The Argus® II Retinal Prosthesis System

Prosthetic Visual Acuity with the PRIMA Subretinal Microchip in Patients with Atrophic Age-Related Macular Degeneration at 4 Years Follow-up

Objective

To assess the efficacy and safety of the PRIMA neurostimulation system with a subretinal microchip for improving visual acuity (VA) in patients with geographic atrophy (GA) due to age-related macular degeneration (AMD) at 48-months postimplantation.

Design

Feasibility clinical trial of the PRIMA subretinal prosthesis in patients with atrophic AMD, measuring best-corrected ETDRS VA (Clinicaltrials.govNCT03333954).

Subjects

Five patients with GA, no foveal light perception, and VA of logarithm of the minimum angle of resolution (logMAR) 1.3 to 1.7 (20/400-20/1000) in their worse-seeing "study" eye.

Methods

In patients subretinally implanted with a photovoltaic neurostimulation array containing 378 pixels of 100 μm in size, the VA was measured with and without the PRIMA system using ETDRS charts at 1 m. The system's external components, augmented reality glasses, and pocket computer provide image processing capabilities, including zoom.

Main Outcome Measures

Visual acuity using ETDRS charts with and without the system, as well as light sensitivity in the central visual field, measured by Octopus perimetry. Anatomical outcomes demonstrated by fundus photography and OCT up to 48 months postimplantation.

Results

All 5 subjects met the primary end point of light perception elicited by the implant in the scotoma area. In 1 patient, the implant was incorrectly inserted into the choroid. One subject died 18 months postimplantation due to study-unrelated reasons. ETDRS VA results for the remaining 3 subjects are reported here. Without zoom, VA closely matched the pixel size of the implant: 1.17 ± 0.13 pixels, corresponding to a mean logMAR of 1.39, or Snellen of 20/500, ranging from 20/438 to 20/565. Using zoom at 48 months, subjects improved their VA by 32 ETDRS letters versus baseline (standard error 5.1) 95% confidence intervals (13.4, 49.9; P < 0.0001). Natural peripheral visual function in the treated eye did not decline after surgery or during the 48-month follow-up period (P = 0.08).

Conclusions

Subretinal implantation of PRIMA in subjects with GA experiencing profound vision loss due to AMD is feasible and well tolerated, with no reduction of natural peripheral vision up to 48 months. Prosthetic central vision provided by photovoltaic neurostimulation enabled patients to reliably recognize letters and sequences of letters, and with zoom, it improved VA of up to 8 ETDRS lines.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Longitudinal stability of individual brain plasticity patterns in blindness

The primary visual cortex (V1) in blindness is engaged in a wide spectrum of tasks and sensory modalities, including audition, touch, language, and memory. This widespread involvement raises questions regarding the constancy of its role and whether it might exhibit flexibility in its function over time, connecting to diverse network functions specific to task demands. This would suggest that reorganized V1 assumes a role like multiple-demand system regions. Alternatively, varying patterns of plasticity in blind V1 may be attributed to individual factors, with different blind individuals recruiting V1 preferentially for different functions. In support of this, we recently showed that V1 functional connectivity (FC) varies greatly across blind individuals. But do these represent stable individual patterns of plasticity, or are they driven more by instantaneous changes, like a multiple-demand system now inhabiting V1? Here, we tested whether individual FC patterns from the V1 of blind individuals are stable over time. We show that over two years, FC from the V1 is unique and highly stable in a small sample of repeatedly sampled congenitally blind individuals. Further, using multivoxel pattern analysis, we demonstrate that the unique reorganization patterns of these individuals allow decoding of participant identity. Together with recent evidence for substantial individual differences in V1 connectivity, this indicates that there may be a consistent role for V1 in blindness, which may differ for each individual. Further, it suggests that the variability in visual reorganization in blindness across individuals could be used to seek stable neuromarkers for sight rehabilitation and assistive approaches.

Neural activity shaping in visual prostheses with deep learning

Objective.The visual perception provided by retinal prostheses is limited by the overlapping current spread of adjacent electrodes. This reduces the spatial resolution attainable with unipolar stimulation. Conversely, simultaneous multipolar stimulation guided by the measured neural responses-neural activity shaping (NAS)-can attenuate excessive spread of excitation allowing for more precise control over the pattern of neural activation. However, defining effective multipolar stimulus patterns is a challenging task. Previous attempts focused on analytical solutions based on an assumed linear nonlinear model of retinal response; an analytical model inversion (AMI) approach. Here, we propose a model-free solution for NAS, using artificial neural networks (ANNs) that could be trained with data acquired from the implant.Approach.Our method consists of two ANNs trained sequentially. The measurement predictor network (MPN) is trained on data from the implant and is used to predict how the retina responds to multipolar stimulation. The stimulus generator network is trained on a large dataset of natural images and uses the trained MPN to determine efficient multipolar stimulus patterns by learning its inverse model. We validate our methodin silicousing a realistic model of retinal response to multipolar stimulation.Main results.We show that our ANN-based NAS approach produces sharper retinal activations than the conventional unipolar stimulation strategy. As a theoretical bench-mark of optimal NAS results, we implemented AMI stimulation by inverting the model used to simulate the retina. Our ANN strategy produced equivalent results to AMI, while not being restricted to any specific type of retina model and being three orders of magnitude more computationally efficient.Significance.Our novel protocol provides a method for efficient and personalized retinal stimulation, which may improve the visual experience and quality of life of retinal prosthesis users.

Pre-processing visual scenes for retinal prosthesis systems: A comprehensive review

BACKGROUND

Retinal prostheses offer hope for individuals with degenerative retinal diseases by stimulating the remaining retinal cells to partially restore their vision. This review delves into the current advancements in retinal prosthesis technology, with a special emphasis on the pivotal role that image processing and machine learning techniques play in this evolution.

METHODS

We provide a comprehensive analysis of the existing implantable devices and optogenetic strategies, delineating their advantages, limitations, and challenges in addressing complex visual tasks. The review extends to various image processing algorithms and deep learning architectures that have been implemented to enhance the functionality of retinal prosthetic devices. We also illustrate the testing results by demonstrating the clinical trials or using Simulated Prosthetic Vision (SPV) through phosphene simulations, which is a critical aspect of simulating visual perception for retinal prosthesis users.

RESULTS

Our review highlights the significant progress in retinal prosthesis technology, particularly its capacity to augment visual perception among the visually impaired. It discusses the integration between image processing and deep learning, illustrating their impact on individual interactions and navigations within the environment through applying clinical trials and also illustrating the limitations of some techniques to be used with current devices, as some approaches only use simulation even on sighted-normal individuals or rely on qualitative analysis, where some consider realistic perception models and others do not.

CONCLUSION

This interdisciplinary field holds promise for the future of retinal prostheses, with the potential to significantly enhance the quality of life for individuals with retinal prostheses. Future research directions should pivot towards optimizing phosphene simulations for SPV approaches, considering the distorted and confusing nature of phosphene perception, thereby enriching the visual perception provided by these prosthetic devices. This endeavor will not only improve navigational independence but also facilitate a more immersive interaction with the environment.

Visual Cortical Thickness Increases with Prolonged Artificial Vision Restoration

The Argus II retinal prosthesis restores visual perception to late blind patients. It has been shown that structural changes occur in the brain due to late-onset blindness, including cortical thinning in visual regions of the brain. Following vision restoration, it is not yet known whether these visual regions are reinvigorated and regain a normal cortical thickness or retain the diminished thickness from blindness. We evaluated the cortical thicknesses of ten Argus II Retinal Prostheses patients, ten blind patients, and thirteen sighted participants. The Argus II patients on average had a thicker left Cuneus Cortex and Lateral Occipital Cortex relative to the blind patients. The duration of the Argus II use (time since implant in active users) significantly partially correlated with thicker visual cortical regions in the left hemisphere. Furthermore, in the two case studies (scanned before and after implantation), the patient with longer device use (44.5 months) had an increase in the cortical thickness of visual regions, whereas the shorter-using patient did not (6.5 months). Finally, a third case, scanned at three time points post-implantation, showed an increase in cortical thickness in the Lateral Occipital Cortex between 43.5 and 57 months, which was maintained even after 3 years of disuse (106 months). Overall, the Argus II patients' cortical thickness was on average significantly rejuvenated in two higher visual regions and, patients using the implant for a longer duration had thicker visual regions. This research raises the possibility of structural plasticity reversing visual cortical atrophy in late-blind patients with prolonged vision restoration.

Photovoltaic, wireless wide-field epiretinal prosthesis to treat retinitis pigmentosa

PURPOSE

To develop and evaluate a photovoltaic, wireless wide-field epiretinal prosthesis for the treatment of retinitis pigmentosa.

METHODS

A mosaic array of thinned silicon-based photodiodes with integrated thin-film stimulation electrodes was fabricated with a flexible polyimide substrate film to form a film-based miniaturized electronic system with wireless optical power and signal transmission and integrated electrostimulation. Manufactured implants were characterized with respect to their optoelectronic performance and biocompatibility following DIN EN ISO 10993.

RESULTS

A 14 mm diameter prosthesis containing 1276 pixels with a maximum sensitivity at a near infrared wavelength of 905 nm and maximized stimulation current density 30-50 μm below the electrodes was developed for direct activation of retinal ganglion cells during epiretinal stimulation. Fabricated prostheses demonstrated mucosal tolerance and the preservation of both metabolic activity, proliferation and membrane integrity of human fibroblasts as well as the retinal functions of bovine retinas. Illumination of the prosthesis, which was placed epiretinally on an isolated perfused bovine retina, with infrared light resulted in electrophysiological recordings reminiscent of an a-wave (hyperpolarization) and b-wave (depolarization).

CONCLUSIONS

A photovoltaic, wireless wide-field epiretinal prosthesis for the treatment of retinitis pigmentosa using near infrared light for signal transmission was designed, manufactured and its biocompatibility and functionality demonstrated in vitro and ex vivo.

Noninvasive imaging-guided ultrasonic neurostimulation with arbitrary 2D patterns and its application for high-quality vision restoration

Retinal degeneration, a leading cause of irreversible low vision and blindness globally, can be partially addressed by retina prostheses which stimulate remaining neurons in the retina. However, existing electrode-based treatments are invasive, posing substantial risks to patients and healthcare providers. Here, we introduce a completely noninvasive ultrasonic retina prosthesis, featuring a customized ultrasound two-dimensional array which allows for simultaneous imaging and stimulation. With synchronous three-dimensional imaging guidance and auto-alignment technology, ultrasonic retina prosthesis can generate programmed ultrasound waves to dynamically and precisely form arbitrary wave patterns on the retina. Neuron responses in the brain's visual center mirrored these patterns, evidencing successful artificial vision creation, which was further corroborated in behavior experiments. Quantitative analysis of the spatial-temporal resolution and field of view demonstrated advanced performance of ultrasonic retina prosthesis and elucidated the biophysical mechanism of retinal stimulation. As a noninvasive blindness prosthesis, ultrasonic retina prosthesis could lead to a more effective, widely acceptable treatment for blind patients. Its real-time imaging-guided stimulation strategy with a single ultrasound array, could also benefit ultrasound neurostimulation in other diseases.

Axonal stimulation affects the linear summation of single-point perception in three Argus II users

Objective.Retinal implants use electrical stimulation to elicit perceived flashes of light ('phosphenes'). Single-electrode phosphene shape has been shown to vary systematically with stimulus parameters and the retinal location of the stimulating electrode, due to incidental activation of passing nerve fiber bundles. However, this knowledge has yet to be extended to paired-electrode stimulation.Approach.We retrospectively analyzed 3548 phosphene drawings made by three blind participants implanted with an Argus II Retinal Prosthesis. Phosphene shape (characterized by area, perimeter, major and minor axis length) and number of perceived phosphenes were averaged across trials and correlated with the corresponding single-electrode parameters. In addition, the number of phosphenes was correlated with stimulus amplitude and neuroanatomical parameters: electrode-retina and electrode-fovea distance as well as the electrode-electrode distance to ('between-axon') and along axon bundles ('along-axon'). Statistical analyses were conducted using linear regression and partial correlation analysis.Main results.Simple regression revealed that each paired-electrode shape descriptor could be predicted by the sum of the two corresponding single-electrode shape descriptors (p < .001). Multiple regression revealed that paired-electrode phosphene shape was primarily predicted by stimulus amplitude and electrode-fovea distance (p < .05). Interestingly, the number of elicited phosphenes tended to increase with between-axon distance (p < .05), but not with along-axon distance, in two out of three participants.Significance.The shape of phosphenes elicited by paired-electrode stimulation was well predicted by the shape of their corresponding single-electrode phosphenes, suggesting that two-point perception can be expressed as the linear summation of single-point perception. The impact of the between-axon distance on the perceived number of phosphenes provides further evidence in support of the axon map model for epiretinal stimulation. These findings contribute to the growing literature on phosphene perception and have important implications for the design of future retinal prostheses.

Great expectations: Aligning visual prosthetic development with implantee needs

Purpose

Visual prosthetics have emerged as a promising assistive technology for individuals with vision loss, yet research often overlooks the human aspects of this technology. While previous studies have concentrated on the perceptual experiences of implant recipients (implantees) or the attitudes of potential implantees towards near-future implants, a systematic account of how current implants are being used in everyday life is still lacking.

Methods

We interviewed six recipients of the most widely used visual implants (Argus II and Orion) and six leading researchers in the field. Through thematic and statistical analyses, we explored the daily usage of these implants by implantees and compared their responses to the expectations of researchers. We also sought implantees' input on desired features for future versions, aiming to inform the development of the next generation of implants.

Results

Although implants are designed to facilitate various daily activities, we found that implantees use them less frequently than researchers expected. This discrepancy primarily stems from issues with usability and reliability, with implantees finding alternative methods to accomplish tasks, reducing the need to rely on the implant. For future implants, implantees emphasized the desire for improved vision, smart integration, and increased independence.

Conclusions

Our study reveals a significant gap between researcher expectations and implantee experiences with visual prostheses, underscoring the importance of focusing future research on usability and real-world application.

Translational relevance

This work advocates for a better alignment between technology development and implantee needs to enhance clinical relevance and practical utility of visual prosthetics.

Focal stimulation of retinal ganglion cells using subretinal 3D microelectrodes with peripheral electrodes of opposite current

Subretinal prostheses have been developed to stimulate survived retinal ganglion cells (RGCs), indirectly following the physiological visual pathways. However, current spreading from the prosthesis electrode causes the activation of unintended RGCs, thereby limiting the spatial resolution of artificial vision. This study proposes a strategy for focal stimulation of RGCs using a subretinal electrode array, in which six hexagonally arranged peripheral electrodes surround a stimulating electrode. RGCs in an in-vitro condition were subretinally stimulated using a fabricated electrode array coated with iridium oxide, following the three different stimulation configurations (with no peripheral, six electrodes of opposite current, and six ground). In-vitro experiments showed that the stimulation with six electrodes of opposite current was most effective in controlling RGC responses with a high spatial resolution. The results suggest that the effective utilization of return electrodes, such as by applying an opposite current to them, could help reduce current spreading beyond the local area targeted for stimulation and elicit RGC responses only in the vicinity of the stimulating electrode.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13534-023-00342-3.

Next generation therapeutics for retinal neurodegenerative diseases

Neurodegenerative diseases affecting the visual system encompass glaucoma, macular degeneration, retinopathies, and inherited genetic disorders such as retinitis pigmentosa. These ocular pathologies pose a serious burden of visual impairment and blindness worldwide. Current treatment modalities include small molecule drugs, biologics, or gene therapies, most of which are administered topically as eye drops or as injectables. However, the topical route of administration faces challenges in effectively reaching the posterior segment and achieving desired concentrations at the target site, while injections and implants risk severe complications, such as retinal detachment and endophthalmitis. This necessitates the development of innovative therapeutic strategies that can prolong drug release, deliver effective concentrations to the back of the eye with minimal systemic exposure, and improve patient compliance and safety. In this review, we introduce retinal degenerative diseases, followed by a discussion of the existing clinical standard of care. We then delve into detail about drug and gene delivery systems currently in preclinical and clinical development, including formulation and delivery advantages/drawbacks, with a special emphasis on potential for clinical translation.

An actor-model framework for visual sensory encoding

A fundamental challenge in neuroengineering is determining a proper artificial input to a sensory system that yields the desired perception. In neuroprosthetics, this process is known as artificial sensory encoding, and it holds a crucial role in prosthetic devices restoring sensory perception in individuals with disabilities. For example, in visual prostheses, one key aspect of artificial image encoding is to downsample images captured by a camera to a size matching the number of inputs and resolution of the prosthesis. Here, we show that downsampling an image using the inherent computation of the retinal network yields better performance compared to learning-free downsampling methods. We have validated a learning-based approach (actor-model framework) that exploits the signal transformation from photoreceptors to retinal ganglion cells measured in explanted mouse retinas. The actor-model framework generates downsampled images eliciting a neuronal response in-silico and ex-vivo with higher neuronal reliability than the one produced by a learning-free approach. During the learning process, the actor network learns to optimize contrast and the kernel's weights. This methodological approach might guide future artificial image encoding strategies for visual prostheses. Ultimately, this framework could be applicable for encoding strategies in other sensory prostheses such as cochlear or limb.

Learning to see via epiretinal implant stimulationin silicowith model-based deep reinforcement learning

OBJECTIVE

Diseases such as age-related macular degeneration and retinitis pigmentosa cause the degradation of the photoreceptor layer. One approach to restore vision is to electrically stimulate the surviving retinal ganglion cells with a microelectrode array such as epiretinal implants. Epiretinal implants are known to generate visible anisotropic shapes elongated along the axon fascicles of neighboring retinal ganglion cells. Recent work has demonstrated that to obtain isotropic pixel-like shapes, it is possible to map axon fascicles and avoid stimulating them by inactivating electrodes or lowering stimulation current levels. Avoiding axon fascicule stimulation aims to remove brushstroke-like shapes in favor of a more reduced set of pixel-like shapes.

APPROACH

In this study, we propose the use of isotropic and anisotropic shapes to render intelligible images on the retina of a virtual patient in a reinforcement learning environment named rlretina. The environment formalizes the task as using brushstrokes in a stroke-based rendering task.

MAIN RESULTS

We train a deep reinforcement learning agent that learns to assemble isotropic and anisotropic shapes to form an image. We investigate which error-based or perception-based metrics are adequate to reward the agent. The agent is trained in a model-based data generation fashion using the psychophysically validated axon map model to render images as perceived by different virtual patients. We show that the agent can generate more intelligible images compared to the naive method in different virtual patients.

SIGNIFICANCE

This work shares a new way to address epiretinal stimulation that constitutes a first step towards improving visual acuity in artificially-restored vision using anisotropic phosphenes.

Survey on Energy Harvesting for Biomedical Devices: Applications, Challenges and Future Prospects for African Countries

Self-powered biomedical devices, which are the new vision of Internet Of Things (IOT) healthcare, are facing many technical and application challenges. Many research works have reported biomedical devices and self-powered applications for healthcare, along with various strategies to improve the monitoring time of self-powered devices or to eliminate the dependence on electrochemical batteries. However, none of these works have especially assessed the development and application of healthcare devices in an African context. This article provides a comprehensive review of self-powered devices in the biomedical research field, introduces their applications for healthcare, evaluates their status in Africa by providing a thorough review of existing biomedical device initiatives and available financial and scientific cooperation institutions in Africa for the biomedical research field, and highlights general challenges for implementing self-powered biomedical devices and particular challenges related to developing countries. The future perspectives of the aforementioned research field are provided, as well as an architecture for improving this research field in developing countries.

Axonal stimulation affects the linear summation of single-point perception in three Argus II users

Purpose

Retinal implants use electrical stimulation to elicit perceived flashes of light ("phosphenes"). Single-electrode phosphene shape has been shown to vary systematically with stimulus parameters and the retinal location of the stimulating electrode, due to incidental activation of passing nerve fiber bundles. However, this knowledge has yet to be extended to paired-electrode stimulation.

Methods

We retrospectively analyzed 3548 phosphene drawings made by three blind participants implanted with an Argus II Retinal Prosthesis. Phosphene shape (characterized by area, perimeter, major and minor axis length) and number of perceived phosphenes were averaged across trials and correlated with the corresponding single-electrode parameters. In addition, the number of phosphenes was correlated with stimulus amplitude and neuroanatomical parameters: electrode-retina and electrode-fovea distance as well as the electrode-electrode distance to ("between-axon") and along axon bundles ("along-axon"). Statistical analyses were conducted using linear regression and partial correlation analysis.

Results

Simple regression revealed that each paired-electrode shape descriptor could be predicted by the sum of the two corresponding single-electrode shape descriptors (p < .001). Multiple regression revealed that paired-electrode phosphene shape was primarily predicted by stimulus amplitude and electrode-fovea distance (p < .05). Interestingly, the number of elicited phosphenes tended to increase with between-axon distance (p < .05), but not with along-axon distance, in two out of three participants.

Conclusions

The shape of phosphenes elicited by paired-electrode stimulation was well predicted by the shape of their corresponding single-electrode phosphenes, suggesting that two-point perception can be expressed as the linear summation of single-point perception. The notable impact of the between-axon distance on the perceived number of phosphenes provides further evidence in support of the axon map model for epiretinal stimulation. These findings contribute to the growing literature on phosphene perception and have important implications for the design of future retinal prostheses.

Patient-specific computational models of retinal prostheses

Retinal prostheses stimulate inner retinal neurons to create visual perception for blind patients. Implanted arrays have many small electrodes. Not all electrodes induce perception at the same stimulus amplitude, requiring clinicians to manually establish a visual perception threshold for each one. Phosphenes created by single-electrode stimuli can also vary in shape, size, and brightness. Computational models provide a tool to predict inter-electrode variability and automate device programming. In this study, we created statistical and patient-specific field-cable models to investigate inter-electrode variability across seven epiretinal prosthesis users. Our statistical analysis revealed that retinal thickness beneath the electrode correlated with perceptual threshold, with a significant fixed effect across participants. Electrode-retina distance and electrode impedance also correlated with perceptual threshold for some participants, but these effects varied by individual. We developed a novel method to construct patient-specific field-cable models from optical coherence tomography images. Predictions with these models significantly correlated with perceptual threshold for 80% of participants. Additionally, we demonstrated that patient-specific field-cable models could predict retinal activity and phosphene size. These computational models could be beneficial for determining optimal stimulation settings in silico, circumventing the trial-and-error testing of a large parameter space in clinic.

PRPF31-retinitis pigmentosa: Challenges and opportunities for clinical translation

Mutations in pre-mRNA processing factor 31 cause autosomal dominant retinitis pigmentosa (PRPF31-RP), for which there is currently no efficient treatment, making this disease a prime target for the development of novel therapeutic strategies. PRPF31-RP exhibits incomplete penetrance due to haploinsufficiency, in which reduced levels of gene expression from the mutated allele result in disease. A variety of model systems have been used in the investigation of disease etiology and therapy development. In this review, we discuss recent advances in both in vivo and in vitro model systems, evaluating their advantages and limitations in the context of therapy development for PRPF31-RP. Additionally, we describe the latest approaches for treatment, including AAV-mediated gene augmentation, genome editing, and late-stage therapies such as optogenetics, cell transplantation, and retinal prostheses.

Prosthetic Visual Acuity with the PRIMA System in Patients with Atrophic Age-related Macular Degeneration at 4 years follow-up

Objective

To assess the efficacy and safety of the PRIMA subretinal neurostimulation system 48-months post-implantation for improving visual acuity (VA) in patients with geographic atrophy (GA) due to age-related macular degeneration (AMD) at 48-months post-implantation.

Design

First-in-human clinical trial of the PRIMA subretinal prosthesis in patients with atrophic AMD, measuring best-corrected ETDRS VA (Clinicaltrials.gov NCT03333954).

Subjects

Five patients with GA, no foveal light perception and VA of logMAR 1.3 to 1.7 in their worse-seeing "study" eye.

Methods

In patients implanted with a subretinal photovoltaic neurostimulation array containing 378 pixels of 100 μm in size, the VA was measured with and without the PRIMA system using ETDRS charts at 1 meter. The system's external components: augmented reality glasses and pocket computer, provide image processing capabilities, including zoom.

Main Outcome Measures

VA using ETDRS charts with and without the system. Light sensitivity in the central visual field, as measured by Octopus perimetry. Anatomical outcomes demonstrated by fundus photography and optical coherence tomography up to 48-months post-implantation.

Results

All five subjects met the primary endpoint of light perception elicited by the implant in the scotoma area. In one patient the implant was incorrectly inserted into the choroid. One subject died 18-months post-implantation due to study-unrelated reason. ETDRS VA results for the remaining three subjects are reported herein. Without zoom, VA closely matched the pixel size of the implant: 1.17 ± 0.13 pixels, corresponding to mean logMAR 1.39, or Snellen 20/500, ranging from 20/438 to 20/565. Using zoom at 48 months, subjects improved their VA by 32 ETDRS letters versus baseline (SE 5.1) 95% CI[13.4,49.9], p<0.0001. Natural peripheral visual function in the treated eye did not decline after surgery compared to the fellow eye (p=0.08) during the 48 months follow-up period.

Conclusions

Subretinal implantation of PRIMA in subjects with GA suffering from profound vision loss due to AMD is feasible and well tolerated, with no reduction of natural peripheral vision up to 48-months. Using prosthetic central vision through photovoltaic neurostimulation, patients reliably recognized letters and sequences of letters,and with zoom it provided a clinically meaningful improvement in VA of up to eight ETDRS lines.

Longitudinal stability of individual brain plasticity patterns in blindness

The primary visual cortex (V1) in individuals born blind is engaged in a wide spectrum of tasks and sensory modalities, including audition, touch, language, and memory. This widespread involvement raises questions regarding the constancy of its role and whether it might exhibit flexibility in its function over time, connecting to diverse network functions in response to task-specific demands. This would suggest that reorganized V1 takes on a role similar to cognitive multiple-demand system regions. Alternatively, it is possible that the varying patterns of plasticity observed in the blind V1 can be attributed to individual factors, whereby different blind individuals recruit V1 for different functions, highlighting the immense idiosyncrasy of plasticity. In support of this second account, we have recently shown that V1 functional connectivity varies greatly across blind individuals. But do these represent stable individual patterns of plasticity or merely instantaneous changes, for a multiple-demand system now inhabiting V1? Here we tested if individual connectivity patterns from the visual cortex of blind individuals are stable over time. We show that over two years, fMRI functional connectivity from the primary visual cortex is unique and highly stable in a small sample of repeatedly sampled congenitally blind individuals. Further, using multivoxel pattern analysis, we demonstrate that the unique reorganization patterns of these individuals allow decoding of participant identity. Together with recent evidence for substantial individual differences in visual cortex connectivity, this indicates there may be a consistent role for the visual cortex in blindness, which may differ for each individual. Further, it suggests that the variability in visual reorganization in blindness across individuals could be used to seek stable neuromarkers for sight rehabilitation and assistive approaches.

Losing, preserving, and restoring vision from neurodegeneration in the eye

The retina is a part of the brain that sits at the back of the eye, looking out onto the world. The first neurons of the retina are the rod and cone photoreceptors, which convert changes in photon flux into electrical signals that are the basis of vision. Rods and cones are frequent targets of heritable neurodegenerative diseases that cause visual impairment, including blindness, in millions of people worldwide. This review summarizes the diverse genetic causes of inherited retinal degenerations (IRDs) and their convergence onto common pathogenic mechanisms of vision loss. Currently, there are few effective treatments for IRDs, but recent advances in disparate areas of biology and technology (e.g., genome editing, viral engineering, 3D organoids, optogenetics, semiconductor arrays) discussed here enable promising efforts to preserve and restore vision in IRD patients with implications for neurodegeneration in less approachable brain areas.

A novel simulation paradigm utilising MRI-derived phosphene maps for cortical prosthetic vision

Objective.We developed a realistic simulation paradigm for cortical prosthetic vision and investigated whether we can improve visual performance using a novel clustering algorithm.Approach.Cortical visual prostheses have been developed to restore sight by stimulating the visual cortex. To investigate the visual experience, previous studies have used uniform phosphene maps, which may not accurately capture generated phosphene map distributions of implant recipients. The current simulation paradigm was based on the Human Connectome Project retinotopy dataset and the placement of implants on the cortices from magnetic resonance imaging scans. Five unique retinotopic maps were derived using this method. To improve performance on these retinotopic maps, we enabled head scanning and a density-based clustering algorithm was then used to relocate centroids of visual stimuli. The impact of these improvements on visual detection performance was tested. Using spatially evenly distributed maps as a control, we recruited ten subjects and evaluated their performance across five sessions on the Berkeley Rudimentary Visual Acuity test and the object recognition task.Main results.Performance on control maps is significantly better than on retinotopic maps in both tasks. Both head scanning and the clustering algorithm showed the potential of improving visual ability across multiple sessions in the object recognition task.Significance.The current paradigm is the first that simulates the experience of cortical prosthetic vision based on brain scans and implant placement, which captures the spatial distribution of phosphenes more realistically. Utilisation of evenly distributed maps may overestimate the performance that visual prosthetics can restore. This simulation paradigm could be used in clinical practice when making plans for where best to implant cortical visual prostheses.

Patient-specific computational models of retinal prostheses

Retinal prostheses stimulate inner retinal neurons to create visual perception for blind patients. Implanted arrays have many small electrodes, which act as pixels. Not all electrodes induce perception at the same stimulus amplitude, requiring clinicians to manually establish a visual perception threshold for each one. Phosphenes created by single-electrode stimuli can also vary in shape, size, and brightness. Computational models provide a tool to predict inter-electrode variability and automate device programming. In this study, we created statistical and patient-specific field-cable models to investigate inter-electrode variability across seven epiretinal prosthesis users. Our statistical analysis revealed that retinal thickness beneath the electrode correlated with perceptual threshold, with a significant fixed effect across participants. Electrode-retina distance and electrode impedance also correlated with perceptual threshold for some participants, but these effects varied by individual. We developed a novel method to construct patient-specific field-cable models from optical coherence tomography images. Predictions with these models significantly correlated with perceptual threshold for 80% of participants. Additionally, we demonstrated that patient-specific field-cable models could predict retinal activity and phosphene size. These computational models could be beneficial for determining optimal stimulation settings in silico, circumventing the trial-and-error testing of a large parameter space in clinic.

A Deep Learning-based in silico Framework for Optimization on Retinal Prosthetic Stimulation

We propose a neural network-based framework to optimize the perceptions simulated by the in silico retinal implant model pulse2percept. The overall pipeline consists of a trainable encoder, a pre-trained retinal implant model and a pre-trained evaluator. The encoder is a U-Net, which takes the original image and outputs the stimulus. The pre-trained retinal implant model is also a U-Net, which is trained to mimic the biomimetic perceptual model implemented in pulse2percept. The evaluator is a shallow VGG classifier, which is trained with original images. Based on 10,000 test images from the MNIST dataset, we show that the convolutional neural network-based encoder performs significantly better than the trivial downsampling approach, yielding a boost in the weighted F1-Score by 36.17% in the pre-trained classifier with 6×10 electrodes. With this fully neural network-based encoder, the quality of the downstream perceptions can be fine-tuned using gradient descent in an end-to-end fashion.

Colloidal self-assembly of soft neural interfaces from injectable photovoltaic microdevices

Biomimetic retinas with a wide field of view and high resolution are in demand for neuroprosthetics and robot vision. Conventional neural prostheses are manufactured outside the application area and implanted as a complete device using invasive surgery. Here, a minimally invasive strategy based on in situ self-assembly of photovoltaic microdevices (PVMs) is presented. The photoelectricity transduced by PVMs upon visible light illumination reaches the intensity levels that could effectively activate the retinal ganglion cell layers. The geometry and multilayered architecture of the PVMs along with the tunability of their physical properties such as size and stiffness allow several routes for initiating a self-assembly process. The spatial distribution and packing density of the PVMs within the assembled device are modulated through concentration, liquid discharge speed, and coordinated self-assembly steps. Subsequent injection of a photocurable and transparent polymer facilitates tissue integration and reinforces the cohesion of the device. Taken together, the presented methodology introduces three unique features: minimally invasive implantation, personalized visual field and acuity, and a device geometry adaptable to retina topography.

Pars Plana Vitrectomy in Inherited Retinal Diseases: A Comprehensive Review of the Literature

Inherited retinal diseases (IRDs) are a group of clinically and genetically heterogeneous disorders that may be complicated by several vitreoretinal conditions requiring a surgical approach. Pars plana vitrectomy (PPV) stands as a valuable treatment option in these cases, but its application in eyes with such severely impaired chorioretinal architectures remains controversial. Furthermore, the spreading of gene therapy and the increasing use of retinal prostheses will end up in a marked increase in demand for PPV surgery for IRD patients. The retinal degeneration that typically affects patients with hereditary retinal disorders may influence the execution of the surgery and the expected results. Considering the importance of PPV application in IRD-related complications, it is fundamental to try to understand from the literature what is adequate and safe in posterior eye segment surgery. Use of dyes, light toxicity, and risk of wounding scar development have always been themes that discourage the execution of vitreoretinal surgery in already impaired eyes. Therefore, this review aims to comprehensively summarize all PPV applications in different IRDs, highlighting the favorable results as well as the potential precautions to consider when performing vitreoretinal surgery in these eyes.

A systematic review of extended reality (XR) for understanding and augmenting vision loss

Over the past decade, extended reality (XR) has emerged as an assistive technology not only to augment residual vision of people losing their sight but also to study the rudimentary vision restored to blind people by a visual neuroprosthesis. A defining quality of these XR technologies is their ability to update the stimulus based on the user's eye, head, or body movements. To make the best use of these emerging technologies, it is valuable and timely to understand the state of this research and identify any shortcomings that are present. Here we present a systematic literature review of 227 publications from 106 different venues assessing the potential of XR technology to further visual accessibility. In contrast to other reviews, we sample studies from multiple scientific disciplines, focus on technology that augments a person's residual vision, and require studies to feature a quantitative evaluation with appropriate end users. We summarize prominent findings from different XR research areas, show how the landscape has changed over the past decade, and identify scientific gaps in the literature. Specifically, we highlight the need for real-world validation, the broadening of end-user participation, and a more nuanced understanding of the usability of different XR-based accessibility aids.

Modeling extracellular stimulation of retinal ganglion cells: theoretical and practical aspects

Objective.Retinal prostheses use electric current to activate inner retinal neurons, providing artificial vision for blind people. Epiretinal stimulation primarily targets retinal ganglion cells (RGCs), which can be modeled with cable equations. Computational models provide a tool to investigate the mechanisms of retinal activation, and improve stimulation paradigms. However, documentation of RGC model structure and parameters is limited, and model implementation can influence model predictions.Approach.We created a functional guide for building a mammalian RGC multi-compartment cable model and applying extracellular stimuli. Next, we investigated how the neuron's three-dimensional shape will influence model predictions. Finally, we tested several strategies to maximize computational efficiency.Main results.We conducted sensitivity analyses to examine how dendrite representation, axon trajectory, and axon diameter influence membrane dynamics and corresponding activation thresholds. We optimized the spatial and temporal discretization of our multi-compartment cable model. We also implemented several simplified threshold prediction theories based on activating function, but these did not match the prediction accuracy achieved by the cable equations.Significance.Through this work, we provide practical guidance for modeling the extracellular stimulation of RGCs to produce reliable and meaningful predictions. Robust computational models lay the groundwork for improving the performance of retinal prostheses.

Design Optimization and Characterization with Fabrication of Nanomaterials-Based Photo Diode Cell for Subretinal Implant Application

An ultrathin nano photodiode array fabricated in a flexible substrate can be an ideal therapeutic replacement for degenerated photoreceptor cells damaged by Age-related Macula Degeneration (AMD) and Retinitis Pigmentosa (RP), such as retinal infections. Silicon-based photodiode arrays have been attempted as artificial retinas. Considering the difficulties caused by hard silicon subretinal implants, researchers have diverted their attention towards organic photovoltaic cells-based subretinal implants. Indium-Tin Oxide (ITO) has been a favorite choice as an anode electrode. A mix of poly(3-hexylthiophene) and [6,6]-phenyl C61-butyric acid methyleste (P3HT: PCBM) has been utilized as an active layer in such nanomaterial-based subretinal implants. Though encouraging results have been obtained during the trial of such retinal implants, the need to replace ITO with a suitable transparent conductive electrode will be a suitable substitute. Further, conjugated polymers have been used as active layers in such photodiodes and have shown delamination in the retinal space over time despite their biocompatibility. This research attempted to fabricate and characterize Bulk Hetero Junction (BHJ) based Nano Photo Diode (NPD) utilizing Graphene-polyethylene terephthalate (G-PET)/semiconducting Single-Wall Carbon Nano Tubes (s-SWCNT): fullerene (C₆₀) blend/aluminium (Al) structure to determine the issues in the development of subretinal prosthesis. An effective design approach adopted in this analysis has resulted in developing an NPD with an Efficiency of 10.1% in a non-ITO-driven NPD structure. Additionally, the results show that the efficiency can be further improved by increasing active layer thickness.

Long term positional stability of the Argus II retinal prosthesis epiretinal implant

BACKGROUND

The Argus II Retinal Prosthesis System (Second Sight Medical Products, Sylmar, California) is an epiretinal prosthesis that serves to provide useful vision to people who are affected by retinal degenerative diseases such as retinitis pigmentosa (RP). The purpose of this study was to analyze postoperative movement of the electrode array.

METHODS

Five patients diagnosed with profound retinal dystrophy who have undergone implantation of retinal prosthesis at Stony Brook University Hospital. Fundoscopy was performed at postoperative month 1 (M1), month 3 (M3), month 6 (M6), month 12 (M12), and month 24 (M24) visits. Fundoscopy was extracted and analyzed via NIH ImageJ. Data analysis was completed using IBM SPSS. Various lengths and angles were measured each postoperative month using ImageJ.

RESULTS

There was no significant change in distance between the optic disc and the surgical handle (length AB) over the two-year span (F = 0.196, p = 0.705). There was a significant change in distance of length AB over time between patients between M3 and M6 (p = 0.025). A repeated measures ANOVA revealed that there was statistically significant change of the optic disc-tack-surgical handle angle (𝛾) (M1 to M24) (F = 3.527, p = 0.030). There was no significant change in angle 𝜟 (the angle to the horizontal of the image), angle 𝜶 (tack-optic disc-surgical handle), and angle 𝜷 (optic-disc-surgical handle-tack).

CONCLUSION

Our results demonstrate that there may be postoperative movement of the retinal prosthesis over time, as a statistically significant downward rotation is reported over the 2 years span. It is important, moving forward, to further study this movement and to take into consideration such movement when designing retinal implants. It is important to note that this study is limited by the small sample size, and therefore, the conclusions drawn are limited.

Explainable Machine Learning Predictions of Perceptual Sensitivity for Retinal Prostheses

To provide appropriate levels of stimulation, retinal prostheses must be calibrated to an individual's perceptual thresholds ('system fitting'), despite thresholds varying drastically across subjects, across electrodes within a subject, and over time. Although previous work has identified electrode-retina distance and impedance as key factors affecting thresholds, an accurate predictive model is still lacking. To address these challenges, we 1) fitted machine learning (ML) models to a large longitudinal dataset with the goal of predicting individual electrode thresholds and deactivation as a function of stimulus, electrode, and clinical parameters ('predictors') and 2) leveraged explainable artificial intelligence (XAI) to reveal which of these predictors were most important. Our models accounted for up to 77% of the perceptual threshold response variance and enabled predictions of whether an electrode was deactivated in a given trial with F1 and AUC scores of up to 0.740 and 0.913, respectively. Deactivation and threshold models identified novel predictors of perceptual sensitivity, including subject age, time since blindness onset, and electrode-fovea distance. Our results demonstrate that routinely collected clinical measures and a single session of system fitting might be sufficient to inform an XAI-based threshold prediction strategy, which may transform clinical practice in predicting visual outcomes.

Failure Reason of PI Test Samples of Neural Implants

Samples that were meant to simulate the behavior of neural implants were put into Ringer's solution, and the occurring damage was assessed. The samples consist of an interdigitated gold-structure and two contact pads embedded between two Polyimide layers, resulting in free-floating structures. The two parts of the interdigitated structure have no electric contacts and are submerged in the solution during the experiment. The samples were held at temperatures of 37 and 57 ∘C in order to undergo an accelerated lifetime test and to compare the results. During the course of the experiment, a voltage was applied and measured over a resistance of 1 kOhm over time. Arduinos were used as measuring devices. As the intact samples are insulating, a sudden rise in voltage indicates a sample failure due to liquid leaking in between the two polyimide layers. Once a short-circuit occurred and a sample broke down, the samples were taken out of the vial and examined under a microscope. In virtually all cases, delamination was observable, with variation in the extent of the delaminated area. A comparison between measured voltages after failure and damage did not show a correlation between voltage and area affected by delamination. However, at a temperature of 37 ∘C, voltage remained constant most of the time after delamination, and a pin-hole lead to a lower measured voltage and strong fluctuations. Visually, no difference in damage between the 37 and the 57 ∘C samples was observed, although fluctuations of measured voltage occurred in numerous samples at a higher temperature. This difference hints at differences in the reasons for failure and thus limited applicability of accelerated lifetime tests.

2D Semiconductor Based Flexible Photoresponsive Ring Oscillators for Artificial Vision Pixels

Artificial retina implantation provides an effective and feasible attempt for vision recovery in addition to retinal transplantation. The most advanced artificial retinas ever developed based on silicon technology are rigid and thus less compatible with the biosystem. Here we demonstrate flexible photoresponsive ring oscillators (PROs) based on the 2D semiconductor MoS2 for artificial retinas. Under natural light illuminations, arrayed PROs on flexible substrates serving as vision pixels can efficiently output light-intensity-dependent electrical pulses that are processable and transmittable in the human visual nerve system. Such PROs can work under low supply voltages below 1 V with a record-low power consumption, e.g. only 12.4 nW at a light intensity of 10 mW/cm2, decreased by ∼500 times compared with that of the state-of-the-art silicon devices. Such flexible artificial retinas with a simple device structure, high light-to-signal conversion efficiency, ultralow power consumption, and high tunability provide an alternative prosthesis for further clinical trials.

Neurostimulators for high-resolution artificial retina: ASIC design challenges and solutions

Objective.Neurostimulator is one of the most important part in artificial retina design. In this paper, we discuss the main challenges in the design of application-specific integrated circuit for high-resolution artificial retina and suggest corresponding solutions.Approach. Problems in the design of the neurostimulator for the existing artificial retina have not been solved yet are analyzed and solutions are presented. For verification of the solutions, mathematical proof, MATLAB and Ansys simulations are used.Main results. The drawbacks of resorting to a high-voltage complementary metal oxide semiconductor (CMOS) process to deal with the large voltage compliance demanded by the stimulator output stage are pointed out, and an alternative approach based on a circuit that switches the voltage of the common reference electrode is proposed to overcome. The necessity of an active discharge circuit to remove the residual charge of electrodes caused by an unbalanced stimulus is investigated. We present a circuit analysis showing that the use of a passive discharge circuit is sufficient to suppress problematic direct current in most situations. Finally, possible restrictions on input and output (I/O) count are investigated by estimating the resistive-capacitive delay caused by the interconnection between the I/O pad and the microelectrode array.Significance. The results of this paper clarified the problems currently faced by neurostimulator design for the artificial retina. Through the solutions presented in this study, circuits with more competitiveness in power and area consumption can be designed.

New frontiers of retinal therapeutic intervention: a critical analysis of novel approaches

A recent wave of pharmacologic and technologic innovations has revolutionized our management of retinal diseases. Many of these advancements have demonstrated efficacy and can increase the quality of life while potentially reducing complications and decreasing the burden of care for patients. Some advances, such as longer-acting anti-vascular endothelial growth factor agents, port delivery systems, gene therapy, and retinal prosthetics have been approved by the US Food and Drug Administration, and are available for clinical use. Countless other therapeutics are in various stages of development, promising a bright future for further improvements in the management of the retinal disease. Herein, we have highlighted several important novel therapies and therapeutic approaches and examine the opportunities and limitations offered by these innovations at the new frontier. KEY MESSAGESNumerous pharmacologic and technologic advancements have been emerging, providing a higher treatment efficacy while decreasing the burden and associated side effects.Anti-vascular endothelial growth factor (anti-VEGF) and its longer-acting agents have dramatically improved visual outcomes and have become a mainstay treatment in various retinal diseases.Gene therapy and retinal prosthesis implantation in the treatment of congenital retinal dystrophy can accomplish the partial restoration of vision and improved daily function in patients with blindness, an unprecedented success in the field of retina.

Assessing people with visual impairments’ access to information, awareness and satisfaction with high-tech assistive technology

Assistive technology (AT) devices are designed to help people with visual impairments (PVIs) perform activities that would otherwise be difficult or impossible. Devices specifically designed to assist PVIs by attempting to restore sight or substitute it for another sense have a very low uptake rate. This study, conducted in England, aimed to investigate why this is the case by assessing accessibility to knowledge, awareness, and satisfaction with AT in general and with sensory restoration and substitution devices in particular. From a sample of 25 PVIs, ranging from 21 to 68 years old, results showed that participants knew where to find AT information; however, health care providers were not the main source of this information. Participants reported good awareness of different ATs, and of technologies they would not use, but reported poor awareness of specific sensory substitution and restoration devices. Only three participants reported using AT, each with different devices and varying levels of satisfaction. The results from this study suggest a possible breakdown in communication between health care providers and PVIs, and dissociation between reported AT awareness and reported access to AT information. Moreover, awareness of sensory restoration and substitution devices is poor, which may explain the limited use of such technology.

Advanced Retina Implants

PURPOSE

To discuss the role of advanced retinal implants in retinitis pigmentosa and age-related macular degeneration.

DESIGN

Presented by Mark S. Humayun as the Charles Schepen's Lecture on the Retina Subspecialty Day of the American Academy of Ophthalmology in 2021.

PARTICIPANTS

The details of subjects, participants, and controls are provided in the references pertaining to each study.

METHODS

Review of published literature and clinical trials.

MAIN OUTCOME MEASURES

Visual and anatomic outcomes from retinal implants.

RESULTS

Retinal implants have been researched over the past few decades, and some have been advanced into the clinic. Two types of implants-bioelectronic and stem cell-based-have shown promising results in restoring some level of vision in patients with inherited retinal degeneration and geographic atrophy. These implants differ in their constructions, locations of implantation, and safety profiles. The results from some of these retinal implants have shown signs of efficacy, and 1 retinal implant, the Argus II, has been approved by the United States Food and Drug Administration.

CONCLUSIONS

Careful consideration of the design of the implant and associated surgical techniques are necessary to obtain a stable and effective long-term interface between the implant and the retina.

Nanocone-Array-Based Platinum-Iridium Oxide Neural Microelectrodes: Structure, Electrochemistry, Durability and Biocompatibility Study

Neural interfaces provide a window for bio-signal modulation and recording with the assistance of neural microelectrodes. However, shrinking the size of electrodes results in high electrochemical impedance and low capacitance, thus limiting the stimulation/recording efficiency. In order to achieve critical stability and low power consumption, here, nanocone-shaped platinum (Pt) with an extensive surface area is proposed as an adhesive layer on a bare Pt substrate, followed by the deposition of a thin layer of iridium oxide (IrO_x) to fabricate high-performance nanocone-array-based Pt-IrO_x neural microelectrodes (200 μm in diameter). A uniform nanocone-shaped Pt with significant roughness is created via controlling the ratio of NH₄⁺ and Pt⁴⁺ ions in the electrolyte, which can be widely applicable for batch production on multichannel flexible microelectrode arrays (fMEAs) and various substrates with different dimensions. The Pt-IrO_x nanocomposite-coated microelectrode presents a significantly low impedance down to 0.72 ± 0.04 Ω cm² at 1 kHz (reduction of ~92.95%). The cathodic charge storage capacity (CSC_c) and charge injection capacity (CIC) reaches up to 52.44 ± 2.53 mC cm^-2 and 4.39 ± 0.36 mC cm^-2, respectively. Moreover, superior chronic stability and biocompatibility are also observed. The modified microelectrodes significantly enhance the adhesion of microglia, the major immune cells in the central nervous system. Therefore, such a coating strategy presents great potential for biomedical and other practical applications.

Brain augmentation and neuroscience technologies: current applications, challenges, ethics and future prospects

Ever since the dawn of antiquity, people have strived to improve their cognitive abilities. From the advent of the wheel to the development of artificial intelligence, technology has had a profound leverage on civilization. Cognitive enhancement or augmentation of brain functions has become a trending topic both in academic and public debates in improving physical and mental abilities. The last years have seen a plethora of suggestions for boosting cognitive functions and biochemical, physical, and behavioral strategies are being explored in the field of cognitive enhancement. Despite expansion of behavioral and biochemical approaches, various physical strategies are known to boost mental abilities in diseased and healthy individuals. Clinical applications of neuroscience technologies offer alternatives to pharmaceutical approaches and devices for diseases that have been fatal, so far. Importantly, the distinctive aspect of these technologies, which shapes their existing and anticipated participation in brain augmentations, is used to compare and contrast them. As a preview of the next two decades of progress in brain augmentation, this article presents a plausible estimation of the many neuroscience technologies, their virtues, demerits, and applications. The review also focuses on the ethical implications and challenges linked to modern neuroscientific technology. There are times when it looks as if ethics discussions are more concerned with the hypothetical than with the factual. We conclude by providing recommendations for potential future studies and development areas, taking into account future advancements in neuroscience innovation for brain enhancement, analyzing historical patterns, considering neuroethics and looking at other related forecasts.

PVGAN: A generative adversarial network for object simplification in prosthetic vision

OBJECTIVE

By means of electrical stimulation of the visual system, visual prostheses provide promising solution for blind patients through partial restoration of their vision. Despite the great success achieved so far in this field, the limited resolution of the perceived vision using these devices hinders the ability of visual prostheses users to correctly recognize viewed objects. Accordingly, we propose a deep learning approach based on Generative Adversarial Networks (GANs), termed PVGAN, to enhance object recognition for the implanted patients by representing objects in the field of view based on a corresponding simplified clip art version.

APPROACH

To assess the performance, an axon map model was used to simulate prosthetic vision in experiments involving normally-sighted participants. In these experiments, four types of image representation were examined. The first and second types comprised presenting phosphene simulation of real images containing the actual high-resolution object, and presenting phosphene simulation of the real image followed by the clip art image, respectively. The other two types were utilized to evaluate the performance in the case of electrode dropout, where the third type comprised presenting phosphene simulation of only clip art images without electrode dropout, while the fourth type involved clip art images with electrode dropout.

MAIN RESULTS

The performance was measured through three evaluation metrics which are the accuracy of the participants in recognizing the objects, the time taken by the participants to correctly recognize the object, and the confidence level of the participants in the recognition process. Results demonstrate that representing the objects using clip art images generated by the PVGAN model results in a significant enhancement in the speed and confidence of the subjects in recognizing the objects.

SIGNIFICANCE

These results demonstrate the utility of using GANs in enhancing the quality of images perceived using prosthetic vision.

Stage-Dependent Changes of Visual Function and Electrical Response of the Retina in the rd10 Mouse Model

One of the critical prerequisites for the successful development of retinal prostheses is understanding the physiological features of retinal ganglion cells (RGCs) in the different stages of retinal degeneration (RD). This study used our custom-made rd10 mice, C57BL/6-Pde6bem1(R560C)Dkl/Korl mutated on the Pde6b gene in C57BL/6J mouse with the CRISPR/Cas9-based gene-editing method. We selected the postnatal day (P) 45, P70, P140, and P238 as representative ages for RD stages. The optomotor response measured the visual acuity across degeneration stages. At P45, the rd10 mice exhibited lower visual acuity than wild-type (WT) mice. At P140 and older, no optomotor response was observed. We classified RGC responses to the flashed light into ON, OFF, and ON/OFF RGCs via in vitro multichannel recording. With degeneration, the number of RGCs responding to the light stimulation decreased in all three types of RGCs. The OFF response disappeared faster than the ON response with older postnatal ages. We elicited RGC spikes with electrical stimulation and analyzed the network-mediated RGC response in the rd10 mice. Across all postnatal ages, the spikes of rd10 RGCs were less elicited by pulse amplitude modulation than in WT RGCs. The ratio of RGCs showing multiple peaks of spike burst increased in older ages. The electrically evoked RGC spikes by the pulse amplitude modulation differ across postnatal ages. Therefore, degeneration stage-dependent stimulation strategies should be considered for developing retinal prosthesis and successful vision restoration.

Flexible ultrasound-induced retinal stimulating piezo-arrays for biomimetic visual prostheses

Electronic visual prostheses, or biomimetic eyes, have shown the feasibility of restoring functional vision in the blind through electrical pulses to initiate neural responses artificially. However, existing visual prostheses predominantly use wired connections or electromagnetic waves for powering and data telemetry, which raises safety concerns or couples inefficiently to miniaturized implant units. Here, we present a flexible ultrasound-induced retinal stimulating piezo-array that can offer an alternative wireless artificial retinal prosthesis approach for evoking visual percepts in blind individuals. The device integrates a two-dimensional piezo-array with 32-pixel stimulating electrodes in a flexible printed circuit board. Each piezo-element can be ultrasonically and individually activated, thus, spatially reconfigurable electronic patterns can be dynamically applied via programmable ultrasound beamlines. As a proof of concept, we demonstrate the ultrasound-induced pattern reconstruction in ex vivo murine retinal tissue, showing the potential of this approach to restore functional, life-enhancing vision in people living with blindness.

StereoPilot: A Wearable Target Location System for Blind and Visually Impaired Using Spatial Audio Rendering

Vision loss severely impacts object recognition and spatial cognition for limited vision individuals. It is a challenge to compensate for this using other sensory modalities, such as touch or hearing. This paper introduces StereoPilot, a wearable target location system to facilitate the spatial cognition of BVI. Through wearing a head-mounted RGB-D camera, the 3D spatial information of the environment is measured and processed into navigation cues. Leveraging spatial audio rendering (SAR) technology, it allows the navigation cues to be transmitted in a type of 3D sound from which the sound orientation can be distinguished by the sound localization instincts in humans. Three haptic and auditory display strategies were compared with SAR through experiments with three BVI and four sighted subjects. Compared with mainstream speech instructional feedback, the experimental results of the Fitts' law test showed that SAR increases the information transfer rate (ITR) by a factor of three for spatial navigation, while the positioning error is reduced by 40%. Furthermore, SAR has a lower learning effect than other sonification approaches such as vOICe. In desktop manipulation experiments, StereoPilot was able to obtain precise localization of desktop objects while reducing the completion time of target grasping tasks in half as compared to the voice instruction method. In summary, StereoPilot provides an innovative wearable target location solution that swiftly and intuitively transmits environmental information to BVI individuals in the real world.

Human-in-the-loop optimization of visual prosthetic stimulation

Retinal prostheses are a promising strategy to restore sight to patients with retinal degenerative diseases. These devices compensate for the loss of photoreceptors by electrically stimulating neurons in the retina. Currently, the visual function that can be recovered with such devices is very limited. This is due, in part, to current spread, unintended axonal activation, and the limited resolution of existing devices. Here we show, using a recent model of prosthetic vision, that optimizing how visual stimuli are encoded by the device can help overcome some of these limitations, leading to dramatic improvements in visual perception.

APPROACH

We propose a strategy to do this in practice, using patients' feedback in a visual task. The main challenge of our approach comes from the fact that, typically, one only has access to a limited number of noisy responses from patients. We propose two ways to deal with this: first, we use a model of prosthetic vision to constrain and simplify the optimization. We show that, if one knew the parameters of this model for a given patient, it would be possible to greatly improve their perceptual performance. Second we propose a preferential Bayesian optimization to efficiently learn these model parameters for each patient, using minimal trials.

MAIN RESULTS

To test our approach, we presented healthy subjects with visual stimuli generated by a recent model of prosthetic vision, to replicate the perceptual experience of patients fitted with an implant. Our optimization procedure led to significant and robust improvements in perceived image quality, that transferred to increased performance in other tasks.

SIGNIFICANCE

Importantly, our strategy is agnostic to the type of prosthesis and thus could readily be implemented in existing implants.

BioAdhere: tailor-made bioadhesives for epiretinal visual prostheses

Introduction: Visual prostheses, i.e. epiretinal stimulating arrays, are a promising therapy in treating retinal dystrophies and degenerations. In the wake of a new generation of devices, an innovative method for epiretinal fixation of stimulator arrays is required. We present the development of tailor-made bioadhesive peptides (peptesives) for fixating epiretinal stimulating arrays omitting the use of traumatic retinal tacks. Materials and methods: Binding motifs on the stimulating array (poly[chloro-p-xylylene] (Parylene C)) and in the extracellular matrix of the retinal surface (collagens I and IV, laminin, fibronectin) were identified. The anchor peptides cecropin A (CecA), KH1, KH2 (author's initials) and osteopontin (OPN) were genetically fused to reporter proteins to assess their binding behavior to coated microtiter plates via fluorescence-based assays. Domain Z (DZ) of staphylococcal protein A was used as a separator to generate a bioadhesive peptide. Following ISO 10993 "biological evaluation of medical materials", direct and non-direct cytotoxicity testing (L-929 and R28 retinal progenitor cells) was performed. Lastly, the fixating capabilities of the peptesives were tested in proof-of-principle experiments. Results: The generation of the bioadhesive peptide required evaluation of the N- and C-anchoring of investigated APs. The YmPh-CecA construct showed the highest activity on Parylene C in comparison with the wildtype phytase without the anchor peptide. eGFP-OPN was binding to all four investigated ECM proteins (collagen I, laminin > collagen IV, fibronectin). The strongest binding to collagen I was observed for eGFP-KH1, while the strongest binding to fibronectin was observed for eGFP-KH2. The selectivity of binding was checked by incubating eGFP-CecA and eGFP-OPN on ECM proteins and on Parylene C, respectively. Direct and non-direct cytotoxicity testing of the peptide cecropin-A-DZ-OPN using L-929 and R28 cells showed good biocompatibility properties. Proof-of-concept experiments in post-mortem rabbit eyes suggested an increased adhesion of CecA-DZ-OPN-coated stimulating arrays. Conclusion: This is the first study to prove the applicability and biocompatibility of peptesives for the fixation of macroscopic objects.

Simulating the perceptual effects of electrode-retina distance in prosthetic vision

OBJECTIVE

Retinal prostheses aim to restore some vision in retinitis pigmentosa and age-related macular degeneration blind patients. Many spatial and temporal aspects have been found to affect prosthetic vision. Our objective is to study the impact of the space-variant distance between the stimulating electrodes and the surface of the retina on prosthetic vision and how to mitigate this impact.

APPROACH

A prosthetic vision simulation was built to demonstrate the perceptual effects of the electrode-retina distance (ERD) with different random spatial variations, such as size, brightness, shape, dropout, and spatial shifts. Three approaches for reducing the ERD effects are demonstrated: electrode grouping (quads), ERD-based input-image enhancement, and object scanning with and without phosphene persistence. A quantitative assessment for the first two approaches was done based on experiments with 20 subjects and three vision-based computational image similarity metrics.

MAIN RESULTS

The effects of various ERDs on phosphenes' size, brightness, and shape were simulated. Quads, chosen according to the ERDs, effectively elicit phosphenes without exceeding the safe charge density limit, whereas single electrodes with large ERD cannot do so. Input-image enhancement reduced the ERD effects effectively. These two approaches significantly improved ERD-affected prosthetic vision according to the experiment and image similarity metrics. A further reduction of the ERD effects was achieved by scanning an object while moving the head.

SIGNIFICANCE

ERD has multiple effects on perception with retinal prostheses. One of them is vision loss caused by the incapability of electrodes with large ERD to evoke phosphenes. The three approaches presented in this study can be used separately or together to mitigate the impact of ERD. A consideration of our approaches in reducing the perceptual effects of the ERD may help improve the perception with current prosthetic technology and influence the design of future prostheses.

Three-dimensional multilayer concentric bipolar electrodes restrict spatial activation in optic nerve stimulation

OBJECTIVE

Intraneural nerve interfaces often operate in a monopolar configuration with a common and distant ground electrode. This configuration leads to a wide spreading of the electric field. Therefore, this approach is suboptimal for intraneural nerve interfaces when selective stimulation is required.

APPROACH

We designed a multilayer electrode array embedding three-dimensional concentric bipolar electrodes. First, we validated the higher stimulation selectivity of this new electrode array compared to classical monopolar stimulation using simulations. Next, we compared them in-vivo by intraneural stimulation of the rabbit optic nerve and recording evoked potentials in the primary visual cortex.

MAIN RESULTS

Simulations showed that three-dimensional concentric bipolar electrodes provide a high localisation of the electric field in the tissue so that electrodes are electrically independent even for high electrode density. Experiments in-vivo highlighted that this configuration restricts spatial activation in the visual cortex due to the fewer fibres activated by the electric stimulus in the nerve.

SIGNIFICANCE

Highly focused electric stimulation is crucial to achieving high selectivity in fibre activation. The multilayer array embedding three-dimensional concentric bipolar electrodes improves selectivity in optic nerve stimulation. This approach is suitable for other neural applications, including bioelectronic medicine.

INTRAOPERATIVE OPTICAL COHERENCE TOMOGRAPHY AND ENDOSCOPY-GUIDED EXPLANTATION OF ARGUS II DEVICE

PURPOSE

To describe a surgical approach using intraoperative optical coherence tomography and endoscopy for successful Argus II retinal prosthesis system removal.

METHODS

Retrospective review of a patient undergoing Argus II explantation 8 months after initial implantation.

RESULTS

Successful explantation of the Argus II device was performed in this patient.

CONCLUSION

Explantation of the Argus II device can be a difficult surgery, and intraoperative optical coherence tomography and endoscopy can be used to help avoid potential complications.

Hexagonal Stimulation Digital Controller Design and Verification for Wireless Subretinal Implant Device

Significant progress has been made in the field of micro/nano-retinal implant technologies. However, the high pixel range, power leakage, reliability, and lifespan of retinal implants are still questionable. Active implantable devices are safe, cost-effective, and reliable. Although a device that can meet basic safety requirements set by the Food and Drug Administration and the European Union is reliable for long-term use and provides control on current and voltage parameters, it will be expensive and cannot be commercially successful. This study proposes an economical, fully controllable, and configurable wireless communication system based on field-programmable gated arrays (FPGAs) that were designed with the ability to cope with the issues that arise in retinal implantation. This system incorporates hexagonal biphasic stimulation pulses generated by a digital controller that can be fully controlled using an external transmitter. The integration of two separate domain analog systems and a digital controller based on FPGAs is proposed in this study. The system was also implemented on a microchip and verified using in vitro results.