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5 (Blue) Cone Pathway Vulnerability in Retinitis Pigmentosa, Diabetes and Glaucoma

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5 (Blue) Cone Pathway Vulnerability in Retinitis Pigmentosa, Diabetes and Glaucoma Investigative Ophthalmology & Visual Science, Vol. 30, No. 8, August 1989 Copyright © Association for Research in Vision and Ophthalmology 5 (Blue) Cone Pathway Vulnerability in Retinitis Pigmentosa, Diabetes and Glaucoma Vivienne C. Greenstein,* Donald C. Hood,t Robert Rirch4 David Sreinberger4 and Ronald E. Carr* A variety of retinal diseases lead to a decrease in the sensitivity of the S (blue) cone pathways. To determine the possible sites and mechanisms of this loss we compared the sensitivities of an S (blue/pi-1) and an M (green/pi-4) cone pathway in patients with retinal diseases that differ as to their primary locus of sensitivity loss. The sensitivities of an S and an M cone pathway were assessed in patients with retinitis pigmentosa, insulin-dependent diabetes mellitus and open-angle glaucoma using Stiles two-color increment threshold technique. A greater loss in sensitivity of an S than an M cone pathway was found for all three disease groups; however, the diabetic patients showed a more selective loss. The results suggest that multiple sites are involved and that the combined effects of metabolic abnormalities and hypoxia contribute to the selective loss. Invest Ophthalmol Vis Sci 30:1732- 1737,1989 A selective loss in sensitivity to short-wavelength The three diseases do not necessarily produce the light has been reported in diseases as diverse as retini- same degree of relative S cone pathway loss and a tis pigmentosa (RP), diabetes mellitus and glau- comparative study may provide some understanding coma.'"7 This selective loss has been attributed to of the factors that contribute to the apparent vulnera- vulnerability of the S "blue" cone photoreceptors to bility or selective sensitivity loss of the S cone path- disease. However, the presence of this loss in sensitiv- way. We compared the pattern of S and M cone ity in such diverse diseases suggests that it may in part pathway sensitivity losses in patients with these three be attributed to involvement of post-receptoral sites. diseases using Stiles two-color increment threshold Until the affected anatomic locus is identified, the technique. The sensitivities of the cone pathways are loss is better described as a selective sensitivity loss of often compared using techniques that isolate each the S cone pathway. cone pathway with a different adapting field. The as- In retinitis pigmentosa, increment threshold data sumption underlying these techniques is that sensitiv- show a greater loss in sensitivity for an S cone path- ity losses in retinal disease are independent of the way (pi-1) than for an M "green" cone pathway level of adaptation. Greenstein et al,8 however, have (pi-4).2-4 A similar selective loss has been reported for shown that sensitivity losses can depend on the level patients with insulin-dependent diabetes mellitus of adaptation used. Consequently in this study we (IDDM) who have minimal or no apparent retinop- obtain measures at several levels of adaptation. A athy,3-5 and for patients with glaucoma.67 These three preliminary report of some of the data for RP and disease groups differ as to their primary retinal locus IDDM patients has been published elsewhere.8 of sensitivity loss. RP is a disease primarily of the photoreceptors, glaucoma a disease of the inner ret- Materials and Methods ina, the ganglion cell layer, whereas diabetic retinop- athy affects both mid and inner retinal layers, and Subjects perhaps even the outer retinal layer. Twenty-three patients with RP, 14 with IDDM and 16 (18 eyes) with open-angle glaucoma (OAG; either From the *Department of Ophthalmology, New York University primary open-angle glaucoma or pigmentary glau- Medical Center, New York, the fDepartment of Psychology, Co- lumbia University, New York and the JNew York Eye and Ear coma) participated in the study. All patients had Infirmary, New York, New York. Snellen acuity of 20/40- or better. Of the 23 RP Supported by NIH Grant EY-02115 and a grant from RP Foun- patients, ten were classified as autosomal recessive, dation Fighting Blindness. one as autosomal dominant, one as X-linked, and 11 Submitted for publication: January 11, 1989; accepted February as RP simplex. None of the RP patients showed evi- 7, 1989. Reprint requests: Vivienne C. Greenstein, Department of Oph- dence of cystoid macular edema or significant lens thalmology, New York University Medical Center, 550 First Ave- opacities. Using full-field nonsummated single-flash nue, New York, NY 10016. ERGs, all had nonrecordable or markedly reduced 1732 Downloaded from iovs.arvojournals.org on 09/25/2021 No. 8 S (DLUE) CONE PATHWAY VULNERABILITY IN RETINAL DISEASE / Greensrein er ol 1733 scotopic and photopic ERGs. Visual fields were mea- Table 1. Clinical findings sured on a Goldmann perimeter using a III/4 "white" test object; and the area of the remaining visual field RP n = 23 Age range 14-55 yrs was estimated; none of the patients studied had a Total area of remaining visual field visual field <10° (see Table 1 for details). 10°-20° 15 20°-30° 4 Of the 14 patients with IDDM, clinical examina- 30°-40° 4 tion and fluorescein angiography revealed evidence IDDM n = 14 Age range of early background retinopathy in 13 patients (see 24-60 yrs Table 1 for level of retinopathy using a modified Air- Level 1 1 9 Level 2 4 lie House classification ). Three of the patients had Level 3 5* macular edema (two at retinopathy level 3, and one Level 4 4* at retinopathy level 4). OAG n = 18 Age range 29-65 yr The patients with OAG had varying degrees of field Field loss loss and cupping. The patients had mild to moderate No appreciable loss 2 glaucomatous damage. Three patients had scotomas Defect 0°-5° from fixation 2 Defect 5°-10° from fixation 1 extending to within 10° of fixation on repeated test- Defect 10°-30° from fixation 3 ing using program 32 on the Octopus 201 R comput- Defects 5°-10°, and 10°-30° from fixation 2 erized perimeter (Interzeag, Schleiren, Switzerland) Defects 0°-5°, 5°-10°, and 10°-30° from 8 fixation (see Table 1). Intraocular pressure was controlled clinically in all patients at the time of examination. Pupil diameters ranged from 2 to 5 mm. Patients with at least 2 min before the test light was presented. For pupil diameters less than 2 mm were excluded from an ascending run, test intensity was increased from the study. below threshold to the level at which two consecutive Eleven subjects ranging in age from 20-55 years presentations were visible, and for a descending run it with no known abnormality of the visual system was decreased to the level at which two consecutive comprised the control group. They were divided into presentations were no longer visible. Test spectral two groups by age (20-40 years and 40-55 years). sensitivities were obtained in selected patients to con- Informed consent was obtained from all subjects. firm the mechanism mediating detection. The use of a 480 nm test light allowed for a measure of the rela- Apparatus tive M and S cone pathway sensitivity loss unaffected by differences in preretinal absorption. For each sub- Light stimulation was provided by a two-channel 10 ject the contribution of macular pigment density to Maxwellian view system previously described. The threshold measures was estimated by comparing the final lens formed 1.8 X 2.0 mm rectangular images of value of M cone pathway thresholds obtained with the source. Monochromatic light was provided by in- the 480 nm test light at an adapting field intensity of terference filters with half bandwidths of approxi- 0.96 log Td to those obtained with a 540 nm test light. mately 6 nm. Retinal illumination was calibrated If the decreased M cone sensitivity measured with a with an EG and G model 550 photometer (Salem, 480 nm test light was due to the presence of increased MA) and calculated using the method described by macular pigment density, then this decrease should Westheimer." be negligible for data obtained with a 540 nm test light. The absorption at 540 nm is minimal even in Procedure subjects with high density macular pigment.13 All A two-color increment threshold procedure was thresholds were adjusted to allow for the contribution used to measure M (green) and S (blue) cone pathway of macular pigment. sensitivity. Foveal increment thresholds were ob- tained for a 480 nm test light (1°, 200 msec) super- Results imposed on 14°, 600 nm steady adapting fields. The The mean foveal increment threshold data for 11 conditions were selected to measure Stiles' pi-4 (an M normals are shown in Figure 1. The filled triangles cone pathway) and pi-1 (an S cone pathway) mecha- 12 represent mean thresholds for six normals in the nisms. Following 10 min of dark adaptation, com- 20-40 year age group and the open circles mean plete increment threshold curves were obtained in thresholds for five normals in the 40-55 year group. approximately 30 min on each patient. Threshold Error bars represent ± 1 SD of the normal means. was defined as the mean of three to five repetitions of Because of the similarity of the thresholds for both an ascending and descending modified method of groups of normals, the patients' data were compared limits. The subject adapted to each adapting field for to the mean thresholds for all the normals shown in Downloaded from iovs.arvojournals.org on 09/25/2021 1734 INVESTIGATIVE OPHTHALMOLOGY 6 VISUAL SCIENCE / August 1989 Vol. 00 IQ: ().96 logTd Io- 2.91 logTd 2 s 6 2- *"x 5 >» >- 1- A I A /\ f / n i - • Z.M Cone 4 pigment 1 >-SCone | pigment SENSITIV V) G -1 - -O i 4 1 1 i 3 D) 400 500 600 400 500 600 O Fig.
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