Sven Erik G. Nilsson

Patients with AMD and a large absolute central scotoma can be trained successfully to use eccentric viewing, as demonstrated in a scanning laser ophthalmoscope

Twenty patients with age-related macular degeneration, an absolute central scotoma and a mean visual acuity of 0.04 (20/475) were studied. A scanning laser ophthalmoscope (SLO) was used for microperimetry and determination of preferred retinal locus, often located to the left of the retinal lesion (corresponding to a location to the left of the visual field scotoma), which is considered unfavorable for reading. All 20 patients were trained to use a new and more favorable retinal locus for reading, above (or occasionally below) the retinal lesion (corresponding to a location below or above the visual field scotoma), first by reading scrolled text under simultaneous fixation monitoring and instruction in the SLO and then by reading printed text, using high magnification (mean 14.3x). For the 18 patients who learned to use eccentric viewing, reading speed with adequate magnification prior to training was 9.0+/-5.8 words/min. With training (mean 5.2 hours), it increased significantly (p<0.001) to 68.3+/-19.4 words per min. Training of eccentric reading has thus proved to be very successful.

Lipofuscin accumulation in cultured retinal pigment epithelial cells causes enhanced sensitivity to blue light irradiation.

Lipofuscin accumulates with age within secondary lysosomes of retinal pigment epithelial (RPE) cells of humans and many animals. The autofluorescent lipofuscin pigment has an excitation maximum within the range of visible blue light, while it is emitting in the yellow-orange area. This physico-chemical property of the pigment indicates that it may have a photo-oxidative capacity and, consequently, then should destabilize lysosomal membranes of blue-light exposed RPE. To test this hypothesis, being of relevance to the understanding of age-related macular degeneration, cultures of heavily lipofuscin-loaded RPE cells were blue-light-irradiated and compared with respect to lysosomal stability and cell viability to relevant controls. To rapidly convert primary cultures of RPE, obtained from neonatal rabbits, into aged, lipofuscin-loaded cells, they were allowed to phagocytize artificial lipofuscin that was prepared from outer segments of bovine rods and cones. Following blue-light irradiation, lysosomal membrane stability was measured by vital staining with the lysosomotropic weak base, and metachromatic fluorochrome, acridine orange (AO). Quantifying red (high AO concentration within intact lysosomes with preserved proton gradient over their membranes) and green fluorescence (low AO concentration in nuclei, damaged lysosomes with decreased or lost proton gradients, and in the cytosol) allowed an estimation of the lysosomal membrane stability after blue-light irradiation. Cellular viability was estimated with the delayed trypan blue dye exclusion test. Lipofuscin-loaded blue-light-exposed RPE cells showed a considerably enhanced loss of both lysosomal stability and viability when compared to control cells. It is concluded that the accumulation of lipofuscin within secondary lysosomes of RPE sensitizes these cells to blue light by inducing photo-oxidative alterations of their lysosomal membranes resulting in a presumed leakage of lysosomal contents to the cytosol with ensuing cellular degeneration of apoptotic type. The suggested mechanism may have bearings on the development of age-related macular degeneration.

Location and stability of a newly established eccentric retinal locus suitable for reading, achieved through training of patients with a dense central scotoma.

Six patients, median age 71 years, with a dense central scotoma in one eye and a median visual acuity of 0.06 (20/330) in the same eye, were all (100%) shown by means of fundus photography including a fixation target to preferably use an unfavorable retinal locus for fixation, i.e., within the lesion (scotoma). None of the patients was able to read novel text with the affected eye. A computer and video display system were used to determine the most suitable area above or below the visual field scotoma (below or above the retinal lesion) for reading and the magnification needed at this eccentricity. The same setup was also used for an introductory training in reading single words as well as scrolled text with the aim of establishing a preferred retinal locus (PRL) at a favorable, eccentric position, the trained retinal locus (TRL). Thereafter, the patients were provided with strong positive lenses (median power, 40 D) for reading printed text at a very short reading distance (median, 2.5 cm), first single words, above and below which help lines were printed to facilitate eccentric fixation, and finally, novel text. The total training time was 4 to 5 h. Thereafter, fundus photography showed that five of the patients (83%) used their TRL as their PRL. Reading speed was 71 words per minute (median). Our results seem to indicate that an eccentric PRL favorable for effective reading can be established through training and that a fairly low number of training sessions is required. (Optom Vis Sci 1998;75:873–878)

Aging of cultured retinal pigment epithelial cells: oxidative reactions, lipofuscin formation and blue light damage

This report reviews our experimental work on cultured retinal pigment epithelial (RPE) cells, fed native or UV-irradiated photoreceptor outer segments (POS). We showed that significantly more lipofuscin (LF) was formed in cells cultured in 40% oxygen than in cells cultured in 8% oxygen, indicating an involvement of oxidative mechanisms in LF formation. The antioxidants α-tocopherol, lycopene, zeaxanthin and lutein significantly reduced LF formation. RPE cells high in melanin content exhibited significantly less formation of LF than cells low in or devoid of melanin, suggesting that melanin acts as an effective antioxidant. The phagocytic capacity of LF-loaded RPE cells was significantly reduced compared to that of unloaded control cells, indicating that LF-loaded RPE cells may be unable to serve the photoreceptors sufficiently regarding phagocytosis of shed outer segment tips. Blue light irradiation destabilized lysosomal membranes in LF-loaded RPE cells and significantly reduced the viability of such cells compared to unloaded, irradiated control cells. These results may be of significance in relation to the development of age-related macular degeneration (AMD).

Lipofuscin accumulation in cultured retinal pigment epithelial cells reduces their phagocytic capacity.

PURPOSE Retinal pigment epithelial (RPE) cells slowly accumulate lipofuscin pigment within their acidic vacuolar apparatus as a result of extra- and/or intralysosomal oxidative alterations of phagocytosed photoreceptor outer segments (POS) with consequent imperfect degradation of these structures. In old age, lipofuscin accumulation may become quite substantial. It has been suggested that pronounced accumulation of lipofuscin is related to decreased RPE function and, possibly, to age-related macular degeneration. The aim of the present investigation was to study whether heavy loading with lipofuscin of RPE acidic lysosomes would affect the further phagocytic ability of the cells. METHODS In the first section of the investigation, cultures of rabbit RPE cells were exposed daily to bovine UV-irradiated POS (artificial lipofuscin) for 4 weeks, resulting in a pronounced lipofuscin accumulation of the cells. Fluorescent latex beads (labelled with a red fluorophore) were added to unloaded control cultures at O and 4 weeks after their establishment, and to lipofuscin loaded cells after 4 weeks of feeding with artificial lipofuscin. Cellular amounts of lipofuscin, and their phagocytotic activity, were quantified by static fluorometry measuring lipofuscin-specific and red bead-specific fluorescence, respectively. The intracellular location of the beads was verified by confocal laser scanning microscopy. RESULTS Unloaded, and thus almost lipofuscin-free, control cells exposed to latex beads showed numerous cytoplasmic particles emitting reddish fluorescence, while few particles were taken up by cells initially loaded with artificial, POS-derived, lipofuscin. Measurement of the latex bead-specific fluorescence showed significantly (p < 0.001) higher levels in unloaded control cells than in lipofuscin-loaded ones. In the second part of the investigation, unloaded control cultures and lipofuscin-loaded cultures were exposed to native bovine Texas Red-X-labelled POS 4 weeks after the establishment of the cultures. Unloaded control cells showed a large number of cytoplasmic POS emitting reddish fluorescence, while fewer POS were phagocytosed by cells loaded with artificial lipofuscin. Measurement of the Texas Red-X-specific fluorescence, thus quantifying the phagocytic ability of the cells, showed significantly (p < 0.001) higher levels in control cells than in lipofuscin-loaded ones. CONCLUSIONS Severe lipofuscin accumulation of RPE cells appears to result in a greatly decreased phagocytic capacity. The resulting reduction in ability to cope with the needs of the overlying photoreceptor cells, in order to eliminate the obsolete tips of their POS, may well be of significance in the development of age-related macular degeneration.

The annualized incidence of contact lens induced keratitis in Sweden and its relation to lens type and wear schedule : Results of a 3-month prospective study

All cases of contact lens induced keratitis (epithelial defects with an underlying infiltrate or ulcer) among cosmetic wearers in Sweden were collected in a 3-month prospective study and analyzed for risk factors in relation to lens type and wear schedule. Every ophthalmologist in Sweden was invited to participate and 100% responded. Viral cases were excluded. The number of lens wearers in Sweden, subdivided by lens type and wear schedule, was obtained in a parallel 3-month study among 71% of the lens fitters, who counted all their wearers, recording lens type and wear schedule as well as revisit and replacement schedules. The annualized incidence per 10,000 wearers was 1.48 for daily wear of rigid gas permeable lenses, 2.16 for daily wear and 10.00 for extended wear of disposable soft lenses, and 2.17 for daily wear and 13.33 for extended wear of conventional soft lenses. Thus, extended wear was associated with a significantly (P < 0.01-0.001) higher (5-6 times) risk of keratitis than daily wear. There were no other significant differences between the incidence figures. The Swedish incidence figures were approximately half as high as those reported in the U.S. Of the lesions, only 12% were located within the pupillary area and only 8% were corneal ulcers. Only three patients (12%) suffered a decrease in visual acuity. Severe keratitis was significantly (P < 0.01) more common among conventional soft lens wearers (accounting for all ulcers, all lesions within the pupillary area, and all decreases in visual acuity) than among wearers of disposable lenses.

CHANGES IN ULTRASTRUCTURE AND FUNCTION OF THE SHEEP PIGMENT EPITHELIUM AND RETINA INDUCED BY SODIUM IODATE1

The present investigation shows that the membrane properties of the sheep pigment epithelial cells were very rapidly and severely affected by sodium iodate, whereas the effects concerning the neuroretina were delayed. The c‐wave of the ERG was immediately abolished and replaced by a cornea‐negative potential, but the a‐ and b‐waves were preserved for about 80–100 min. Ultrastructurally the plasma membranes (particularly the basal plasma membrane) of the pigment epithelial cells were destroyed or less distinct than normally. The cell organelles were swollen and ruptured. There were indications that the pigment epithelium could no longer participate in the receptor outer segment turnover. The photoreceptor cells were morphologically undamaged, and few or no signs of injury were observed in the inner layers of the retina. The effects upon the neuroretinal functions seen after 80–100 min, consisting of a reduction of a‐ and b‐wave amplitudes, were most likely caused by an inability of the pigment epithelium to maintain in the long run its metabolic and barrier properties. It appears that at an early stage after sodium iodate injection, the present preparation may be useful for the study of the effects on the neuro‐retina proper of drugs and other agents.

Lipofuscin-formation in retinal pigment epithelial cells is reduced by antioxidants.

The accumulation of lipofuscin by retinal pigment epithelium may be an important feature in the pathogenesis of age-related macular degeneration, suggesting the possibility that this common cause of blindness might be prevented or delayed by antioxidants. In support of this idea, we now report significantly reduced formation of lipofuscin when the antioxidant substances lutein, zeaxanthin, lycopene (carotenoids), or alpha-tocopherol were added to rabbit and bovine (calf) retinal pigment epithelial (RPE) cells exposed to normobaric hyperoxia (40%) and photoreceptor outer segments. Rabbit and calf RPE cells were grown for 2 weeks with addition of one of the test substances every 48 h. The cellular uptake of carotenoids and alpha-tocopherol was assayed by HPLC after 2 weeks. The lipofuscin-content was measured by static fluorometry (rabbit cells) or by image analysis (calf cells). Both rabbit and calf RPE showed similar results with significantly lower amounts of lipofuscin in antioxidant-treated cells. The effect of carotenoids is especially interesting, since the result is not dependent on their protective effect against photo-oxidative reactions. The chain-breaking abilities of these antioxidants in peroxidative reactions of lipid membranes and quenching of free radicals seem to be of importance for inhibition of lipofuscin formation.

Contact lens wear in dry environments

Abstract The relation between relative humidity at the place of work and subjective discomfort as well as a number of objective parameters was studied in 34 contact lens wearers. Subjects in a low relative humidity (< about 30%) showed significantly shorter BUT on the lens and more prominent lens deposits than subjects in a higher relative humidity (> 40%). A short BUT on the lens was associated with lens deposits (and vice versa) and restricted lens movements. Discomfort was particularly prominent when humidity was less than about 25%, when BUT on the lens was < 20 sec, and when lens deposits were present. An experiment where relative humidity was manipulated between about 20 and 50% showed that subjects with a short BUT on the lens and prominent lens deposits were much more sensitive to a low relative humidity than other subjects. Enzymatic cleaners, frequent lens replacements, and loose fits were valuable to lessen discomfort.

COVARIATION OF THE SIMULTANEOUSLY RECORDED c‐WAVE AND STANDING POTENTIAL OF THE HUMAN EYE

The c‐wave and the directly recorded standing potential (SP) of the human eye were studied with the aid of a recently developed method including matched temperature stabilized calomel electrodes, d.c. amplifiers and a suction contact lens. This technique, which does not require general anaesthesia, permits simultaneous direct d.c. recordings of the SP and the c‐wave in human volunteers during long‐term experiments. Upon repetitive light flashes (stimulus duration 1 sec, interval 20 sec and flash intensity 4.5 rel. log units above b‐wave threshold) both variables responded with slow amplitude oscillations with a frequency of about 2/hour. The oscillations were similar as to phases and frequencies. Both the potentials are held to be generated mainly in the pigment epithelium. Considering this partly common origin the observed covariation was an interesting finding.