Multifocal stimulation techniques in ophthalmology -- Current knowledge and perspectives

Comparison of DTL and gold cup skin electrodes for recordings of the multifocal electroretinogram

OBJECTIVE

To compare mfERG recordings with the Dawson-Trick-Litzkow (DTL) and gold cup skin electrode in healthy young and old adults and to test the sensitivity of both electrodes to age-related changes in the responses.

METHODS

Twenty participants aged 20-27 years ("young") and 20 participants aged 60-75 ("old") with a visual acuity of ≤ 0 logMAR were included. The mfERG responses were recorded simultaneously using DTL and skin electrodes. P1 amplitudes, peak times and signal-to-noise ratios (SNRs) were compared between both electrodes and across age groups, and correlation analyses were performed. The electrode's performance in discriminating between age groups was assessed via area under curve (AUC) of receiver operating characteristics.

RESULTS

Both electrodes reflected the typical waveform of mfERG recordings. For the skin electrode, however, P1 amplitudes were significantly reduced (p < 0.001; reduction by over 70%), P1 peak times were significantly shorter (p < 0.001; by approx. 1.5 ms), and SNRs were reduced [(p < 0.001; logSNR ± SEM DTL young (old) vs gold cup: 0.79 ± 0.13 (0.71 ± 0.15) vs 0.37 ± 0.15 (0.34 ± 0.13)]. All mfERG components showed strong significant correlations (R² ≥ 0.253, p < 0.001) between both electrodes for all eccentricities. Both electrodes allowed for the identification of age-related P1 changes, i.e., P1-amplitude reduction and peak-time delay in the older group. There was a trend to higher AUC for the DTL electrode to delineate these differences between age groups, which, however, failed to reach statistical significance.

CONCLUSIONS

Both electrode types enable successful mfERG recordings. However, in compliant patients, the use of the DTL electrode appears preferable due to the larger amplitudes, higher signal-to-noise ratio and its better reflection of physiological changes, i.e., age effects. Nevertheless, skin electrodes appear a viable alternative for mfERG recordings in patients in whom the use of corneal electrodes is precluded, e.g., children and disabled patients.

[Multifocal electroretinography in assessment of the functional state of the central retina in patients with retinitis pigmentosa]

Retinitis pigmentosa (RP) is an inherited disease associated with various genetic mutations. Developments in the field of genetic engineering give relevance to the search for methods of studying retinal function, which can prove informative in the selection of patients for treatment.

PURPOSE

To evaluate the information content of multifocal electroretinography (mfERG) in the diagnostics of the functional state of the central retina in retinitis pigmentosa (RP).

MATERIAL AND METHODS

The study included 115 patients (228 eyes) with PR and 15 people (30 eyes) who comprised the control group. All subjects underwent standard ophthalmological examination, computer perimetry, color vision study, retinal spectral optical coherence tomography, ganzfeld electroretinography (gERG) and mfERG. The relationship between mfERG parameters and the degree of gERG changes, as well as various functional and morphological parameters of the retina was assessed.

RESULTS

Visual acuity and perimetry indices varied over a wide range. GERG was unrecordable in 50.4% of cases. MfERG was registered in 214 (98.3%) eyes with varying degrees of change in visual acuity, visual field and gERG parameters. A medium degree positive relationship was revealed between the biopotential density of the retina in the foveal and parafoveal zones and visual acuity (r_s=0.68; 0.63), a high degree - between the density of ttotal biopotential of the central retina (DValue) and the average light sensitivity (r_s=0.9), a weak degree - between DValue and the thickness and volume of the peripheral retina (r_s=0.37; 0.42), a medium negative correlation was found between the average defect in light sensitivity and the biopotential density in the periphery (Rings 4-5) on mfERG, DValue (r_s= -0.67; -0.65; -0.69).

CONCLUSION

MfERG detects retinal dysfunctions at an early stage of RP, in eyes with high visual acuity, normal parameters of the central visual field and gERG, as well as in low visual acuity, a pronounced decrease in light sensitivity, unrecordable gERG. MfERG can be informative in the selection of patients with RP for gene therapy.

Multimodal assessment of microscopic morphology and retinal function in patients with geographic atrophy

PURPOSE

To correlate retinal function and visual sensitivity with retinal morphology revealed by ultrahigh-resolution imaging with adaptive optics-optical coherence tomography (AO-OCT), on patients with geographic atrophy.

METHODS

Five eyes from five subjects were tested (four with geographic atrophy [66.3 ± 6.4 years, mean ± 1 SD] and one normal [61 years]). Photopic and scotopic multifocal electroretinograms (mfERGs) were recorded. Visual fields were assessed with microperimetry (mP) combined with a scanning laser ophthalmoscope for high-resolution confocal retinal fundus imaging. The eye tracker of the microperimeter identified the preferred retinal locus that was then used as a reference for precise targeting of areas for advanced retinal imaging. Images were obtained with purpose-built, in-house, ultrahigh resolution AO-OCT. Fundus autofluorescence (FAF) and color fundus (CF) photographs were also acquired.

RESULTS

The AO-OCT imaging provided detailed cross-sectional structural representation of the retina. Up to 12 retinal layers were identified in the normal subject while many severe retinal abnormalities (i.e., calcified drusen, drusenoid pigment epithelium detachment, outer retinal tubulation) were identified in the retinae of the GA patients. The functional tests showed preservation of sensitivities, although somewhat compromised, at the border of the GA.

CONCLUSIONS

The images provided here advance our knowledge of the morphology of retinal layers in GA patients. While there was a strong correlation between altered retinal structure and reduction in visual function, there were a number of examples in which the photoreceptor inner/outer segment (IS/OS) junctions lost reflectivity at the margins of GA, while visual function was still demonstrated. This was shown to be due to changes in photoreceptor orientation near the GA border.

MfERG responses to long-duration white stimuli in glaucoma patients

The intent of our study was to evaluate whether the response to a long-duration white stimulus in the multifocal electroretinogram (mfERG) is sufficiently sensitive to detect early retinal dysfunction in glaucoma. On-off mfERGs were recorded from 15 NTG and 15 HTG patients and compared with 14 control subjects. Recording parameters were the following: LED stimulus screen (RETIscan™), 100-ms stimulus duration, 200-ms stimulus interval, 11-min total recording time, stimulus matrix of 61 elements, frame rate: 70 Hz, Lmax: 180 cd/m(2), Lmin: 0 cd/m(2), and filter setting: 1-200 Hz. The second negative response following stimulus onset (N2-on), as well as following stimulus offset (N2-off), was analyzed as an overall response and in quadrants, as well as in 4 small central and four adjoining peripheral areas per quadrant. The latency of the N2-on was significantly delayed in HTG in all response averages tested, while in NTG this was only seen in the overall response and in the small central response averages (P < 0.05). The most sensitive measure in HTG was the latency of the N2-on of the small peripheral response average of the superior temporal quadrant with an area under the ROC curve of 0.881. For NTG, the most representative measure was the latency of the N2-on of the small central response average of the inferior nasal quadrant with an area under the ROC curve of 0.793. Our results showed that in stimulation with long-duration flashes, the second negative response following the on response, representative of the early PhNR, is affected in glaucoma where N2-on showed a latency delay in POAG patients. The latency delay of the N2-on was more prominent for HTG than for NTG.

30 Hz-flicker mfERG in primary open-angle glaucoma patients : 30 Hz-flicker-mfERG in POAG

PURPOSE

This study was performed in an attempt to gain more information on whether the 30 Hz-flicker mfERG indeed provides a sensitive measure of dysfunction in patients with primary open-angle glaucoma (POAG) as has been suggested previously.

METHODS

Eighteen POAG patients with visual field defects (MD > 2.2 dB) and glaucomatous optic neuropathies as well as 10 control subjects underwent mfERG recording as follows: 30 Hz-flicker mfERG, LED stimulus screen, 61 hexagons, Lmax: 180 cd/m2, Lmin: 0 cd/m2, recording time: approximately 5 min, filter setting: 10-200 Hz. The 30 Hz response (also called the fundamental or the first harmonic response (1HW) and the second harmonic wave at 60 Hz (2HW) were analysed as an overall response and in quadrants, as well as in 4 small neighbouring areas per quadrant. The patients' mfERGs were compared to those of the control group and to the mean defect values (MD) of the corresponding quadrants of the Octopus perimetry.

RESULTS

Neither in the overall response, nor in the quadrants, nor in the smaller areas examined did amplitudes and phases of the 1HW and the 2HW or the amplitude ratio of the 2HW to the 1HW (DFT-ratio) differ from the controls (P > 0.05-ANOVA). There was no significant correlation between mfERG values and the MD (Spearman-test, Bonferroni).

CONCLUSION

Thus, the 30 Hz-flicker mfERG does not seem to be sensitive enough to separate glaucoma patients from normal.

Slow-stimulated multifocal ERG in high- and normal-tension glaucoma

PURPOSE

To study the ability and sensitivity of the slow stimulation multifocal ERG (mfERG) to detect glaucomatous damage.

METHODS

Right eyes of 20 patients with normal-tension glaucoma (NTG), 15 patients with high-tension glaucoma (HTG) and 15 healthy volunteers underwent testing with the mfERG (VERIS 4.1). The central 50 degrees of the retina were stimulated by 103 hexagons (m-sequence: 2(13)-1, Lmax: 100 cd/m(2), Lmin: 1 cd/m(2), background: 50 cd/m(2)). Each m-sequence step was followed by 3 black frames (Lmax: < 1 cd/m(2)). Five response averages of the first order response component (KI) were analyzed: the central 7.5 degrees and the 4 adjoining quadrants. The amplitudes from the first minimum, N1, to the first maximum, P1, and from P1 to the second minimum, N2, were analyzed as well as the latencies of N1, P1, N2 and the latencies of 3 multifocal oscillatory potentials (mfOPs) with their maxima at about 73, 80 and 85 ms.

RESULTS

For each parameter the percentage of deviation from the mean of the control group was calculated. These values were then added for each individual to form a deviation index (DI). Seventeen patients (85.0%) with NTG and 3 patients (20.0%) with HTG showed a DI outside the normal range. The major changes were observed in the mfOPs of the NTG patients. MfOPs were then selectively filtered at 100-300 Hz and their scalar product was analyzed over an epoch of 68-105 ms. This confirmed that mfOPs differed significantly from the control in the central 7.5 degrees and, for NTG, in the nasal field. With a logistic regression analysis the mfOPs had a sensitivity to differentiate 85% of the NTG patients and 73% of the HTG patients from normal.

CONCLUSIONS

Under these conditions, the slow-stimulated mfERG can detect glaucomatous dysfunction in NTG (85.0%). The differences observed between NTG and HTG are in support of a different underlying pathomechanism.

A Comparison of the Fast Stimulation Multifocal-ERG in Patients with an IOL and Control Groups of Different Age

PURPOSE

It has been shown that a cataract significantly reduces mfERG responses in the central 4-14 degrees . Removing the cataract, leads to a significant increase in the response of the central 4 degrees . In this study we compare the mfERG of Woerdehoff et al.'s patients' [Doc Ophthalmol 2004; 108(1): 67-75] following cataract surgery to a healthy control group in order to assess whether, in the elderly, further influences of age need to be considered in addition to optical effects.

METHODS

Eighteen patients with an IOL following cataract surgery and 29 healthy volunteers (without clouding of the media or retinal changes) underwent testing of the mfERG (103 hexagons stimulating the central 50 degrees , M-sequence 2(15), Lmax: 200 cd/m2, Lmin<1 cd/m2). For the first order response component we compared the latencies of N1,P1 and N2 as well as the natural logarithm (ln) of the amplitudes N1P1 and P1N2 for four group averages: I. the central 4 degrees, II. 4-7 degrees, III. 7-10 degrees and IV. 10-15 degrees.

RESULTS

Mean age was 67 years (SD 10.1) for the IOL patients, 28.5 years (SD 5.6) for a young group of controls (n=15) and 60.2 years (SD 9.2) for the older control group (n=14). Patients with an IOL did not differ in latency from either control group (ANOVA, Tukey). Interestingly, at 10-15 degrees eccentricity, the latency of N2 differed significantly between the younger (41.4 ms, SD 1.4) and the older (43.0 ms, SD 1.9) control group. In the central 4 degrees LnN1P1 amplitudes were significantly lower in the IOL group (mean: 3.7, SD 0.2) than either the younger (mean: 3.9, SD 3.3) or the older (mean: 4.0, SD 0.3) control group. In all other amplitude measures, the older control group had slightly larger mean amplitudes than the younger control group and significantly larger amplitudes than the patients with an IOL, whose amplitudes were lowest.

DISCUSSION

Both, primarily optical but also neural phenomena have been described to affect the mfERG changes observed with age. Our results, are in support of this, as the improvement of the mfERG response following cataract surgery does not seem to reach the level of a healthy control group of equal age. Thus, our results suggest, that a control group with an IOL should be used when retinal function is tested in subjects with an IOL.

Retinal perfusion response to a slow multifocal M-sequence flicker stimulation

PURPOSE

To assess, if a slow multifocal stimulus (mfS) can provoke a perfusion response that can be measured with the Retinal Vessel Analyzer (RVA).

METHODS

Seventeen eyes were examined. Pupils were dilated. A 120-second baseline recording was obtained with the RVA. The subject then turned to view an mfS for 56 s. The mfS consisted of 103 hexagons flickering according to an m-sequence with a stimulus base interval of 53.3 ms (L(max) = 100 cd/m(2), L(min) < 1 cd/m(2)). Immediately thereafter, the subject turned to the RVA, where measurements were resumed as soon as the same retinal vessel was targeted and continued for 104 s. Stimulation and recording was repeated twice. The diameter of a retinal vein and artery was measured for a length of at least 1 mm. The maximum vessel response was obtained by linear interpolation of the measured response within the 20 s following mfS.

RESULTS

On average, veins dilated by 6.8% and arteries by 7% following mfS (p > 0.005). Such a dilatation could be observed in 9 veins and 7 arteries. Three venous and 2 arterial measurements did not show a dilatation following mfS. However, 13 of 34 measurements could not be analyzed due to signal problems or because the time from the end of mfS and the uptake of measurement exceeded 20 s.

CONCLUSION

This slow multifocal ERG stimulus results in a dilatation of arteries and veins that can be measured with the RVA. Coupling an mfS to the RVA has the potential to topographically map changes in retinal perfusion in relation to the respective retinal area stimulated. When implementing the mfS into the RVA setup in order not to lose time due to the refixation in the RVA following mfS, one is required to take the transient nature of this perfusion change into consideration.