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Glassman AR, Elmasry MA, Baskin DE, Brigell M, Chong V, Davis Q, Lesmes L, Levin LA, Maddess T, Taylor LJ, Wenzel A. Visual Function Measurements in Eyes With Diabetic Retinopathy: An Expert Opinion on Available Measures. OPHTHALMOLOGY SCIENCE 2024; 4:100519. [PMID: 38881606 PMCID: PMC11179417 DOI: 10.1016/j.xops.2024.100519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/18/2024] [Accepted: 03/18/2024] [Indexed: 06/18/2024]
Abstract
Clinical Relevance Visual function impairment from diabetic retinopathy can have a considerable impact on patient's quality of life. Best-corrected visual acuity (BCVA) is most commonly used to assess visual function and guide clinical trials. However, BCVA is affected late in the disease process, is not affected in early disease, and does not capture some of the visual disturbances described by patients with diabetes. The goal of this report is to evaluate the relationship between diabetic retinal disease (DRD) and visual function parameters to determine which if any of them may be used in a future DRD staging system. Methods The visual functions working group was 1 of 6 areas of DRD studied as part of the DRD staging system update, a project of the Mary Tyler Moore Vision Initiative. The working group identified 12 variables of possible interest, 7 of which were judged to have sufficient preliminary data to suggest an association with DR to warrant further review: microperimetry, static automated perimetry, electroretinogram (ERG) oscillatory potentials, flicker ERG, low luminance visual acuity (LLVA), contrast sensitivity (CS), and BCVA. The objective field analyzer (OFA) was added after subsequent in-person workshops. Results Currently, the only visual function test available for immediate use is BCVA; the remaining tests are either promising (within 5 years) or have potential (>5 years) use. Besides BCVA, most visual function tests had a limited role in current clinical care; however, LLVA, CS, flicker ERG, and OFA demonstrated potential for screening and research purposes. Conclusions Although current visual function tests are promising, future prospective studies involving patients with early and more advanced retinopathy are necessary to determine if these tests can be used clinically or as endpoints for clinical studies. Financial Disclosures Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
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Affiliation(s)
| | - Mohamed Ashraf Elmasry
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
- Joslin Diabetes Center, Boston, Massachusetts
| | - Darrell E Baskin
- University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | | | | | | | - Luis Lesmes
- Adaptive Sensory Technology, San Diego, California
| | - Leonard A Levin
- Departments of Ophthalmology & Visual Sciences and Neurology & Neurosurgery, McGill University, Montreal, Canada
| | - Ted Maddess
- John Curtin School of Medical Research, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Laura J Taylor
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Andreas Wenzel
- Roche Pharma Research & Early Development, F. Hoffmann - La Roche Ltd, Basel, Switzerland
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Rai BB, van Kleef JP, Sabeti F, Vlieger R, Suominen H, Maddess T. Early diabetic eye damage: Comparing detection methods using diagnostic power. Surv Ophthalmol 2024; 69:24-33. [PMID: 37797701 DOI: 10.1016/j.survophthal.2023.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 08/22/2023] [Accepted: 09/06/2023] [Indexed: 10/07/2023]
Abstract
It is now clear that retinal neuropathy precedes classical microvascular retinopathy in diabetes. Therefore, tests that underpin useful new endpoints must provide high diagnostic power well before the onset of moderate diabetic retinopathy. Hence, we compare detection methods of early diabetic eye damage. We reviewed data from a range of functional and structural studies of early diabetic eye disease and computed standardized effect size as a measure of diagnostic power, allowing the studies to be compared quantitatively. We then derived minimum performance criteria for tests to provide useful clinical endpoints. This included the criteria that tests should be rapid and easy so that children with type 1 diabetes can be followed into adulthood with the same tests. We also defined attributes that lend test data to further improve performance using Machine/Deep Learning. Data from a new form of objective perimetry suggested that the criteria are achievable.
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Affiliation(s)
- Bhim B Rai
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia; ANU Eccles Institute of Neuroscience, Australian National University, Canberra, ACT, Australia.
| | - Joshua P van Kleef
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia; ANU Eccles Institute of Neuroscience, Australian National University, Canberra, ACT, Australia
| | - Faran Sabeti
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia; School of Optometry, Faculty of Health, 2 University of Canberra, Canberra, ACT, Australia
| | - Robin Vlieger
- ANU School of Computing, Australian National University, Canberra, ACT, Australia
| | - Hanna Suominen
- ANU Eccles Institute of Neuroscience, Australian National University, Canberra, ACT, Australia; ANU School of Computing, Australian National University, Canberra, ACT, Australia; University of Turku, Turku, Finland
| | - Ted Maddess
- John Curtin School of Medical Research, Australian National University, Canberra, ACT, Australia; ANU Eccles Institute of Neuroscience, Australian National University, Canberra, ACT, Australia
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Antemie RG, Samoilă OC, Clichici SV. Blue Light-Ocular and Systemic Damaging Effects: A Narrative Review. Int J Mol Sci 2023; 24:ijms24065998. [PMID: 36983068 PMCID: PMC10052719 DOI: 10.3390/ijms24065998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 03/13/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023] Open
Abstract
Light is a fundamental aspect of our lives, being involved in the regulation of numerous processes in our body. While blue light has always existed in nature, with the ever-growing number of electronic devices that make use of short wavelength (blue) light, the human retina has seen increased exposure to it. Because it is at the high-energy end of the visible spectrum, many authors have investigated the theoretical harmful effects that it poses to the human retina and, more recently, the human body, given the discovery and characterization of the intrinsically photosensitive retinal ganglion cells. Many approaches have been explored, with the focus shifting throughout the years from examining classic ophthalmological parameters, such as visual acuity, and contrast sensitivity to more complex ones seen on electrophysiological assays and optical coherence tomographies. The current study aims to gather the most recent relevant data, reveal encountered pitfalls, and suggest future directions for studies regarding local and/or systemic effects of blue light retinal exposures.
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Affiliation(s)
- Răzvan-Geo Antemie
- Department of Physiology, Faculty of Medicine, "Iuliu Haţieganu" University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Ovidiu Ciprian Samoilă
- Department of Ophthalmology, Faculty of Medicine, "Iuliu Hatieganu" University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
| | - Simona Valeria Clichici
- Department of Physiology, Faculty of Medicine, "Iuliu Haţieganu" University of Medicine and Pharmacy, 400006 Cluj-Napoca, Romania
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4
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Rapid, non-contact multifocal visual assessment in multiple sclerosis. Neurol Sci 2023; 44:273-279. [PMID: 36098887 PMCID: PMC9816274 DOI: 10.1007/s10072-022-06387-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/31/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Previous work on temporally sparse multifocal methods suggests that the results are correlated with disability and progression in people with multiple sclerosis (PwMS). Here, we assess the diagnostic power of three cortically mediated sparse multifocal pupillographic objective perimetry (mfPOP) methods that quantified response-delay and light-sensitivity at up to 44 regions of both visual fields concurrently. METHODS One high-spatial-resolution mfPOP method, P129, and two rapid medium-resolution methods, W12 and W20, were tested on 44 PwMS and controls. W12 and W20 took 82 s to test both visual fields concurrently, providing response delay and sensitivity at each field location, while P129 took 7 min. Diagnostic power was assessed using areas under the receiver operating characteristic (AUROC) curves and effect-size (Hedges' g). Linear models examined significance. Concurrent testing of both eyes permitted assessment of between-eye asymmetries. RESULTS Per-region response delays and asymmetries achieved AUROCs of 86.6% ± 4.72% (mean ± SE) in relapsing-remitting MS, and 96.5% ± 2.30% in progressive MS. Performance increased with increasing disability scores, with even moderate EDSS 2 to 4.5 PwMS producing AUROCs of 82.1 to 89.8%, Hedge's g values up to 2.06, and p = 4.0e - 13. All tests performed well regardless of any history of optic neuritis. W12 and W20 performed as well or better than P129. CONCLUSION Overall, the 82-s tests (W12 and W20) performed better than P129. The results suggest that mfPOP assesses a correlate of disease severity rather than a history of inflammation, and that it may be useful in the clinical management of PwMS.
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Maddess T, Carle CF, Rohan EM, Baird-Gunning J, van Kleef JP, Lueck CJ. Objective perimetry and progression of multiple sclerosis. eNeurologicalSci 2022; 29:100430. [PMID: 36254171 PMCID: PMC9568864 DOI: 10.1016/j.ensci.2022.100430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/07/2022] [Accepted: 10/07/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction We re-examined the per-region response amplitudes and delays obtained from multifocal pupillographic objective perimetry (mfPOP) after 10 years in 44 persons living with multiple sclerosis (PwMS), both to examine which parts of the visual field had progressed in terms of response properties and to examine if the baseline data could predict the overall progression of disease. Methods Expanded Disability Status Scale (EDSS) scores were assessed in 2009 and 2019. Both eyes of each participant were concurrently tested at 44 locations/eye on both occasions. Several measures of clinical progression were examined, using logistic regression to determine the odds of progression. Results At the second examination the 44 PwMS (31 females) were aged 61.0 ± 12.2 y. Mean EDSS had not changed significantly (3.69 ± 1.23 in 2009, 3.81 ± 2.00 in 2019). mfPOP delay increased progressively from inferior to superior regions of the visual fields while amplitudes demonstrated a temporal to nasal gradient. The mean of the 3 most delayed visual field regions was correlated with progression of MS by 2019 (p = 0.023). Logistic regression indicated a significant association between delay and odds of progression (p = 0.045): an individual with 3 regions at least 1 SD (40 ms) slower than the mean in 2009 had 2.05× (±SE: 1.43× to 2.95×) the odds of progression by 2019. A 1 SD shorter delay was associated with 2.05× lower odds of progression. Amplitude changes were not predictive of progression. Significance mfPOP may provide a rapid, convenient method of monitoring and predicting MS progression.
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Affiliation(s)
- Ted Maddess
- Eccles Institute of Neuroscience, John Curtin School of Medical Research, Australian National University, Acton, ACT, Australia
| | - Corinne F. Carle
- Eccles Institute of Neuroscience, John Curtin School of Medical Research, Australian National University, Acton, ACT, Australia
| | - Emilie M.F. Rohan
- Eccles Institute of Neuroscience, John Curtin School of Medical Research, Australian National University, Acton, ACT, Australia
| | | | - Josh P. van Kleef
- Eccles Institute of Neuroscience, John Curtin School of Medical Research, Australian National University, Acton, ACT, Australia
| | - Christian J. Lueck
- Department of Neurology, the Canberra Hospital, Canberra, ACT, Australia
- Australian National University Medical School, Acton, ACT, Australia
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Carle CF, James AC, Sabeti F, Kolic M, Essex RW, Shean C, Jeans R, Saikal A, Licinio A, Maddess T. Clustered Volleys Stimulus Presentation for Multifocal Objective Perimetry. Transl Vis Sci Technol 2022; 11:5. [PMID: 35113130 PMCID: PMC8819283 DOI: 10.1167/tvst.11.2.5] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose Multifocal pupillographic objective perimetry (mfPOP) is being developed as an alternative to subjective threshold perimetry for the management of visual and neurological disorders. Here, we evaluate, in normal subjects, differences in signal quality between the original mfPOP method of spatially sparse Continuous stimulus presentation and the new Clustered Volleys (CVs) method. We hypothesized that the CVs method would lead to increased signal-to-noise ratios (SNRs) over the original method due to the stabilization of gain within the pupillary system. Methods Data were collected from six separate studies where otherwise-identical pairs of mfPOP tests using either the original Continuous stimulus presentation method or the new CVs method were undertaken; 440 6-minute tests from 96 normal subjects of varying ages were included. Per-region SNRs were compared between the two methods. Results Mean SNRs for the CVs mfPOP variants were between 35% and 57% larger than the original Continuous mfPOP variants (P < 0.001 in five of six studies). Similarly, the goodness-of-fit measure (r2) demonstrated large and significant fold increases of between 2.3× and 3.4× over the original method (all P < 0.001). Significant improvements in SNRs were present in all of the 88 test regions (44/eye), ranging between 8.4% and 93.7%; mean SNRs were significantly larger in 98% of test subjects. Conclusions The CVs mfPOP stimulus presentation method produced substantial increases in signal quality over the original method. This is likely due to the stabilization of pupillary gain during stimulus presentation. Translational Relevance These improvements increase diagnostic accuracy and have enabled shorter, 80-second mfPOP tests to be developed.
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Affiliation(s)
- Corinne F Carle
- John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - Andrew C James
- John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - Faran Sabeti
- John Curtin School of Medical Research, Australian National University, Canberra, Australia.,Optometry and Vision Science, University of Canberra, Canberra, Australia
| | - Maria Kolic
- John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - Rohan W Essex
- John Curtin School of Medical Research, Australian National University, Canberra, Australia.,Canberra Hospital, Canberra, Australia
| | - Chris Shean
- John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - Rhiannon Jeans
- John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - Aiasha Saikal
- John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - Alice Licinio
- John Curtin School of Medical Research, Australian National University, Canberra, Australia
| | - Ted Maddess
- John Curtin School of Medical Research, Australian National University, Canberra, Australia
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7
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Villar-Martinez MD, Goadsby PJ. Dim the Lights: A Narrative Review of Photophobia in Migraine. Neurology 2022. [DOI: 10.17925/usn.2022.18.1.14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
A preference for darkness is one of the main associated features in people with migraine, the cause remaining a mystery until some decades ago. In this article, we describe the epidemiology of photophobia in migraine and explain the pathophysiological mechanisms following an anatomical structure. In addition, we review the current management of migraine and photophobia. Ongoing characterization of patients with photophobia and its different manifestations continues to increase our understanding of the intricate pathophysiology of migraine and vice versa. Detailed phenotyping of the patient with photophobia is encouraged.
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8
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Najjar RP, Rukmini AV, Finkelstein MT, Nusinovici S, Mani B, Nongpiur ME, Perera S, Husain R, Aung T, Milea D. Handheld chromatic pupillometry can accurately and rapidly reveal functional loss in glaucoma. Br J Ophthalmol 2021; 107:663-670. [PMID: 34853018 PMCID: PMC10176376 DOI: 10.1136/bjophthalmol-2021-319938] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 11/06/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIMS Early detection and treatment of glaucoma can delay vision loss. In this study, we evaluate the performance of handheld chromatic pupillometry (HCP) for the objective and rapid detection of functional loss in glaucoma. METHODS In this clinic-based, prospective study, we enrolled 149 patients (median (IQR) years: 68.5 (13.6) years) with confirmed glaucoma and 173 healthy controls (55.2 (26.7) years). Changes in pupil size in response to 9 s of exponentially increasing blue (469 nm) and red (640 nm) light-stimuli were assessed monocularly using a custom-built handheld pupillometer. Pupillometric features were extracted from individual traces and compared between groups. Features with the highest classification potential, selected using a gradient boosting machine technique, were incorporated into a generalised linear model for glaucoma classification. Receiver operating characteristic curve analyses (ROC) were used to compare the performance of HCP, optical coherence tomography (OCT) and Humphrey Visual Field (HVF). RESULTS Pupillary light responses were altered in glaucoma compared with controls. For glaucoma classification, HCP yielded an area under the ROC curve (AUC) of 0.94 (95% CI 0.91 to 0.96), a sensitivity of 87.9% and specificity of 88.4%. The classification performance of HCP in early-moderate glaucoma (visual field mean deviation (VFMD) > -12 dB; AUC=0.91 (95% CI 0.87 to 0.95)) was similar to HVF (AUC=0.91) and reduced compared with OCT (AUC=0.97; p=0.01). For severe glaucoma (VFMD ≤ -12 dB), HCP had an excellent classification performance (AUC=0.98, 95% CI 0.97 to 1) that was similar to HVF and OCT. CONCLUSION HCP allows for an accurate, objective and rapid detection of functional loss in glaucomatous eyes of different severities.
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Affiliation(s)
- Raymond P Najjar
- Visual Neurosciences Research Group, Singapore Eye Research Institute, Singapore.,Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, Singapore
| | - A V Rukmini
- Visual Neurosciences Research Group, Singapore Eye Research Institute, Singapore
| | | | - Simon Nusinovici
- Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, Singapore.,Ocular Epidemiology Research Group, Singapore Eye Research Institute, Singapore
| | - Baskaran Mani
- Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, Singapore.,Glaucoma Department, Singapore National Eye Centre, Singapore.,Glaucoma Research Group, Singapore Eye Research Institute, Singapore
| | - Monisha Esther Nongpiur
- Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, Singapore.,Glaucoma Department, Singapore National Eye Centre, Singapore.,Glaucoma Research Group, Singapore Eye Research Institute, Singapore
| | - Shamira Perera
- Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, Singapore.,Glaucoma Department, Singapore National Eye Centre, Singapore
| | - Rahat Husain
- Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, Singapore.,Glaucoma Department, Singapore National Eye Centre, Singapore
| | - Tin Aung
- Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, Singapore.,Glaucoma Department, Singapore National Eye Centre, Singapore.,Glaucoma Research Group, Singapore Eye Research Institute, Singapore.,Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Dan Milea
- Visual Neurosciences Research Group, Singapore Eye Research Institute, Singapore .,Ophthalmology and Visual Sciences Academic Clinical Programme, Duke-NUS Medical School, Singapore.,Neuro-Ophthalmology Department, Singapore National Eye Center, Singapore
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9
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Kaiser EA, McAdams H, Igdalova A, Haggerty EB, Cucchiara BL, Brainard DH, Aguirre GK. Reflexive Eye Closure in Response to Cone and Melanopsin Stimulation: A Study of Implicit Measures of Light Sensitivity in Migraine. Neurology 2021; 97:e1672-e1680. [PMID: 34493620 DOI: 10.1212/wnl.0000000000012734] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 08/16/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To quantify interictal photophobia in migraine with and without aura using reflexive eye closure as an implicit measure of light sensitivity and to assess the contribution of melanopsin and cone signals to these responses. METHODS Participants were screened to meet criteria for 1 of 3 groups: headache-free (HF) controls, migraine without aura (MO), and migraine with visual aura (MA). MO and MA participants were included if they endorsed ictal and interictal photophobia. Exclusion criteria included impaired vision, inability to collect usable pupillometry, and history of either head trauma or seizure. Participants viewed light pulses that selectively targeted melanopsin, the cones, or their combination during recording of orbicularis oculi EMG (OO-EMG) and blinking activity. RESULTS We studied 20 participants in each group. MA and MO groups reported increased visual discomfort to light stimuli (discomfort rating, 400% contrast, MA: 4.84 [95% confidence interval 0.33, 9.35]; MO: 5.23 [0.96, 9.50]) as compared to HF controls (2.71 [0, 6.47]). Time course analysis of OO-EMG and blinking activity demonstrated that reflexive eye closure was tightly coupled to the light pulses. The MA group had greater OO-EMG and blinking activity in response to these stimuli (EMG activity, 400% contrast: 42.9%Δ [28.4, 57.4]; blink activity, 400% contrast: 11.2% [8.8, 13.6]) as compared to the MO (EMG activity, 400% contrast: 9.9%Δ [5.8, 14.0]; blink activity, 400% contrast: 4.7% [3.5, 5.9]) and HF control (EMG activity, 400% contrast: 13.2%Δ [7.1, 19.3]; blink activity, 400% contrast: 4.5% [3.1, 5.9]) groups. DISCUSSION Our findings suggest that the intrinsically photosensitive retinal ganglion cells (ipRGCs), which integrate melanopsin and cone signals, provide the afferent input for light-induced reflexive eye closure in a photophobic state. Moreover, we find a dissociation between implicit and explicit measures of interictal photophobia depending on a history of visual aura in migraine. This implies distinct pathophysiology in forms of migraine, interacting with separate neural pathways by which the amplification of ipRGC signals elicits implicit and explicit signs of visual discomfort.
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Affiliation(s)
- Eric A Kaiser
- From the Departments of Neurology (E.A.K., A.I., E.B.H., B.L.C., G.K.A.) and Neuroscience (H.M.), Perelman School of Medicine, and Department of Psychology (D.H.B.), University of Pennsylvania, Philadelphia.
| | - Harrison McAdams
- From the Departments of Neurology (E.A.K., A.I., E.B.H., B.L.C., G.K.A.) and Neuroscience (H.M.), Perelman School of Medicine, and Department of Psychology (D.H.B.), University of Pennsylvania, Philadelphia
| | - Aleksandra Igdalova
- From the Departments of Neurology (E.A.K., A.I., E.B.H., B.L.C., G.K.A.) and Neuroscience (H.M.), Perelman School of Medicine, and Department of Psychology (D.H.B.), University of Pennsylvania, Philadelphia
| | - Edda B Haggerty
- From the Departments of Neurology (E.A.K., A.I., E.B.H., B.L.C., G.K.A.) and Neuroscience (H.M.), Perelman School of Medicine, and Department of Psychology (D.H.B.), University of Pennsylvania, Philadelphia
| | - Brett L Cucchiara
- From the Departments of Neurology (E.A.K., A.I., E.B.H., B.L.C., G.K.A.) and Neuroscience (H.M.), Perelman School of Medicine, and Department of Psychology (D.H.B.), University of Pennsylvania, Philadelphia
| | - David H Brainard
- From the Departments of Neurology (E.A.K., A.I., E.B.H., B.L.C., G.K.A.) and Neuroscience (H.M.), Perelman School of Medicine, and Department of Psychology (D.H.B.), University of Pennsylvania, Philadelphia
| | - Geoffrey K Aguirre
- From the Departments of Neurology (E.A.K., A.I., E.B.H., B.L.C., G.K.A.) and Neuroscience (H.M.), Perelman School of Medicine, and Department of Psychology (D.H.B.), University of Pennsylvania, Philadelphia
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