Color vision and neuroretinal function in diabetes.

PURPOSE: We investigate how type 2 diabetes (T2DM) and diabetic retinopathy (DR) affect color vision (CV) and mfERG implicit time (IT), whether CV and IT are correlated, and whether CV and IT abnormality classifications agree. METHODS: Adams desaturated D-15 color test, mfERG, and fundus photographs were examined in 37 controls, 22 T2DM patients without DR (NoRet group), and 25 T2DM patients with DR (Ret group). Color confusion score (CCS) was calculated. ITs were averaged within the central 7 hexagons (central IT; ≤4.5°) and outside this area (peripheral IT; ≥4.5°). DR was within (DRIN) or outside (DROUT) of the central 7 hexagons. Group differences, percentages of abnormalities, correlations, and agreement were determined. RESULTS: CCS was greater in the NoRet (P = 0.002) and Ret (P < 0.0001) groups than in control group. CCS was abnormal in 3, 41, and 48 % of eyes in the control, NoRet, and Ret groups, respectively. Ret group CV abnormalities were more frequent in DRIN than in DROUT subgroups (71 vs. 18 %, respectively; P < 0.0001). CCS and IT were correlated only in the Ret group, in both retinal zones (P ≤ 0.028). Only in the Ret group did CCS and peripheral IT abnormality classifications agree (72 %; P < 0.05). CONCLUSION: CV is affected in patients with T2DM, even without DR. Central DR increases the likelihood of a CV deficit compared with non-central DR. mfERG IT averaged across central or peripheral retinal locations is less frequently abnormal than CV in the absence of DR, and these two measures are correlated only when DR is present.

Towards optimal filtering of "standard" multifocal electroretinogram (mfERG) recordings: findings in normal and diabetic subjects.

AIMS: To study the effects of two commonly used pre-amplifier filtering bandwidths on normal multifocal electroretinogram (mfERG) responses and their comparative abilities to detect retinal disease. METHODS: 103 standard mfERGs were recorded simultaneously in two channels with different pre-amplifier settings (10-100 Hz and 10-300 Hz) from one eye of each of 20 normal subjects, 17 diabetics with non-proliferative diabetic retinopathy (NPDR), and 12 diabetics without retinopathy. Signal to noise ratios (SNR) of the normal subjects' first order mfERGs were compared between channels. All subjects' amplitudes and implicit times were derived using a "template stretching" method. For comparison, implicit time was also measured using a "template sliding" method. mfERG amplitudes and implicit times were compared between the channels and among subject groups. RESULTS: Normal mean amplitudes and implicit times were similar for the two channels. However, normal 10-100 Hz recordings had significantly higher SNR and lower intersubject variability than 10-300 Hz recordings. In NPDR, the 10-100 Hz channel identified significantly more implicit time and amplitude abnormalities. In the diabetics without retinopathy, 10-100 Hz filtering identified significantly more implicit time abnormalities than 10-300 Hz filtering. For both filter settings, diabetic implicit times were more often abnormal than amplitudes. The 10-100 Hz channel was superior for both implicit time measurements. CONCLUSION: Standard mfERGs recorded from normal eyes and filtered 10-100 Hz contain less noise, higher SNR, and less intersubject variability than those filtered at 10-300 Hz. This underlies the finding that the 10-100 Hz filter setting identifies more retinal dysfunction than the 10-300 Hz setting.

Reading performance in older adults with good acuity.

PURPOSE: This study evaluated factors affecting reading performance in a sample (N = 544) of older adults (mean age 72.8 years, range 58 to 102) with good high-contrast acuity (> or = 20/32). METHODS: Using the Pepper Reading Test, the relationship between reading rate and several vision measures was assessed. RESULTS: Mean corrected reading rate fell substantially over the age range tested despite the fact that these individuals all had good acuity. However, multiple regression analysis indicated that when other measures were taken into account (most notably, low-contrast vision, motor ability, and attentional field integrity), age was not a significant independent predictor of corrected reading rate. CONCLUSION: Reading is an important skill, and ways of enhancing reading performance should be explored. Good high-contrast acuity does not assure that older individuals can read satisfactorily.

Ocular contributions to age-related loss in coarse stereopsis.

PURPOSE: To determine the basis for the dramatic decline in coarse stereopsis that occurs with age. METHODS: The Frisby test was used to assess stereopsis in a large sample of randomly selected persons over the age of 58 years. A number of other vision functions were also assessed in the same persons. The data were used to address the question of whether the decline in stereopsis reflects age-related alterations in cortical stereopsis mechanisms themselves (e.g., disparity detectors) or a degradation of the signal reaching the cortex as a result of alterations in earlier visual components. Two of three vision measures were binocular and thus reflect predominantly the function of the better eye. RESULTS: We find, as many others have reported, that even very coarse stereopsis declines dramatically with age. Despite not having separately assessed each eye, we find that among those selected to have good ocular function there was no significant decline in coarse stereopsis with age. CONCLUSION: These findings suggest that the enormous decline in coarse stereopsis with age can be accounted for by alterations in early stages of vision processing.

The fast oscillation of the electrooculogram reveals sensitivity of the human outer retina/retinal pigment epithelium to glucose level.

The effect of acute blood glucose elevations on human outer retinal function was examined. Electrooculograms were recorded as the background light cycled on/off with a 2-min period, eliciting rapid changes in the corneo-retinal standing potential known as the fast-oscillation of the electrooculogram. Recordings were made while subjects fasted and after they consumed 100 g of D-glucose. In all subjects, blood glucose levels strongly affected fast oscillation amplitude, which reflects photoreceptor-driven changes in RPE cell chloride concentration. The sensitivity of RPE metabolism to glucose fluctuations may relate to changes in the blood-retinal barrier that are known to occur in diabetes (e.g. macular edema).

The relation between visual acuity and other spatial vision measures.

PURPOSE: To examine to what extent measurement of standard visual acuity allows prediction of other spatial vision measures on an individual basis when high correlations exist between visual acuity and the other measures. METHODS: A series of spatial vision functions were measured in a sample of 900 community-dwelling older observers. Regression analysis was performed, and correlation coefficients were calculated between standard high-contrast visual acuity and other spatial vision measures including contrast sensitivity, low-contrast acuity, low-contrast low-luminance acuity (SKILL card), and disability glare acuity. RESULTS: All measures were highly and significantly correlated with standard visual acuity (r = 0.68 to 0.91). Despite the high correlations, many predictions of the other spatial vision measures from the correlation with standard acuity fell considerably outside of acceptable ranges determined by repeatability. The influence of the range of values in correlations is emphasized. CONCLUSIONS: Other spatial vision measures cannot be predicted on an individual basis from visual acuity despite high and significant correlations between the measures.

Multifocal electroretinogram delays reveal local retinal dysfunction in early diabetic retinopathy.

PURPOSE: To identify local retinal abnormalities in diabetic patients with and without retinopathy, by using the multifocal electroretinogram (M-ERG). METHODS: Electroretinograms were recorded at 103 discrete retinal locations in each eye of eight persons with nonproliferative diabetic retinopathy (NPDR) and eight diabetic persons without retinopathy, using VERIS (EDI, San Mateo, CA). The amplitude and implicit time of each local (first-order) retinal response were derived and compared with normal values obtained from 16 age-matched, nondiabetic subjects. Maps of local response amplitude and implicit time were compared with fundus photographs taken at the time of testing. RESULTS: In eyes with NPDR, the implicit times of responses from retinal sites manifesting clinical pathologic fundus lesions (e.g., microaneurysms and focal edema), were markedly delayed (e.g., up to 7 msec from normal). Responses from adjacent retinal sites that were more normal in clinical appearance were also delayed, but to a lesser extent (e.g., 2-5 msec). Smaller, yet significant local response delays were also found in eyes without retinopathy. By contrast, local response amplitudes bore no consistent relationship to fundus abnormalities in eyes with retinopathy, and amplitudes were typically normal in eyes without retinopathy. CONCLUSIONS: The M-ERG reveals local retinal dysfunction in diabetic eyes even before retinopathy. The magnitude of delay of local ERG implicit time reflects the degree of local clinical abnormality in eyes with retinopathy. Local response delays found in some eyes without retinopathy suggest that the M-ERG detects subclinical local retinal dysfunction in diabetes. Analysis of M-ERG implicit time, independent of amplitude, improves the sensitivity of detection of local retinal dysfunction in diabetes.

Seeing into old age: vision function beyond acuity.

PURPOSE: To provide a comprehensive description of vision function beyond acuity in older individuals. METHODS: A sample of 900 individuals between the ages of 58 and 102 years (mean age of 75.5) was binocularly tested wearing habitual correction on a battery of psychophysical tests including high and low contrast acuity, low contrast low luminance acuity, disability glare, contrast sensitivity, color vision, stereoacuity, recovery from glare, and attentional visual fields. RESULTS: High contrast acuity is reasonably well maintained on average, even into very old ages. Spatial vision measures under conditions of reduced contrast or luminance, or glare reveal significant impairment in a large portion of the aged. Many older individuals also have greatly reduced stereopsis, poor color discrimination, and severely restricted peripheral fields under conditions of divided attention. A single exponential function relating performance to age fits all spatial vision data sets. The function for individual spatial measures lies at different positions along the age scale. The derived aging function with a time constant of approximately 15 years also fits results from other recent aging studies of acuity and contrast sensitivity. CONCLUSIONS: Standard visual acuity underestimates the degree of vision function loss suffered by many older individuals under the nonoptimal viewing conditions encountered in daily life. All spatial vision functions show a similar rate of decline with age of the population, but the age at which decline begins varies among measures.

Color vision defect type and spatial vision in the optic neuritis treatment trial.

PURPOSE: To describe the types of color vision defects present in the acute phase of the disease and 6 months into recovery in the 438 participants of the Optic Neuritis Treatment Trial. METHODS: Patients meeting strict eligibility criteria were seen within 8 days of the onset of symptoms and then at regular follow-up visits. At the first and 6-month visits (and subsequent annual visits), spatial vision (acuity, contrast sensitivity), visual fields, and color vision were measured. Farnsworth-Munsell 100-hue tests were scored by a variant of the method of quadrant analysis described by Smith et al (Am J Ophthalmol. 1985; 100:176-182). RESULTS: Most persons show mixed red-green (RG) and blue-yellow (BY) color defects (one type predominating, accompanied by a lesser defect of the other type). BY defects tend to be slightly more common in the acute phase of the disease, with slightly more RG defects at 6 months. Persons may shift defect type over time. Defect type was not related to any of the spatial vision measures at either test time or to treatment group; however, severity of color defect was related to both spatial vision measures and treatment group. CONCLUSIONS: Contrary to common clinical wisdom, optic neuritis is not characterized by selective RG defects. Color defect type cannot be used for differential diagnosis of optic neuritis.

Acute effects of blood glucose on chromatic visually evoked potentials in persons with diabetes and in normal persons.

PURPOSE: To determine whether specific chromatic pathways are selectively affected by short-term variations in blood glucose levels in observers with and without diabetes. METHODS: Ten subjects with diabetes, all with type 1 diabetes and no retinopathy, and eight age-similar normal subjects were tested. Cortical visually evoked potentials (VEPs) in response to stimuli designed to selectively activate the short-wavelength-sensitive (S) or long- and middle-wavelength-sensitive (LM) chromatic (isoluminant) pathways or the achromatic pathway were recorded over a period of several hours. Capillary blood glucose also was measured repeatedly over the same period. The relation between VEP latency and blood glucose was determined. RESULTS: The S-pathway VEP latency was correlated significantly with blood glucose in a slight majority (6/10) of persons with diabetes; S-pathway latency was longer at higher blood glucose levels. This association between S-pathway latency and blood glucose was not dependent on the pattern of blood glucose variation over time (i.e., significant correlations between blood glucose and latency were observed in persons for whom blood glucose increased, decreased, or rose and then fell over time). No dependence on blood glucose was observed for LM- or achromatic-pathway VEP latency in subjects with diabetes. CONCLUSIONS: Acute variations in blood glucose of subjects with diabetes over hours selectively affect the function of the short-wavelength-sensitive chromatic pathway. The findings are discussed within the context of known mechanisms by which elevated glucose affects cellular metabolism with a time course consistent with the transient nature of the effect observed.

The SKILL Card. An acuity test of reduced luminance and contrast. Smith-Kettlewell Institute Low Luminance.

PURPOSE: To design and evaluate a new vision test that combines low contrast and reduced illumination to stress the visual system and be sensitive to subtle alterations in function. METHODS: A simple new clinical test, the Smith-Kettlewell Institute Low Luminance (SKILL) Card, is designed to measure spatial vision under conditions of reduced contrast and luminance using normal office lighting. The SKILL Card consists of two near acuity charts mounted back to back. One side has a chart with black letters on a dark gray background designed to simulate reduced contrast and luminance conditions. The other side has a high-contrast, black-on-white letter chart. The SKILL score is the acuity loss (number of letters) between the light and dark sides. RESULTS: Age norms for a large normal population have been established and show that test scores increase with age, particularly after age 50. Repeatability is as good as that of standard Snellen acuity. The SKILL score is affected minimally by blur, but it is affected by large variations in light level. SKILL scores are sensitive to the presence of visual disease such as "recovered" optic neuritis. CONCLUSIONS: The SKILL card allows quick, reliable measurement of the effect of reduced luminance and contrast on acuity SKILL scores are not correlated with other vision measures in patients with optic neuritis, which shows that the SKILL card measures a different dimension of vision function than existing clinical tests.

Clinical vision characteristics of the congenital achromatopsias. I. Visual acuity, refractive error, and binocular status.

Visual acuity, refractive error, and binocular status were determined in 43 autosomal recessive (AR) and 15 X-linked (XL) congenital achromats. The achromats were classified by color matching and spectral sensitivity data. Large interindividual variation in refractive error and visual acuity was present within each achromat group (complete AR, incomplete AR, and XL). However, the number of individuals with significant interocular acuity differences is very small. Most XLs are myopic; ARs show a wide range of refractive error from high myopia to high hyperopia. Acuity of the AR and XL groups was very similar. With-the-rule astigmatism of large amount is very common in achromats, particularly ARs. There is a close association between strabismus and interocular acuity differences in the ARs, with the fixating eye having better than average acuity. The large overlap of acuity and refractive error of XL and AR achromats suggests that these measures are less useful for differential diagnosis than generally indicated by the clinical literature.

Clinical vision characteristics of the congenital achromatopsias. II. Color vision.

Twelve X-linked (XL) achromats and 43 autosomal recessive (AR) achromats were tested using the Farnsworth D-15, Nagel anomaloscope, Sloan achromatopsia test, and Berson test using standard procedures. All of the tests identify achromatopsia, but very few differentially diagnose the various types. AR achromats were subclassified as complete (rods only) or incomplete (residual cone function present) by additional psychophysical testing. Complete and incomplete ARs do not perform differently on any clinical color vision measure, indicating that (1) rods predominantly mediate vision in both groups and (2) these tests are not useful for distinguishing between the groups. Both groups show considerable interindividual variation on all measures. Only one of the measures, the Berson test, designed to distinguish XLs from ARs, does so reliably. XLs and ARs do not differ significantly on the Nagel anomaloscope or most of the Sloan plates. The confusion angles of the D-15 do differ for the two groups, but the variability in each group makes the measure unreliable for classifying individuals. The Berson test is recommended to distinguish the XL from AR achromats.

Visual evoked potentials in three-dimensional color space: correlates of spatio-chromatic processing.

Visual evoked potentials (VEPs) were measured for sinusoidal gratings with spatio-chromatic modulation defined in a three-dimensional color space. The spatio-chromatic modulation of the gratings can be decomposed into contributions from an achromatic luminance varying component, an isoluminant component which modulates only the activities of L cones and M cones, and an isoluminant component corresponding to modulation of only S-cone activity. The emphasis of this report is the nature of VEPs resulting from isoluminant spatio-chromatic modulation. The VEP response was characterized along a number of spatial, temporal, and chromatic stimulus dimensions: contrast, spatial frequency, chromaticity in the isoluminant plane, chrominance/luminance ratio, orientation, and temporal frequency. Isoluminant VEPs resulting from stimuli modulating L and M cones are compared with those from S-cone modulation. When appropriate spatiotemporal conditions are employed, both types produce robust VEPs; however, the S-pathway VEPs show considerably longer latencies than do those from LM-pathway activation. The VEP results are compared to psychophysical and single unit electrophysiological observations. VEP latencies exhibit the lowpass character of psychophysical chromatic contrast sensitivity functions but VEP amplitudes show bandpass tuning along both the S and LM axes. An oblique effect, i.e. shorter latencies for horizontal and vertical gratings than for diagonal, is observed in the isoluminant VEP. S-pathway VEPs are used to demonstrate an electophysiological correlate of transient tritanopia. Normative amplitude and latency data for VEPs from selectivity stimulated chromatic mechanisms provide a baseline for clinical electrodiagnostic applications.

Diabetic short-wavelength sensitivity: variations with induced changes in blood glucose level.

PURPOSE: To investigate variations in diabetic short-wavelength sensitivity with acute, induced changes in blood glucose level. METHODS: Increment threshold measures were obtained for short-wavelength-sensitive and middle/long-wavelength-sensitive cone pathways after an induced, acute change in blood glucose level in diabetic observers. RESULTS: Diabetic observers showed an increase in short-wavelength sensitivity, but no change in middle/long-wavelength sensitivity, with a rapid drop in blood glucose level. CONCLUSIONS: Experimentally induced changes in diabetic blood glucose levels can directly affect diabetic short-wavelength sensitivity.

Application of the spatiochromatic visual evoked potential to detection of congenital and acquired color-vision deficiencies.

Visual evoked potentials were recorded in response to spatiochromatic stimuli modulated in different directions in cone-activation color space from subjects with congenital and acquired color defects. This technique was effective for detection and classification of both mild and severe forms of congenital deficits. Results suggest that the visual evoked potential is useful for early identification of color abnormalities in acquired deficits such as diabetes and that it is sensitive enough to detect regional retinal losses of sensitivity (e.g., as in central serous choroidopathy). The spatiochromatic visual evoked potential provides a systematic and sensitive indication of different color-vision anomalies.

Low-income pregnant adolescents and their infants: dietary findings and health outcomes.

Dietary and other health-related data were obtained for 99 low-income, pregnant adolescents aged 13 to 19 years and their infants who were enrolled in the Teen Pregnancy Service (TPS). The dietetic services provided through TPS are highlighted for this sample of teens, 97% of whom were eligible for the WIC program. Average gestational age at time of enrollment for prenatal care was 18 weeks; 59% of the sample was anemic (hemoglobin value less than 120 gm/L). The average number of servings teens consumed each day from the four food groups was as follows: bread/grain, 5.0; milk, 2.8; meat, 2.8; and fruit/vegetable, 2.3. Teens who were overweight before pregnancy had heavier infants (mean = 3,344 gm) than their underweight peers (mean = 2,770 gm). Teens who gained 24 lb or less during pregnancy and who gave birth to full-term infants had infants with significantly lower birth weights (mean = 3,094 gm, p less than .008) than those who gained at least 25 lb (mean = 3,356 gm). Teens who smoked also had infants with lower birth weights than teens who did not smoke. Most teens bottle-fed their infants (82%). On the basis of our data, we conclude that low-income pregnant teens are likely to be at dietary risk. Dietary work with low-income pregnant adolescents is challenging and requires a thorough knowledge base about adolescent pregnancy, coupled with the ability to adapt traditional dietary counseling practices to meet the unique needs of these clients.

LWS cone effects on rod threshold and saturation in achromats with residual cone function.

Rod saturation on flashed and steady red backgrounds was investigated in normals and three achromats, two of whom were found to have some residual cone function. LWS cones selectively reduce the background level at which rod saturation occurs and elevate rod thresholds at flashed background levels well below saturation. Both of these LWS cone actions are also present in eyes with greatly reduced LWS cone function. In normal eyes LWS cones also elevate rod thresholds on steady backgrounds. We thus conclude that LWS cones influence rods through different mechanisms under transient (flashed) and steady-state background stimulation and that the increase in rod visual sensitivity observed during prolonged presentation of a background is due to a time-dependent reduction of LWS cone influence on rods. Finally, the finding that rod-cone interactions of the same magnitude found in normals can be seen in individuals where the cones' ability to mediate vision is severely reduced suggests the rod saturation paradigm as a sensitive technique for revealing residual LWS cone function.

Tritan discriminations by 1- and 2-month-old human infants.

The capacity of 1- and 2-month-old infants to make a tritan discrimination between a 4 degree, 416 nm test field and a 547 nm surround was tested by means of the forced-choice preferential looking technique. Most of the 2-month-olds and the other 1-month-olds made the tritan discrimination and must therefore have functional SWS cones. Most of the youngest 1-month-olds failed to make the tritan discrimination and therefore either do not encode or do not preserve the information ordinarily encoded by SWS cones. The implications of these data and the prior data of Hamer et al. [Vision Res. 22, 575-587 (1982)] are discussed in relation to color theory.