Visual evoked potentials and the localization of visual pathway lesions

What can visual electrophysiology tell about possible visual-field defects in paediatric patients

Recognising a potential visual-field (VF) defect in paediatric patients might be challenging, especially in children before the age of 5 years and those with developmental delay or intellectual disability. Visual electrophysiological testing is an objective and non-invasive technique for evaluation of visual function in paediatric patients, which can characterise the location of dysfunction and differentiate between disorders of the retina, optic nerve and visual pathway. The recording of electroretinography (ERG) and visual-evoked potentials (VEP) is possible from early days of life and requires no subjective input from the patient. As the origins of ERG and VEP tests are known, the pattern of electrophysiological changes can provide information about the VF of a child unable to perform accurate perimetry. This review summarises previously published electrophysiological findings in several common types of VF defects that can be found in paediatric patients (generalised VF defect, peripheral VF loss, central scotoma, bi-temporal hemianopia, altitudinal VF defect, quadrantanopia and homonymous hemianopia). It also shares experience on using electrophysiological testing as additional functional evidence to other tests in the clinical challenge of diagnosing or excluding VF defects in complex paediatric patients. Each type of VF defect is illustrated with one or two clinical cases.

Visually evoked responses from the blind field of hemianopic patients

Hemianopia is a visual field defect characterized by decreased vision or blindness in the contralesional visual field of both eyes. The presence of well documented above-chance unconscious behavioural responses to visual stimuli presented to the blind hemifield (blindsight) has stimulated a great deal of research on the neural basis of this important phenomenon. The present study is concerned with electrophysiological responses from the blind field. Since previous studies found that transient Visual Evoked Potentials (VEPs) are not entirely suitable for this purpose here we propose to use Steady-State VEPs (SSVEPs). A positive result would have important implications for the understanding of the neural bases of conscious vision. We carried out a passive SSVEP stimulation with healthy participants and hemianopic patients. Stimuli consisted of four black-and-white sinusoidal Gabor gratings presented one in each visual field quadrant and flickering one at a time at a 12Hz rate. To assess response reliability a Signal-to-Noise Ratio analysis was conducted together with further analyses in time and frequency domains to make comparisons between groups (healthy participants and patients), side of brain lesion (left and right) and visual fields (sighted and blind). The important overall result was that stimulus presentation to the blind hemifield yielded highly reliable responses with time and frequency features broadly similar to those found for cortical extrastriate areas in healthy controls. Moreover, in the intact hemifield of hemianopics and in healthy controls there was evidence of a role of prefrontal structures in perceptual awareness. Finally, the presence of different patterns of brain reorganization depended upon the side of lesion.

Visual electrophysiology in the clinical evaluation of optic neuritis, chiasmal tumours, achiasmia, and ocular albinism: an overview

BACKGROUND AND METHODS

In routine clinical evaluation of optic neuritis and chiasmal tumours, pattern electroretinography and visual evoked potentials (VEPs) to pattern-reversal stimulation are useful examinations. Similarly, in achiasmia and ocular albinism, VEPs to flash and pattern-onset stimulation provide relevant information.

RESULTS

The role of visual electrophysiology in these diseases is to assess potential dysfunction of the visual pathway: (a) at the acute stage of optic neuritis, to determine the magnitude of conduction block of the optic nerve fibres; (b) at the clinical recovery stage of optic neuritis, to determine optic nerve conduction delay due to demyelination, and to follow possible remyelination; (c) at the recovery of optic neuritis when visual acuity does not normalise, to define loss of optic nerve fibres and retrograde degeneration of retinal ganglion cells; (d) in tumours at the chiasm, to detect abnormal conduction along the crossed and/or uncrossed fibres; and (e) in achiasmia or albinism, which are both congenital disorders associated with nystagmus, to detect achiasmia and absence of or reduced optic nerve fibre decussation at the chiasm, or to detect ocular albinism and excess of optic nerve fibre decussation at the chiasm. In optic neuritis, two recent examinations have been used to detect retrograde axonal degeneration: photopic negative response of the electroretinogram, to assess dysfunction of ganglion cell axons; and optic coherence tomography, to measure thinning of the retinal nerve fibre layer. In optic neuritis, multifocal VEPs provide a promising clinical examination, because this can show areas that are associated with normal or abnormal optic nerve fibre function.

CONCLUSIONS

Visual electrophysiology defines function of the visual pathway and is relevant: (1) in optic neuritis, when visual acuity does not recover well; (2) in tumours of the chiasm with normal visual fields, as in paediatric patients who cannot adequately perform perimetry; and (3) in children with congenital nystagmus and suspected achiasmia or ocular albinism.

Electrodiagnostics of chiasmal compressive lesions

Recording of visual evoked potentials (VEPs) is not yet a routine test in patients with suspected chiasmal compressive lesions, but has proved useful to a clinician in assessing and following-up visual pathway dysfunctions. Abnormalities of VEPs can be found even in patients without clinical evidence of the visual impairment: VEP delays and alterations of the waveform, asymmetric distribution in one eye or in both eyes (crossed asymmetry) can indicate chiasmal compressive lesion. Simultaneous recording of pattern electroretinograms (PERGs) can additionally provide useful information about the patient's cooperation as well as about eventual retrograde degeneration of the ganglion cells. Electrophysiologic tests can be regarded as an integral part of diagnostic procedures--ocular diagnostic tests and neuroimaging--in suspected compressive lesions of the optic chiasm.

A VEP study of the visual pathway function in compressive lesions of the optic chiasm. Full-field versus half-field stimulation

Changes of the pattern reversal visual evoked potentials (VEPs) to half- and full-field stimulation in 50 patients with compressive lesions of the optic chiasm are presented. Temporal half-field stimulation yielded abnormal responses in 85% of the eyes, showing non-recordable P100 in 50% of eyes, while in 35% the P100 was significantly attenuated or delayed. With nasal half-field the percentage of all detectable abnormalities was lower (36% of the eyes). Full-field stimulation revealed VEP abnormalities in 74% of eyes and therefore proved less sensitive than the half-field stimulation. This study adds new evidence that half-field stimulation can be an important adjunct for assessing the function of the optic chiasm.

Electrophysiologic evaluation of the visual pathway in children. Case reports

Clinical findings and results of electrophysiologic evaluation of the visual pathway were studied in seven children ranging in age from 10 months to 13 years. Using skin electrodes for electroretinographic and visual evoked potential testing, we obtained reliable results without sedation or pupil dilation. The half-field stimulation was indispensable for localizing lesions along the visual pathway and thus for specific diagnosis.