Multimodal fundus imaging in fundus albipunctatus with RDH5 mutation: a newly identified compound heterozygous mutation and review of the literature.

The aim of this study was to describe multimodal retinal imaging of fundus albipunctatus (FA) with the newly identified compound heterozygous RDH5 mutation and to review the relevant literature. Five family members were examined, and the RDH5 gene was analyzed by direct sequencing. The clinical features and genetic study of FA are reviewed. The proband had a compound heterozygotic missense mutation of Cys59Ser (TGC → AGC) and a nonsense mutation of Trp95ter (TGG → TGA) in the RDH5 gene. Fundus examination revealed diffuse yellow flecks with foveal sparing. Infrared reflectance (IR) imaging showed multiple discrete round lesions, and fundus autofluorescence (FAF) imaging showed decreased autofluorescence. In spectral domain optical coherence tomography (SD-OCT), the lesions spanned across the retinal pigment epithelium complex and the photoreceptor inner segment ellipsoid band. The outer nuclear layer thickness is decreased compared to normal control. Electroretinography (ERG) showed improved dark-adapted responses after a prolonged 2.5-h dark adaptation. The fundi of the patient's son and daughter both appeared unremarkable. The clinical findings, differential diagnosis, and genetic studies of these features are reviewed. This is the first time that IR imaging of this disease has been reported; IR imaging showed more detail than did FAF imaging. Although retinal imaging (fundus photographs, FAF, IR, SD-OCT) of FA showed characteristic findings, ERG and genetic study remain the most reliable tests for making the diagnosis.

Fundus autofluorescence, optical coherence tomography, and electroretinogram findings in choroidal sclerosis.

PURPOSE: The purpose of this study was to describe fundus autofluorescence (FAF), optical coherence tomography, and electroretinogram findings in choroidal sclerosis. METHODS: This is a retrospective case series. Eight eyes of four patients with choroidal sclerosis were evaluated with FAF, optical coherence tomography, and electroretinogram testing. RESULTS: In all eight eyes, FAF imaging showed hypofluorescent placoid lesions corresponding to areas of chorioretinal atrophy seen on stereo biomicroscopy. Prominent hyperfluorescent linear markings underlying regions of atrophic disease were observed in all eyes, likely representative of normal choroidal vessel autofluorescence. In two eyes, FAF showed punctate hypofluorescent lesions in the fovea that were not visualized on biomicroscopy. In one eye, FAF identified a central island of preserved retinal pigment epithelium that was not realized on ophthalmoscopic examination. Optical coherence imaging was significant for loss of choroidal fine tubular structures, retinal pigment epithelium, and outer nuclear layer in regions of chorioretinal atrophy. Full-field electroretinogram testing showed generalized rod-cone dysfunction in all patients with a lower B- to A-wave ratio in two patients. CONCLUSION: Fundus autofluorescence and optical coherence tomography are nonin-vasive diagnostic adjuncts that can aid in the diagnosis of choroidal sclerosis. Fundus autofluorescence may be a more sensitive marker of disease extent and progression than clinical examination alone. Electroretinogram testing can result in an electronegative maximal response.

Fundus autofluorescence in cone dystrophy.

PURPOSE: To describe fundus autofluorescence (FAF) finding in a case of cone dystrophy. METHODS: Interventional case report. RESULTS: A 23-year-old woman presented with increasing photophobia and decreasing vision in both eyes for 2 years. Fundus examination showed several drusen-like dots. FAF revealed hyper-autofluorescence in the foveola. Electroretinogram (ERG) demonstrated a pure "cone" dystrophy. CONCLUSION: Hyper-autofluorescence in the foveola is a non-specific manifestation of photoreceptor-retinal pigment epithelium dysfunction. ERG studies are essential for accurate diagnosis.

Inflammatory mediators induced by amyloid-beta in the retina and RPE in vivo: implications for inflammasome activation in age-related macular degeneration.

PURPOSE: Drusen are hallmarks of age-related macular degeneration (AMD). Amyloid-beta 1-40 (Aß 1-40), a constituent of drusen, is known to stimulate inflammatory pathways in RPE; however, its effect in vivo is not known. The purpose of this study was to examine the effect of Aß 1-40 on cytokine expression and inflammasome activation relevant to AMD in an animal model. METHODS: Wild-type rats received intravitreal injections of Aß 1-40, and eyes were taken at days 1, 4, 14, and 49 postinjection. The RPE, neuroretina, and vitreous were analyzed for cytokine expression, inflammasome activation, and microglial response via RT-PCR, immunohistochemistry, and suspension array assay. Retinal cell loss was assessed via apoptotic markers and retinal thickness. RESULTS: Aß 1-40 stimulated upregulation of IL-6, TNF-α, IL-1ß, IL-18, caspase-1, NLRP3, and XAF1 genes in the RPE/choroid and the neuroretina. Increased IL-1ß and IL-6 immunoreactivity was found in retinal sections, and elevated levels of IL-1ß and IL-18 were found in the vitreous of Aß-injected eyes. Aß 1-40 induced a moderate increase in CD11b/c-reactive cells on day 1 postinjection only. No evidence of the proapoptotic XAF1 protein, p53, TUNEL immunoreactivity, or retinal thinning was observed. CONCLUSIONS: These results confirm earlier in vitro work and support the proinflammatory role of drusen component Aß 1-40 in the RPE and retina. Inflammasome activation may be responsible for this effect in vivo. This model is useful for understanding cellular triggers of inflammasome activation and proposed early inflammatory events in the outer retina associated with the etiology of AMD.

Origin of fundus hyperautofluorescent spots and their role in retinal degeneration in a mouse model of Goldmann-Favre syndrome.

Goldmann-Favre syndrome, also known as enhanced S-cone syndrome, is an inherited retinal degeneration disease in which a gain of photoreceptor cell types results in retinal dysplasia and degeneration. Although microglia have been implicated in the pathogenesis of many neurodegenerative diseases, the fundamental role of these cells in this disease is unknown. In the current study, sequential analyses suggest that microglia are recruited and appear after outer nuclear layer folding. By crossing rd7 mice (a model for hereditary retinal degeneration owing to Nr2e3 mutation) with mice carrying the macrophage Fas-induced apoptosis (Mafia) transgene, we generated double-mutant mice and studied the role of the resident retinal microglia. Microglial cells in these double-mutant mice express enhanced green fluorescent protein (EGFP) and a suicide gene that can trigger Fas-mediated apoptosis via systemic treatment with AP20187 (FK506 dimerizer). We demonstrated that more than 80% of the EGFP+ cells in retinas from rd7/rd7;Tg/Tg mice express Iba-1 (a microglial marker), and resident microglia are still present in the retina because AP20187 does not cross the blood-brain barrier. Hence, only circulating bone marrow (BM)-derived microglia are depleted. Depletion of circulating BM-derived microglia accelerates retinal degeneration in rd7 mice. An increased number of autofluorescent (AF) spots is a consequence of resident microglia proliferation, which in turn establishes an inflammatory cytokine milieu via the upregulation of IL-1ß, IL-6 and TNFα expression. This inflammation is likely to accelerate retinal degeneration. This study not only identifies inflammation as a crucial step in the pathogenesis of retinal degeneration, but also highlights the involvement of specific cytokine genes that could serve as future treatment targets in retinal degenerations.

Choroidal thickness and biometric markers for the screening of lacquer cracks in patients with high myopia.

OBJECTIVES: Validation of choroidal thickness and other biometrics measured by spectral domain optical coherence tomography (SD-OCT) in predicting lacquer cracks formation in highly myopic eyes. METHODS: Patients with a refractive error worse than -8 diopters and moderate myopic maculopathy were recruited into two groups based on the presence or absence of lacquer cracks (36 eyes without and 33 eyes with lacquer cracks). Choroidal thickness, refractive error, and axial length were measured and subjected to receiver operating characteristic curve analysis to identify the optimal cutoff values at predicting lacquer crack formation. The width of the retinal pigment epithelium (RPE), RPE to the inner segment/outer segment line, RPE to the external limiting membrane were also measured and compared to the subfoveal choroidal thickness to assess their relationships as potential markers of lacquer crack formation. RESULTS: Lacquer crack is associated with decreased choroidal thickness, lower best-corrected visual acuity, longer axial length and higher refractive errors. Choroidal thickness has the strongest association with lacquer crack formation versus axial length and refractive error. In eyes with lacquer cracks, stellate lacquer cracks are associated with thinner choroidal thickness compared to eyes with linear lacquer cracks. Subfoveal choroidal thickness less than the width of the retinal pigment epithelium to the inner segment/outer segment line is also associated with lacquer crack formation (sensitivity 78.8%, specificity 88.3%, and accuracy 81.2%). CONCLUSIONS: This study suggests that choroidal thickness and other SD-OCT measurements could be employed clinically to predict the development and severity of lacquer cracks in patients with high myopia.

Progressive constriction of the hyperautofluorescent ring in retinitis pigmentosa.

PURPOSE: To evaluate the constriction of the hyperautofluorescent ring over time in patients with retinitis pigmentosa (RP). DESIGN: Prospective study. METHODS: Fourteen eyes of 14 RP patients with a hyperautofluorescent ring were studied. Ring constriction was evaluated by measurements of its external and internal boundaries along the vertical and horizontal axes at baseline and at 12-, 24-, 36-, and 48-month follow-ups. Repeat fundus autofluorescence was obtained at 12, 24, 36, and 48 months in 13, 7, 5, and 1 eyes respectively. Spectral-domain optical coherence tomography (SD-OCT) images were obtained on 8 eyes and the horizontal extent of the inner segment/outer segment (IS/OS) junction was measured. SD-OCT was repeated at 12 and 24 months in 6 and 4 eyes respectively. RESULTS: The external boundaries of the ring were identified along the horizontal axis in 12 eyes and along the vertical axis in 13. Internal boundaries were identified in 7 eyes. Constriction was demonstrated in all patients except 1 who demonstrated minimal expansion of the internal boundary along the horizontal axis. SD-OCT measurements showed a decrease in the IS/OS junction length. CONCLUSION: Progressive constriction of the hyperautofluorescent ring and a concordant decrease in IS/OS junction length were observed over time.

Comparing different imaging modalities in harada disease: a case report.

PURPOSE: The purpose of this study was to compare fluorescein angiography, infrared imaging, fundus autofluorescence, and optical coherent tomography for the diagnosing and monitoring of Harada disease. METHODS: This was an interventional case report. RESULTS: A 46-year-old Chinese woman presented with headache, tinnitus, and diminished vision in both eyes. Examination revealed bilateral exudative retinal detachment. Optical coherence tomography showed fluid accumulation in three different layers (intraretinal, subretinal, and subretinal pigment epithelium). Fundus autofluorescence revealed regions of hypoautofluorescence as a result of the thick fluid accumulation. Infrared imaging revealed more clinically relevant information than did fundus autofluorescence in this case. CONCLUSION: In Harada disease, excessive fluid accumulates in three different layers. Optical coherence tomography is the most effective modality in measuring the axial distribution of the fluid in the z-plane, whereas infrared imaging is better at providing the information in the x-y plane, compared with fundus autofluorescence.

Rapid and noninvasive imaging of retinal ganglion cells in live mouse models of glaucoma.

PURPOSE: We report a noninvasive method for the monitoring of retinal ganglion cell (RGC) survival in live mice utilizing standard fluorescence microscopy. PROCEDURES: Transgenic mice expressing cyan fluorescent protein (CFP) under the regulation of an RGC-specific promoter Thy1 were used in this study. RESULTS: We established that Thy1-CFP expression is a quantitative reflection of the number of surviving RGCs, the fluorescence emission is stable for at least a year and that the loss of fluorescence correlates directly to glaucomatous damage. In high pressure glaucoma model, the peripheral retina is preferentially affected. CONCLUSIONS: Our live-imaging technique allows for the longitudinal assessment of RGC survival from the same animal. Noninvasive monitoring of neuronal cell death and survival is a powerful technique that would allow investigators to validate new potential glaucoma therapy based on neuroprotection.

Transplantation of reprogrammed embryonic stem cells improves visual function in a mouse model for retinitis pigmentosa.

BACKGROUND: To study whether C57BL/6J-Tyr/J (C2J) mouse embryonic stem (ES) cells can differentiate into retinal pigment epithelial (RPE) cells in vitro and then restore retinal function in a model for retinitis pigmentosa: Rpe65/Rpe65 C57BL6 mice. METHODS: Yellow fluorescent protein (YFP)-labeled C2J ES cells were induced to differentiate into RPE-like structures on PA6 feeders. RPE-specific markers are expressed from differentiated cells in vitro. After differentiation, ES cell-derived RPE-like cells were transplanted into the subretinal space of postnatal day 5 Rpe65/Rpe65 mice. Live imaging of YFP-labeled C2J ES cells demonstrated survival of the graft. Electroretinograms (ERGs) were performed on transplanted mice to evaluate the functional outcome of transplantation. RESULTS: RPE-like cells derived from ES cells sequentially express multiple RPE-specific markers. After transplantation, YFP-labeled cells can be tracked with live imaging for as long as 7 months. Although more than half of the mice were complicated with retinal detachments or tumor development, one fourth of the mice showed increased electroretinogram responses in the transplanted eyes. Rpe65/Rpe65 mice transplanted with RPE-like cells showed significant visual recovery during a 7-month period, whereas those injected with saline, PA6 feeders, or undifferentiated ES cells showed no rescue. CONCLUSIONS: ES cells can differentiate, morphologically, and functionally, into RPE-like cells. Based on these findings, differentiated ES cells have the potential for the development of new therapeutic approaches for RPE-specific diseases such as certain forms of retinitis pigmentosa and macular degeneration. Nevertheless, stringent control of retinal detachment and teratoma development will be necessary before initiation of treatment trials.

Electronegative electroretinogram associated with topiramate toxicity and vitelliform maculopathy.

Topiramate is known to cause ocular side effects such as refractive changes and angle closure. We describe a patient with an electronegative electroretinogram (ERG) which may have been related to topiramate use. Electronegative ERG's have been associated with other drugs in humans as well as topiramate use in rabbits. However, this would be the first suggestion of causality in humans.

Phenotype-genotype correlations in autosomal dominant retinitis pigmentosa caused by RHO, D190N.

PURPOSE: To phenotype a family with RHO (Asp190Asn or D190N) dominantly inherited retinitis pigmentosa (RP) and to describe an approach to surveying affected families. METHODS: Four patients from a family with a history of autosomal dominant RP had complete clinical examinations and underwent full-field electroretinography (ERG), fundus autofluorescence (AF) imaging, and genetic testing. One patient had microperimetry (MP) mapping. RESULTS: The patients' ages ranged from 6 years to 47 years. The proband, the father, had fundoscopic findings typical of RP. A small hyperfluorescent ring centered at the fovea was apparent on AF. MP showed preservation of central 7 degrees of visual field within this ring. The three children were all asymptomatic with visual acuity of 20/15 in each eye. One child had mild retinal pigment epithelium migration on fundoscopy; the other two children had normal fundoscopic examinations. Two children showed increased parafoveal AF. In the two affected children, average ERG b-wave implicit times were delayed in scotopic conditions, and maximal ERG tracings had abnormal waveforms. Genetic analysis confirmed that two of three asymptomatic children carried the D190N allele. CONCLUSIONS: Patients with RHO (D190N) autosomal dominant retinitis pigmentosa (adRP) can show classic signs of RP on fundus examination and may be able to maintain good central visual acuity into adulthood. By combining clinical examination with AF imaging and electrophysiology, it is possible to offer presymptomatic clinical evaluation to families with this RP.

A novel mutation and phenotypes in phosphodiesterase 6 deficiency.

PURPOSE: To develop a systematic approach for the molecular diagnosis of retinitis pigmentosa (RP) and to report new genotype-phenotype correlations for phosphodiesterase 6 (PDE6)-based RP mutations. DESIGN: Clinical and molecular studies on a retrospective case series. METHODS: We screened 40 unrelated RP patients with an autosomal recessive RP microarray. Individuals with RP caused by PDE6 deficiency underwent genetic segregation and phenotype analysis. RESULTS: A disease-associated allele was identified in 32% of patients. Two probands (5%) had PDE6 mutations. The first proband was a compound heterozygote for known R102C and N216S alleles in PDE6A (MIM#180071). Pedigree analysis determined that the N216S variant was benign and direct sequencing discovered a novel, S303C allele. The second proband had a homozygous D600N mutation in the PDE6B gene (MIM#180072). Visual acuities of PDE6-deficient patients ranged from 20/40 to 20/200. Clinical studies showed unusual vitreomacular traction, cystoid macular edema, macular atrophy, and ring hyperfluorescence in PDE6-deficient patients. Such extensive vitreoretinal degeneration is not characteristic of photoreceptor-specific enzyme deficiencies. CONCLUSION: High-throughput deoxyribonucleic acid microarray chips can be used in combination with clinical imaging to precisely characterize patients with RP. Identifying the precise mutation in RP may become the standard of care as gene therapy emerges.

Non-vascular vision loss in pseudoxanthoma elasticum.

Pseudoxanthoma elasticum patients with angioid streaks are well-known to have acute vision loss due to choroidal bleeding. However, chronic vision loss due to macular atrophy is less well characterized. We describe a patient with sub-acute vision loss in one eye due to loss of macular retinal pigment epithelium function. Autofluorescence and pattern electroretinogram were useful adjuncts to help diagnose the source of her vision loss.