Retinal Prostheses Development in Retinitis Pigmentosa Patients-Progress and Comparison

PURPOSE

Since 2000, several groups have initiated chronic studies, implanting electronic retinal prostheses into the blind eyes of patients with retinitis pigmentosa to produce formed vision.

DESIGN

A review and comparison of their techniques and results.

METHODS

The 4 groups reviewed comprise 2 epiretinal and 2 subretinal groups. Visual function results reported in their publications during approximately the past 2 years are compared.

RESULTS

Serious adverse effects occurred in both epiretinal groups but none in the 2 subretinal groups. Phosphenes with some similarity to the multielectrode stimulation pattern were induced by 1 group (EpiRet GmbH), and a somewhat higher phosphene pattern was created by another group (Second Sight). In 1 subretinal group (Retina Implant AG), an even higher phosphene pattern allowed recognition of letters and objects such as a cup or saucer. In the second subretinal group (Optobionics), besides perceived phosphenes, a neurotrophic rescue of visual function produced a marked improvement of visual acuity, color and contrast perception, visual field size, and improved darkness perception. In some subjects, recognition of facial features and household objects was restored.

CONCLUSIONS

Both epiretinal and subretinal prostheses created phosphene-type patterned vision in some subjects. The phosphene resolution of Retina Implant AG's subretinal device was substantially greater than both epiretinal devices. Of the 4 groups, only Optobionic's paracentrally placed subretinal Artificial Silicon Retina implant induced an unexpected neurotrophic rescue and return of lost visual function resulting in the greatest return of visual acuity, color and contrast perception, visual field enlargement, and darkness perception.

The artificial silicon retina in retinitis pigmentosa patients (an American Ophthalmological Association thesis)

PURPOSE

In a published pilot study, a light-activated microphotodiode-array chip, the artificial silicon retina (ASR), was implanted subretinally in 6 retinitis pigmentosa (RP) patients for up to 18 months. The ASR electrically induced retinal neurotrophic rescue of visual acuity, contrast, and color perception and raised several questions: (1) Would neurotrophic effects develop and persist in additionally implanted RP patients? (2) Could vision in these patients be reliably assessed? (3) Would the ASR be tolerated and function for extended periods?

METHODS

Four additional RP patients were implanted and observed along with the 6 pilot patients. Of the 10 patients, 6 had vision levels that allowed for more standardized testing and were followed up for 7+ years utilizing ETDRS charts and a 4-alternative forced choice (AFC) Chow grating acuity test (CGAT). A 10-AFC Chow color test (CCT) extended the range of color vision testing. Histologic examination of the eyes of one patient, who died of an unrelated event, was performed.

RESULTS

The ASR was well tolerated, and improvement and/or slowing of vision loss occurred in all 6 patients. CGAT extended low vision acuity testing by logMAR 0.6. CCT expanded the range of color vision testing and correlated well with PV-16 (r = 0.77). An ASR recovered from a patient 5 years after implantation showed minor disruption and excellent electrical function.

CONCLUSION

ASR-implanted RP patients experienced prolonged neurotrophic rescue of vision. CGAT and CCT extended the range of acuity and color vision testing in low vision patients. ASR implantation may improve and prolong vision in RP patients.

Status of the feline retina 5 years after subretinal implantation

Retinal prosthetics are designed to restore functional vision to patients with photoreceptor degeneration by detecting light and stimulating the retina. Since devices are surgically implanted into the eye, long-term biocompatibility and durability are critical for viable treatment of retinal disease. To extend our previous work, which demonstrated the biocompatibility of a microphotodiode array (MPA) for 10 to 27 months in the normal feline retina, we implanted normal cats with an MPA implant backed with either an iridium oxide or platinum electrode and examined retinal function and biocompatibility for 3 to 5 years. All implants functioned throughout the study period. Retinal function remained steady and normal with a less than 15 percent decrease in electroretinogram response. The retinas had normal laminar structure with no signs of inflammation or rejection in areas adjacent to or distant from the implants. Directly over the implants, a loss of photoreceptor nuclei and remodeling of inner retinal layers existed. These results indicate that the subretinal MPA device is durable and well tolerated by the retina 5 years postimplantation.

Neuroprotective effect of subretinal implants in the RCS rat

PURPOSE

Retinal prosthetics have been designed to interface with the neural retina by electrically stimulating the remaining retinal circuits after photoreceptor degeneration. However, the electrical stimulation provided by the subretinal implant may also stimulate neurotrophic factors that provide neuroprotection to the retina. This study was undertaken to determine whether electrical stimulation from a subretinal photodiode-based implant has a neuroprotective effect on photoreceptors in the RCS rat, a model of photoreceptor degeneration.

METHODS

Eyes of RCS rats were implanted with an active or inactive device or underwent sham surgery before photoreceptor degeneration. Outer retinal function was assessed with electroretinogram (ERG) recordings weekly until 8 weeks after surgery, at which time retinal tissue was collected and processed for morphologic assessment, including photoreceptor cell counts and retinal layer thickness.

RESULTS

At 4 to 6 weeks after surgery, the ERG responses in the active-implant eyes were 30% to 70% greater in b-wave amplitude than the responses from eyes implanted with inactive devices, those undergoing sham surgery, or the nonsurgical control eyes. At 8 weeks after surgery the ERG responses from active-implant eyes were not significantly different from the control groups. However, the number of photoreceptors in eyes implanted with the active or inactive device was significantly greater in the regions over and around the implant versus sham-surgical and nonsurgical control eyes.

CONCLUSIONS

These results suggest that subretinal electrical stimulation provides temporary preservation of retinal function in the RCS rat. In addition, implantation of an active or inactive device into the subretinal space causes morphologic preservation of photoreceptors in the RCS rat until 8 weeks after surgery. Further studies are needed to determine whether the correlation of neuropreservation with subretinal implantation is due to electrical stimulation and/or a mechanical presence of the implant in the subretinal space.

Possible sources of neuroprotection following subretinal silicon chip implantation in RCS rats

Current retinal prosthetics are designed to stimulate existing neural circuits in diseased retinas to create a visual signal. However, implantation of retinal prosthetics may create a neurotrophic environment that also leads to improvements in visual function. Possible sources of increased neuroprotective effects on the retina may arise from electrical activity generated by the prosthetic, mechanical injury due to surgical implantation, and/or presence of a chronic foreign body. This study evaluates these three neuroprotective sources by implanting Royal College of Surgeons (RCS) rats, a model of retinitis pigmentosa, with a subretinal implant at an early stage of photoreceptor degeneration. Treatment groups included rats implanted with active and inactive devices, as well as sham-operated. These groups were compared to unoperated controls. Evaluation of retinal function throughout an 18 week post-implantation period demonstrated transient functional improvements in eyes implanted with an inactive device at 6, 12 and 14 weeks post-implantation. However, the number of photoreceptors located directly over or around the implant or sham incision was significantly increased in eyes implanted with an active or inactive device or sham-operated. These results indicate that in the RCS rat localized neuroprotection of photoreceptors from mechanical injury or a chronic foreign body may provide similar results to subretinal electrical stimulation at the current output evaluated here.

The Artificial Silicon Retina Microchip for the Treatment of VisionLoss From Retinitis Pigmentosa

OBJECTIVE

To determine the safety and efficacy of the artificial silicon retina (ASR) microchip implanted in the subretinal space to treat vision loss from retinitis pigmentosa.

METHODS

The ASR microchip is a 2-mm-diameter silicon-based device that contains approximately 5000 microelectrode-tipped microphotodiodes and is powered by incident light. The right eyes of 6 patients with retinitis pigmentosa were implanted with the ASR microchip while the left eyes served as controls. Safety and visual function information was collected.

RESULTS

During follow-up that ranged from 6 to 18 months, all ASRs functioned electrically. No patient showed signs of implant rejection, infection, inflammation, erosion, neovascularization, retinal detachment, or migration. Visual function improvements occurred in all patients and included unexpected improvements in retinal areas distant from the implant.

MAIN OUTCOME MEASURES

Subjective improvements included improved perception of brightness, contrast, color, movement, shape, resolution, and visual field size.

CONCLUSIONS

No significant safety-related adverse effects were observed. The observation of retinal visual improvement in areas far from the implant site suggests a possible generalized neurotrophic-type rescue effect on the damaged retina caused by the presence of the ASR. A larger clinical trial is indicated to further evaluate the safety and efficacy of a subretinally implanted ASR.

Subretinal implantation of semiconductor-based photodiodes: durability of novel implant designs

Selective degeneration of the retinal photoreceptor layers underlies blindness in retinitis pigmentosa (RP) and other inherited retinal disorders. Because there are no therapies for these patients, we are evaluating the possibility that electrical stimulation delivered to the subretinal space by a microphotodiode array (MPA) could replace, in some aspect, the function of diseased photoreceptors. Early MPA prototypes utilized gold as the electrode material, which gradually dissolved during the postoperative period following subretinal implantation. Here we present the results obtained when different MPA materials were used. Semiconductor-based silicon MPAs (2 mm in diameter; 50 microm in thickness), incorporating iridium/iridium oxide (IrOx) or platinum (Pt) electrodes, were implanted into the subretinal space of the right eye of normal cats with the use of vitreoretinal surgical techniques. Indirect ophthalmoscopy, fundus photography, ganzfeld electroretinography, and histology were used for the evaluation of the implanted retinas postoperatively. Infrared (IR) stimulation was used to isolate electrical responses generated by the MPA. The unimplanted left eyes were used for control purposes. After the implantation surgery, subretinal MPAs retained a stable position in the subretinal space. Up to 12 months after surgery, there was little change in the magnitude of the electrical response of IrOx- and Pt-based MPAs to a standard IR light stimulus. Overlying the implant, there was a near-complete loss of the outer retinal layer, which is likely to reflect obstruction of choroidal nourishment to these layers by the solid disk implant. In addition, the inner retinal layers showed variable disorganization. Away from the implant, the retina displayed a normal appearance. In comparison to electroretinograms (ERGs) obtained from unimplanted eyes, responses recorded from implanted eyes had a normal waveform but were slightly smaller in amplitude. These results indicate that IrOx and Pt improve implant electrode durability and that implants incorporating these materials into the electrode layer do not induce panretinal abnormalities.

Immunohistochemical studies of the retina following long-term implantation with subretinal microphotodiode arrays

This study evaluates the feline retina following surgical placement of a semiconductor-based microphotodiode array (MPA) into the subretinal space. Post-operative evaluations of implant durability and clinical biocompatibility have been carried out in these animals. Here, we examine the integrity of the implanted retina using anatomical techniques and immunocytochemical metabolic indicators. After appropriate fixation, the retina was divided into strips to compare areas directly over the implant versus those adjacent to the implant or in the opposite, unimplanted eye. In addition to histological analyses, the distribution of glial fibrillary acidic protein (GFAP), Na, K-ATPase, and the neurotransmitters (glutamate, glycine, and GABA) was examined using immunohistochemistry. Directly above the implant there was a near-complete loss of photoreceptor outer and inner segments and the outer nuclear layer. In comparison, the retina immediately adjacent to the implant appeared normal. In the inner nuclear layer overlying the implant, some cellular disorganization was present, however, the content was not significantly reduced. Also GFAP was up-regulated in the Müller cells directly overlying the MPA, but the retina adjacent to the implant showed a normal distribution of GFAP in the astrocytes located in the ganglion cell layer. The distributions of Na, K-ATPase adjacent to and overlying the implant were not different. Glutamate showed a decrease in overall labeling, but no change in the inner retinal layers. Glycine was found to be up-regulated in the inner nuclear layer immediately overlying the implant, while GABA showed decreased labeling over the MPA. Since photoreceptors overlying the implant degenerate, we compared the changes observed in the implanted retina to those in the Abyssinian cat model of photoreceptor degeneration. Generally, the retinal changes observed over the implant were similar to those seen in the Abyssinian cat, indicating that they may be associated with photoreceptor degeneration. Future studies will concentrate on MPAs designed to improve circulation to the outer retina which may decrease cell loss.

Visual evoked potentials to infrared stimulation in normal cats and rats

The absence of effective treatments for retinal degenerative diseases has inspired several laboratories to pursue the development of a retinal prosthetic. In our laboratory, we have focused on the subretinal approach, using an array of photodiodes housed within a silicon chip. These photodiodes generate electrical current in response to wavelengths ranging from 500-1100 nm. Because the native retina is traditionally thought to be insensitive to wavelengths beyond approximately 750 nm, we and others have attempted to isolate implant-mediated electrophysiological responses from those of the native retina by using longer wavelength stimuli in the near infrared range. Evoked potentials recorded over the visual cortex in response to infrared stimuli have been reported as evidence of a functional subretinal implant due to the typical physiological characteristics of the waveform: a direct relationship between amplitude and intensity, increased amplitude over the visual cortex, and repeatability of the response. However, these results should be interpreted with caution since here we report an unappreciated sensitivity of the native retina to infrared light under dark-adapted conditions.

Implantation of silicon chip microphotodiode arrays into the cat subretinal space

There are currently no therapies to restore vision to patients blinded by photoreceptor degeneration. This project concerns an experimental approach toward a semiconductor-based subretinal prosthetic designed to electrically stimulate the retina. The present study describes surgical techniques for implanting a silicon microphotodiode array in the cat subretinal space and subsequent studies of implant biocompatibility and durability. Using a single-port vitreoretinal approach, implants were placed into the subretinal space of the right eye of normal cats. Implanted retinas were evaluated post-operatively over a 10 to 27 month period using indirect ophthalmoscopy, fundus photography, electroretinography, and histology. Infrared stimulation was used to isolate the electrical response of the implant from that of the normal retina. Although implants continued to generate electrical current in response to light, the amplitude of the implant response decreased gradually due to dissolution of the implant's gold electrode. Electroretinograms recorded from implanted eyes had normal waveforms but were typically 10-15% smaller in amplitude than those in unimplanted left eyes. The nonpermeable silicon disks blocked choroidal nourishment to the retina, producing degeneration of the photoreceptors. The laminar structure of the inner retinal layers was preserved. Retinal areas located away from the implantation site appeared normal in all respects. These results demonstrate that silicon-chip microphotodiode-based implants can be successfully placed into the subretinal space. Gold electrode-based subretinal implants, however, appear to be unsuitable for long-term use due to electrode dissolution and subsequent decreased electrical activity.

Scar remodeling after strabismus surgery

PURPOSE

We sought to investigate abnormal scar lengthening after strabismus surgery.

METHODS

Patients with overcorrection after strabismus surgery or undercorrection after extraocular muscle resection underwent exploration of previously operated muscles. Abnormal findings were documented by inspection and photography, and repair was undertaken at first with absorbable sutures and later with nonabsorbable sutures.

RESULTS

Lengthened scars, consisting of amorphous connective tissue, were repaired on 198 muscles in 134 procedures by excision of the scar and reattachment of the muscle to sclera; absorbable sutures were used in 64 procedures, and nonabsorbable sutures were used in 70 procedures. Thirty-one procedures were followed by partial recurrence of the original overcorrection; 7 of these had documented restretching. The use of nonabsorbable sutures decreased the recurrence of strabismus from 42% to 6%. Factors that distinguished patients with stretched scars from patients with classic slipped muscles included minimal or no limitation of versions, less separation of the tendons from sclera, and thicker appearance of the scar segments.

CONCLUSIONS

A lengthened or stretched remodeled scar between an operated muscle tendon and sclera may contribute to variability of outcome after strabismus repair, even years later. Definitive repair requires firm reattachment of tendon to sclera with nonabsorbable suture support.

Subretinal implantation of semiconductor-based photodiodes: progress and challenges

Retinal diseases that result in photoreceptor degeneration may spare the inner retinal layers. This review concerns a prosthetic approach to restoring visual function through the use of a semiconductor-based microphotodiode array implant, designed to be placed under the neural retina in the subretinal space. The fundamental idea is that current generated by the device in response to light stimulation will alter the membrane potential of overlying neurons and thereby activate the visual system. Initial acute studies indicated that the implant will function in the subretinal space in the absence of an external power supply. More recent and ongoing studies involve chronic subretinal implantations in normal animals. Post-operative studies have demonstrated that implant function will persist for many months. These chronic studies have also assessed the biocompatibility of the implant. Photoreceptors are lost directly overlying the implant, due to the blockade of choroidal circulation to the outer retina by the solid disk device. In comparison, the inner retina maintains its characteristic lamellar structure. Away from the implant site, the retina retains normal anatomy and function. Future studies are needed to determine whether the implant can establish a functional connection to the inner retina and to determine the quality of this connection.

Subretinal semiconductor microphotodiode array

BACKGROUND AND OBJECTIVE

To examine the function of a semiconductor microphotodiode array (SMA) surgically implanted in the subretinal space.

MATERIALS AND METHODS

Positive-intrinsic layer-negative (PiN) or negative-intrinsic layer-positive (NiP) SMAs were surgically placed into the subretinal space of rabbits through a pars plana incision and a posterior retinotomy. The implants required no external connections for power and were sensitive to light over the visible and infrared (IR) spectrum; IR stimuli were used to isolate implant-mediated responses from the activity of native photoreceptors. A stimulator ophthalmoscope was used to superimpose IR stimuli on the implant and adjacent retinal areas, and responses were recorded during the postoperative recovery period. SMA responses were also evaluated in vitro. The animals were given lethal anesthetic overdoses, and the retinas were examined histologically.

RESULTS

The in vitro implant response consisted of an electrical spike, followed by a small-amplitude DC offset that followed the time course of the IR stimulation, and an overshoot at the stimulus offset. The SMAs placed in the subretinal space retained a stable position and continued to function throughout the postoperative period. The SMA responses recorded in vivo included additional slow-wave components that were absent from the in vitro recordings. These responses reverted to the in vitro configuration following the death of the animal. There was a significant loss of retinal cells in areas overlying the implant, and the retina appeared normal away from the implant and surgical site.

CONCLUSION

SMAs can be successfully implanted into the subretinal space and will generate current in response to light stimulation during an extended period of time.

Subretinal electrical stimulation of the rabbit retina

A number of disorders results in photoreceptor degeneration, yet spare the inner retinal layers. We are investigating the possibility that retinal function may be restored in such a situation by electric current applied from the subretinal space. In the present study, bipolar strip electrodes receiving electric current from external photodiodes were implanted into the subretinal space of adult rabbits. Recordings were made from the scalp overlying the visual cortex in response to photic flash stimulation of one eye before surgery. This was compared to the visual cortex response caused by subretinal electrical stimulation of the same eye from an implanted strip electrode. Electric current to the strip electrode was provided by an externally connected photodiode that was stimulated at a remote location with a photoflash. The electrical stimulus was recordable as a brief electrical implant spike during stimulation. In addition, after the implant spike, cortical responses were obtained in response to subretinal electrical stimulation that resembled closely the normal light induced visual evoked potential produced by the pre-implanted eye. These results indicate that the visual system can be activated by electrical stimulation from the subretinal space and indicate that this approach may provide a means to restore vision to eyes blinded by outer retinal disease.

Evulsion of the optic nerve in association with basketball injuries

A case of optic nerve evulsion resulted from a finger poke injury to the globe during a basketball game. Significantly, almost no external damage to the eye was evident. The damage may be caused by sudden forceful anterior-posterior displacement and rotation of the globe, inducing a tear of the optic nerve at the papilla. The seriousness and permanence of this injury stress the importance of protective eye wear in contact sports.

Percutaneous absorption of hexachlorophene in rats, guinea pigs and pigs

A comparative study of the percutaneous absorption of hexachlorophene (HCP) was undertaken in rats, guinea pigs and pigs. [14C]Hexachlorophene ([14C]HCP) was applied evenly over the shaved back of the animals at a dose of 40 microgram/cm2 skin surface. Urine and feces were collected at 24-h intervals for 5 days from animals kept in metabolism cages. Different methods were used for quantitating the percutaneous absorption of HCP. This study showed that skin permeability to HCP decreased in the following order: rat, guinea pig and pig. The permeability characteristics of the pig skin to topically applied HCP were comparable to the published human data. We suggest that pig may be a suitable animal model for studying the percutaneous absorption of antimicrobial drugs.

Glutathione alterations in rat liver after acute and subacute oral administration of paracetamol

1. The effect on hepatic glutathione was studied in rats pretreated orally with various dosages of paracetamol (acetaminophen) for varying time intervals. 2. Paracetamol caused a dose-dependent depletion of hepatic glutathione, the maximum depletion occurring 3 h after acute dosing, the levels returning to normal by 12 h after low doses (0-1 or 0-25 g/kg, p.o.) and by 72 h after the highest doses (1 g/kg, p.o.). 3. Before returning to normal, the liver glutathione levels became significantly greater than the control values (35-40%) at 24 and 48 h in 0-5 and 1 g/kg paracetamol-treated rats, respectively, suggesting thereby a 'glutathione rebound action' of paracetamol-pretreatment. 4. In contrast with the acutely treated rats, the liver glutathione content remained unchanged when 0-5 g/kg paracetamol was administered twice daily for 7 consecutive days. 5. Fasting caused a significant reduction in hepatic glutathione, the glutathione stores were replenished within 6 h after feeding. 6. The results suggest that the hepatic glutathione levels are reversibly depleted by single large doses of paracetamol, while the glutathione depletory effect appears to decrease after the repeated administration of this hepatotoxic agent.

Perinatal development of cavian plasma, hepatic and renal esterases

The perinatal development of plasma cholinesterases and plasma hepatic and renal carboxylesterases was examined quantitatively by spectrophotometric techniques. Between 32 and 63 days of gestation, the plasma, hepatic and renal carboxylesterase activities were extremely low but, within 5 days of birth (66 days gestation), there were no significant differences between infant and adult activities. Plasma cholinesterase developed rapidly after 56 days of gestation, achieving a level comparable to adult activity 3 days after birth.