Early impairment of the full-field photopic negative response in patients with Stargardt disease and pathogenic variants of the ABCA4 gene.

BACKGROUND: To study the photopic negative response of the full-field photopic electroretinography (ERG) in Stargardt patients with pathogenic variants in the ABCA4 gene. METHODS: A retrospective analysis of 35 Stargardt patients with ABCA4 gene pathogenic variants, compared to normal age-matched controls. Patients were clinically followed at the Ophthalmology Department of Fondazione Policlinico Universitario A. Gemelli/Università Cattolica del Sacro Cuore, Rome, Italy. RESULTS: The photopic negative response of the full-field photopic ERG was compromised in most Stargardt patients. In the presence of a normal B-wave, the amplitude ratio between the photopic negative response and the B-wave displayed a 97% accuracy in detecting diseased eyes (receiver operating characteristic curves). CONCLUSIONS: In Stargardt patients with ABCA4 pathogenic mutations, the photopic negative response of the full-field photopic ERG is a very sensitive disease read-out. Its inclusion in standard ERG analysis would be a no-cost addition of practical consequence in the follow-up of Stargardt disease. The early impairment of the photopic negative response suggests that inner retinal function might be affected in Stargardt disease earlier than previously acknowledged.

Nerve growth factor improves visual loss in childhood optic gliomas: a randomized, double-blind, phase II clinical trial.

Paediatric optic pathway gliomas are low-grade brain tumours characterized by slow progression and invalidating visual loss. Presently there is no strategy to prevent visual loss in this kind of tumour. This study evaluated the effects of nerve growth factor administration in protecting visual function in patients with optic pathway glioma-related visual impairment. A prospective randomized double-blind phase II clinical trial was conducted in 18 optic pathway glioma patients, aged from 2 to 23 years, with stable disease and severe visual loss. Ten patients were randomly assigned to receive a single 10-day course of 0.5 mg murine nerve growth factor as eye drops, while eight patients received placebo. All patients were evaluated before and after treatment, testing visual acuity, visual field, visual-evoked potentials, optic coherence tomography, electroretinographic photopic negative response, and magnetic resonance imaging. Post-treatment evaluations were repeated at 15, 30, 90, and 180 days Brain magnetic resonance imaging was performed at baseline and at 180 days. Treatment with nerve growth factor led to statistically significant improvements in objective electrophysiological parameters (electroretinographic photopic negative response amplitude at 180 days and visual-evoked potentials at 30 days), which were not observed in placebo-treated patients. Furthermore, in patients in whom visual fields could still be measured, visual field worsening was only observed in placebo-treated cases, while three of four nerve growth factor-treated subjects showed significant visual field enlargement. This corresponded to improved visually guided behaviour, as reported by the patients and/or the caregivers. There was no evidence of side effects related to nerve growth factor treatment. Nerve growth factor eye drop administration appears a safe, easy and effective strategy for the treatment of visual loss associated with optic pathway gliomas.

NGF eye-drops topical administration in patients with retinitis pigmentosa, a pilot study.

BACKGROUND: Preclinical trials have shown beneficial effects of nerve growth factor (NGF) administration on visual function in animal models of retinitis pigmentosa (RP). The aim of this pilot study was to explore the potential efficacy of short term NGF eye drops treatment in patients affected by RP. METHODS: The trial consisted in 10 days daily administration of murine NGF as eye-drops for a total dose of 1 mg NGF/pt. Eight RP patients at an advanced stage of the disease were included in the trial. To monitor safety and potential adverse effects subjects underwent standard clinical measures and were requested to report any general or topic alterations following NGF assumption. Retinal function was assessed at baseline and after treatment by best-corrected visual acuity measurement (BCVA), macular focal electroretinogram (fERG) recording and Goldmann visual field testing. RESULTS: A transient tolerable local corneal irritation was the only adverse effect reported. fERG and BCVA remained within the limits determined by test-retest analysis of a large cohort of RP patients. Three patients reported a subjective feeling of improved visual performance. This was associated to a temporary enlargement of the visual field in all three patients and to improved fERG in two of the three. CONCLUSIONS: Short-term administration of NGF eye-drops caused neither significant adverse effects nor visual function losses in the tested RP patients. A minority of patients experienced an improvement of visual performance as shown by Goldmann visual field and fERG. This study supports the safety and possible efficacy of NGF eye-drops administration in RP patients. TRIAL REGISTRATION: EudraCT n. 2008-004561-26.

Botulinum neurotoxin A impairs neurotransmission following retrograde transynaptic transport.

The widely used botulinum neurotoxin A (BoNT/A) blocks neurotransmission via cleavage of the synaptic protein SNAP-25 (synaptosomal-associated protein of 25 kDa). Recent evidence demonstrating long-distance propagation of SNAP-25 proteolysis has challenged the idea that BoNT/A remains localized to the injection site. However, the extent to which distant neuronal networks are impacted by BoNT/A retrograde trafficking remains unknown. Importantly, no studies have addressed whether SNAP-25 cleavage translates into structural and functional changes in distant intoxicated synapses. Here we show that the BoNT/A injections into the adult rat optic tectum result in SNAP-25 cleavage in retinal neurons two synapses away from the injection site, such as rod bipolar cells and photoreceptors. Retinal endings displaying cleaved SNAP-25 were enlarged and contained an abnormally high number of synaptic vesicles, indicating impaired exocytosis. Tectal injection of BoNT/A in rat pups resulted in appearance of truncated-SNAP-25 in cholinergic amacrine cells. Functional imaging with calcium indicators showed a clear reduction in cholinergic-driven wave activity, demonstrating impairments in neurotransmission. These data provide the first evidence for functional effects of the retrograde trafficking of BoNT/A, and open the possibility of using BoNT/A fragments as drug delivery vehicles targeting the central nervous system.

Loss of retinal capillary vasoconstrictor response to Endothelin-1 following pressure increments in living isolated rat retinas.

Increased intraocular pressure (IOP) is a major risk factor for glaucoma, and its contribution to neuronal damage appears multi-factorial. An open issue is whether pressure effects on blood vessels contribute to neuronal damage. In particular, little is known about pressure effects on capillaries, which are the site of most metabolic exchange in the retina, but cannot be easily visualized in vivo. To address this issue, here we have imaged retinal capillaries in acutely isolated living rat retinas, and measured alterations in capillary viability, caliber and response to vasoactive stimuli after controlled pressure stimuli. We found that capillary viability, diameter and response to vasodilator stimulation are not affected after pressure increments; yet, a prolonged lack of capillary response to the vasoconstrictor Endothelin-1 (Et-1) is observed. Considering that Et-1 is a major component of the endogenous control of retinal blood flow the present data lead to the hypothesis that prolonged or repeated IOP elevation could induce capillary disregulation contributing to neuronal damage over time.

The genesis of retinal architecture: an emerging role for mechanical interactions?

Patterns in nature have always fascinated human beings. They convey the idea of order, organization and optimization, and, to the enquiring mind, the alluring promise that understanding their building rules may uncover the forces that shaped them. In the retina, two patterns are outstanding: the stacking of cells in layers and, within the layers, the prevalent arrangement of neurons of the same type in orderly arrays, often referred to as mosaics for the crystalline-like order that some can display. Layers and mosaics have been essential keys to our present understanding of retinal circuital organization and function. Now, they may also be a precious guide in our exploration of how the retina is built. Here, we will review studies addressing the mechanisms controlling the formation of retinal mosaics and layers, illustrating common themes and unsolved problems. Among the intricacies of the building process, a world of physical forces is making its appearance. Cells are extremely complex to model as "physical entities", and many aspects of cell mechanotransduction are still obscure. Yet, recent experiments, focusing on the mechanical aspects of growth and differentiation, suggest that adopting this viewpoint will open new ways of understanding retinal formation and novel possibilities to approach retinal pathologies and repair.

Visual Cortical Plasticity in Retinitis Pigmentosa.

Purpose: Retinitis pigmentosa is a family of genetic diseases inducing progressive photoreceptor degeneration. There is no cure for retinitis pigmentosa, but prospective therapeutic strategies are aimed at restoring or substituting retinal input. Yet, it is unclear whether the visual cortex of retinitis pigmentosa patients retains plasticity to react to the restored visual input. Methods: To investigate short-term visual cortical plasticity in retinitis pigmentosa, we tested the effect of short-term (2 hours) monocular deprivation on sensory ocular dominance (measured with binocular rivalry) in a group of 14 patients diagnosed with retinitis pigmentosa with a central visual field sparing greater than 20° in diameter. Results: After deprivation most patients showed a perceptual shift in ocular dominance in favor of the deprived eye (P < 0.001), as did control subjects, indicating a level of visual cortical plasticity in the normal range. The deprivation effect correlated negatively with visual acuity (r = -0.63, P = 0.015), and with the amplitude of the central 18° focal electroretinogram (r = -0.68, P = 0.015) of the deprived eye, revealing that in retinitis pigmentosa stronger visual impairment is associated with higher plasticity. Conclusions: Our results provide a new tool to assess the ability of retinitis pigmentosa patients to adapt to altered visual inputs, and suggest that in retinitis pigmentosa the adult brain has sufficient short-term plasticity to benefit from prospective therapies.

Central Retina Functional Damage in Usher Syndrome Type 2: 22 Years of Focal Macular ERG Analysis in a Patient Population From Central and Southern Italy.

Purpose: Recent studies show that patients with Usher syndrome type 2 (USH2) have abnormal cone structure and density in the central retina. This occurs in the presence of normal acuity, opening the quest for additional sensitive functional measures of central cone function in USH. We tested here whether focal macular cone electroretinogram (fERG) could be such a tool. Methods: This retrospective study of central cone function loss was based on data from 47 patients with USH2 from the Ophthalmology Department of the Policlinico Gemelli/Catholic University in Rome. The analysis focused on the decrease of the fERG, obtained in response to a 41-Hz sinusoidal modulation of a uniform field presented to the central 18°, generated by red light-emitting diodes (LEDs) and superimposed on an equiluminant steady adapting background. fERG decrease was compared with the decrease of best-corrected visual acuity and Goldmann kinetic perimetry V4E field. Results: fERG follow-up data document a severe and precocious loss of central cone function in USH2 patients, preceding losses in other measures of cone function. fERG is already reduced to 40% of control at the beginning of the second decade of life, and by 25 years of age, all USH2 patients have fERGs less than 30% of control values. Conclusions: fERG represents a sensitive tool to evaluate central cone function in USH2, anticipating the decline of other central cone function measures, such as visual acuity and Goldmann perimetry.

Putting neurons in the right places: local interactions in the genesis of retinal architecture.

Development of the nervous system can be schematically summarized as (1) making the necessary cells, (2) putting these cells in the right places, and then (3) connecting them appropriately. Each of these steps represents an enormous challenge to our understanding. Focusing on the vertebrate retina, I will consider the question of what defines the right place for a neuron to go. I will illustrate data pointing to the prominent role played by short-range cellular interactions, possibly coordinated by global factors, and will discuss how a few sets of local rules could control cell positioning and proper wiring in retinal circuits.

Bilateral Symmetry of Visual Function Loss in Cone-Rod Dystrophies.

PURPOSE: To investigate bilateral symmetry of visual impairment in cone-rod dystrophy (CRD) patients and understand the feasibility of clinical trial designs treating one eye and using the untreated eye as an internal control. METHODS: This was a retrospective study of visual function loss measures in 436 CRD patients followed at the Ophthalmology Department of the Catholic University in Rome. Clinical measures considered were best-corrected visual acuity, focal macular cone electroretinogram (fERG), and Ganzfeld cone-mediated and rod-mediated electroretinograms. Interocular agreement in each of these clinical indexes was assessed by t- and Wilcoxon tests for paired samples, structural (Deming) regression analysis, and intraclass correlation. Baseline and follow-up measures were analyzed. A separate analysis was performed on the subset of 61 CRD patients carrying likely disease-causing mutations in the ABCA4 gene. RESULTS: Statistical tests show a very high degree of bilateral symmetry in the extent and progression of visual impairment in the fellow eyes of CRD patients. CONCLUSIONS: These data contribute to a better understanding of CRDs and support the feasibility of clinical trial designs involving unilateral eye treatment with the use of fellow eye as internal control.

The spatial order of horizontal cells is not affected by massive alterations in the organization of other retinal cells.

To test whether retinal mosaics develop through interactions that are restricted primarily to the mosaic cells, we studied the horizontal cell mosaic in mutant mice (rd/rd and rd/bcl2) displaying severe retinal abnormalities. These mutants show that the horizontal cell mosaic develops normally even if these cells lack part of their synaptic input, have anomalous morphologies, eventually decrease in number, and reside in an abnormally packed retinal layer. These data strongly support a developmental design in which the final position of each cell in a retinal mosaic is controlled by interactions between homotypic cells and is independent of other cell types. The present analysis is also an investigation of the effects of photoreceptor degeneration on the horizontal cells in an established animal model of retinitis pigmentosa, the rd/rd mouse. We find that the organization of the horizontal cell mosaic resists photoreceptor degeneration and, furthermore, that bcl2 overexpression prevents the partial loss of horizontal cells secondary to photoreceptor loss. Secondary degeneration hampers attempts to restore retinal function by transplanting photoreceptors or promoting their survival. The anti-apoptotic gene bcl2 appears to be a promising tool to rescue inner retinal neurons, increasing the probability that photoreceptor rescue or substitution may be beneficial to subjects suffering from retinal degenerative diseases.

Mechanisms controlling the formation of retinal mosaics.

Most regions of the nervous system derive their power of processing from a modular architecture. The retina is an outstanding example of modular circuit design. Retinal neurons are stacked in layers and within each layer neurons of the same type commonly form orderly arrays, or mosaics. Here we review current knowledge on the mechanisms of retinal mosaic formation, and discuss the hypothesis that retinal mosaics are the building blocks in the assembly of retinal circuitry.

The role of tangential dispersion in retinal mosaic formation.

Individual types of retinal nerve cell are spaced across the retina in an orderly manner, ensuring a uniform sampling of the visual field. This regularity in cellular spacing has been commonly attributed to fate determination mechanisms operating around the time of cell birth, an hypothesis presuming that the position of a nerve cell is fixed within the plane of the retina from the time of its determination. At odds with this view, recent results from X-inactivation mosaic mice indicate that certain classes of retinal nerve cell, those known to form orderly mosaics in the adult retina, disperse tangentially during development. Furthermore, studies defining the spatial characteristics of developing and mature retinal mosaics suggest that cell-cell interactions around the time of morphological differentiation lead to mutual repulsion. Modelling studies in turn show that nothing more than a simple minimal spacing rule between neighboring cells of the same type is sufficient for the creation of the global patterning observed in biological retinal mosaics. For some cell types, the size of this "exclusion zone" surrounding individual cells is shown to be an intrinsic characteristic of each cell type, invariant across the retina, and accounting for the variation in mosaic regularity across changes in cell density. These results show how short-distance movements driven by intercellular interactions at the local level may mediate the emergence of the global patterning characteristic of retinal mosaics during development.

Early detection of central visual function decline in cone-rod dystrophy by the use of macular focal cone electroretinogram.

PURPOSE: To evaluate macular focal cone ERG (fERG) as a tool for reliable and early detection of central retinal function decay in cone-rod dystrophy (CRD). METHODS: A retrospective study of the time course of fERG amplitude and its relation to visual acuity alterations was performed in 47 CRD patients followed yearly for 6.0 ± 3.1 years. Macular focal cone ERG was evoked by a flickering uniform red field overlaying the central 18° of visual field. RESULTS: Macular focal cone ERG follow-up allowed a clear-cut identification of CRD patients as stationary or progressive, in agreement with visual acuity follow-up. In all progressive patients, fERG declined whenever visual acuity declined, and--in 50% of the cases--fERG loss anticipated acuity loss of several years. CONCLUSIONS: Macular focal cone ERG represents a sensitive assay to detect, categorize, and follow the progression of central retinal dysfunction in CRD. Its use as a diagnostic tool in CRD may help anticipate, for an individual patient, the likelihood and rate of further disease progression before visual acuity loss has occurred.

Long-term decline of central cone function in retinitis pigmentosa evaluated by focal electroretinogram.

PURPOSE: We evaluated long-term changes of central cone-mediated function in retinitis pigmentosa (RP) patients by recording focal electroretinograms (fERG). METHODS: A cohort of 43 RP patients was followed from 4 to 16 years (average follow-up 9.3 years, average 10 examinations/patient) by recording the fERG response to a flickering uniform red field overlaying the central 18° of visual field (VF). Statistical censoring led to a reduced dataset of 32 patients (autosomal dominant 9, recessive 5, sporadic 5, x-linked 1, Usher II 12), from which long-term decay rates were estimated by global fitting of individual fERG amplitude time-curves. RESULTS: Long-term follow-up of central cone FERG amplitude showed two main features: short-term variability and long-term decline. fERG short-term variability range was 0.14 to 0.2 log units. Mean yearly decay rate of central fERG was 5.6% (95% confidence interval [CI] 4%-7%). Yearly decline depended on inheritance pattern, being significantly greater in autosomal recessive and sporadic compared to autosomal dominant RP. The degree of central cone fERG decline was unrelated to the size of the residual VF. CONCLUSIONS: The decline of central cone function is significantly slower than global cone function decline in RP. Central cone fERG loss is independent of residual VF.

A three-dimensional analysis of the development of the horizontal cell mosaic in the rat retina: implications for the mechanisms controlling pattern formation.

The horizontal cells are known to form a mono-layered mosaic in the adult retina, but are scattered at different retinal depths in early development. To help clarifying when and which spatial constraints appear in the relative positioning of these cells, we have performed a quantitative analysis of the three-dimensional (3D) organization of the horizontal cell mosaic at different developmental stages in the postnatal rat retina. We first analyzed the two-dimensional (2D) distribution of the horizontal cell projections onto a plane parallel to the upper retinal surface in retinal flat-mounts, and thus to the future mature horizontal cell mosaic. We found that this 2D distribution was non random since postnatal day 1 (P1), and had a subsequent stepwise improvement in regularity. This preceded the alignment of cells in a single monolayer, which was observed on P6. We then computed true horizontal cell spacing in 3D, finding non-random 3D positioning already on P1. Simulation studies showed that this order might simply derive from the 2D order observed in the projections of the cells in flat-mount, combined with their limited spread in retinal depth. Throughout the period analyzed, the relative positions of horizontal cells are in good agreement with a minimal spacing rule in which the exclusion zone corresponds to the average size of the inner core of the cell dendritic tree estimated from P1 samples. These data indicate the existence of different phases in the process of horizontal cell 3D spatial ordering, supporting the view that multiple mechanisms are involved in the development of the horizontal cell mosaic.

Acute retinal ganglion cell injury caused by intraocular pressure spikes is mediated by endogenous extracellular ATP.

Elevated intraocular pressure may lead to retinal ganglion cell injury and consequent visual deficits. Chronic intraocular pressure increase is a major risk factor for glaucoma, a leading blinding disease, and permanent visual deficits can also occur following acute pressure increments due to trauma, acute glaucoma or refractive surgery. How pressure affects retinal neurons is not firmly established. Mechanical damage at the optic nerve head, reduced blood supply, inflammation and cytotoxic factors have all been called into play. Reasoning that the analysis of retinal neurons soon after pressure elevation would provide useful cues, we imaged individual ganglion cells in isolated rat retinas before and after short hydrostatic pressure increments. We found that slowly rising pressure to peaks observed in trauma, acute glaucoma or refractive surgery (50-90 mmHg) did not damage ganglion cells, whereas a rapid 1 min pulse to 50 mmHg injured 30% of these cells within 1 h. The severity of damage and the number of affected cells increased with stronger or repeated insults. Degrading extracellular ATP or blocking the P2X receptors for ATP prevented acute pressure-induced damage in ganglion cells. Similar effects were observed in vivo. A short intraocular pressure transient increased extracellular ATP levels in the eye fluids and damaged ganglion cells within 1 h. Reducing extracellular ATP in the eye prevented damage to ganglion cells and accelerated recovery of their response to light. These data show that rapid pressure transients induce acute ganglion cell injury and unveil the causal role of extracellular ATP elevation in such injury.

Neuronal death induced by endogenous extracellular ATP in retinal cholinergic neuron density control.

The precise assembly of neuronal circuits requires that the correct number of pre- and postsynaptic neurons form synaptic connections. Neuronal cell number is thus tightly controlled by cell death during development. Investigating the regulation of cell number in the retina we found an ATP gated mechanism of neuronal death control. By degrading endogenous extracellular ATP or blocking the P2X(7) ATP receptors we found that endogenous extracellular ATP triggers the death of retinal cholinergic neurons during normal development. ATP-induced death eliminates cholinergic cells too close to one another, thereby controlling the total number, the local density and the regular spacing of these neurons.

Dynamic microtubule-dependent interactions position homotypic neurones in regular monolayered arrays during retinal development.

In the vertebrate retina cell layers support serial processing, while monolayered arrays of homotypic neurones tile each layer to allow parallel processing. How neurones form layers and arrays is still largely unknown. We show that monolayered retinal arrays are dynamic structures based on dendritic interactions between the array cells. The analysis of three developing retinal arrays shows that these become regular as a net of dendritic processes links neighbouring array cells. Molecular or pharmacological perturbations of microtubules within dendrites lead to a stereotyped and reversible disruption of array organization: array cells lose their regular spacing and the arrangement in a monolayer. This leads to a micro-mechanical explanation of how monolayers of regularly spaced 'like-cells' are formed.