also be obtained with an alternating blue-orange flicker protocol. We added the S-cone response to our regular ERG protocol for a number of months. Although most normal subjects and patients showed recognizable S-cone responses with this stimulator, the amplitudes were small and there was too much variability to make the technique effective for routine clinical testing. In general, the S-cone responses followed the standard cone ERG responses in disease.

The S-cone electroretinogram: a comparison of techniques, normative data and age-related variation

The blue sensitive mechanism in human colour vision is highly susceptible to damage in ocular disease. There is a need for objective methods to assess this and several methods of recording the blue cone (S-cone) electroretinogram (ERG) have been described. We therefore compared a silent substitution technique (SST) and a selective adaptation technique (SAT) using a novel combination of optical filters, on 24 normal subjects. The age-related variation in the S-cone ERG was also investigated in a further 73 normal subjects. S-cone ERGs elicited by SAT were of higher amplitude, (p < 0.001) with smaller coefficients of variation than those elicited with SST. The SST method has already been shown to be highly sensitive in primary open angle glaucoma and, unlike SAT, has no significant age related variation. However, the results of this study suggest that the new, SAT method may prove to be more convenient and effective in clinical practice, provided that age norms are applied.

Spectral characteristics of light sources for S-cone stimulation

PURPOSE

Electrophysiological investigations of the short-wavelength sensitive pathway of the human eye require the use of a suitable light source as a S-cone stimulator. Different light sources with their spectral distribution properties were investigated and compared with the ideal S-cone stimulator.

METHODS

First, the theoretical background of the calculation of relative cone energy absorption from the spectral distribution function of the light source is summarized. From the results of the calculation, the photometric properties of the ideal S-cone stimulator will be derived. The calculation procedure was applied to virtual light sources (computer generated spectral distribution functions with different medium wavelengths and spectrum widths) and to real light sources (blue and green light emitting diodes, blue phosphor of CRT-monitor, multimedia projector, LCD monitor and notebook display). The calculated relative cone absorbencies are compared to the conditions of an ideal S-cone stimulator.

RESULTS

Monochromatic light sources with wavelengths of less than 456 nm are close to the conditions of an ideal S-cone stimulator. Spectrum widths up to 21 nm do not affect the S-cone activation significantly (S-cone activation change < 0.2%). Blue light emitting diodes with peak wavelength at 448 nm and spectrum bandwidth of 25 nm are very useful for S-cone stimulation (S-cone activation approximately 95%). A suitable display for S-cone stimulation is the Trinitron computer monitor (S-cone activation approximately 87%). The multimedia projector has a S-cone activation up to 91%, but their spectral distribution properties depends on the selected intensity. LCD monitor and notebook displays have a lower S-cone activation (< or = 74%).

CONCLUSION

Carefully selecting the blue light source for S-cone stimulation can reduce the unwanted L-and M-cone activation down to 4% for M-cones and 1.5% for L-cones.

S-cone ERGs elicited by a simple technique in normals and in tritanopes

PURPOSE

To measure changes in the relative spectral sensitivities of the dark adapted and light adapted ERG and thus to establish the possible contribution of rods to the 'blue cone' ERG elicited by flashes of blue light.

BACKGROUND

Short wavelength stimuli in the light-adapted eye evoke small rounded b-waves which have been considered to be S-cone responses. We have recorded such responses from tritanopes, which called the assumptions into question.

METHODS

Small ERGs were recorded to blue and green flashes. The stimulus was a Ganzfeld which employed light emitting diodes. ERGs were obtained in both the dark-adapted eye and after light adaptation to intense orange light (peak wavelength 610 nm). The change in sensitivity with light adaptation and the relative spectral sensitivity was determined from the voltage/log light intensity functions, using a 10 microV criterion.

RESULTS

(1) peak times and changes in sensitivity did not help distinguish light-adapted rod from possible S-cone responses; (2) analysis of the change in the ratio of blue:green sensitivity from darkness to 4.4 log Td. 610 nm background suggests that in seven normal subjects, 90% or more of the ERG evoked by 440 nm flashes is generated by S-cones; (3) three tritanopes have insignificantly reduced S-cone responses.

CONCLUSIONS

(1) clinical techniques used to isolate S-cone ERGs are appropriate; (2) there are at least two types of tritanope and in those we investigated, functional S-cones are probably displaced into the retinal periphery.