Optic Disc Edema Is an Under-Recognized Feature of Birdshot Chorioretinitis.

BACKGROUND: Optic disc edema is a feature of many ophthalmic and neurologic conditions. It remains an underappreciated feature of birdshot chorioretinitis (BSCR), leading to delay in diagnosis and treatment. The purpose of our study was to identify clinical features that are concomitant with optic disc edema and suggest a diagnosis of BSCR. METHODS: Retrospective multicenter case series of 29 patients who were referred to a neuro-ophthalmologist or uveitis specialist for evaluation of disc edema and were ultimately diagnosed with BSCR. RESULTS: Fifty-four eyes of 30 patients, from the practices of 15 uveitis specialists, met the eligibility criteria. In addition to disc edema, concomitant features in all patients included vitritis, chorioretinal lesions, and retinal vasculitis. Visual recovery to 20/40 or better occurred in 26 of 29 patients. Visual acuity remained 20/100 or worse in 2 patients previously diagnosed with idiopathic intracranial hypertension, 1 patient previously diagnosed with optic neuritis, and 1 patient for whom treatment was delayed for years, leading to optic disc atrophy. CONCLUSIONS: Optic disc edema is a presenting feature in some cases of BSCR. A diagnosis of BSCR should be considered when disc edema occurs with vitritis, chorioretinal inflammation, and retinal vasculitis. Patients should be referred to a uveitis specialist for treatment.

Patterns of Gene Expression, Splicing, and Allele-Specific Expression Vary among Macular Tissues and Clinical Stages of Age-Related Macular Degeneration.

Age-related macular degeneration (AMD) is a leading cause of blindness, and elucidating its underlying disease mechanisms is vital to the development of appropriate therapeutics. We identified differentially expressed genes (DEGs) and differentially spliced genes (DSGs) across the clinical stages of AMD in disease-affected tissue, the macular retina pigment epithelium (RPE)/choroid and the macular neural retina within the same eye. We utilized 27 deeply phenotyped donor eyes (recovered within a 6 h postmortem interval time) from Caucasian donors (60-94 years) using a standardized published protocol. Significant findings were then validated in an independent set of well-characterized donor eyes (n = 85). There was limited overlap between DEGs and DSGs, suggesting distinct mechanisms at play in AMD pathophysiology. A greater number of previously reported AMD loci overlapped with DSGs compared to DEGs between disease states, and no DEG overlap with previously reported loci was found in the macular retina between disease states. Additionally, we explored allele-specific expression (ASE) in coding regions of previously reported AMD risk loci, uncovering a significant imbalance in C3 rs2230199 and CFH rs1061170 in the macular RPE/choroid for normal eyes and intermediate AMD (iAMD), and for CFH rs1061147 in the macular RPE/choroid for normal eyes and iAMD, and separately neovascular AMD (NEO). Only significant DEGs/DSGs from the macular RPE/choroid were found to overlap between disease states. STAT1, validated between the iAMD vs. normal comparison, and AGTPBP1, BBS5, CERKL, FGFBP2, KIFC3, RORα, and ZNF292, validated between the NEO vs. normal comparison, revealed an intricate regulatory network with transcription factors and miRNAs identifying potential upstream and downstream regulators. Findings regarding the complement genes C3 and CFH suggest that coding variants at these loci may influence AMD development via an imbalance of gene expression in a tissue-specific manner. Our study provides crucial insights into the multifaceted genomic underpinnings of AMD (i.e., tissue-specific gene expression changes, potential splice variation, and allelic imbalance), which may open new avenues for AMD diagnostics and therapies specific to iAMD and NEO.

A multi-omics atlas of the human retina at single-cell resolution.

Cell classes in the human retina are highly heterogeneous with their abundance varying by several orders of magnitude. Here, we generated and integrated a multi-omics single-cell atlas of the adult human retina, including more than 250,000 nuclei for single-nuclei RNA-seq and 137,000 nuclei for single-nuclei ATAC-seq. Cross-species comparison of the retina atlas among human, monkey, mice, and chicken revealed relatively conserved and non-conserved types. Interestingly, the overall cell heterogeneity in primate retina decreases compared with that of rodent and chicken retina. Through integrative analysis, we identified 35,000 distal cis-element-gene pairs, constructed transcription factor (TF)-target regulons for more than 200 TFs, and partitioned the TFs into distinct co-active modules. We also revealed the heterogeneity of the cis-element-gene relationships in different cell types, even from the same class. Taken together, we present a comprehensive single-cell multi-omics atlas of the human retina as a resource that enables systematic molecular characterization at individual cell-type resolution.

A systems biology approach uncovers novel disease mechanisms in age-related macular degeneration.

Age-related macular degeneration (AMD) is a leading cause of blindness, affecting 200 million people worldwide. To identify genes that could be targeted for treatment, we created a molecular atlas at different stages of AMD. Our resource is comprised of RNA sequencing (RNA-seq) and DNA methylation microarrays from bulk macular retinal pigment epithelium (RPE)/choroid of clinically phenotyped normal and AMD donor eyes (n = 85), single-nucleus RNA-seq (164,399 cells), and single-nucleus assay for transposase-accessible chromatin (ATAC)-seq (125,822 cells) from the retina, RPE, and choroid of 6 AMD and 7 control donors. We identified 23 genome-wide significant loci differentially methylated in AMD, over 1,000 differentially expressed genes across different disease stages, and an AMD Müller state distinct from normal or gliosis. Chromatin accessibility peaks in genome-wide association study (GWAS) loci revealed putative causal genes for AMD, including HTRA1 and C6orf223. Our systems biology approach uncovered molecular mechanisms underlying AMD, including regulators of WNT signaling, FRZB and TLE2, as mechanistic players in disease.

The spectrum of COVID-19-associated chorioretinal vasculopathy.

Purpose: Although conjunctivitis represents the most common ocular manifestation of COVID-19 infection, sight-threatening retinal involvement has been reported. Herein, we report and characterize with multimodal retinal imaging 5 cases of acute vision loss secondary to presumed chorioretinal vasculopathy temporally associated with COVID-19 infection with varying severity, visual morbidity, and treatment response, and review the available literature on the association between COVID-19 infection and retinal microvascular changes. Design: Observational case series and literature review. Methods: Multicenter case series of 5 patients who presented to academic centers and private offices with acute vision loss temporally associated with COVID-19 infection. A review of the literature was conducted using online databases. Results: 10 eyes of 5 patients, 3 men and 2 women, with a mean age of 30.8 years (median 33, range 16-44) were described. All patients had a recently preceding episode of COVID-19, with symptomatology ranging from mild infection to life-threatening encephalopathy. Treatment for their retinal disease included topical, oral, intravitreal, and intravenous steroids, steroid-sparing immunosuppression, retinal photocoagulation, antivirals, and antiplatelet and anticoagulant agents. Treatment response and visual recovery ranged from complete recovery of baseline acuity to permanent vision loss and need for chronic immunosuppression. Conclusions and Importance: Clinicians should be mindful of the potential for vision-threatening retinal involvement after COVID-19 infection. If found, treatment with both anti-inflammatory therapy and anticoagulation should be considered, in addition to close monitoring, as some patients with this spectrum of disease may require chronic immune suppression and/or anti-VEGF therapy.

Pyramidal Inflammatory Deposits of the Retinal Pigment Epithelium and Outer Retina in Ocular Syphilis.

PURPOSE: To evaluate the role of OCT in the diagnosis of uveitis secondary to syphilis. DESIGN: Consecutive, retrospective case series. PARTICIPANTS: All patients 18 years of age or older with ocular syphilis from 2 tertiary referral centers. METHODS: All patients who were diagnosed with intermediate uveitis, posterior uveitis, or panuveitis secondary to syphilis were included in the study (40 patients representing a total of 62 eyes) to identify important imaging features to aid in diagnosis. Patients underwent confirmatory serologic testing, OCT imaging, and dilated examination by a uveitis specialist. MAIN OUTCOME MEASURE: Hyperreflective retinal lesions on OCT. RESULTS: The mean age of the study population was 42.9 ± 12.16 years. Forty-five percent of the eyes included in this study harbored hyperreflective pyramidal lesions of the outer retina and retinal pigment epithelium on OCT. Fifty-four percent of eyes with these imaging findings did not show a placoid retinal lesion on examination. Sixty-eighty percent of the described outer retinal lesions on OCT resolved after treatment for syphilis. Visual acuity ranged from normal (20/20) to no light perception, with a mean of 20/43 at diagnosis, and improved significantly to a mean visual acuity of 20/26 after treatment (P < 0.05). Vision-threatening complications were seen in less than 5% of eyes and included both treatable and irreversible causes of vision loss, including retinal detachment, cystoid macular edema, and optic neuropathy. CONCLUSIONS: Patients treated for uveitis secondary to syphilis achieve good visual recoveries. Outer retinal lesions seen on OCT are common and can serve as an additional imaging finding of the disease.

Implication of N-Methyl-d-Aspartate Receptor in Homocysteine-Induced Age-Related Macular Degeneration.

Age-related macular degeneration (AMD) is a leading cause of vision loss. Elevated homocysteine (Hcy) (Hyperhomocysteinemia) (HHcy) has been reported in AMD. We previously reported that HHcy induces AMD-like features. This study suggests that N-Methyl-d-aspartate receptor (NMDAR) activation in the retinal pigment epithelium (RPE) is a mechanism for HHcy-induced AMD. Serum Hcy and cystathionine-ß-synthase (CBS) were assessed by ELISA. The involvement of NMDAR in Hcy-induced AMD features was evaluated (1) in vitro using ARPE-19 cells, primary RPE isolated from HHcy mice (CBS), and mouse choroidal endothelial cells (MCEC); (2) in vivo using wild-type mice and mice deficient in RPE NMDAR (NMDARR-/-) with/without Hcy injection. Isolectin-B4, Ki67, HIF-1α, VEGF, NMDAR1, and albumin were assessed by immunofluorescence (IF), Western blot (WB), Optical coherence tomography (OCT), and fluorescein angiography (FA) to evaluate retinal structure, fluorescein leakage, and choroidal neovascularization (CNV). A neovascular AMD patient's serum showed a significant increase in Hcy and a decrease in CBS. Hcy significantly increased HIF-1α, VEGF, and NMDAR in RPE cells, and Ki67 in MCEC. Hcy-injected WT mice showed disrupted retina and CNV. Knocking down RPE NMDAR improved retinal structure and CNV. Our findings underscore the role of RPE NMDAR in Hcy-induced AMD features; thus, NMDAR inhibition could serve as a promising therapeutic target for AMD.

Diabetic and Retinal Vascular Eye Disease.

The retinal vasculature is the only neurovascular system directly visible to the human eye, easily evaluated by fundoscopy and many imaging modalities. This window allows physicians to diagnose and treat retinal pathologies and detect systemic diseases including diabetes, hypertension, hypercoagulable/hyperviscosity syndromes, and vasculitis. Diabetic retinopathy is the most common retinal vascular disease, followed by retinal vein and artery occlusion. Patients with these conditions require medical optimization to prevent further damage to the eyes and to the other organs. Both the internists and medical subspecialists play a crucial role in the prevention, detection, evaluation, and management of vision-threatening retinal vascular diseases.

Intentional retinal injury with handheld lasers is an underrecognized form of self-harm.

Self-inflicted damage to the retina using handheld lasers is a growing and underrecognized form of self-harm. Here was share retinal images from two patients with histories of major depressive disorder and self-harm behaviors that ultimately resulted in legal blindness. Mental health providers should be aware of this clinical entity as they are in the best position to screen for laser pointer access in at risk individuals and prevent permanent vision loss.

Branch Retinal Vein Occlusion and Venous Abnormalities in CADASIL.

INTRODUCTION: Individuals with the inherited progressive microangiopathy Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts (CADASIL) most classically develop migraine with aura and recurrent subcortical ischemic infarcts with progressive cognitive decline, gait dysfunction, psychiatric disturbances culminating in early death. However, clinically important venous pathologies may not be anticipated by treating neurologists such as branch retinal vein occlusions (BRVOs). Herein we describe a case of CADASIL with a BRVO and a brief review of venous pathology in CADASIL. CASE REPORT: A 66-year-old man with CADASIL and clinical symptoms of chronic migraine with aura, episodic "CADASIL coma," recurrent subcortical ischemic infarcts and normal cognition presented with an asymptomatic superior BRVO. Retinal analysis by wide-field fluorescein angiography revealed dye extravasation and optical coherence tomography identified macular edema prompting a monthly regimen of intravitreal bevacizumab. Systemic investigations for provoking etiologies was unfruitful tentatively attributing the BRVO to his underlying CADASIL. CONCLUSIONS: Within CADASIL, the venous circulation undergoes similar pathologic changes as compared with the arterial circulation. The retinal veins of CADASIL exhibit increased venous compliance, vessel wall diameter and wall thickness which may represent a structurally causative factor for retinal venous disease. However, these findings are not isolated to the retina as lower extremity varicose veins have associated with a family pedigree of CADASIL. Although presently it is uncertain whether those with CADASIL should undergo routine retinal screening, neurologists, and ophthalmologists, need to be cognizant of the extra-arterial manifestations of CADASIL to provide comprehensive clinical care.

Systemic Disease and Ocular Comorbidity Analysis of Geographically Isolated Federally Recognized American Indian Tribes of the Intermountain West.

BACKGROUND: The American Indian Navajo and Goshute peoples are underserved patient populations residing in the Four Corners area of the United States and Ibupah, Utah, respectively. METHODS: We conducted a cross-sectional study of epidemiological factors and lipid biomarkers that may be associated with type II diabetes, hypertension and retinal manifestations in tribal and non-tribal members in the study areas (n = 146 participants). We performed multivariate analyses to determine which, if any, risk factors were unique at the tribal level. Fundus photos and epidemiological data through standardized questionnaires were collected. Blood samples were collected to analyze lipid biomarkers. Univariate analyses were conducted and statistically significant factors at p < 0.10 were entered into a multivariate regression. RESULTS: Of 51 participants for whom phenotyping was available, from the Four Corners region, 31 had type II diabetes (DM), 26 had hypertension and 6 had diabetic retinopathy (DR). Of the 64 participants from Ibupah with phenotyping available, 20 had diabetes, 19 had hypertension and 6 had DR. Navajo participants were less likely to have any type of retinopathy as compared to Goshute participants (odds ratio (OR) = 0.059; 95% confidence interval (CI) = 0.016-0.223; p < 0.001). Associations were found between diabetes and hypertension in both populations. Older age was associated with hypertension in the Four Corners, and the Navajo that reside there on the reservation, but not within the Goshute and Ibupah populations. Combining both the Ibupah, Utah and Four Corners study populations, being American Indian (p = 0.022), residing in the Four Corners (p = 0.027) and having hypertension (p < 0.001) increased the risk of DM. DM (p < 0.001) and age (p = 0.002) were significantly associated with hypertension in both populations examined. When retinopathy was evaluated for both populations combined, hypertension (p = 0.037) and living in Ibupah (p < 0.001) were associated with greater risk of retinopathy. When combining both American Indian populations from the Four Corners and Ibupah, those with hypertension were more likely to have DM (p < 0.001). No lipid biomarkers were found to be significantly associated with any disease state. CONCLUSIONS: We found different comorbid factors with retinal disease outcome between the two tribes that reside within the Intermountain West. This is indicated by the association of tribe and with the type of retinopathy outcome when we combined the populations of American Indians. Overall, the Navajo peoples and the Four Corners had a higher prevalence of chronic disease that included diabetes and hypertension than the Goshutes and Ibupah. To the best of our knowledge, this is the first study to conduct an analysis for disease outcomes exclusively including the Navajo and Goshute tribe of the Intermountain West.

Bone Morphogenetic Protein (BMP)4 But Not BMP2 Disrupts the Barrier Integrity of Retinal Pigment Epithelia and Induces Their Migration: A Potential Role in Neovascular Age-Related Macular Degeneration.

Disruption of retinal pigment epithelial (RPE) barrier integrity and RPE migration are hallmark features in neovascular age-related macular degeneration (nAMD), but the underlying causes and pathophysiology are not completely well-defined. Herein, we aimed to evaluate the effect of bone morphogenetic proteins (BMPs) on the barrier function and migration of RPE. In particular, we investigated the role of BMP2 and BMP4 in these processes as our analysis of RNA-sequencing (seq) data from human donor eyes demonstrated that they are highly differentially expressed BMP members in macular RPE/choroid versus macular retina. We used electrical cell-substrate impedance sensing (ECIS) system to monitor precisely in real time the barrier integrity and migration of ARPE-19 after treatment with various concentrations of BMP2 or BMP4. Immunofluorescence was also used to assess the changes in the expression and the organization of the key tight junction protein, zona occludens (ZO)-1, in ARPE-19 cells under BMP2 or BMP4 treatment. This was followed by measuring the activity of matrix metalloproteinases (MMPs). Finally, RNA-seq and ELISA were used to determine the local and circulating levels of BMP2 and BMP4 in retinas and serum samples from nAMD donors. Our ECIS results showed that BMP4 but not BMP2 decreased the transcellular electrical resistance (TER) of ARPE-19 and increased their migration in comparison with control (vehicle-treated cells). Furthermore, immunofluorescence showed a disorganization of ZO-1 in BMP4-treated ARPE-19 not in BMP2-treated cells or vehicle-treated controls. This effect of BMP4 was associated with significant increases in the activity of MMPs, specifically MMP2. Lastly, these results were corroborated by additional findings that circulating but not local BMP4 levels were significantly higher in nAMD donor samples compared to controls. Collectively, our results demonstrated unreported effects of BMP4 on inducing RPE dysfunction and suggest that BMP4 but not BMP2 may represent a potential therapeutic target in nAMD.

Prevalence of Retinal Diseases and Associated Risk Factors in an African Population From Mwanza, Tanzania.

BACKGROUND AND OBJECTIVE: To determine the prevalence of retinal disease among a population in Mwanza, Tanzania, and to identify relevant risk factors for retinal disorders in this cohort. PATIENTS AND METHODS: A cross-sectional population-based study was conducted in Mwanza, Tanzania, among patients older than 18 years. Participants completed a demographics survey and underwent an ophthalmic examination that included fundus photography. RESULTS: Complete data were available for 1,007 (93.8%) of the 1,073 persons examined. The prevalence of vitreoretinal disorders was 22.8% (230/1,007). The leading retinal diseases were age-related macular degeneration (7.0%), hypertensive retinopathy (4.5%), and macular scars (2.7%). CONCLUSION: This study is the first population-based study of retinal disease in Mwanza. The findings reveal a considerable burden of retinal disease in this region, suggesting a need for trained local ophthalmic personnel and resources. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:S17-S25.].

Long-term visual outcomes of endophthalmitis and the role of systemic steroids in addition to intravitreal dexamethasone.

BACKGROUND: The purpose of this study was to evaluate the role of systemic steroids in post-procedural endophthalmitis as the role of intravitreal steroids in treatment algorithms of endophthalmitis remain controversial. METHODS: This is a retrospective analysis from a single tertiary referral center of all patients older than 18 years old that developed presumed post-procedure endophthalmitis and were treated at our center from 2009 to 2018. RESULTS: Eighty-three patients were followed after being treated for post-procedural endophthalmitis that either received systemic steroids or did not around the time of diagnosis. Almost 30 % of all patients regained a final visual acuity of 20/40 or better, while 31.2% had poor visual outcomes of count fingers or worse. Non-clearing debris was the most significant long-term complication. Visual improvement plateaued in 67.7% by 1 month after diagnosis and initial treatment in both groups. There was no difference in visual outcomes when comparing the sixteen patients that received systemic steroids and the sixty-seven that did not; however, no enucleation or evisceration was required in patients receiving systemic steroids. Five patients that did not receive systemic steroids required an enucleation or evisceration due to a blind, painful eye. CONCLUSIONS: The use of systemic steroids does not seem to worsen long-term outcomes of endophthalmitis compared to those patients that did not receive them and they may prove beneficial in the most severe cases by reducing the risk of losing the globe altogether.

Combined Phacoemulsification and Pars Plana Vitrectomy for the Treatment of Cataract in Patients With Noninfectious Uveitis.

Purpose: This work evaluates the role of combined phacoemulsification and vitrectomy surgery in the management of cataract associated with noninfectious uveitis. Methods: A retrospective chart review was conducted of all patients aged 7 years or older who underwent a combined surgical approach from 2005 to 2018. Results: Eighty-five eyes of 67 patients were included in the study; 10.7% of eyes had a best-corrected visual acuity (BCVA) of 20/40 or better at time of surgery. At 1-year follow-up, 63.4% of eyes had a BCVA 20/40 or better and 7.6% had a BCVA of 20/200 or worse. There was an overall decrease in cystoid macular edema after surgery compared with preoperatively (47.6% vs 34.5% presurgery and postsurgery, respectively). Complete inflammatory disease remission off immunomodulatory therapy and systemic steroids was achieved in 21.1% of patients. Conclusions: A combined surgical approach is effective in visual rehabilitation in patients with uveitic cataracts and may promote inflammatory disease remission specifically in intermediate uveitis.

Rituximab-Associated Retinal Occlusive Vasculopathy: A Case Report and Literature Review.

PURPOSE: To describe a case of retinal occlusive vasculopathy associated with intravitreal administration of rituximab. METHODS: A single case report from a tertiary referral center. RESULTS: The patient described in the following case report developed a diffuse retinal occlusive vasculopathy following intravitreal rituximab for intraocular lymphoma. He required panretinal photocoagulation, avastin, and cyclophotocoagulation to control his intraocular pressure from ocular ischemia resulting in neovascular glaucoma. CONCLUSIONS: This is the first reported case of occlusive retinal vasculopathy subsequent to intravitreal administration of rituximab. Whereas hypersensitivity reactions to intravenous infusion of rituximab have been noted in the literature, no such reports exist in response to intravitreal therapy.

Single-nuclei RNA-seq on human retinal tissue provides improved transcriptome profiling.

Single-cell RNA-seq is a powerful tool in decoding the heterogeneity in complex tissues by generating transcriptomic profiles of the individual cell. Here, we report a single-nuclei RNA-seq (snRNA-seq) transcriptomic study on human retinal tissue, which is composed of multiple cell types with distinct functions. Six samples from three healthy donors are profiled and high-quality RNA-seq data is obtained for 5873 single nuclei. All major retinal cell types are observed and marker genes for each cell type are identified. The gene expression of the macular and peripheral retina is compared to each other at cell-type level. Furthermore, our dataset shows an improved power for prioritizing genes associated with human retinal diseases compared to both mouse single-cell RNA-seq and human bulk RNA-seq results. In conclusion, we demonstrate that obtaining single cell transcriptomes from human frozen tissues can provide insight missed by either human bulk RNA-seq or animal models.

Genetic Epidemiologic Analysis of Hypertensive Retinopathy in an Underrepresented and Rare Federally Recognized Native American Population of the Intermountain West.

Understanding disease risk is challenging in multifactorial conditions as it can differ by environment, ethnicity and race. The Confederated Tribes of the Goshute Reservation are one of the most isolated populations in the United States. Retinal changes are a reliable indicator for systemic disease. We conducted a cross-sectional study to identify correlations between genetic data and epidemiological risk factors for blinding retinal disease in this tribe. As part of the "Supporting Prediction and Prevention Blindness Project (SPBPP)" in the Native American Population of the Intermountain West, we found that hypertensive retinopathy was the most prevalent retinal disease. We found that forty-two percent of the Goshute population was affected. Blood samples, fundus photos and intraocular pressure were obtained for all participants. In addition, a standardized questionnaire was administered. DNA and total cholesterol, HDL, LDL, VLDL, triglycerides and HbA1c were also evaluated. Our study interrogated genetic variants from the PAGE study (ARMS2 rs10490924, CFH rs800292, rs1061170) and additional studies that looked at previously associated genetic variants with retinal disease associated with cardiovascular disease. We conducted univariate and multivariate logistic regression in Stata v15.0. We found an association between hypertriglyceridemia and HTR (adjp = .05) within the Goshute population. To the best of our knowledge, this is the first study to demonstrate the prevalence of hypertensive retinopathy in a Native American population. Moreover, our study is the first to demonstrate an independently predictive relationship between hypertriglyceridemia and hypertensive retinopathy in an American Indian population. This study furthers our knowledge about prevalent blinding eye disease within the most geographically isolated federally recognized native United States American tribe, for which nothing has been published with respect to any disease. Although, this study furthers our understanding about the prevalence of genetic epidemiological risk factors within this population, it has greater implications for the screening of blinding diseases in underserved populations in general. This study can inform public health on planning and delivering of quality, accessible and relevant care to this population.

Generation, transcriptome profiling, and functional validation of cone-rich human retinal organoids.

Rod and cone photoreceptors are light-sensing cells in the human retina. Rods are dominant in the peripheral retina, whereas cones are enriched in the macula, which is responsible for central vision and visual acuity. Macular degenerations affect vision the most and are currently incurable. Here we report the generation, transcriptome profiling, and functional validation of cone-rich human retinal organoids differentiated from hESCs using an improved retinal differentiation system. Induced by extracellular matrix, aggregates of hESCs formed single-lumen cysts composed of epithelial cells with anterior neuroectodermal/ectodermal fates, including retinal cell fate. Then, the cysts were en bloc-passaged, attached to culture surface, and grew, forming colonies in which retinal progenitor cell patches were found. Following gentle cell detachment, retinal progenitor cells self-assembled into retinal epithelium-retinal organoid-that differentiated into stratified cone-rich retinal tissue in agitated cultures. Electron microscopy revealed differentiating outer segments of photoreceptor cells. Bulk RNA-sequencing profiling of time-course retinal organoids demonstrated that retinal differentiation in vitro recapitulated in vivo retinogenesis in temporal expression of cell differentiation markers and retinal disease genes, as well as in mRNA alternative splicing. Single-cell RNA-sequencing profiling of 8-mo retinal organoids identified cone and rod cell clusters and confirmed the cone enrichment initially revealed by quantitative microscopy. Notably, cones from retinal organoids and human macula had similar single-cell transcriptomes, and so did rods. Cones in retinal organoids exhibited electrophysiological functions. Collectively, we have established cone-rich retinal organoids and a reference of transcriptomes that are valuable resources for retinal studies.