Can subretinal microphotodiodes successfully replace degenerated photoreceptors?

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.

Structural changes in the retina after implantation of subretinal three-dimensional implants in mini pigs

The retinal structural changes after subretinal implantation of three-dimensional (3D) microelectrodes were investigated in a mini pig. Three types of electrode were implanted into the subretinal spaces of nine mini pigs: 75-μm-high 3D electrodes on a 200-μm-thick right-angled polydimethylsiloxane (PDMS) substrate (group 1); a 140-μm-thick sloped PDMS substrate without electrodes (group 2); and a 140-μm-thick sloped PDMS substrate with 20-μm-high 3D electrodes (group 3). One mini pig was used as a control. Spectral domain–optical coherence tomography (SD–OCT) images were obtained at baseline and 2, 6, and 12 weeks post-surgery. Retinal specimens were immunostained using a tissue-clearing method 3 months post-implantation. The 75-μm-high 3D electrodes progressively penetrated the inner nuclear layer (INL) and touched the inner plexiform layer (IPL) 2 weeks post-surgery. At 6 weeks post-operatively, the electrodes were in contact with the nerve-fiber layer, accompanied by a severe fibrous reaction. In the other groups, the implants remained in place without subretinal migration. Immunostaining showed that retinal ganglion and bipolar cells were preserved without fibrosis over the retinal implants in groups 2 and 3 during the 12-week implantation period. In summary, SD–OCT and immunohistology results showed differences in the extent of reactions, such as fibrosis over the implants and penetration of the electrodes into the inner retinal layer depending on different types of electrodes. A sloped substrate performed better than a right-angled substrate in terms of retinal preservation over the implanted electrodes. The 20-μm-high electrodes showed better structural compatibility than the 75-μm-high 3D electrodes. There was no significant difference between the results of sloped implants without electrodes and 20-μm-high 3D electrodes, indicating that the latter had no adverse effects on retinal tissue.

Light Controlled Signaling Initiated by Subretinal Semiconducting-Polymer Layer in Developing-Blind-Retina Mimics the Response of the Neonatal Retina

Optoelectronic semiconducting polymer material interfaced with a blind-developing chick-retina (E13-E18) in subretinal configuration reveals a response to full-field flash stimulus that resembles an elicited response from natural photoreceptors in a mature chick retina. The response manifests as evoked-firing of action potentials was recorded using a multi-electrode array in contact with the retinal ganglion layer. Characteristics of increasing features in the signal unfold during different retina-development stages and highlight the emerging network mediated pathways typically present in the vision process of the artificial photoreceptor interfaced retina.

Spatial Resolution of Suprachoroidal-Transretinal Stimulation Estimated by Recording Single-Unit Activity From the Cat Lateral Geniculate Nucleus

Retinal prostheses are devices used to restore visual sensation in patients suffering from photoreceptor degeneration, such as retinitis pigmentosa. Suprachoroidal–transretinal stimulation (STS) is a prosthesis with retinal electrodes located in the sclera. STS has the advantage that it is safer than epiretinal or subretinal prostheses, as the implant is not directly attached to the retinal tissue. We have previously reported feasibility of STS with animal experiments and clinical trials. However, functional evaluation with neurophysiological experiments is still largely missing. To estimate the spatial resolution of STS, single-unit activities in response to STS were recorded from relay cells in the dorsal lateral geniculate nucleus of cats, and the response probability of the units was analyzed in relation to the distance between the stimulus location and the receptive field of each recorded unit. A platinum electrode was attached to the sclera after lamellar resection, and the return electrode was placed in the vitreous. The stimulating current, which ranged from 50 to 500 μA, was applied between these electrodes, and the probability of spike responses occurring just after retinal stimulation was measured. The distance at half-maximum of response was determined from the collected response probabilities as a function of stimulus intensity for all units characterized by their distances from the receptive field center to the stimulation point. As the stimulation became weaker, this distance decreased to 1.8° at 150 and 100 μA. As another estimation, the radius of 25% response probability was 1.4° at 100 μA. The diameter of the stimulated cat retinal area, 3.6° or 2.8°, corresponds to human visual acuity of 0.005 or 0.007, or finger counting. Considering the lower hazard to the retina of STS and its potentially large visual field coverage, STS is an attractive method for retinal prosthetic device development.

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

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

A new blind color watermarking based on a psychovisual model

In this paper, we address the problem of the use of a human visual system (HVS) model to improve watermark invisibility. We propose a new color watermarking algorithm based on the minimization of the perception of color differences. This algorithm is based on a psychovisual model of the dynamics of cone photoreceptors. We used this model to determine the discrimination power of the human for a particular color and thus the best strategy to modify color pixels. Results were obtained on a color version of the lattice quantization index modulation (LQIM) method and showed improvements on psychovisual invisibility and robustness against several image distortions.

In vitro reliability testing and in vivo lifespan estimation of wireless Pixium Vision PRIMA photovoltaic subretinal prostheses suggest prolonged durability and functionality in clinical practice

OBJECTIVE

Retinal implants have the potential to restore some sight in patients with retinal degeneration. The PRIMA implant's novel design features simpler insertion and no transscleral cabling or extraocular components. This in vitro study investigated PRIMA's durability under real time and accelerated conditions and estimated the device's lifespan in vivo.

APPROACH

Two potential failure modes were examined: corrosion and overstimulation. Real-time aging was tested using implants immersed in balanced saline solution (BSS) at 37 °C, mimicking the intraocular environment. Accelerated aging was examined at 77 °C (Arrhenius theory). Confirmatory testing of acceleration factor was performed using different temperatures (37 °C-87 °C) and weakened implant coatings. The effect of repeated maximum stimulation was tested using a pulsed infrared laser (6x acceleration factor). Data were used to estimate device lifespan.

MAIN RESULTS

175 implants were tested for up to 33 months. No corrosion or water ingress was observed after approximately 20 accelerated years. A pixel failure rate of 0.15% was recorded after 10 accelerated years' stimulation. The derived lifespan estimation for the PRIMA implant was 27.0 years with a reliability of 90% (95% confidence interval).

SIGNIFICANCE

The PRIMA implant was found to be robust, with in vitro reliability of at least 10 years. The PRIMA implant shows durability and functionality for clinically relevant timespans under similar environmental conditions to the human eye. These results require in vivo confirmation.

Optogenetic Stimulation for Restoring Vision to Patients Suffering From Retinal Degenerative Diseases: Current Strategies and Future Directions

Optogenetic strategies for vision restoration involve photosensitizing surviving retinal neurons following retinal degeneration, using emerging optogenetic techniques. This approach opens the door to a minimally-invasive retinal vision restoration approach. Moreover, light stimulation has the potential to offer better spatial and temporal resolution than conventional retinal electrical prosthetics. Although proof-of-concept studies in animal models have demonstrated the possibility of restoring vision using optogenetic techniques, and initial clinical trials are underway, there are still hurdles to pass before such an approach restores naturalistic vision in humans. One limitation is the development of light stimulation devices to activate optogenetic channels in the retina. Here we review recent progress in the design and implementation of optogenetic stimulation devices and outline the corresponding technological challenges. Finally, while most work to date has focused on providing therapy to patients suffering from retinitis pigmentosa, we provide additional insights into strategies for applying optogenetic vision restoration to patients suffering from age-related macular degeneration.

A 3D flexible microelectrode array for subretinal stimulation

OBJECTIVE

Various retinal prostheses have been developed to restore the vision for blind patients, and some of them are already in clinical use. In this paper, we present a three-dimensional (3D) microelectrode array for a subretinal device that can effectively stimulate retinal cells.

APPROACH

To investigate the effect of electrode designs on the electric field distribution, we simulated various electrode shapes and sizes using finite element analysis. Based on the simulation results, the 3D microelectrode array was fabricated and evaluated in in vitro condition.

MAIN RESULTS

Through the simulation, we verified that an electrode design of square frustum was effective to stimulate with high contrast. Also, the 3D flexible and transparent microelectrode array based on silicon and polydimethylsiloxane was fabricated using micro-electro-mechanical system technologies. In in vitro experiments, the subretinally positioned 3D microelectrodes properly evoked spikes in retinal ganglion cells. The mean threshold current was 7.4 µA and the threshold charge density was 33.64 µC·cm^-2 per phase.

SIGNIFICANCE

The results demonstrate the feasibility of the fabricated 3D microelectrodes as the subretinal prosthesis. The developed microelectrode array would be integrated with the stimulation circuitry and implanted in animals for further in vivo experiments.

Contemporary approaches to visual prostheses

Visual prostheses serve to restore visual function following acquired blindness. Acquired blindness (as opposed to congenital blindness) has many causes, including diseases such as retinitis pigmentosa, glaucoma, and macular degeneration, or trauma such as caused by automobile accident or blast damage from explosions. Many of the blindness-causing diseases target the retina or other ocular structure. Often, despite the loss of sensitivity to light, the remainder of the visual pathway is still functional, enabling electrical devices to deliver effective and meaningful visual information to the brain via arrays of electrodes. These arrays can be placed in any part of the early visual pathway, such as the retina, optic nerve, lateral geniculate nucleus, or visual cortex. A camera or other imaging source is used to drive electrical stimulation of remaining healthy cells or structures to create artificial vision and provide restoration of function. In this review, each approach to visual prostheses is described, including advantages and disadvantages as well as assessments of the current state of the art. Most of the work to-date has been targeting stimulation of (a) the retina, with three devices approved for general use and two more in clinical testing; (b) the lateral geniculate nucleus, with efforts still in the pre-clinical stage; and (c) the cortex, with three devices in clinical testing and none currently approved for general use despite the longest history of investigation of the three major approaches. Each class of device has different medical indications, and different levels of invasiveness required for implantation. All contemporary devices deliver relatively poor vision. There has been remarkable progress since the first proof-of-concept demonstration that used stimulation of the primary visual cortex, with the field exploring all viable options for restoration of function. Much of the progress has been recent, driven by advances in microelectronics and biocompatibility. With three devices currently approved for general use in various parts of the world, and a handful of additional devices well along in the pipeline toward approval, prospects for wide deployment of a device-based therapy to treat acquired blindness are good.

Progress in artificial vision through suprachoroidal retinal implants

Retinal implants have proven their ability to restore visual sensation to people with degenerative retinopathy, characterized by photoreceptor cell death and the retina's inability to sense light. Retinal bionics operate by electrically stimulating the surviving neurons in the retina, thus triggering the transfer of visual sensory information to the brain. Suprachoroidal implants were first investigated in Australia in the 1950s. In this approach, the neuromodulation hardware is positioned between the sclera and the choroid, thus providing significant surgical and safety benefits for patients, with the potential to maintain residual vision combined with the artificial input from the device. Here we review the latest advances and state of the art devices for suprachoroidal prostheses, highlight future technologies and discuss challenges and perspectives towards improved rehabilitation of vision.

Implantation, removal and replacement of subretinal electronic implants for restoration of vision in patients with retinitis pigmentosa

PURPOSE OF REVIEW

The purpose of this review is to provide an update on the efforts to restore vision through subretinal implants in patients with degenerative retinal diseases. In addition to the current technique and its latest improvements, it will focus on the surgical technique of implantation as well as explantation and reimplantation.

RECENT FINDINGS

The durability of the current subretinal implant RETINA IMPLANT Alpha AMS has increased substantially compared with the predecessor model RETINA IMPLANT Alpha IMS. According to validated examinations in the laboratory, a median lifetime of 4.7 years will be reached in clinical use; in similar examinations, the previous model has reached only 8 months. Visual function has slightly increased. The surgical technique for subretinal implants is complex and demanding for ophthalmic surgeons, as it is multifaceted and combines novel surgical steps in areas, which are not commonly entered such as the suprachoroidal and the subretinal space. The surgical approach for implantation has matured considerably and has led to successful implantation in 64 patient cases. Surgical challenges are now mainly encountered with the exact subfoveal positioning of the device. The explantation procedure is relatively straight-forward because the implant can be withdrawn in a reverse direction along the already existent subretinal path. Reimplantations, however, are more challenging because some degree of scar tissue may exist along the path of the chip and around the scleral trapdoor. Nevertheless, reimplantations have now been carried out successfully in four patients.

SUMMARY

The new RETINA IMPLANT Alpha AMS shows significantly improved durability compared with the predecessor model RETINA IMPLANT Alpha IMS. The subretinal implant offers excellent visual results but requires experienced surgeons. Explantation of devices is straight-forward, and reimplantations are challenging but have been successful in four patients.

Methodology for Biomimetic Chemical Neuromodulation of Rat Retinas with the Neurotransmitter Glutamate In Vitro

Photoreceptor degenerative diseases cause irreparable blindness through the progressive loss of photoreceptor cells in the retina. Retinal prostheses are an emerging treatment for photoreceptor degenerative diseases that seek to restore vision by artificially stimulating the surviving retinal neurons in the hope of eliciting comprehensible visual perception in patients. Current retinal prostheses have demonstrated success in restoring limited vision to patients using an array of electrodes to electrically stimulate the retina but face substantial physical barriers in restoring high acuity, natural vision to patients. Chemical neurostimulation using native neurotransmitters is a biomimetic alternative to electrical stimulation and could bypass the fundamental limitations associated with retinal prostheses using electrical neurostimulation. Specifically, chemical neurostimulation has the potential to restore more natural vision with comparable or better visual acuities to patients by injecting very small quantities of neurotransmitters, the same natural agents of communication used by retinal chemical synapses, at much finer resolution than current electrical prostheses. However, as a relatively unexplored stimulation paradigm, there is no established protocol for achieving chemical stimulation of the retina in vitro. The purpose of this work is to provide a detailed framework for accomplishing chemical stimulation of the retina for investigators who wish to study the potential of chemical neuromodulation of the retina or similar neural tissues in vitro. In this work, we describe the experimental setup and methodology for eliciting retinal ganglion cell (RGC) spike responses similar to visual light responses in wild-type and photoreceptor-degenerated wholemount rat retinas by injecting controlled volumes of the neurotransmitter glutamate into the subretinal space using glass micropipettes and a custom multiport microfluidic device. This methodology and protocol are general enough to be adapted for neuromodulation using other neurotransmitters or even other neural tissues.

A comparative study of light and electrically evoked response of retinal ganglion cells

Understanding of the evoked neural discharges from retinal tissues is vital for designing of any retinal prosthesis. In this study, retinal ganglion cell activity to light and electrical stimulus is recorded using multielectrode arrays. For an effective epiretinal prosthetic device, the electrical stimulus through the prosthesis should be able to evoke responses similar to those of light response in normal condition. This pilot study was intended to design the experimental protocol for in-vitro retinal stimulation. Light and electrical stimulus of same duration to normal goat retina evoked different responses. Electrical stimulus produces greater number of spikes as compared with light response of same duration. With the experimental set up and the analysis technique presented here, stimulation parameters such as frequency of input pulse, amplitude, type of pulse required to generate responses close to that of light response can be optimized.

Polarized, Cobblestone, Human Retinal Pigment Epithelial Cell Maturation on a Synthetic PEG Matrix

Cell attachment is essential for the growth and polarization of retinal pigment epithelial (RPE) cells. Currently, surface coatings derived from biological proteins are used as the gold standard for cell culture. However, downstream processing and purification of these biological products can be cumbersome and expensive. In this study, we constructed a library of chemically modified nanofibers to mimic the Bruch's membrane of the retinal pigment epithelium. Using atmospheric-pressure plasma-induced graft polymerization with a high-throughput screening platform to modify the nanofibers, we identified three polyethylene glycol (PEG)-grafted nanofiber surfaces (PEG methyl ether methacrylate, n = 4, 8, and 45) from a library of 62 different surfaces as favorable for RPE cell attachment, proliferation, and maturation in vitro with cobblestone morphology. Compared with the biologically derived culture matrices such as vitronectin-based peptide Synthemax, our newly discovered synthetic PEG surfaces exhibit similar growth and polarization of retinal pigment epithelial (RPE) cells. However, they are chemically defined, are easy to synthesize on a large scale, are cost-effective, are stable with long-term storage capability, and provide a more physiologically accurate environment for RPE cell culture. To our knowledge, no one has reported that PEG derivatives directly support attachment and growth of RPE cells with cobblestone morphology. This study offers a unique PEG-modified 3D cell culture system that supports RPE proliferation, differentiation, and maturation with cobblestone morphology, providing a new avenue for RPE cell culture, disease modeling, and cell replacement therapy.

Advances in Retinal Prosthetic Research: A Systematic Review of Engineering and Clinical Characteristics of Current Prosthetic Initiatives

PURPOSE

To date, reviews of retinal prostheses have focused primarily on devices undergoing human trials in the Western Hemisphere and fail to capture significant advances in materials and engineering research in countries such as Japan and Korea, as well as projects in early stages of development. To address these gaps, this systematic review examines worldwide advances in retinal prosthetic research, evaluates engineering characteristics and clinical progress of contemporary device initiatives, and identifies potential directions for future research in the field of retinal prosthetics.

METHODS

A literature search using PubMed, Google Scholar, and IEEExplore was conducted following the PRISMA Guidelines for Systematic Review. Inclusion criteria were peer-reviewed papers demonstrating progress in human or animal trials and papers discussing the prosthetic engineering design. For each initiative, a description of the device, its engineering considerations, and recent clinical results were provided.

RESULTS

Ten prosthetic initiatives met our inclusion criteria and were organized by stimulation location. Of these initiatives, four have recently completed human trials, three are undergoing multi- or single-center human trials, and three are undergoing preclinical animal testing. Only the Argus II (FDA 2013, CE 2011) has obtained FDA approval for use in the United States; the Alpha-IMS (CE 2013) has achieved the highest visual acuity using a Landolt-C test to date and is the only device presently undergoing a multicenter clinical trial.

CONCLUSION

Several distinct approaches to retinal stimulation have been successful in eliciting visual precepts in animals and/or humans. However, many clinical needs are still not met and engineering challenges must be addressed before a retinal prosthesis with the capability to fully and safely restore functional vision can be realized.

Optimal voltage stimulation parameters for network-mediated responses in wild type and rd10 mouse retinal ganglion cells

To further improve the quality of visual percepts elicited by microelectronic retinal prosthetics, substantial efforts have been made to understand how retinal neurons respond to electrical stimulation. It is generally assumed that a sufficiently strong stimulus will recruit most retinal neurons. However, recent evidence has shown that the responses of some retinal neurons decrease with excessively strong stimuli (a non-monotonic response function). Therefore, it is necessary to identify stimuli that can be used to activate the majority of retinal neurons even when such non-monotonic cells are part of the neuronal population. Taking these non-monotonic responses into consideration, we establish the optimal voltage stimulation parameters (amplitude, duration, and polarity) for epiretinal stimulation of network-mediated (indirect) ganglion cell responses. We recorded responses from 3958 mouse retinal ganglion cells (RGCs) in both healthy (wild type, WT) and a degenerating (rd10) mouse model of retinitis pigmentosa-using flat-mounted retina on a microelectrode array. Rectangular monophasic voltage-controlled pulses were presented with varying voltage, duration, and polarity. We found that in 4-5 weeks old rd10 mice the RGC thresholds were comparable to those of WT. There was a marked response variability among mouse RGCs. To account for this variability, we interpolated the percentage of RGCs activated at each point in the voltage-polarity-duration stimulus space, thus identifying the optimal voltage-controlled pulse (-2.4 V, 0.88 ms). The identified optimal voltage pulse can activate at least 65% of potentially responsive RGCs in both mouse strains. Furthermore, this pulse is well within the range of stimuli demonstrated to be safe and effective for retinal implant patients. Such optimized stimuli and the underlying method used to identify them support a high yield of responsive RGCs and will serve as an effective guideline for future in vitro investigations of retinal electrostimulation by establishing standard stimuli for each unique experimental condition.

Electronic retinal implant surgery

Blindness due to outer retinal degeneration still remains largely untreatable. Photoreceptor loss removes light sensitivity, but the remaining inner retinal layers, the optic nerve, and indeed the physical structure of the eye itself may be unaffected by the degenerative processes. This provides the opportunity to restore some degree of vision with an electronic device in the subretinal space. In this lecture I will provide an overview of our experiences with the first-generation retinal implant Alpha IMS, developed by Retina Implant AG and based on the technology developed by Eberhart Zrenner as part of a multicentre clinical trial (NCT01024803). We are currently in the process of running a second NIHR-funded clinical trial to assess the next-generation device. The positive results from both studies to date indicate that the retinal implant should be included as a potential treatment for patients who are completely blind from retinitis pigmentosa. Evolution of the technology in future may provide further opportunities for earlier intervention or for other diseases.

Ocular Biocompatibility of Poly-N-Isopropylacrylamide (pNIPAM)

Purpose. To study the safety of intravitreal injections of poly-N-isopropylacrylamide (pNIPAM) tissue adhesive in rabbit eyes. Methods. Twelve study rabbits received an intravitreal injection of 0.1 mL 50% pNIPAM in the right eye. Follow-up examinations included color fundus photography, fundus fluorescein angiography (FA), optical coherence tomography (OCT), and electroretinography (ERG). Subsequent to the last follow-up assessment, the rabbits were sacrificed and histopathological study on the scleral incision sites was performed. Results. All study animals developed mild to moderate levels of inflammatory reaction in the conjunctiva, anterior chamber, and the anterior vitreous during the first month of follow-up. After this period, the level of the inflammatory reaction progressively decreased and completely disappeared after the third month of follow-up. The lens and cornea remained clear during the entire follow-up period. OCT and FA did not show areas of retinal damage or neovascularization. Histological and ERG studies of eyes injected with pNIPAM demonstrated absence of retinal toxicity. Conclusion. Intravitreal injections of pNIPAM were nontoxic in this animal study, and pNIPAM may be safe to be used as a bioadhesive in certain retinal diseases.

Perspectives on: Materials Aspects for Retinal Prostheses

Retinitis pigmentosa and age-related macular degeneration are both incurable eye diseases that lead to blindness due to photoreceptor degeneration. Electrically stimulating the remaining intact nerve cells may generate some useful vision for patients afflicted with these diseases. Various types of retinal prostheses, sub- and epi-retinal electrode arrays, as well as subretinal microphotodiode arrays are considered from a materials and biocompatibility point of view. Other, more innovative approaches to restoring vision, such as microfluidic pumps and activated nanosystems that deliver neurotransmitters in a controlled way and photodynamic therapy are being developed. This article discusses materials aspects of retinal prostheses that are currently in use or under development.

Evaluation of Subretinal Implants Coated with Amorphous Aluminum Oxide and Diamond-like Carbon

Retinal prostheses may be used to support patients suffering from age-related macular degeneration (AMD) or retinitis pigmentosa (RP). A hermetic encapsulation of the poly(imide) (PI)-based prosthesis is important in order to prevent the leakage of water and ions into the electric circuitry embedded in the poly(imide) matrix. The deposition of amorphous aluminum oxide (by sputtering) and diamond like carbon (by pulsed laser ablation) were made for applications in retinal prostheses. The thin films obtained were characterized for composition, thickness, adhesion and smoothness by scanning electron microscopy-energy dispersive spectroscopy, atomic force microscopy, profilometry and light microscopy. Biocompatibility was tested in vivo by implanting coated specimen subretinally in the eye of Yucatan pigs. While amorphous aluminum oxide is more readily deposited with sufficient adhesion quality, superior biocompatibility behavior was shown by diamond-like carbon. Amorphous aluminum oxide had more adverse effects and caused more severe damage to the retinal tissue.

Interactions of Prosthetic and Natural Vision in Animals With Local Retinal Degeneration

PURPOSE

Prosthetic restoration of partial sensory loss leads to interactions between artificial and natural inputs. Ideally, the rehabilitation should allow perceptual fusion of the two modalities. Here we studied the interactions between normal and prosthetic vision in a rodent model of local retinal degeneration.

METHODS

Implantation of a photovoltaic array in the subretinal space of normally sighted rats induced local degeneration of the photoreceptors above the chip, and the inner retinal neurons in this area were electrically stimulated by the photovoltaic implant powered by near-infrared (NIR) light. We studied prosthetic and natural visually evoked potentials (VEP) in response to simultaneous stimulation by NIR and visible light patterns.

RESULTS

We demonstrate that electrical and natural VEPs summed linearly in the visual cortex, and both responses decreased under brighter ambient light. Responses to visible light flashes increased over 3 orders of magnitude of contrast (flash/background), while for electrical stimulation the contrast range was limited to 1 order of magnitude. The maximum amplitude of the prosthetic VEP was three times lower than the maximum response to a visible flash over the same area on the retina.

CONCLUSIONS

Ambient light affects prosthetic responses, albeit much less than responses to visible stimuli. Prosthetic representation of contrast in the visual scene can be encoded, to a limited extent, by the appropriately calibrated stimulus intensity, which also depends on the ambient light conditions. Such calibration will be important for patients combining central prosthetic vision with natural peripheral sight, such as in age-related macular degeneration.

Mechanical and Biological Interactions of Implants with the Brain and Their Impact on Implant Design

Neural prostheses have already a long history and yet the cochlear implant remains the only success story about a longterm sensory function restoration. On the other hand, neural implants for deep brain stimulation are gaining acceptance for variety of disorders including Parkinsons disease and obsessive-compulsive disorder. It is anticipated that the progress in the field has been hampered by a combination of technological and biological factors, such as the limited understanding of the longterm behavior of implants, unreliability of devices, biocompatibility of the implants among others. While the field's understanding of the cell biology of interactions at the biotic-abiotic interface has improved, relatively little attention has been paid on the mechanical factors (stress, strain), and hence on the geometry that can modulate it. This focused review summarizes the recent progress in the understanding of the mechanisms of mechanical interaction between the implants and the brain. The review gives an overview of the factors by which the implants interact acutely and chronically with the tissue: blood-brain barrier (BBB) breach, vascular damage, micromotions, diffusion etc. We propose some design constraints to be considered in future studies. Aspects of the chronic cell-implant interaction will be discussed in view of the chronic local inflammation and the ways of modulating it.

Retinal safety of near infrared radiation in photovoltaic restoration of sight

Photovoltaic restoration of sight requires intense near-infrared light to effectively stimulate retinal neurons. We assess the retinal safety of such radiation with and without the retinal implant. Retinal damage threshold was determined in pigmented rabbits exposed to 880nm laser radiation. The 50% probability (ED50) of retinal damage during 100s exposures with 1.2mm diameter beam occurred at 175mW, corresponding to a modeled temperature rise of 12.5°C. With the implant, the same temperature was reached at 78mW, close to the experimental ED50 of 71mW. In typical use conditions, the retinal temperature rise is not expected to exceed 0.43°C, well within the safety limits for chronic use.

Effect of Pixel’s Spatial Characteristics on Recognition of Isolated Pixelized Chinese Character

The influence of pixel’s spatial characteristics on recognition of isolated Chinese character was investigated using simulated prosthestic vision. The accuracy of Chinese character recognition with 4 kinds of pixel number (6*6, 8*8, 10*10, and 12*12 pixel array) and 3 kinds of pixel shape (Square, Dot and Gaussian) and different pixel spacing were tested through head-mounted display (HMD). A captured image of Chinese characters in font style of Hei were pixelized with Square, Dot and Gaussian pixel. Results showed that pixel number was the most important factor which could affect the recognition of isolated pixelized Chinese Chartars and the accuracy of recognition increased with the addition of pixel number. 10*10 pixel array could provide enough information for people to recognize an isolated Chinese character. At low resolution (6*6 and 8*8 pixel array), there were little difference of recognition accuracy between different pixel shape and different pixel spacing. While as for high resolution (10*10 and 12*12 pixel array), the fluctuation of pixel shape and pixel spacing could not affect the performance of recognition of isolated pixelized Chinese Character.

Electrical Characterization of 3D Au Microelectrodes for Use in Retinal Prostheses

In order to provide high-quality visual information to patients who have implanted retinal prosthetic devices, the number of microelectrodes should be large. As the number of microelectrodes is increased, the dimensions of each microelectrode must be decreased, which in turn results in an increased microelectrode interface impedance and decreased injection current dynamic range. In order to improve the trade-off envelope between the number of microelectrodes and the current injection characteristics, a 3D microelectrode structure can be used as an alternative. In this paper, the electrical characteristics of 2D and 3D Au microelectrodes were investigated. In order to examine the effects of the structural difference, 2D and 3D Au microelectrodes with different base areas but similar effective surface areas were fabricated and evaluated. Interface impedances were measured and similar dynamic ranges were obtained for both 2D and 3D Au microelectrodes. These results indicate that more electrodes can be implemented in the same area if 3D designs are used. Furthermore, the 3D Au microelectrodes showed substantially enhanced electrical durability characteristics against over-injected stimulation currents, withstanding electrical currents that are much larger than the limit measured for 2D microelectrodes of similar area. This enhanced electrical durability property of 3D Au microelectrodes is a new finding in microelectrode research, and makes 3D microelectrodes very desirable devices.

Subretinal Visual Implant Alpha IMS--Clinical trial interim report

A subretinal visual implant (Alpha IMS, Retina Implant AG, Reutlingen, Germany) was implanted in 29 blind participants with outer retinal degeneration in an international multicenter clinical trial. Primary efficacy endpoints of the study protocol were a significant improvement of activities of daily living and mobility to be assessed by activities of daily living tasks, recognition tasks, mobility, or a combination thereof. Secondary efficacy endpoints were a significant improvement of visual acuity/light perception and/or object recognition (clinicaltrials.gov, NCT01024803). During up to 12 months observation time twenty-one participants (72%) reached the primary endpoints, of which thirteen participants (45%) reported restoration of visual function which they use in daily life. Additionally, detection, localization, and identification of objects were significantly better with the implant power switched on in the first 3 months. Twenty-five participants (86%) reached the secondary endpoints. Measurable grating acuity was up to 3.3 cycles per degree, visual acuities using standardized Landolt C-rings were 20/2000, 20/2000, 20/606 and 20/546. Maximal correct motion perception ranged from 3 to 35 degrees per second. These results show that subretinal implants can restore very-low-vision or low vision in blind (light perception or less) patients with end-stage hereditary retinal degenerations.

Inner retinal preservation in rat models of retinal degeneration implanted with subretinal photovoltaic arrays

Photovoltaic arrays (PVA) implanted into the subretinal space of patients with retinitis pigmentosa (RP) are designed to electrically stimulate the remaining inner retinal circuitry in response to incident light, thereby recreating a visual signal when photoreceptor function declines or is lost. Preservation of inner retinal circuitry is critical to the fidelity of this transmitted signal to ganglion cells and beyond to higher visual targets. Post-implantation loss of retinal interneurons or excessive glial scarring could diminish and/or eliminate PVA-evoked signal transmission. As such, assessing the morphology of the inner retina in RP animal models with subretinal PVAs is an important step in defining biocompatibility and predicting success of signal transmission. In this study, we used immunohistochemical methods to qualitatively and quantitatively compare inner retinal morphology after the implantation of a PVA in two RP models: the Royal College of Surgeons (RCS) or transgenic S334ter-line 3 (S334ter-3) rhodopsin mutant rat. Two PVA designs were compared. In the RCS rat, we implanted devices in the subretinal space at 4 weeks of age and histologically examined them at 8 weeks of age and found inner retinal morphology preservation with both PVA devices. In the S334ter-3 rat, we implanted devices at 6-12 weeks of age and again, inner retinal morphology was generally preserved with either PVA design 16-26 weeks post-implantation. Specifically, the length of rod bipolar cells and numbers of cholinergic amacrine cells were maintained along with their characteristic inner plexiform lamination patterns. Throughout the implanted retinas we found nonspecific glial reaction, but none showed additional glial scarring at the implant site. Our results indicate that subretinally implanted PVAs are well-tolerated in rodent RP models and that the inner retinal circuitry is preserved, consistent with our published results showing implant-evoked signal transmission.

Simultaneous recording of mouse retinal ganglion cells during epiretinal or subretinal stimulation

We compared response patterns and electrical receptive fields (ERF) of retinal ganglion cells (RGCs) during epiretinal and subretinal electrical stimulation of isolated mouse retina. Retinas were stimulated with an array of 3200 independently controllable electrodes. Four response patterns were observed: a burst of activity immediately after stimulation (Type I cells, Vision Research (2008), 48, 1562-1568), delayed bursts beginning >25ms after stimulation (Type II), a combination of both (Type III), and inhibition of ongoing spike activity. Type I responses were produced more often by epiretinal than subretinal stimulation whereas delayed and inhibitory responses were evoked more frequently by subretinal stimulation. Response latencies were significantly shorter with epiretinal than subretinal stimulation. These data suggest that subretinal stimulation is more effective at activating intraretinal circuits than epiretinal stimulation. There was no significant difference in charge threshold between subretinal and epiretinal configurations. ERFs were defined by the stimulating array surface area that successfully stimulated spikes in an RGC. ERFs were complex in shape, similar to receptive fields mapped with light. ERF areas were significantly smaller with subretinal than epiretinal stimulation. This may reflect the greater distance between stimulating electrodes and RGCs in the subretinal configuration. ERFs for immediate and delayed responses mapped within the same Type III cells differed in shape and size, consistent with different sites and mechanisms for generating these two response types.

Vision rehabilitation in the case of blindness

This article examines the various vision rehabilitation procedures that are available for early and late blindness. Depending on the pathology involved, several vision rehabilitation procedures exist, or are in development. Visual aids are available for low vision individuals, as are sensory aids for blind persons. Most noninvasive sensory substitution prostheses as well as implanted visual prostheses in development are reviewed. Issues dealing with vision rehabilitation are also discussed, such as problems of biocompatibility, electrical safety, psychosocial aspects, and ethics. Basic studies devoted to vision rehabilitation such as simulation in mathematical models and simulation of artificial vision are also presented. Finally, the importance of accurate rehabilitation assessment is addressed, and tentative market figures are given.

Artificial human vision

Can vision be restored to the blind? As early as 1929 it was discovered that stimulating the visual cortex of an individual led to the perception of spots of light, known as phosphenes [1] . The aim of artificial human vision systems is to attempt to utilize the perception of phosphenes to provide a useful substitute for normal vision. Currently, four locations for electrical stimulation are being investigated; behind the retina (subretinal), in front of the retina (epiretinal), the optic nerve and the visual cortex (using intra- and surface electrodes). This review discusses artificial human vision technology and requirements, and reviews the current development projects.

Holographic display system for restoration of sight to the blind

OBJECTIVE

We present a holographic near-the-eye display system enabling optical approaches for sight restoration to the blind, such as photovoltaic retinal prosthesis, optogenetic and other photoactivation techniques. We compare it with conventional liquid crystal displays (LCD) or digital light processing (DLP)-based displays in terms of image quality, field of view, optical efficiency and safety.

APPROACH

We detail the optical configuration of the holographic display system and its characterization using a phase-only spatial light modulator.

MAIN RESULTS

We describe approaches to controlling the zero diffraction order and speckle related issues in holographic display systems and assess the image quality of such systems. We show that holographic techniques offer significant advantages in terms of peak irradiance and power efficiency, and enable designs that are inherently safer than LCD or DLP-based systems. We demonstrate the performance of our holographic display system in the assessment of cortical response to alternating gratings projected onto the retinas of rats.

SIGNIFICANCE

We address the issues associated with the design of high brightness, near-the-eye display systems and propose solutions to the efficiency and safety challenges with an optical design which could be miniaturized and mounted onto goggles.

The Detection of Motion by Blind Subjects With the Epiretinal 60-Electrode (Argus II) Retinal Prosthesis

OBJECTIVE

To investigate the ability of 28 blind subjects implanted with a 60-electrode Argus II (Second Sight Medical Products Inc) retinal prosthesis system to detect the direction of a moving object.

METHODS

Blind subjects (bare light perception or worse in both eyes) with retinitis pigmentosa were implanted with the Argus II prosthesis as part of a phase 1/2 feasibility study at multiple clinical sites worldwide. The experiment measured their ability to detect the direction of motion of a high-contrast moving bar on a flatscreen monitor in 3 conditions: with the prosthesis system on and a 1-to-1 mapping of spatial information, with the system off, and with the system on but with randomly scrambled spatial information.

RESULTS

Fifteen subjects (54%) were able to perform the task significantly better with their prosthesis system than they were with their residual vision, 2 subjects had significantly better performance with their residual vision, and no difference was found for 11 subjects. Of the 15 better-performing subjects, 11 were available for follow-up testing, and 10 of them had significantly better performance with normal rather than with scrambled spatial information.

CONCLUSIONS

This work demonstrates that blind subjects implanted with the Argus II retinal prosthesis were able to perform a motion detection task they could not do with their native vision, confirming that electrical stimulation of the retina provides spatial information from synchronized activation of multiple electrodes.

TRIAL REGISTRATION

clinicaltrials.gov Identifier:NCT00407602

Factors Affecting Perceptual Threshold in Argus II Retinal Prosthesis Subjects

PURPOSE

The Argus II epiretinal prosthesis has been developed to provide partial restoration of vision to subjects blinded from outer retinal degenerative disease. Participants were surgically implanted with the system in the United States and Europe in a single arm, prospective, multicenter clinical trial. The purpose of this investigation was to determine which factors affect electrical thresholds in order to inform surgical placement of the device.

METHODS

Electrode-retina and electrode-fovea distances were determined using SD-OCT and fundus photography, respectively. Perceptual threshold to electrical stimulation of electrodes was measured using custom developed software, in which current amplitude was varied until the threshold was found. Full field stimulus light threshold was measured using the Espion D-FST test. Relationships between electrical threshold and these three explanatory variables (electrode-retina distance, electrode-fovea distance, and monocular light threshold) were quantified using regression.

RESULTS

Regression analysis showed a significant correlation between electrical threshold and electrode-retina distance (R² = 0.50, P = 0.0002; n = 703 electrodes). 90.3% of electrodes in contact with the macula (n = 207) elicited percepts at charge densities less than 1 mC/cm²/phase. These threshold data also correlated well with ganglion cell density profile (P = 0.03). A weaker, but still significant, inverse correlation was found between light threshold and electrical threshold (R² < 0.52, P = 0.01). Multivariate modeling indicated that electrode-retina distance and light threshold are highly predictive of electrode threshold (R² = 0.87; P < 0.0005).

CONCLUSIONS

Taken together, these results suggest that while light threshold should be used to inform patient selection, macular contact of the array is paramount.

TRANSLATIONAL RELEVANCE

Reported Argus II clinical study results are in good agreement with prior in vitro and in vivo studies, and support the development of higher-density systems that employ smaller diameter electrodes. (clinicaltrials.gov identifier: NCT00407602).

Electrical characteristics of 2D and 3D microelectrodes for high-resolution retinal prostheses

In order to provide high quality visual information to patients who have implanted retinal prosthetic devices, the number of microelectrode should be large. As the number of microelectrode is increased, the dimension of the microelectrode is decreased, which in turn results in the increased interface impedance of microelectrode and decreased dynamic range of injection current. In addition, the reduced maximum limit of injection current may not be sufficiently large to stimulate the ganglion cells in a retina. In order to improve the trade-off envelope between number of microelectrode and current injection limit, a 3D microelectrode structure can be used as an alternative. From the advancement of microfabrication technology, the fabrication of highly-accurate 3D structures with small dimensions is possible. This paper presents a first comprehensive electrical characterization of 2D and 3D microelectrodes for high-resolution retinal prostheses. Microelectrodes which differ in shapes and diameters are analyzed. Their interface impedances and charge injection limits are quantitatively analyzed. This research can be used to define requirements for further retinal prosthetic device research.

Development and evaluation of thin-film flexible microelectrode arrays for retinal stimulation and recording

We have described the development of a flexible microelectrode array with potential applications in the large scale recording of neural signals and in focal electrical stimulation for use as a prosthetic implant in degenerative retinal diseases. The array under test consisted of 61 platinum electrodes of 5 µm diameter with 60 µm spacing connected by 8 µm wide gold tracks encased in a flexible polyimide substrate of 15 µm thickness from which recordings were taken from 16 electrodes. The device was tested on an exposed frog eyecup preparation which is characterized by small retinal ganglion cells of similar dimensions to those present in the human retina. The responses of these cells evoked by photic stimulation consisted of trains of action potentials of high signal-to noise ratio at each of the recording sites. Delivery of cathodal constant voltage pulses and constant current pulses to specific electrodes in the array led to the generation of action potentials in adjacent electrodes, implying that retinal ganglion cells in the proximity had been stimulated. Since prolonged stimulation with supra-threshold voltages impaired neither electrode structure nor retinal function, these results provide a sound basis for scaling up the number of array electrodes to deliver focal electrical pulses to the retina, as would be required by a viable epiretinal prosthesis.

Photovoltaic retinal prosthesis: implant fabrication and performance

The objective of this work is to develop and test a photovoltaic retinal prosthesis for restoring sight to patients blinded by degenerative retinal diseases. A silicon photodiode array for subretinal stimulation has been fabricated by a silicon-integrated-circuit/MEMS process. Each pixel in the two-dimensional array contains three series-connected photodiodes, which photovoltaically convert pulsed near-infrared light into bi-phasic current to stimulate nearby retinal neurons without wired power connections. The device thickness is chosen to be 30 µm to absorb a significant portion of light while still being thin enough for subretinal implantation. Active and return electrodes confine current near each pixel and are sputter coated with iridium oxide to enhance charge injection levels and provide a stable neural interface. Pixels are separated by 5 µm wide trenches to electrically isolate them and to allow nutrient diffusion through the device. Three sizes of pixels (280, 140 and 70 µm) with active electrodes of 80, 40 and 20 µm diameter were fabricated. The turn-on voltages of the one-diode, two-series-connected diode and three-series-connected diode structures are approximately 0.6, 1.2 and 1.8 V, respectively. The measured photo-responsivity per diode at 880 nm wavelength is ∼0.36 A W(-1), at zero voltage bias and scales with the exposed silicon area. For all three pixel sizes, the reverse-bias dark current is sufficiently low (<100 pA) for our application. Pixels of all three sizes reliably elicit retinal responses at safe near-infrared light irradiances, with good acceptance of the photodiode array in the subretinal space. The fabricated device delivers efficient retinal stimulation at safe near-infrared light irradiances without any wired power connections, which greatly simplifies the implantation procedure. Presence of the return electrodes in each pixel helps to localize the current, and thereby improves resolution.

A novel in vitro sensing configuration for retinal physiology analysis of a sub-retinal prosthesis

This paper presents a novel sensing configuration for retinal physiology analysis, using two microelectrode arrays (MEAs). In order to investigate an optimized stimulation protocol for a sub-retinal prosthesis, retinal photoreceptor cells are stimulated, and the response of retinal ganglion cells is recorded in an in vitro environment. For photoreceptor cell stimulation, a polyimide-substrate MEA is developed, using the microelectromechanical systems (MEMS) technology. For ganglion cell response recording, a conventional glass-substrate MEA is utilized. This new sensing configuration is used to record the response of retinal ganglion cells with respect to three different stimulation methods (monopolar, bipolar, and dual-monopolar stimulation methods). Results show that the geometrical relation between the stimulation microelectrode locations and the response locations seems very low. The threshold charges of the bipolar stimulation and the monopolar stimulation are in the range of 10∼20 nC. The threshold charge of the dual-monopolar stimulation is not obvious. These results provide useful guidelines for developing a sub-retinal prosthesis.

Sensory rehabilitation in the plastic brain

The purpose of this review is to consider new sensory rehabilitation avenues in the context of the brain's remarkable ability to reorganize itself following sensory deprivation. Here, deafness and blindness are taken as two illustrative models. Mainly, two promising rehabilitative strategies based on opposing theoretical principles will be considered: sensory substitution and neuroprostheses. Sensory substitution makes use of the remaining intact senses to provide blind or deaf individuals with coded information of the lost sensory system. This technique thus benefits from added neural resources in the processing of the remaining senses resulting from crossmodal plasticity, which is thought to be coupled with behavioral enhancements in the intact senses. On the other hand, neuroprostheses represent an invasive approach aimed at stimulating the deprived sensory system directly in order to restore, at least partially, its functioning. This technique therefore relies on the neuronal integrity of the brain areas normally dedicated to the deprived sense and is rather hindered by the compensatory reorganization observed in the deprived cortex. Here, we stress that our understanding of the neuroplastic changes that occur in sensory-deprived individuals may help guide the design and the implementation of such rehabilitative methods.