Microcurrent stimulation in the treatment of dry and wet macular degeneration

Optimal transcorneal electrical stimulation parameters for preserving photoreceptors in a mouse model of retinitis pigmentosa

JOURNAL/nrgr/04.03/01300535-202419110-00034/figure1/v/2024-03-08T184507Z/r/image-tiff Retinitis pigmentosa is a hereditary retinal disease that affects rod and cone photoreceptors, leading to progressive photoreceptor loss. Previous research supports the beneficial effect of electrical stimulation on photoreceptor survival. This study aims to identify the most effective electrical stimulation parameters and functional advantages of transcorneal electrical stimulation (tcES) in mice affected by inherited retinal degeneration. Additionally, the study seeked to analyze the electric field that reaches the retina in both eyes in mice and post-mortem humans. In this study, we recorded waveforms and voltages directed to the retina during transcorneal electrical stimulation in C57BL/6J mice using an intraocular needle probe with rectangular, sine, and ramp waveforms. To investigate the functional effects of electrical stimulation on photoreceptors, we used human retinal explant cultures and rhodopsin knockout (Rho-/-) mice, demonstrating progressive photoreceptor degeneration with age. Human retinal explants isolated from the donors' eyes were then subjected to electrical stimulation and cultured for 48 hours to simulate the neurodegenerative environment in vitro. Photoreceptor density was evaluated by rhodopsin immunolabeling. In vivo Rho-/- mice were subjected to two 5-day series of daily transcorneal electrical stimulation using rectangular and ramp waveforms. Retinal function and visual perception of mice were evaluated by electroretinography and optomotor response (OMR), respectively. Immunolabeling was used to assess the morphological and biochemical changes of the photoreceptor and bipolar cells in mouse retinas. Oscilloscope recordings indicated effective delivery of rectangular, sine, and ramp waveforms to the retina by transcorneal electrical stimulation, of which the ramp waveform required the lowest voltage. Evaluation of the total conductive resistance of the post-mortem human compared to the mouse eyes indicated higher cornea-to-retina resistance in human eyes. The temperature recordings during and after electrical stimulation indicated no significant temperature change in vivo and only a subtle temperature increase in vitro (~0.5-1.5°C). Electrical stimulation increased photoreceptor survival in human retinal explant cultures, particularly at the ramp waveform. Transcorneal electrical stimulation (rectangular + ramp) waveforms significantly improved the survival and function of S and M-cones and enhanced visual acuity based on the optomotor response results. Histology and immunolabeling demonstrated increased photoreceptor survival, improved outer nuclear layer thickness, and increased bipolar cell sprouting in Rho-/- mice. These results indicate that transcorneal electrical stimulation effectively delivers the electrical field to the retina, improves photoreceptor survival in both human and mouse retinas, and increases visual function in Rho-/- mice. Combined rectangular and ramp waveform stimulation can promote photoreceptor survival in a minimally invasive fashion.

Glaucoma Rehabilitation using ElectricAI Transcranial Stimulation (GREAT)-study protocol for randomized controlled trial using combined perceptual learning and transcranial electrical stimulation for vision enhancement

BACKGROUND

Glaucoma patients with irreversible visual field loss often experience decreased quality of life, impaired mobility, and mental health challenges. Perceptual learning (PL) and transcranial electrical stimulation (tES) have emerged as promising interventions for vision rehabilitation, showing potential in restoring residual visual functions. The Glaucoma Rehabilitation using ElectricAI Transcranial stimulation (GREAT) project aims to investigate whether combining PL and tES is more effective than using either method alone in maximizing the visual function of glaucoma patients. Additionally, the study will assess the impact of these interventions on brain neural activity, blood biomarkers, mobility, mental health, quality of life, and fear of falling.

METHODS

The study employs a three-arm, double-blind, randomized, superiority-controlled design. Participants are randomly allocated in a 1:1:1 ratio to one of three groups receiving: (1) real PL and real tES, (2) real PL and sham tES, and (3) placebo PL and sham tES. Each participant undergoes 10 sessions per block (~ 1 h each), with a total of three blocks. Assessments are conducted at six time points: baseline, interim 1, interim 2, post-intervention, 1-month post-intervention, and 2-month post-intervention. The primary outcome is the mean deviation of the 24-2 visual field measured by the Humphrey visual field analyzer. Secondary outcomes include detection rate in the suprathreshold visual field, balance and gait functions, and electrophysiological and biological responses. This study also investigates changes in neurotransmitter metabolism, biomarkers, self-perceived quality of life, and psychological status before and after the intervention.

DISCUSSION

The GREAT project is the first study to assess the effectiveness of PL and tES in the rehabilitation of glaucoma. Our findings will offer comprehensive assessments of the impact of these treatments on a wide range of brain and vision-related metrics including visual field, neural activity, biomarkers, mobility, mental health, fear of falling, and quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05874258 . Registered on May 15, 2023.

Application of electrostimulation and magnetic stimulation in patients with optic neuropathy: A mechanistic review

Visual impairment caused by optic neuropathies is irreversible because retinal ganglion cells (RGCs), the specialized neurons of the retina, do not have the capacity for self-renewal and self-repair. Blindness caused by optic nerve neuropathies causes extensive physical, financial, and social consequences in human societies. Recent studies on different animal models and humans have established effective strategies to prevent further RGC degeneration and replace the cells that have deteriorated. In this review, we discuss the application of electrical stimulation (ES) and magnetic field stimulation (MFS) in optic neuropathies, their mechanisms of action, their advantages, and limitations. ES and MFS can be applied effectively in the field of neuroregeneration. Although stem cells are becoming a promising approach for regenerating RGCs, the inhibitory environment of the CNS and the long visual pathway from the optic nerve to the superior colliculus are critical barriers to overcome. Scientific evidence has shown that adjuvant treatments, such as the application of ES and MFS help direct thetransplanted RGCs to extend their axons and form new synapses in the central nervous system (CNS). In addition, these techniques improve CNS neuroplasticity and decrease the inhibitory effects of the CNS. Possible mechanisms mediating the effects of electrical current on biological tissues include the release of anti-inflammatory cytokines, improvement of microcirculation, stimulation of cell metabolism, and modification of stem cell function. ES and MFS have the potential to promote angiogenesis, direct axon growth toward the intended target, and enhance appropriate synaptogenesis in optic nerve regeneration.

Electrical, Electromagnetic, Ultrasound Wave Therapies, and Electronic Implants for Neuronal Rejuvenation, Neuroprotection, Axonal Regeneration, and IOP Reduction

The peripheral nervous system (PNS) of mammals and nervous systems of lower organisms possess significant regenerative potential. In contrast, although neural plasticity can provide some compensation, the central nervous system (CNS) neurons and nerves of adult mammals generally fail to regenerate after an injury or damage. However, use of diverse electrical, electromagnetic and sonographic energy waves are illuminating novel ways to stimulate neuronal differentiation, proliferation, neurite growth, and axonal elongation/regeneration leading to various levels of functional recovery in animals and humans afflicted with disorders of the CNS, PNS, retina, and optic nerve. Tools such as acupuncture, electroacupuncture, electroshock therapy, electrical stimulation, transcranial magnetic stimulation, red light therapy, and low-intensity pulsed ultrasound therapy are demonstrating efficacy in treating many different maladies. These include wound healing, partial recovery from motor dysfunctions, recovery from ischemic/reperfusion insults and CNS and ocular remyelination, retinal ganglion cell (RGC) rejuvenation, and RGC axonal regeneration. Neural rejuvenation and axonal growth/regeneration processes involve activation or intensifying of the intrinsic bioelectric waves (action potentials) that exist in every neuronal circuit of the body. In addition, reparative factors released at the nerve terminals and via neuronal dendrites (transmitter substances), extracellular vesicles containing microRNAs and neurotrophins, and intercellular communication occurring via nanotubes aid in reestablishing lost or damaged connections between the traumatized tissues and the PNS and CNS. Many other beneficial effects of the aforementioned treatment paradigms are mediated via gene expression alterations such as downregulation of inflammatory and death-signal genes and upregulation of neuroprotective and cytoprotective genes. These varied techniques and technologies will be described and discussed covering cell-based and animal model-based studies. Data from clinical applications and linkage to human ocular diseases will also be discussed where relevant translational research has been reported.

Evaluation of visual acuity in dry AMD patients after microcurrent electrical stimulation

BACKGROUND

To assess micro current to improve vision for dry age-related macular degeneration. Dry age-related macular degeneration is a major cause of blindness, disability, and severe erosion of quality of life, throughout the world. Beyond nutritional supplementation, there is no approved therapy.

METHODS

This was a prospective randomized sham controlled clinical trial for participants with confirmed dry AMD with documented visual loss. Participants were randomized three to one, to receive transpalpebral external micro current electrical stimulation with the MacuMira device. The Treatment group received four treatments in the first two weeks, and two further treatments at weeks 14 and 26. Differences in BCVA and contrast sensitivity (CS) were estimated with mixed-effects repeated measures analysis of variance.

RESULTS

Change of visual acuity with ETDRS assessment of number of letters read (NLR) and contrast sensitivity at week 4 and 30, compared to the first visit, between 43 treatment and 19 sham control participants. The Sham Control group had NLR of 24.2 (SD 7.1) at baseline, 24.2 (SD 7.2) at 4 weeks, and 22.1 (SD7.4) at 30 weeks. The Treatment group had NLR of 19.6 (SD 8.9) at baseline, 27.6 (SD 9.1) at 4 weeks, and 27.8 (SD 8.4) at 30 weeks. The change in NLR from baseline in the Treatment compared to the Sham control group was 7.7 (95% CI 5.7, 9.7, p < 0.001) at 4 weeks and 10.4 (95% CI 7.8, 13.1, p < 0.001) at 30 weeks. There were similar benefits in CS.

CONCLUSIONS

This pilot study of transpalpebral microcurrent demonstrated improved visual measures and is very encouraging as a potential treatment for dry AMD.

TRIAL REGISTRATION

NCT02540148, ClinicalTrials.gov.

Direct modulation of microglial function by electrical field

Non-invasive electric stimulation (ES) employing a low-intensity electric current presents a potential therapeutic modality that can be applied for treating retinal and brain neurodegenerative disorders. As neurons are known to respond directly to ES, the effects of ES on glia cells are poorly studied. A key question is if ES directly mediates microglial function or modulates their activity merely via neuron-glial signaling. Here, we demonstrated the direct effects of ES on microglia in the BV-2 cells—an immortalized murine microglial cell line. The low current ES in a biphasic ramp waveform, but not that of rectangular or sine waveforms, significantly suppressed the motility and migration of BV-2 microglia in culture without causing cytotoxicity. This was associated with diminished cytoskeleton reorganization and microvilli formation in BV-2 cultures, as demonstrated by immunostaining of cytoskeletal proteins, F-actin and β-tubulin, and scanning electron microscopy. Moreover, ES of a ramp waveform reduced microglial phagocytosis of fluorescent zymosan particles and suppressed lipopolysaccharide (LPS)-induced pro-inflammatory cytokine expression in BV-2 cells as shown by Proteome Profiler Mouse Cytokine Array. The results of quantitative PCR and immunostaining for cyclooxygenase-2, Interleukin 6, and Tumor Necrosis Factor-α corroborated the direct suppression of LPS-induced microglial responses by a ramp ES. Transcriptome profiling further demonstrated that ramp ES effectively suppressed nearly half of the LPS-induced genes, primarily relating to cellular motility, energy metabolism, and calcium signaling. Our results reveal a direct modulatory effect of ES on previously thought electrically “non-responsive” microglia and suggest a new avenue of employing ES for anti-inflammatory therapy.

An in-silico analysis of retinal electric field distribution induced by different electrode design of trans-corneal electrical stimulation

OBJECTIVE

Trans-corneal electrical stimulation (TcES) produces therapeutic effects on many ophthalmic diseases non-invasively. Existing clinical TcES devices use largely variable design of electrode distribution and stimulation parameters. Better understanding of how electrode configuration paradigms and stimulation parameters influence the electric field distribution on the retina, will be beneficial to the design of next-generation TcES devices.

APPROACH

In this study, we constructed a realistic finite element human head model with fine eyeball structure. Commonly used DTL-Plus and ERG-Jet electrodes were simulated. We then conducted in silico investigations of retina observation surface (ROS) electric field distributions induced by different return electrode configuration paradigms and different stimulus intensities.

MAIN RESULTS

Our results suggested that the ROS electric field distribution could be modulated by re-designing TcES electrode settings and stimulus parameters. Under far return location (FRL) paradigms, either DTL-Plus or ERG-Jet approach could induce almost identical ROS electric field distribution regardless where the far return was located. However, compared with the ERG-Jet mode, DTL-Plus stimulation induced stronger nasal lateralization. In contrast, ERG-Jet stimulation induced relatively stronger temporal lateralization. The ROS lateralization can be further tweaked by changing the DTL-Plus electrode length.

SIGNIFICANCE

These results may contribute to the understanding of the characteristics of DTL-Plus and ERG-Jet electrodes based electric field distribution on the retina, providing practical implications for the therapeutic application of TcES.

Vision recovery with perceptual learning and non-invasive brain stimulation: Experimental set-ups and recent results, a review of the literature

BACKGROUND

Vision is the sense which we rely on the most to interact with the environment and its integrity is fundamental for the quality of our life. However, around the globe, more than 1 billion people are affected by debilitating vision deficits. Therefore, finding a way to treat (or mitigate) them successfully is necessary.

OBJECTIVE

This narrative review aims to examine options for innovative treatment of visual disorders (retinitis pigmentosa, macular degeneration, optic neuropathy, refractory disorders, hemianopia, amblyopia), especially with Perceptual Learning (PL) and Electrical Stimulation (ES).

METHODS

ES and PL can enhance visual abilities in clinical populations, inducing plastic changes. We describe the experimental set-ups and discuss the results of studies using ES or PL or their combination in order to suggest, based on literature, which treatment is the best option for each clinical condition.

RESULTS

Positive results were obtained using ES and PL to enhance visual functions. For example, repetitive transorbital Alternating Current Stimulation (rtACS) appeared as the most effective treatment for pre-chiasmatic disorders such as optic neuropathy. A combination of transcranial Direct Current Stimulation (tDCS) and visual training seems helpful for people with hemianopia, while transcranial Random Noise Stimulation (tRNS) makes visual training more efficient in people with amblyopia and mild myopia.

CONCLUSIONS

This narrative review highlights the effect of different ES montages and PL in the treatment of visual disorders. Furthermore, new options for treatment are suggested. It is noteworthy to mention that, in some cases, unclear results emerged and others need to be more deeply investigated.

Evaluating the efficacy and safety of transdermal electrical stimulation on the visual functions of patients with retinitis pigmentosa: a clinical trial protocol for a prospective, multicentre, randomised, double-masked and sham-controlled design (ePICO trial)

INTRODUCTION

Previously, we conducted a clinical trial to evaluate the safety and efficacy of transdermal electrical stimulation (TdES) with skin electrodes to improve the visual functions in patients with retinitis pigmentosa (RP). No adverse events were related to the treatment during follow-up examinations, and TdES significantly improved the mean visual acuity and visual field sensitivity.

METHODS AND ANALYSIS

We developed a study protocol for a prospective, multicentre, randomised, double-masked and sham-controlled clinical trial, planned to commence on June 2021. We intend to compare the maintenance or improvement in best-corrected visual acuity, and safety of TdES using skin electrodes between patients with RP and the sham group. The primary endpoint comprises the superiority of the logarithm of the minimum angle of resolution (logMAR) visual acuity change at week 24 from baseline in the treatment and sham groups. Secondary endpoints involve the comparison of the treatment and sham groups at week 24 for the logMAR visual acuity, early treatment diabetic retinopathy study visual acuity, the mean deviation value of Humphrey field analyser 10-2, monocular Humphrey Esterman visual field test score, ellipsoid zone length, central foveal thickness and 25-item National Eye Institute Visual Function Questionnaire score. We intend to enrol 50 patients from three Japanese institutions within 1 year and follow them up for 1 years.

ETHICS AND DISSEMINATION

The protocol was approved by the institutional review board at the Chiba University Hospital and two other institutions, and was registered with the Japan Registry of Clinical Trials on 17 May 2021. The trial will be conducted in accordance with the principles of the Declaration of Helsinki, and is in accordance with Good Clinical Practice standards. The findings will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

JRCT2032210094.

Effect of Electrical Stimulation on Ocular Cells: A Means for Improving Ocular Tissue Engineering and Treatments of Eye Diseases

Tissue engineering is biomedical engineering that uses suitable biochemical and physicochemical factors to assemble functional constructs that restore or improve damaged tissues. Recently, cell therapies as a subset of tissue engineering have been very promising in the treatment of ocular diseases. One of the most important biophysical factors to make this happen is noninvasive electrical stimulation (ES) to target ocular cells that may preserve vision in multiple retinal and optic nerve diseases. The science of cellular and biophysical interactions is very exciting in regenerative medicine now. Although the exact effect of ES on cells is unknown, multiple mechanisms are considered to underlie the effects of ES, including increased production of neurotrophic agents, improved cell migration, and inhibition of proinflammatory cytokines and cellular apoptosis. In this review, we highlighted the effects of ES on ocular cells, especially on the corneal, retinal, and optic nerve cells. Initially, we summarized the current literature on the in vitro and in vivo effects of ES on ocular cells and then we provided the clinical studies describing the effect of ES on ocular complications. For each area, we used some of the most impactful articles to show the important concepts and results that advanced the state of these interactions. We conclude with reflections on emerging new areas and perspectives for future development in this field.

Ocular direct current stimulation affects retinal ganglion cells

Ocular current stimulation (oCS) with weak current intensities (a few mA) has shown positive effects on retinal nerve cells, which indicates that neurodegenerative ocular diseases could be treated with current stimulation of the eye. During oCS, a significant polarity-independent reduction in the characteristic P50 amplitude of a pattern-reversal electroretinogram was found, while no current stimulation effect was found for a full field electroretinogram (ffERG). The ffERG data indicated a trend for a polarity-dependent influence during oCS on the photopic negative response (PhNR) wave, which represents the sum activity of the retinal ganglion cells. Therefore, an ffERG with adjusted parameters for the standardized measurement of the PhNR wave was combined with simultaneous oCS to study the potential effects of direct oCS on cumulative ganglion cell activity. Compared with that measured before oCS, the PhNR amplitude in the cathodal group increased significantly during current stimulation, while in the anodal and sham groups, no effect was visible (α = 0.05, p_cathodal = 0.006*). Furthermore, repeated-measures ANOVA revealed a significant difference in PhNR amplitude between the anodal and cathodal groups as well as between the cathodal and sham groups (p* ≤ 0.0167, p_{cathodal − anodal} = 0.002*, p_{cathodal − sham} = 0.011*).

Effectiveness of Microcurrent Stimulation in Preserving Retinal Function of Blind Leading Retinal Degeneration and Optic Neuropathy: A Systematic Review

OBJECTIVES

To systematically identify and summarize the effectiveness and the parameters of electrical stimulation (ES) for the preservation of visual function in major retinal degeneration and optic neuropathy.

MATERIALS AND METHODS

A systematic review of clinical studies, using ES therapy in patients with blind leading retinal degenerations, including retinitis pigmentosa (RP), age-related macular degeneration (AMD), glaucoma, retinal vein occlusion (RVO), retinal artery occlusion (RAO), and optic neuropathy was conducted. PubMed, EMBASE, Cochrane Library, and Web of Science were searched for relevant interventional studies including randomized controlled trials (RCTs) and observational studies.

RESULTS

A total of 10 RCTs and 15 observational studies were included. Transcorneal ES (TcES), transpalpebral ES (TpES), transdermal ES (TdES), and repetitive transorbital alternating current stimulation (rtACS) were used for the treatment of the patients. ES using 20 Hz biphasic pulses with current strength at 150%-200% of individual electrical phosphene threshold (EPT) for RP patients showed improved retinal function detected by visual acuity (VA), visual field (VF), or electrical retinal graphs (ERG). rtACS on patients with optic neuropathy showed significant preservation of VA and VF. Clinical studies on AMD, RAO, and glaucoma indicated promising protective effects of ES on the visual function, though the amount of evidence is limited.

CONCLUSIONS

ES treatment has promising therapeutic effects on RP and optic neuropathy. More large-scale RCT studies should be conducted to elucidate the potential of ES, especially on AMD, RAO, and glaucoma. A comparison of the effects by different ES methods in the same disease populations is still lacking. Parameters of the electric current and sensitive detection method should be optimized for the evaluation of ES treatment effects in future studies.

Vitreous composition modification after transpalpebral electrical stimulation of the eye: Biochemical analysis

Electrical stimulation (ES) of the eye represents a therapeutic approach in various clinical applications ranging from retinal dystrophies, age-related macular degeneration, retinal artery occlusion and nonarteritic ischemic optic neuropathy. In clinical practice, ES of the eye is mainly performed with a transcorneal or transpalpebral approach. These procedures are non-invasive and well-tolerated by the patients, reporting only minimal and transient adverse events, while serious adverse effects were not observed. Despite the growing literature on animal models, only clinical parameters have been investigated in humans and few data are available about biochemical changes induced by ES of the eye. The purpose of this study is to investigate the possible mechanism that regulates the beneficial effects of ES on retinal cells function and survival in humans. 28 patients undergoing pars plana vitrectomy (PPV) for idiopathic epiretinal membrane (iERM) were randomly divided in two groups: 13 patients were treated with transpalpebral ES before surgery and 15 underwent surgery with no prior treatment. Vitreous samples were collected for biochemical analysis during PPV. ES treatment leads to a reduction in the vitreous expression of both proinflammatory cytokines, namely IL-6 and IL-8, and proinflammatory lipid mediators, such as lysophosphatidylcholine. Indeed, we observed a 70% decrease of lysophosphatidylcholine 18:0, which has been proven to exert the greatest proinflammatory activities among the lysophosphatidylcholine class. The content of triglycerides is also affected and significantly decreased following ES application. The vitreous composition of patients undergoing PPV for iERM displays significant changes following ES treatment. Proinflammatory cytokines and bioactive lipid mediators expression decreases, suggesting an overall anti-inflammatory potential of ES. The investigation of the mechanism by which this treatment alters the retinal neurons leading to good outcomes is essential for supporting ES therapeutic application in various types of retinal diseases.

Effects of Ocular Direct Current Stimulation on Full Field Electroretinogram

Studies on weak current stimulation (1-2 mA) examine effects on neuronal cells for the treatment of neurological diseases, like depression. Ocular current stimulation showed positive effects on retinal nerve cells which indicate that neurodegenerative ocular diseases, e.g., glaucoma, can be treated with current stimulation of the eye. However, up to now it remains unclear which exact retinal cells can be influenced. During an ocular direct current stimulation, a significant reduction of the characteristic P50 amplitude of a pattern-reversal electroretinogram (PERG) was found for an anodal and a cathodal stimulation. This current stimulation effect could originate from the modulation of pre-ganglion cell activity or by changes in local ON and OFF responses of ganglion cells. For clarification, we investigate acute direct current stimulation effects on a full field electroretinogram (ERG), which represents the activity of pre-ganglion cells (specifically cones and bipolar cells). The ERG from 15 subjects was evaluated before (ERG 1) and during (ERG 2) an ocular direct current stimulation with 800 μA over 5 min. The current was applied through a ring rubber electrode placed around the eye and a 25 cm2 rubber electrode placed at the ipsilateral temple. For ERG measurements, sintered Ag/AgCl skin-electrodes were positioned on the lower eyelid (active), the earlobe (reference), and the forehead (ground). The volunteers were stimulated in three independent sessions, each with a different current application (randomized order): cathodal polarity, anodal polarity (referred to the electrode around the eye), or sham stimulation. The changes between the two ERG measurements of the characteristic full field ERG amplitudes, a-wave, b-wave, and b'-wave (b-wave measured from zero line) were tested with the Wilcoxon signed-rank test (α = 0.05). Comparing before to during the current stimulation for all applications, the ERG waves showed no effects on amplitudes or latencies. Furthermore, no significant difference between the cathodal, anodal, and sham stimulation could be found by a Friedman test. These results indicate an unlikely contribution of pre-ganglion cells to the previously reported stimulation effect on PERG signals.

Noninvasive Electrical Stimulation Improves Photoreceptor Survival and Retinal Function in Mice with Inherited Photoreceptor Degeneration

Purpose

Neurons carry electrical signals and communicate via electrical activities. The therapeutic potential of electrical stimulation (ES) for the nervous system, including the retina, through improvement of cell survival and function has been noted. Here we investigated the neuroprotective and regenerative potential of ES in a mouse model of inherited retinal degeneration.

Methods

Rhodopsin-deficient (Rho^−/−) mice received one or two sessions of transpalpebral ES or sham treatments for 7 consecutive days. Intraperitoneal injection of 5-ethynyl-2′-deoxyuridine was used to label proliferating cells. Weekly electroretinograms were performed to monitor retinal function. Retinal morphology, photoreceptor survival, and regeneration were evaluated in vivo using immunohistochemistry and genetic fate-mapping techniques. Müller cell (MC) cultures were employed to further define the optimal conditions of ES application.

Results

Noninvasive transpalpebral ES in Rho^−/− mice improved photoreceptor survival and electroretinography function in vivo. ES also triggered residential retinal progenitor-like cells such as MCs to reenter the cell cycle, possibly producing new photoreceptors, as shown by immunohistochemistry and genetic fate-mapping techniques. ES directly stimulated cell proliferation and the expression of progenitor cell markers in MC cultures, at least partially through bFGF signaling.

Conclusions

Our study showed that transpalpebral ES improved photoreceptor survival and retinal function and induced the proliferation, probably photoreceptor regeneration, of MCs; this occurs via stimulation of the bFGF pathways. These results suggest the exciting possibility of applying noninvasive ES as a versatile tool for preventing photoreceptor loss and mobilizing endogenous progenitors for reversing vision loss in patients with photoreceptor degeneration.

Non-invasive current stimulation in vision recovery: a review of the literature

Background:

Around 253 million people worldwide suffer from irreversible visual damage. Numerous studies have been carried out in order to unveil the effects of electrical stimulation (ES) as a useful tool for rehabilitation for different visual conditions and pathologies.

Objective:

This systematic review aimed to 1) examine the current evidence of ES efficacy for the treatment of visual pathologies and 2) define the corresponding degree of the recommendation of different ES techniques.

Methods:

A systematic review was conducted in MEDLINE and Cochrane Library database to collect documents published between 2000 and 2018. For each study, Level of Evidence of Effectiveness of ES as well as the Class of Quality for the treatment of different visual pathologies were determined.

Results:

Thirty-eight articles were included. Studies were grouped according to the pathology treated and the type of stimulation administered. The first group included studies treating pre-chiasmatic pathologies (age-related macular degeneration, macular dystrophy, retinal artery occlusion, retinitis pigmentosa, glaucoma, optic nerve damage, and optic neuropathy) using pre-chiasmatic stimulation; the second group included studies treating both pre-chiasmatic pathologies (amblyopia, myopia) and post-chiasmatic pathologies or brain conditions (hemianopsia, brain trauma) by means of post-chiasmatic stimulation. In the first group, repetitive transorbital alternating current stimulation (rtACS) reached level A recommendation, and transcorneal electrical stimulation (tcES) reached level B. In the second group, both high-frequency random noise stimulation (hf-RNS) and transcranial direct current stimulation (tDCS) reached level C recommendation.

Conclusions:

Study’s findings suggest conclusive evidence for rtACS treatment. For other protocols results are promising but not conclusive since the examined studies assessed different stimulation parameters and endpoints. A comparison of the effects of different combinations of these variables still lacks in the literature. Further studies are needed to optimize existing protocols and determine if different protocols are needed for different diseases.

Enayati K, Xie J, Zhao E, Turunen T, Sehic A, Lu L, Utheim TP, Chen DF. Electrical Stimulation Induces Retinal Müller Cell Proliferation and Their Progenitor Cell Potential

Non-invasive electrical stimulation (ES) is increasingly applied to improve vision in untreatable eye conditions, such as retinitis pigmentosa and age-related macular degeneration. Our previous study suggested that ES promoted retinal function and the proliferation of progenitor-like glial cells in mice with inherited photoreceptor degeneration; however, the underlying mechanism remains obscure. Müller cells (MCs) are thought to be dormant residential progenitor cells that possess a high potential for retinal neuron repair and functional plasticity. Here, we showed that ES with a ramp waveform of 20 Hz and 300 µA of current was effective at inducing mouse MC proliferation and enhancing their expression of progenitor cell markers, such as Crx (cone-rod homeobox) and Wnt7, as well as their production of trophic factors, including ciliary neurotrophic factor. RNA sequencing revealed that calcium signaling pathway activation was a key event, with a false discovery rate of 5.33 × 10-8 (p = 1.78 × 10-10) in ES-mediated gene profiling changes. Moreover, the calcium channel blocker, nifedipine, abolished the observed effects of ES on MC proliferation and progenitor cell gene induction, supporting a central role of ES-induced Ca2+ signaling in the MC changes. Our results suggest that low-current ES may present a convenient tool for manipulating MC behavior toward neuroregeneration and repair.

Pulsed Electrical Stimulation of the Human Eye Enhances Retinal Vessel Reaction to Flickering Light

Recent studies indicate therapeutic benefits of electrical stimulation in cases of specific ophthalmic diseases that are associated with dysfunctional ocular microcirculation. This suggests effects of electrical stimulation on vascular functions. In the present study, we investigated the effects of electrical stimulation on retinal vessel reactions using dynamic vessel analysis (DVA). Eighty healthy subjects were randomly assigned to one of three groups receiving electrical stimulation with different current intensities: 400 μA (n = 26); 800 μA (n = 27); 1200 μA (n = 27). The electrode montage for electrical stimulation consisted of a ring-shaped active electrode surrounding one eye and a square return electrode at the occiput. Rectangular, monophasic, positive current pulses were applied at 10 Hz for a duration of 60 s per stimulation period. DVA was used to observe the stimulation-induced reactions of retinal vessel diameters in response to different provocations. In three DVA measurements, three stimulus conditions were investigated: flicker light stimulation (FLS); electrical stimulation (ES); simultaneous electrical and flicker light stimulation (ES+FLS). Retinal vasodilation caused by these stimuli was compared using paired t-test. The subjects receiving electrical stimulation with 800 μA showed significantly increased retinal vasodilation for ES+FLS compared to FLS (p < 0.05). No significant differences in retinal vessel reactions were found between ES+FLS and FLS in the 400 and 1200 μA groups. No retinal vasodilation was observed for ES for all investigated current intensities. The results indicate that positive pulsed electrical stimulation of an adequate intensity enhances the flicker light-induced retinal vasodilation.

Treatments for dry age-related macular degeneration and Stargardt disease: a systematic review

BACKGROUND

Age-related macular degeneration (AMD) is the leading cause of visual loss in older people. Advanced AMD takes two forms, neovascular (wet) and atrophic (dry). Stargardt disease (STGD) is the commonest form of inherited macular dystrophy.

OBJECTIVE

To carry out a systematic review of treatments for dry AMD and STGD, and to identify emerging treatments where future NIHR research might be commissioned.

DESIGN

Systematic review.

METHODS

We searched MEDLINE, EMBASE, Web of Science and The Cochrane Library from 2005 to 13 July 2017 for reviews, journal articles and meeting abstracts. We looked for studies of interventions that aim to preserve or restore vision in people with dry AMD or STGD. The most important outcomes are those that matter to patients: visual acuity (VA), contrast sensitivity, reading speed, ability to drive, adverse effects of treatment, quality of life, progression of disease and patient preference. However, visual loss is a late event and intermediate predictors of future decline were accepted if there was good evidence that they are strong predictors of subsequent visual outcomes. These include changes detectable by investigation, but not necessarily noticed by people with AMD or STGD. ClinicalTrials.gov, the World Health Organization search portal and the UK Clinical Trials gateway were searched for ongoing and recently completed clinical trials.

RESULTS

The titles and abstracts of 7948 articles were screened for inclusion. The full text of 398 articles were obtained for further screening and checking of references and 112 articles were included in the final report. Overall, there were disappointingly few good-quality studies (including of sufficient size and duration) reporting useful outcomes, particularly in STGD. However we did identify a number of promising research topics, including drug treatments, stem cells, new forms of laser treatment, and implantable intraocular lens telescopes. In many cases, research is already under way, funded by industry or governments.

LIMITATIONS

In AMD, the main limitation came from the poor quality of much of the evidence. Many studies used VA as their main outcome despite not having sufficient duration to observe changes. The evidence on treatments for STGD is sparse. Most studies tested interventions with no comparison group, were far too short term, and the quality of some studies was poor.

FUTURE WORK

We think that the topics on which the Health Technology Assessment (HTA) and Efficacy Mechanism and Evaluation (EME) programmes might consider commissioning primary research are in STGD, a HTA trial of fenretinide (ReVision Therapeutics, San Diego, CA, USA), a visual cycle inhibitor, and EME research into the value of lutein and zeaxanthin supplements, using short-term measures of retinal function. In AMD, we suggest trials of fenretinide and of a potent statin. There is epidemiological evidence from the USA that the drug, levodopa, used for treating Parkinson's disease, may reduce the incidence of AMD. We suggest that similar research should be carried out using the large general practice databases in the UK. Ideally, future research should be at earlier stages in both diseases, before vision is impaired, using sensitive measures of macular function. This may require early detection of AMD by screening.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016038708.

FUNDING

The National Institute for Health Research HTA programme.

Neuroprotective strategies for retinal disease

Diseases that affect the eye, including photoreceptor degeneration, diabetic retinopathy, and glaucoma, affect 11.8 million people in the US, resulting in vision loss and blindness. Loss of sight affects patient quality of life and puts an economic burden both on individuals and the greater healthcare system. Despite the urgent need for treatments, few effective options currently exist in the clinic. Here, we review research on promising neuroprotective strategies that promote neuronal survival with the potential to protect against vision loss and retinal cell death. Due to the large number of neuroprotective strategies, we restricted our review to approaches that we had direct experience with in the laboratory. We focus on drugs that target survival pathways, including bile acids like UDCA and TUDCA, steroid hormones like progesterone, therapies that target retinal dopamine, and neurotrophic factors. In addition, we review rehabilitative methods that increase endogenous repair mechanisms, including exercise and electrical stimulation therapies. For each approach, we provide background on the neuroprotective strategy, including history of use in other diseases; describe potential mechanisms of action; review the body of research performed in the retina thus far, both in animals and in humans; and discuss considerations when translating each treatment to the clinic and to the retina, including which therapies show the most promise for each retinal disease. Despite the high incidence of retinal diseases and the complexity of mechanisms involved, several promising neuroprotective treatments provide hope to prevent blindness. We discuss attractive candidates here with the goal of furthering retinal research in critical areas to rapidly translate neuroprotective strategies into the clinic.

Restoring vision

Restoring vision to the blind by retinal repair has been a dream of medicine for centuries, and the first successful procedures have recently been performed. Although we are still far from the restoration of high-resolution vision, step-by-step developments are overcoming crucial bottlenecks in therapy development and have enabled the restoration of some visual function in patients with specific blindness-causing diseases. Here, we discuss the current state of vision restoration and the problems related to retinal repair. We describe new model systems and translational technologies, as well as the clinical conditions in which new methods may help to combat blindness.

Electrical Stimulation as a Means for Improving Vision

Evolving research has provided evidence that noninvasive electrical stimulation (ES) of the eye may be a promising therapy for either preserving or restoring vision in several retinal and optic nerve diseases. In this review, we focus on minimally invasive strategies for the delivery of ES and accordingly summarize the current literature on transcorneal, transorbital, and transpalpebral ES in both animal experiments and clinical studies. Various mechanisms are believed to underlie the effects of ES, including increased production of neurotrophic agents, improved chorioretinal blood circulation, and inhibition of proinflammatory cytokines. Different animal models have demonstrated favorable effects of ES on both the retina and the optic nerve. Promising effects of ES have also been demonstrated in clinical studies; however, all current studies have a lack of randomization and/or a control group (sham). There is thus a pressing need for a deeper understanding of the underlying mechanisms that govern clinical success and optimization of stimulation parameters in animal studies. In addition, such research should be followed by large, prospective, clinical studies to explore the full potential of ES. Through this review, we aim to provide insight to guide future research on ES as a potential therapy for improving vision.

Transcutaneous periorbital electrical stimulation in the treatment of dry eye

PURPOSE

To evaluate efficacy and safety of transcutaneous application of electrical current on symptoms and clinical signs of dry eye (DE).

METHODS

27 patients with DE underwent transcutaneous electrostimulation with electrodes placed onto the periorbital region of both eyes and manual stimulation with a hand-piece conductor moved by the operator. Each patient underwent 12 sessions of 22 min spread over 2 months, two sessions per week in the first month and one session per week in the second month. Ocular Surface Disease Index (OSDI) questionnaire, tear break-up time (TBUT), fluorescein staining of the cornea, Schirmer I test and adverse events were evaluated at baseline, at end of treatment and at 6 and 12 months.

RESULTS

OSDI improved from 43.0±19.2 at baseline to 25.3±22.1 at end of treatment (mean±SD, p=0.001). These effects were substantially maintained at 6-month and 12-month follow-up evaluations. Improvement of the values of TBUT was recorded for the right eye at the end of treatment (p=0.003) and found in the left eye after 12 months (p=0.02). The Oxford scores changed in both eyes at the end of treatment and at the 6-month evaluation (p<0.001), and in the right eye at the 12-month evaluation (p=0.035). Schirmer I improved significantly at the end of treatment in the left eye (p=0.001) and in both eyes at the 12-month evaluation (p=0.004 and p=0.039 for the left and right eye, respectively). A significant reduction of the use of tear substitutes was found at the end of treatment (p=0.003), and was maintained during the follow-up (p<0.001).No complications occurred and patients found the treatment satisfying.

CONCLUSIONS

Transcutaneous electrical stimulation was shown to improve DE, both subjectively and objectively, without any adverse effects and has the potential to enlarge the armamentarium for treating DE.