Macular pigment optical density measured by heterochromatic modulation photometry

Selective Stimulation of the Different Photoreceptor Classes by Silent Substitution in Psychophysical and Electroretinographic Measurements

The silent substitution technique allows creating photoreceptor-selective stimuli for psychophysical and electrophysiological tests. In contrast to other techniques, the purpose of silent substitution is not to make the targeted photoreceptor type more sensitive in comparison to the other types, but to make the stimulus invisible ("silent") to the other photoreceptor types. This allows selectivity independent of the retinal state of adaptation and enables comparing photoreceptor types under identical conditions. The foundations of these techniques will be explained in this paper. Furthermore, the importance of postreceptoral processing for the perception of photoreceptor-selective stimuli is discussed here. Although this technique is currently only available in specialized vision science labs, there is an enormous potential for clinical application.

[New techniques for quantification of color vision in disorders of cone function : Cambridge color test and photoreceptor-specific temporal contrast sensitivity in patients with heterozygous RP1L1 and RPGR mutations]

Hintergrund

Erbliche Netzhauterkrankungen mit Zapfendysfunktion können trotz relativ unauffälligem Fundusbefund ausgeprägte Visusminderung und deutliche Farbsinnstörungen aufweisen. Beispiele hierfür sind die autosomal-dominante okkulte Makuladystrophie (RP1L1-Gen) und die X‑chromosomale Retinitis pigmentosa (RPGR-Gen) – Letztere auch bei heterozygoten, weiblichen Merkmalsträgerinnen (Konduktorinnen). Neue Untersuchungsmethoden erlauben es, das Ausmaß der Farbsinnstörung zu quantifizieren.

Methoden

Nach einer umfangreichen klinischen Untersuchung führten wir Messungen zur Quantifizierung der Farbdiskriminierung und der Zapfenfunktion durch. Beim Cambridge-Color-Test werden pseudoisochromatische Tafeln mit Landolt-C-Figuren computergesteuert generiert, um die Farbunterscheidungsschwelle entlang mehrerer Achsen im Farbraum zu bestimmen. Bei der Untersuchung der photorezeptorspezifischen zeitlichen Kontrastempfindlichkeit kann durch geschickte zyklische Veränderung der spektralen Zusammensetzung eines Lichtreizes die Kontrastwahrnehmungsschwelle isolierter Photorezeptortypen bestimmt werden. Die molekulargenetische Diagnostik erfolgte mithilfe von Next Generation Sequencing(NGS)-basierter gezielter Genpanelanalyse sowie Sanger-Sequenzierung.

Ergebnisse

Bei 2 Patienten mit okkulter Makuladystrophie und 2 heterozygoten Trägerinnen von RPGR-Mutationen zeigten sich eine deutlich verminderte Fähigkeit zur Farbdiskriminierung und eine verminderte photorezeptorspezifische zeitliche Kontrastempfindlichkeit.

Diskussion

Bei erblichen Netzhauterkrankungen sind neben den modernen bildgebenden Verfahren (okuläre Kohärenztomographie [OCT] und Fundusautofluoreszenz) auch die sinnesphysiologischen Untersuchungen diagnostisch wegweisend – der Nachweis von Farbsinnstörungen spielt hierbei eine wichtige Rolle. Neuere Methoden erlauben eine Quantifizierung der Farbsinnstörungen und könnten in klinischen Studien zu gen- und stammzellbasierter Therapie zur Messung des Therapieerfolges dienen.

Photoreceptor-Specific Loss of Perifoveal Temporal Contrast Sensitivity in Retinitis Pigmentosa

Purpose

Inherited retinal diseases affect the L-, M-, S-cones and rods in distinct ways, which calls for new methods that enable quantification of photoreceptor-specific functions. We tested the feasibility of using the silent substitution paradigm to estimate photoreceptor-driven temporal contrast sensitivity (tCS) functions in patients with retinitis pigmentosa.

Methods

The silent substitution paradigm is based on substitution of lights of different spectral composition; this offers considerable advantage over other stimulation techniques. We used a four-primary LED stimulator to create perifoveal annular stimuli (2° inner, 12° outer diameters) and used a triple silent substitution to probe photoreceptor-selective tCS. Measurements were performed in a heterogeneous cohort of 15 patients with retinitis pigmentosa and related to those in a control group of nine color-normal healthy observers. Age differences between groups were addressed with a model of age-related normal contrast sensitivity derived from measurements in 20 healthy observers aged between 23 and 83 years.

Results

The age-related loss of tCS amounted to 0.1 dB/year in healthy subjects across all photoreceptor subtypes. In patients, tCS was decreased for every photoreceptor subtype; however, S-cone- and rod-driven sensitivities were most strongly affected. Postreceptoral mechanisms were not affected.

Conclusions

This feasibility study provides evidence that the silent substitution technique enables the estimation of photoreceptor-selective tCS functions and can serve as an accurate biomarker of photoreceptor-specific contrast sensitivity loss in patients with retinitis pigmentosa.

Translational Relevance

We aim to develop tests of visual function for clinical trials of novel therapies for inherited retinal diseases from methods that can currently be used only in vision research labs.

Photoreceptor-specific light adaptation of critical flicker frequency in trichromat and dichromat observers

The silent substitution paradigm offers possibilities to investigate and compare the temporal properties of mechanisms driven by single photoreceptor types, including the critical flicker frequency (CFF), in which the state of adaptation can be kept as invariant. We have (1) measured CFFs using triple silent substitutions to isolate L-, M-, and S-cone as well as rod-driven pathways under identical mean luminances and chromaticities; (2) repeated the CFF measurements at different mean luminances in order to validate the Ferry-Porter law (stating that the relationship between CFF and the log retinal illuminance-log I-is linear); and (3) compared these CFF versus log I functions for L-, M-, S-cone-, and rod-isolating stimuli for five trichromats and four X-linked dichromats (two protanopes, two deuteranopes). We show that the effects of luminance on the CFFs with silent substitution are comparable to those measured previously with chromatic stimuli. We found that M-cone-driven CFFs are smaller in trichromats than in protanopes. Furthermore, the slopes of the M-cone-driven CFF versus log I functions are smaller in trichromats. Possibly, the lacking L-cones are replaced by M-cones in these two protanopes and the CFF depends on cone density. Furthermore, we found that in trichromats, the slopes of the CFF-log I functions are smaller for M-cone- than for L-cone-isolating stimuli. This contradicts the current interpretation of the CFF-log I functions for chromatic stimuli, which states that CFF is mediated by the most strongly modulated photoreceptor type. Thus, the larger slopes that were previously found with medium-wavelength chromatic stimuli compared with long-wavelength chromatic stimuli seem to be the result of an addition of signals from different photoreceptors and do not necessarily result from M-cones being inherently faster.

Electroretinographical determination of human color vision type

It has been previously demonstrated that electroretinography (ERG) elicited by heterochromatically modulated stimuli can be used for objective determination of color vision type. Color vision of trichromatic, deuteranopic, and protanopic participants was psychophysically assessed by the Cambridge Color Test and confirmed genetically. ERG responses to red and green lights modulating in counterphase at 12 and 36 Hz were recorded, while the fraction of red modulation was varied. At 36 Hz (and second harmonics at 12 Hz), the responses were minimal at red fractions that differed significantly in protanopes. At 12 Hz (fundamental component), the responses of the trichromats differed significantly compared to those of the dichromats. An improved protocol shows that the three subject groups can be separated with no overlap.

Perifoveal S-cone and rod-driven temporal contrast sensitivities at different retinal illuminances

We evaluated a technique for measuring temporal contrast sensitivities to sine-wave modulation driven by S-cones and rods in the perifovea using triple silent substitution. Isolating stimuli for S-cones and rods were created using an eight-channel, four-primary LED stimulator that has been validated before. Sensitivities were measured at 10 different temporal frequencies between 1 and 28 Hz in three normal observers at 14 different retinal illuminances between 0.07 and 587 photopic troland (phot Td) and at three different retinal illuminances over the same range in one S-cone monochromat. The technique was further validated by measuring bleaching adaptation in two normal subjects, demonstrating sufficient isolation in rods. Good isolation was apparent from the differences in the temporal contrast sensitivity functions and the sensitivity-versus-retinal illuminance functions between S-cones and rods, and also from the results in the S-cone monochromats and the delayed recovery of rod sensitivities after bleaching. The results will help to determine optimal stimulus conditions in future studies. The results in the S-cone monochromat demonstrate the potential clinical value of our protocol.

Perifoveal L- and M-cone-driven temporal contrast sensitivities at different retinal illuminances

We established a protocol using a well-established LED stimulator to measure temporal contrast sensitivities driven by sine-wave modulation of L- and M-cones in the perifovea using triple silent substitution. The stimulus was presented in an annular field (2° inner diameter, 13° outer diameter). We validated this technique by studying the contrast sensitivity of three color normal observers at 10 different temporal frequencies (between 1 and 28 Hz) over a large range of retinal illuminances (between 0.07 and 587 phot Td), spanning the complete mesopic range. In one subject, sensitivities to counterphase modulation of L- and M-cones and in-phase modulation of L, M, and S-cones were additionally measured, which putatively reflected the parvo- and magnocellular retinogeniculate pathways, respectively. Furthermore, we performed measurements of temporal contrast sensitivities as a function of frequency at 294 phot Td in two protanopes, in two deuteranopes, and in one subject with S-cone monochromacy. Quality of isolation was satisfactory and we were able to reproduce known physiological patterns of temporal vision, such as the typical temporal contrast sensitivity functions of the L- and M-cone, the parvo- and magnocellular retinogeniculate pathways, as well as the light adaptation curves. These results will help determine optimal stimulus conditions in future studies. Results from the dichromats and the S-cone monochromat also support the quality of isolation of our protocol and underpin its potential clinical value.

Increased Macular Pigment Optical Density and Visual Acuity following Consumption of a Buttermilk Drink Containing Lutein-Enriched Egg Yolks: A Randomized, Double-Blind, Placebo-Controlled Trial

Purpose. To study the effect of 1-year daily consumption of a dairy drink containing lutein-enriched egg yolks on macular pigment optical density (MPOD) and visual function parameters in elderly subjects with ocular drusen and/or retinal pigment abnormalities. Methods. One hundred and one subjects were recruited to participate in this randomized, double-blind, placebo-controlled parallel intervention trial. Statistical analyses were performed with 46 subjects in the lutein group and 43 in the control group. MPOD, best corrected visual acuity (BCVA, logMAR), and dark adaptation were measured at the start of the study, after 6 months and after 12 months. Plasma lutein and zeaxanthin concentrations were assessed at baseline and at the end of the study. Results. In the lutein group, plasma lutein concentrations increased significantly from 205 ng/mL at baseline to 399 ng/mL after twelve months of intervention. MPOD increased significantly from 0.45 to 0.52 and BCVA improved significantly from −0.04 to −0.09 LogMar. Differences in rod dark adaptation rate between both groups were not significant. Conclusion. Daily consumption of a dairy drink containing lutein-enriched egg yolks for one year improves visual acuity, MPOD, and plasma lutein concentration in elderly subjects with drusen and/or retinal pigment epithelial abnormalities.