Defining the nature of motion perception deficits in glaucoma using simple and complex motion stimuli

Sodium Hyaluronate-Induced Ocular Hypertension in Rats Damages the Direction-Selective Circuit and Inner/Outer Retinal Plexiform Layers

Purpose

To assess the changes in retinal morphology in a rat model of chronic glaucoma induced by ocular hypertension.

Methods

Intraocular pressure (IOP) was surgically increased through weekly injections of sodium hyaluronate (HYA) in the anterior eye chamber of the left eye of male Wistar rats, whereas the right eyes were sham operated (salt solution). During the 10-week experimental period, IOP was measured weekly with a rebound tonometer. Retinal cryosections were prepared for histological/immunohistochemical analysis and morphometry.

Results

IOP was higher in HYA-treated eyes than in sham-operated eyes along the 10-week period, which was significant from the fourth to the nineth week. Ocular hypertension in HYA-treated eyes was associated with morphologic and morphometric changes in bipolar cells, ON-OFF direction-selective ganglion cells, ON/OFF starburst amacrine cells, and inner plexiform layer sublamina.

Conclusions

Serial HYA treatment in the rat anterior eye chamber results in mild-to-moderate elevated and sustained IOP and ganglion cell death, which mimics most human open-angle glaucoma hallmarks. The reduced number of direction-selective ganglion cells and starburst amacrine cells accompanied by a deteriorated ON/OFF plexus in this glaucoma model could lend insight to the abnormalities in motion perception observed in patients with glaucoma.

Immediate Impact of Acute Elevation of Intraocular Pressure on Cortical Visual Motion Processing

Purpose

To physiologically examine the impairment of cortical sensitivity to visual motion during acute elevation of intraocular pressure (IOP).

Methods

Motion processing in the cat brain is well characterized, its X and Y cell visual pathways being functionally analogous to parvocellular and magnocellular pathways in primates. Using this model, we performed ocular anterior chamber perfusion to reversibly elevate IOP over a range from 30 to 90 mm Hg while monitoring cortical activity with intrinsic signal optical imaging. Drifting random-dot fields and gratings were used to characterize cortical population responses to motion direction and orientation in early visual areas 17 and 18.

Results

We found that acute IOP elevations at 50 mm Hg and above, which is often observed in acute glaucoma, suppressed cortical motion direction responses. This suppression was more profound in area 17 than in area 18, and more profound in central than peripheral visual field (eccentricities 0°–4° vs. 4°–8°) within area 17. In addition, orientation responses were more suppressed than motion direction responses for the same IOP modulation.

Conclusions

In contrast to human chronic glaucoma that may cause greater dysfunction in large-cell magnocellular than in small-cell parvocellular visual pathways, our direct measurement of cortical processing networks implies that the small X-cell pathway shows greater vulnerability to acute IOP elevation than the large Y-cell pathway in visual motion processing. The results demonstrate that fine discrimination mechanisms for motion in the central visual field are particularly impacted by acute IOP attacks, suggesting a neural basis for immediate visual deficits in the fine motion perception of acute glaucoma patients.

Reduced Cerebral Blood Flow in the Visual Cortex and Its Correlation With Glaucomatous Structural Damage to the Retina in Patients With Mild to Moderate Primary Open-angle Glaucoma

PURPOSE

Altered ocular and cerebral vascular autoregulation and vasoreactivity have been demonstrated in patients with primary open-angle glaucoma (POAG). In the present study, we investigated the correlations between reduced cerebral blood flow (CBF) in early and higher-tier visual cortical areas and glaucomatous changes in the retinas of patients with mild to moderate POAG.

PATIENTS AND METHODS

3-dimensional pseudocontinuous arterial spin labelling magnetic resonance imaging at 3 T was performed in 20 normal controls and 15 mild to moderate POAG patients. Regions of interest were selected based on the Population-Average, Landmark- and Surface-based (PALS) atlas of the human cerebral cortex. Arterial spin labelling-measured CBF values were extracted in the early and higher-tier visual cortical areas and were compared between patients and controls using a 2-sample t test. Pearson correlation analyses were used to assess the correlations between reduced CBF and cup-to-disc ratio, retinal nerve fiber layer thickness, and ganglion cell complex thickness.

RESULTS

Reduced CBF in early visual cortical areas (V1, V2, and ventral posterior area) and in the higher-tier visual left lateral occipital cortex was presented in mild to moderate POAG patients compared with controls. Furthermore, reduced CBF of the right areas V2 and ventral posterior area was correlated with cup-to-disc ratio, total ganglion cell complex thickness, and average retinal nerve fiber layer thickness.

CONCLUSIONS

In conclusion, the complex pathologic progress of POAG includes abnormal cerebral perfusion within the visual cortex since the mild to moderate disease stages. The association of cerebral perfusion changes with alterations of the optic disc and the retina may contribute to the early diagnosis of POAG.

Fear of falling and postural reactivity in patients with glaucoma

Purpose

To investigate the relationship between postural metrics obtained by dynamic visual stimulation in a virtual reality environment and the presence of fear of falling in glaucoma patients.

Methods

This cross-sectional study included 35 glaucoma patients and 26 controls that underwent evaluation of postural balance by a force platform during presentation of static and dynamic visual stimuli with head-mounted goggles (Oculus Rift). In dynamic condition, a peripheral translational stimulus was used to induce vection and assess postural reactivity. Standard deviations of torque moments (SDTM) were calculated as indicative of postural stability. Fear of falling was assessed by a standardized questionnaire. The relationship between a summary score of fear of falling and postural metrics was investigated using linear regression models, adjusting for potentially confounding factors.

Results

Subjects with glaucoma reported greater fear of falling compared to controls (-0.21 vs. 0.27; P = 0.039). In glaucoma patients, postural metrics during dynamic visual stimulus were more associated with fear of falling (R² = 18.8%; P = 0.001) than static (R² = 3.0%; P = 0.005) and dark field (R² = 5.7%; P = 0.007) conditions. In the univariable model, fear of falling was not significantly associated with binocular standard perimetry mean sensitivity (P = 0.855). In the multivariable model, each 1 Nm larger SDTM in anteroposterior direction during dynamic stimulus was associated with a worsening of 0.42 units in the fear of falling questionnaire score (P = 0.001).

Conclusion

In glaucoma patients, postural reactivity to a dynamic visual stimulus using a virtual reality environment was more strongly associated with fear of falling than visual field testing and traditional balance assessment.

Evaluation of Postural Control in Patients with Glaucoma Using a Virtual Reality Environment

PURPOSE

To evaluate postural control using a dynamic virtual reality environment and the relationship between postural metrics and history of falls in patients with glaucoma.

DESIGN

Cross-sectional study.

PARTICIPANTS

The study involved 42 patients with glaucoma with repeatable visual field defects on standard automated perimetry (SAP) and 38 control healthy subjects.

METHODS

Patients underwent evaluation of postural stability by a force platform during presentation of static and dynamic visual stimuli on stereoscopic head-mounted goggles. The dynamic visual stimuli presented rotational and translational ecologically valid peripheral background perturbations. Postural stability was also tested in a completely dark field to assess somatosensory and vestibular contributions to postural control. History of falls was evaluated by a standard questionnaire.

MAIN OUTCOME MEASURES

Torque moments around the center of foot pressure on the force platform were measured, and the standard deviations of the torque moments (STD) were calculated as a measurement of postural stability and reported in Newton meters (Nm). The association with history of falls was investigated using Poisson regression models. Age, gender, body mass index, severity of visual field defect, best-corrected visual acuity, and STD on dark field condition were included as confounding factors.

RESULTS

Patients with glaucoma had larger overall STD than controls during both translational (5.12 ± 2.39 Nm vs. 3.85 ± 1.82 Nm, respectively; P = 0.005) and rotational stimuli (5.60 ± 3.82 Nm vs. 3.93 ± 2.07 Nm, respectively; P = 0.022). Postural metrics obtained during dynamic visual stimuli performed better in explaining history of falls compared with those obtained in static and dark field condition. In the multivariable model, STD values in the mediolateral direction during translational stimulus were significantly associated with a history of falls in patients with glaucoma (incidence rate ratio, 1.85; 95% confidence interval, 1.30-2.63; P = 0.001).

CONCLUSIONS

The study presented and validated a novel paradigm for evaluation of balance control in patients with glaucoma on the basis of the assessment of postural reactivity to dynamic visual stimuli using a virtual reality environment. The newly developed metrics were associated with a history of falls and may help to provide a better understanding of balance control in patients with glaucoma.

Progressive thinning of visual cortex in primary open-angle glaucoma of varying severity

The aim of this study was to investigate possible changes of cortical thickness in the visual cortex in primary open-angle glaucoma (POAG) of varying severity. Twenty normal controls (NC), 20 mild (MP) and 17 severe (SP) POAG patients were recruited and scanned using magnetic resonance imaging. Cortical thickness analyses with regions of interest (V1, V2, ventral V3, V4 and V5/MT+) were used to assess the cortical changes among the three groups. Furthermore, the associations of cortical thickness with retinal nerve fiber layer (RNFL) thickness and mean deviation of visual field were analyzed. Compared with the NC group, decreased cortical thickness was detected in the bilateral V5/MT+ areas in the MP group and the left V1, bilateral V2 and V5/MT+ areas in the SP group. Cortical thinning of the bilateral V2 areas was detected in the SP group compared with the MP group. In addition, cortical thinning of these visual areas was related to the ophthalmologic measurements. In conclusion, POAG patients exhibit cortical thinning in the bilateral V5/MT+ in the early stage of disease. The cortical degeneration in visual areas is discrepant with disease progressing and the dorsal pathway might be selectively damaged in POAG. Therefore, the cortical thinning of these visual areas may play a key role in the progression of POAG and can serve as a novel biomarker for accurately evaluating the severity of POAG.

Morphologic changes in the anterior and posterior subregions of V1 and V2 and the V5/MT+ in patients with primary open-angle glaucoma

The aim of this study was to investigate possible morphologic changes of the visual cortex in primary open-angle glaucoma (POAG) with varying severity. Twenty normal controls (NC), 19 mild (MP) and 17 severe (SP) POAG patients were recruited and scanned using magnetic resonance imaging. Multi-parameter morphologic analyses with regions of interest (V5/MT+, anterior and posterior subregions of V1 and V2) were used to assess the cortical changes among the three groups. Compared with the NC group, decreased cortical thickness was detected in the V5/MT+ area in the MP group and in all of the investigated visual areas except the posterior subregion of V1 in the SP group. Unexpectedly, cortical thinning of the posterior subregion of V2 was detected in the SP group compared with the NC and MP groups. For the other morphologic parameters, only gray matter volume in the posterior subregion of V2 and mean curvature in the V5/MT+ were significantly changed in the SP group. In addition, the clinical measurements were positively correlated with the cortical thickness of the V5/MT+ and the posterior subregion of V2. In conclusion, the V5/MT+ area is involved in early disruption of POAG and the cortical degeneration may be progressive and heterogeneous in different visual cortices. Early neuroprotective therapies on the retina and central visual system may help to preserve vision in patients with POAG.