Prosthetic Visual Acuity with the PRIMA System in Patients with Atrophic Age-related Macular Degeneration at 4 years follow-up.

Objective: To assess the efficacy and safety of the PRIMA subretinal neurostimulation system 48-months post-implantation for improving visual acuity (VA) in patients with geographic atrophy (GA) due to age-related macular degeneration (AMD) at 48-months post-implantation. Design: First-in-human clinical trial of the PRIMA subretinal prosthesis in patients with atrophic AMD, measuring best-corrected ETDRS VA (Clinicaltrials.gov NCT03333954). Subjects: Five patients with GA, no foveal light perception and VA of logMAR 1.3 to 1.7 in their worse-seeing "study" eye. Methods: In patients implanted with a subretinal photovoltaic neurostimulation array containing 378 pixels of 100 µm in size, the VA was measured with and without the PRIMA system using ETDRS charts at 1 meter. The system's external components: augmented reality glasses and pocket computer, provide image processing capabilities, including zoom. Main Outcome Measures: VA using ETDRS charts with and without the system. Light sensitivity in the central visual field, as measured by Octopus perimetry. Anatomical outcomes demonstrated by fundus photography and optical coherence tomography up to 48-months post-implantation. Results: All five subjects met the primary endpoint of light perception elicited by the implant in the scotoma area. In one patient the implant was incorrectly inserted into the choroid. One subject died 18-months post-implantation due to study-unrelated reason. ETDRS VA results for the remaining three subjects are reported herein. Without zoom, VA closely matched the pixel size of the implant: 1.17 ± 0.13 pixels, corresponding to mean logMAR 1.39, or Snellen 20/500, ranging from 20/438 to 20/565. Using zoom at 48 months, subjects improved their VA by 32 ETDRS letters versus baseline (SE 5.1) 95% CI[13.4,49.9], p<0.0001. Natural peripheral visual function in the treated eye did not decline after surgery compared to the fellow eye (p=0.08) during the 48 months follow-up period. Conclusions: Subretinal implantation of PRIMA in subjects with GA suffering from profound vision loss due to AMD is feasible and well tolerated, with no reduction of natural peripheral vision up to 48-months. Using prosthetic central vision through photovoltaic neurostimulation, patients reliably recognized letters and sequences of letters,and with zoom it provided a clinically meaningful improvement in VA of up to eight ETDRS lines.

[CRISPR/Cas9: From research to therapeutic application]. / CRISPR/Cas9 : de la recherche à l'application thérapeutique.

For several decades, genome engineering has raised interest among many researchers and physicians in the study of genetic disorders and their treatments. Compared to its predecessors, zinc-finger nucleases (ZFN) and transcription activator-like effectors (TALEN), clustered regularly interspaced short palindromic repeats (CRISPR/Cas9) is currently the most efficient molecular tool for genome editing. This system, originally identified as a bacterial adaptive immune system, is capable of cutting and modifying any gene of a large number of living organisms. Numerous trials using this technology are being developed to provide effective treatment for several diseases, such as cancer, cardiovascular and ophthalmic disorders. In research, this technology is increasingly used for genetic disease modelling, providing meaningful models of relevant studies as well as a better understanding of underlying pathological mechanisms. Many molecular tools are now available to put this technique into practice in laboratories, and despite the technical and ethical issues raised by manipulation of the genome, CRIPSR/Cas9 offers a new breath of hope for therapeutic research around the world.

Deep learning based diagnostic quality assessment of choroidal OCT features with expert-evaluated explainability.

Various vision-threatening eye diseases including age-related macular degeneration (AMD) and central serous chorioretinopathy (CSCR) are caused due to the dysfunctions manifested in the highly vascular choroid layer of the posterior segment of the eye. In the current clinical practice, screening choroidal structural changes is widely based on optical coherence tomography (OCT) images. Accordingly, to assist clinicians, several automated choroidal biomarker detection methods using OCT images are developed. However, the performance of these algorithms is largely constrained by the quality of the OCT scan. Consequently, determining the quality of choroidal features in OCT scans is significant in building standardized quantification tools and hence constitutes our main objective. This study includes a dataset of 1593 good and 2581 bad quality Spectralis OCT images graded by an expert. Noting the efficacy of deep-learning (DL) in medical image analysis, we propose to train three state-of-the-art DL models: ResNet18, EfficientNet-B0 and EfficientNet-B3 to detect the quality of OCT images. The choice of these models was inspired by their ability to preserve the salient features across all the layers without information loss. To evaluate the attention of DL models on the choroid, we introduced color transparency maps (CTMs) based on GradCAM explanations. Further, we proposed two subjective grading scores: overall choroid coverage (OCC) and choroid coverage in the visible region(CCVR) based on CTMs to objectively correlate visual explanations vis-à-vis DL model attentions. We observed that the average accuracy and F-scores for the three DL models are greater than 96%. Further, the OCC and CCVR scores achieved for the three DL models under consideration substantiate that they mostly focus on the choroid layer in making the decision. In particular, of the three DL models, EfficientNet-B3 is in close agreement with the clinician's inference. The proposed DL-based framework demonstrated high detection accuracy as well as attention on the choroid layer, where EfficientNet-B3 reported superior performance. Our work assumes significance in bench-marking the automated choroid biomarker detection tools and facilitating high-throughput screening. Further, the methods proposed in this work can be adopted for evaluating the attention of DL-based approaches developed for other region-specific quality assessment tasks.

Volumetric quantification of choroid and Haller's sublayer using OCT scans: An accurate and unified approach based on stratified smoothing.

BACKGROUND AND OBJECTIVE: The choroid, a dense vascular structure in the posterior segment of the eye, maintains the health of the retina by supplying oxygen and nutrients, and assumes clinical significance in screening ocular diseases including age-related macular degeneration (AMD) and central serous chorioretinopathy (CSCR). As a technological assist, algorithmic estimation of choroidal biomarkers has been suggested based on sectional (B-scan) optical coherence tomography (OCT) images. However, most such 2D estimation techniques are compute-intensive, yet enjoy limited accuracy and have only been validated on OCT image datasets of healthy eyes. Not surprisingly, fine-scale analyses, including those involving Haller's sublayer, remain relatively rare and unsophisticated. Against this backdrop, we propose an efficient algorithm to quantify desired biomarkers with improved accuracy based on volume OCT scans. Specifically, we attempted an accurate, computationally light volumetric segmentation method involving stratified smoothing to detect choroid and Haller's sublayer. METHODS: For detecting the various boundaries of the choroid and the Haller's sublayer, we propose a common volumetric method that performs suitable exponential enhancement and maintains smooth spatial continuity across 2D B-scans. Further, we achieve suitable volumetric smoothing by primarily deploying light-duty linear regression, and sparingly using compute-intensive tensor voting, and hence significantly reduce overall complexity. The proposed methodology is tested on five health and five diseased OCT volumes considering various metrics including volumetric Dice coefficient and corresponding quotient measures to facilitate comparison vis-à-vis intra-observer repeatability. RESULTS: On five healthy and five diseased OCT volumes, respectively, the proposed method for choroid segmentation recorded volumetric Dice coefficients of 93.53 % and 93.30 %, which closely approximate the respective reference observer repeatability values of 95.60 % and 95.49 %. In terms of related quotient measures, our method achieved more than 50 % improvement over a recently reported method. In detecting Haller's sublayer as well, our algorithm records statistical performance closely matching that of reference manual method. CONCLUSION: Advancing the state-of-the-art, the proposed volumetric segmentation, tested on both healthy and diseased datasets, demonstrated close match with the manual reference. Our method assumes significance in accurate screening of chorioretinal diseases including AMD, CSCR and pachychoroid. Further, it enables generating accurate training data for developing deep learning models for improved detection of choroid and Haller's sublayer.

Simultaneous perception of prosthetic and natural vision in AMD patients.

Loss of photoreceptors in atrophic age-related macular degeneration (AMD) results in severe visual impairment. Since the low-resolution peripheral vision is retained in such conditions, restoration of central vision should not jeopardize the surrounding healthy retina and allow for simultaneous use of the natural and prosthetic sight. This interim report, prespecified in the study protocol, presents the first clinical results with a photovoltaic substitute of the photoreceptors providing simultaneous use of the central prosthetic and peripheral natural vision in atrophic AMD. In this open-label single group feasibility trial (NCT03333954, recruitment completed), five patients with geographic atrophy have been implanted with a wireless 2 x 2 mm-wide 30 µm-thick device, having 378 pixels of 100 µm in size. All 5 patients achieved the primary outcome of the study by demonstrating the prosthetic visual perception in the former scotoma. The four patients with a subretinal placement of the chip demonstrated the secondary outcome: Landolt acuity of 1.17 ± 0.13 pixels, corresponding to the Snellen range of 20/460-20/565. With electronic magnification of up to a factor of 8, patients demonstrated prosthetic acuity in the range of 20/63-20/98. Under room lighting conditions, patients could simultaneously use prosthetic central vision and their remaining peripheral vision in the implanted eye and in the fellow eye.

Vitreous cytokine expression profiles in patients with retinal detachment.

PURPOSE: To compare the expression profiles of various cytokines and chemokines in vitreous samples from patients with retinal detachment (RD) to those from controls and to analyze their association with various clinical features. METHODS: In this prospective study, undiluted vitreous fluid was obtained from 41 patients with primary RD and 33 controls with macular hole or vitreomacular traction. A multiplex bead immunoassay was performed to determine the expression of 27 inflammatory mediators. RESULTS: Eleven mediators were significantly upregulated in the vitreous of RD patients compared with controls, including the following: cytokines IL-1ra, IL-6, IL-7, IL-8, IFN-γ; chemokines CCL2, CCL3, CCL4, CXCL10 and CCL11 and growth factor G-CSF. Correlation analyses showed that levels of IL-1ra, CXCL10, CCL11 and G-CSF were positively correlated to the extent of detachment, while those of IL-1ra and CXCL10 were associated with the duration of detachment. There was also a positive association between the concentrations of CXCL10 and CCL11 and preoperative flare values. Additional analysis revealed that flare values and both CXCL10 and CCL11 levels were significantly higher in eyes with grade B or C proliferative vitreoretinopathy (PVR). CONCLUSION: Our results confirm that RD induces a marked inflammatory response with a complex cytokine network. We identified proteins specifically linked to several clinical features that might contribute to photoreceptor degeneration and PVR-related redetachment. These proteins may represent potential therapeutic targets for improving the anatomical and functional outcomes of RD surgery.

Functional ultrasound imaging of the spreading activity following optogenetic stimulation of the rat visual cortex.

Optogenetics has revolutionized neurosciences by allowing fine control of neuronal activity. An important aspect for this control is assessing the activation and/or adjusting the stimulation, which requires imaging the entire volume of optogenetically-induced neuronal activity. An ideal technique for this aim is fUS imaging, which allows one to generate brain-wide activation maps with submesoscopic spatial resolution. However, optical stimulation of the brain with blue light might lead to non-specific activations at high irradiances. fUS imaging of optogenetic activations can be obtained at these wavelengths using lower light power (< 2mW) but it limits the depth of directly activatable neurons from the cortical surface. Our main goal was to report that we can detect specific optogenetic activations in V1 even in deep layers following stimulation at the cortical surface. Here, we show the possibility to detect deep optogenetic activations in anesthetized rats expressing the red-shifted opsin ChrimsonR in V1 using fUS imaging. We demonstrate the optogenetic specificity of these activations and their neuronal origin with electrophysiological recordings. Finally, we show that the optogenetic response initiated in V1 spreads to downstream (LGN) and upstream (V2) visual areas.

En-face analysis of short posterior ciliary arteries crossing the sclera to choroid using wide-field swept-source optical coherence tomography.

To study the topographic distribution of the short posterior ciliary arteries (SPCA) entry sites into the choroid in normal eyes using structural en-face swept source optical coherence tomography (SS-OCT). Retrospective analysis of SS-OCT scans (wide-field structural SS-OCT 12 × 12 mm) of 13 healthy subjects was performed. Cross-sectional swept-source OCT scans derived from a volume scan were represented as en-face image display following the Choroid-Scleral Interface to obtain en-face OCT. SPCAs in their last scleral location before choroidal entrance were identified manually, counted and localized by two masked observers. Correlations between two masked observers were analyzed using inter- and intra-class correlation. Accuracy for the choroidal inner and outer border segmentation was 95-99%. Eighteen eyes from 13 normal subjects were included for SPCA analysis. The mean number of arteries was 13.8 ± 3.5 per eye. Thirty-six percent were in the center of the posterior pole image; however, 21% were in the temporal part of the posterior pole. Median accuracy of the detection is 0.94. The correlation between the two observers was fair (0.54). Our algorithm allows visualization of the SPCA at the posterior pole of the eye using wide-field en-face SS-OCT. It can also help the clinicians to study the SPCAs in numerous ocular diseases, particularly its relationship with focal choroidal diseases.

Effectiveness and safety comparison of three eye and orbital reconstruction techniques in facial plastic surgery.

PURPOSE: To compare the effectiveness and the safety of three eye reconstruction techniques with porous bioceramic implantation in facial surgery: the "four petals" eye evisceration (EE) technique, the "russian doll" EE technique and the enucleation with "on-the-table" evisceration technique. METHODS: Retrospective review of patients who underwent surgical orbit reconstruction with primary placement of a porous bioceramic orbital implant using three techniques at Quinze-Vingts National Center (Paris, France). We compared outcomes of three surgical orbit reconstruction techniques: the "four petal" EE technique, the "russian doll" EE technique and the enucleation with "on-the-table" evisceration technique. The primary endpoint was to determine the rate of implant exposure and the facial cosmetic result during the first year after surgery for each technique. The mean of the Numeric Pain Rating Scale (NRS) after surgery at day 1 was also a primary endpoint. In addition, data such as analgesic intake and rate of revision surgery were compared for each technique. RESULTS: One hundred and ten patients were included: 70 patients in the "four petals" procedure group, 31 in the "on-the-table" procedure group and 9 in the "russian doll" procedure group. NRS pain at day 1 was statistically significantly lower in the "four petals" procedure group 0.9 [standard deviation (SD)] (1.8) and in the "russian doll" procedure group 1 (1.7) than in the "on-the-table" procedure group 2.5 (2.4) (P=0.001). Implant exposure was statistically significantly lower in the "four petals" procedure group (2.9%) and in the "on-the-table" procedure group (3.2%) when compared to the "russian doll" procedure group (22.2%) (P=0.03). Rate of revision surgery was lower in the "four petals" procedure group (11.5%) than in the "russian doll" procedure group (33.3%) and the "on-the-table" procedure group (22.6%). "russian doll" evisceration procedure group had the highest orbital lipofilling rate due to the highest rate of enophthalmos. Therefore, the cosmetic result was better in the "four petals" and the "on-the-table" procedure group. CONCLUSION: The "four petals" EE technique for surgical eye and orbital reconstruction seems to be a method that reduce implant extrusion, postoperative pain and improve facial esthetic result.

In vivo laser Doppler holography of the human retina.

The eye offers a unique opportunity for the non-invasive exploration of cardiovascular diseases. Optical angiography in the retina requires sensitive measurements, which hinders conventional full-field laser Doppler imaging schemes. To overcome this limitation, we used digital holography to perform laser Doppler perfusion imaging of human retina with near-infrared light. Two imaging channels with a slow and a fast CMOS camera were used simultaneously for real-time narrowband measurements, and offline wideband measurements, respectively. The beat frequency spectrum of optical interferograms recorded with the fast (up to 75 kHz) CMOS camera was analyzed by short-time Fourier transformation. Power Doppler images drawn from the Doppler power spectrum density qualitatively revealed blood flow in retinal vessels over 512 × 512 pixels covering 2.4 × 2.4 mm2 on the retina with a temporal resolution down to 1.6 ms. The sensitivity to lateral motion as well as the requirements in terms of sampling frequency are discussed.

A novel nonsense variant in REEP6 is involved in a sporadic rod-cone dystrophy case.

Rod-cone dystrophy (RCD), also called retinitis pigmentosa, is the most common form of progressive inherited retinal disorders secondary to photoreceptor degeneration. It is a genetically heterogeneous disease characterized by night blindness, followed by visual field constriction and, in most severe cases, total blindness. The aim of our study was to identify the underlying gene defect leading to severe RCD in a 60-year-old woman. The patient's DNA was investigated by targeted next generation sequencing followed by whole exome sequencing. A novel nonsense variant, c.267G>A p.(Trp89*), was identified at a homozygous state in the proband in REEP6 gene, recently reported mutated in 7 unrelated families with RCD. Further functional studies will help to understand the physiopathology associated with REEP6 mutations that may be linked to a protein trafficking defect.

Multimodal imaging and functional correlations identify unusual cases of macular retinal pigment epithelium hypopigmentation occurring without functional loss.

PURPOSE: Patients with unusual macular retinal pigment epithelium (RPE) hypopigmentation are described and analyzed using retinal multimodal imaging. METHODS: We report three cases of patients with unilateral (2) or bilateral (1) macular lesions discovered incidentally on fundoscopy. A comprehensive ophthalmic examination including visual acuity, fundoscopy, spectral-domain optical coherence tomography (SD-OCT), short-wavelength light and near-infrared autofluorescence, fluorescein angiography, microperimetry, multifocal electroretinogram, adaptive optics (AO), and OCT-angiography (OCT-A) has been performed. RESULTS: Visual acuity was 20/20 in both eyes of all patients. The lesion appeared hyperautofluorescent on short-wavelength light and hypoautofluorescent on near-infrared light. Fluorescein angiography revealed a sharply demarcated macular hyperfluorescence without any leakage, suggesting a window defect. Interestingly, SD-OCT revealed only a choroidal hyperreflectivity in relation to the lesions without any abnormality of the outer retinal layers. Microperimetry was normal except for 1 patient with bilateral lesion and subtle decrease in macular sensitivity. Mf ERG was normal in all three patients. AO showed a well-preserved cone mosaic, suggesting that the abnormality was localized under the photoreceptor layers. OCT-A revealed hyperreflectivity just below the RPE layer, corresponding to the macular lesion observed on fundoscopy and the choroidal hyperreflectivity seen on SD-OCT. CONCLUSIONS: Macular RPE hypopigmentation should be considered in case of an isolated macular lesion without functional visual impairment or anatomical defect on SD-OCT.

ARL2BP mutations account for 0.1% of autosomal recessive rod-cone dystrophies with the report of a novel splice variant.

We report a novel ARL2BP splice site mutation after whole-exome sequencing (WES) applied to a Moroccan family including two sisters affected with autosomal recessive rod-cone dystrophy (arRCD). Subsequent analysis of 844 index cases did not reveal further pathogenic chances in ARL2BP indicating that mutations in ARL2B are a rare cause of arRCD (about 0.1%) in a large cohort of French patients.

High speed optical holography of retinal blood flow.

We performed noninvasive video imaging of retinal blood flow in a pigmented rat by holographic interferometry of near-infrared laser light backscattered by retinal tissue, beating against an off-axis reference beam sampled at a frame rate of 39 kHz with a high throughput camera. Local Doppler contrasts emerged from the envelopes of short-time Fourier transforms and the phase of autocorrelation functions of holograms rendered by Fresnel transformation. This approach permitted imaging of blood flow in large retinal vessels (∼30 microns diameter) over 400×400 pixels with a spatial resolution of ∼8 microns and a temporal resolution of ∼6.5 ms.

[Eales' disease]. / La maladie de Eales.

The syndrome of recurrent vitreous hemorrhages in young men was described for the first time by Henry Eales in 1880. The association with a clinical manifestation of ocular inflammation was reported 5years later. Eales disease affects young adults who present with ischemic retinal vasculitis, with the peripheral retina most commonly affected. Most cases have been reported in South Asia. Although the etiology of this abnormality is unknown, it may be related to an immune sensitivity to Mycobacterium tuberculosis antigens. Its pathogenesis is related to extensive ischemia that affects the retina, secondary to an obliterative retinal vasculopathy with release of angiogenic factors of the VEGF type. Involvement of the retina is the hallmark of the disease, which manifests as follows: periphlebitis, retinal capillary ischemia most often affecting the periphery with secondary proliferative retinopathy and retinal and/or papillary neovascularization, recurrent vitreous hemorrhages and tractional retinal detachment. These complications are potentially blinding. The natural history of Eales disease varies, with temporary or permanent remission in some cases and continuous progression in others. Progression is often bilateral, which necessitates regular follow-up. The treatment of Eales disease depends on the stage of the disease and is not well defined. Observation only, pars plana vitrectomy surgery and/or intravitreal injections of anti-VEGF are recommended in cases of vitreous hemorrhage, associated with corticosteroids when retinal vasculitis is present. Laser pan-retinal photocoagulation is necessary when neovascularization is present.

Next-generation sequencing confirms the implication of SLC24A1 in autosomal-recessive congenital stationary night blindness.

Congenital stationary night blindness (CSNB) is a clinically and genetically heterogeneous retinal disorder which represents rod photoreceptor dysfunction or signal transmission defect from photoreceptors to adjacent bipolar cells. Patients displaying photoreceptor dysfunction show a Riggs-electroretinogram (ERG) while patients with a signal transmission defect show a Schubert-Bornschein ERG. The latter group is subdivided into complete or incomplete (ic) CSNB. Only few CSNB cases with Riggs-ERG and only one family with a disease-causing variant in SLC24A1 have been reported. Whole-exome sequencing (WES) in a previously diagnosed icCSNB patient identified a homozygous nonsense variant in SLC24A1. Indeed, re-investigation of the clinical data corrected the diagnosis to Riggs-form of CSNB. Targeted next-generation sequencing (NGS) identified compound heterozygous deletions and a homozygous missense variant in SLC24A1 in two other patients, respectively. ERG abnormalities varied in these three cases but all patients had normal visual acuity, no myopia or nystagmus, unlike in Schubert-Bornschein-type of CSNB. This confirms that SLC24A1 defects lead to CSNB and outlines phenotype/genotype correlations in CSNB subtypes. In case of unclear clinical characteristics, NGS techniques are helpful to clarify the diagnosis.

The protein tyrosine phosphatase interacting protein 51 (PTPIP51) is required for the differentiation of photoreceptors.

Proliferation and differentiation of retinal progenitor cells (RPCs) are tightly controlled by extrinsic cues and distinct combinations of transcription factors leading to the generation of retinal cell type diversity. In this context, we investigated the role of the protein tyrosine phosphatase interacting protein 51 (PTPIP51) in the differentiation of RPCs. The expression pattern of PTPIP51 was analyzed by immunostaining during post-natal retinal development in the rat. Ex vivo electroporation has been used to silence or misexpress PTPIP51 in post-natal retinal explants, and the retinal phenotype was investigated after 3-7days in vitro (div). PTPIP51 expression in the retina started postnatally and was maintained throughout adulthood, especially in retinal ganglion cells and in the inner segment of photoreceptor cells. Silencing of Ptpip51 expression in postnatal retina failed to modify the commitment of late RPCs in the different lineages but severely impaired the final differentiation of photoreceptors, observed by a decrease in the fraction of Rhodopsin-positive cells after 7div. By contrast, misexpression of PTPIP51 in early or late RPCs failed to modify the differentiation of the RPCs. Our data demonstrate that PTPIP51 is implicated in the differentiation process of immature photoreceptors. Because PTPIP51 is specifically localized in the inner segment, PTPIP51 may contribute to the complex stage of maturation of the apical segment of these cells.

Thioredoxin rod-derived cone viability factor protects against photooxidative retinal damage.

Rod-derived cone viability factor (RdCVF) is a trophic factor of the thioredoxins family that promotes the survival of cone photoreceptors. It is encoded by the nucleoredoxin-like gene 1 Nxnl1 which also encodes by alternative splicing a long form of RdCVF (RdCVFL), a thioredoxin enzyme that interacts with TAU. The known role of thioredoxins in the defense mechanism against oxidative damage led us to examine the retinal phenotype of the Nxnl1(-/-) mice exposed to photooxidative stress. Here we found that, in contrast to wild-type mice, the rod photoreceptors of Nxnl1(-/-) mice are more sensitive to light after exposure to 1700 or 2500 lx. The delivery of RdCVF by AAV to mice deficient of Nxnl1(-/-) protects rod photoreceptors from light damage. Interestingly, the RdCVF2L protein, encoded by the paralog gene Nxnl2, is able to reduce TAU phosphorylation, as does RdCVFL, but does not protect the rod from light damage. Our result shows that the Nxnl1 gene, through the thioredoxin RdCVFL, is part of an endogenous defense mechanism against photooxidative stress that is likely of great importance for human vision.