1040-5488/14/9104-0472/0 VOL. 91, NO. 4, PP. 472Y476 OPTOMETRY AND VISION SCIENCE Copyright * 2014 American Academy of Optometry
ORIGINAL ARTICLE
Interocular Amplitude and Latency Differences of Pattern ERG and Pattern VEP Parameters Imre Fejes*, Pe´ter Bala´zs Kocsis†, Gyo¨rgy Benedek‡, and Ma´rta Jana´ky*
ABSTRACT Purpose. To determine the normal interocular differences in amplitudes and peak times of the pattern electroretinograms (PERGs) and pattern visual evoked potentials (PVEPs) and to investigate whether the PERG and PVEP parameters correspond in lateral dominance or whether the eye-side distributions of the functional parameters are similar. Methods. The PERGs and PVEPs were recorded in healthy subjects (N = 77) according to the standards of the International Society for Clinical Electrophysiology of Vision, with the modification of the check size of the PERG to 0.5 degrees. This allows stimulation of the macular ganglion cells and their corresponding visual pathways in healthy subjects. Results. Comparison of the averaged higher and lower response amplitudes and the shorter and longer response peak times showed significant differences (p G 0.001) in both the PERG and the PVEP parameters (median [5 to 95%]): the P50 (1.92% [0 to 5.48%]) and N95 (2.06% [0 to 13.95%]) peak times and the P50 (11.82% [1.32 to 29.93%) and N95 (9.45% [1.17 to 30.38%]) amplitudes of the PERGs and the P100 (1.04% [0 to 4.15%]) and N135 (1.96% [0 to 12.36%]) peak times and the P100 (9.86% [1.26 to 29.76%]) and N135 (11.19% [1.18 to 29.99%]) amplitudes of the PVEPs. No significant correlation was found concerning the eye dominance of the PERG and PVEP parameters. Conclusions. Our results reveal a significant interocular difference on PERG and PVEP recording, but this could not be ascribed to the anatomy of the retina and related visual pathways. If the difference between the eyes is not taken into account, misinterpretation may occur in a pathological process. (Optom Vis Sci 2014;91:472Y476) Key Words: pattern electroretinography, visual evoked potential, interocular difference
T
he objective assessment of the macular function and subsequent visual pathways can be carried out by using pattern electroretinography (PERG) and pattern visual evoked potentials (PVEPs).1 Parameters measured by PERG and PVEPs are compared with normative data determined by each laboratory for their own individual population according to the standards of the International Society for Clinical Electrophysiology of Vision (ISCEV).2,3 Normal responses are reproducible, and their coefficients of variability have been determined.4Y6 Some data have been reported on histological and functional interocular differences,7Y11 but PERG and PVEP results on the same subjects have not been reported to date, although testing of the whole visual pathway from the retina to the visual cortex may be important in evaluating monocular pathologies. Both PERG *MD, PhD † MD ‡ MD, DSc Department of Ophthalmology, Albert Szent-Gyo¨rgyi Clinical Center, Faculty of Medicine, University of Szeged, Szeged, Hungary (IF, PBK, MJ); and Department of Physiology, Faculty of Medicine, University of Szeged, Szeged, Hungary (GB).
and PVEPs are applied to test central vision: PERG is recorded to examine the function of the macular area, whereas PVEPs reflect the function of the consecutive retinal ganglion cells, the optic nerve, and the visual pathway up to the visual cortex. We set out to determine whether interocular differences can serve as an important parameter for evaluation of the asymmetric macular and optic nerve functions, because their variability may also be of value in pathological follow-ups. Furthermore, the correspondence of the amplitude values of the two tests within each eye might be important. A strong correlation would imply an anatomical or physiological reason for the individual lateralization at the level of the retina, as the responses of the consequent structures of the visual pathway depend on the function of the structures situated before them. A difference in the retinal response between eyes would affect the response of the visual pathway and the visual cortex. To the best of our knowledge, no previous study has compared the lateralization (correspondence within but not between eyes) of PERG and PVEP responses and, therefore, an additional aim of this study was to determine its possible existence.
Optometry and Vision Science, Vol. 91, No. 4, April 2014
Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
Pattern ERG and VEP Interocular DifferencesVFejes et al.
METHODS Participants A total of 77 subjects free of any ophthalmologic pathology (men, n =16; women, n = 61; mean age, 35.6 T 12.9 years) were tested. The subjects gave their written consent for the anonymous analysis of their test results in harmony with the institutional ethical rules. On ophthalmologic examination, no alteration of the refractive media or fundus was detected, and the best corrected visual acuity was 20/20. Subjects were selected from a group of normal control patients free of any systemic disease (n = 32) and from among patients referred for PVEP examination because of a suspicion of multiple sclerosis, which was excluded by subsequent cerebrospinal fluid and magnetic resonance imaging diagnostics (n = 45).
Electrophysiological Examinations Electrophysiological examinations were performed with the RetiPort Science 4.9.8.9. program (Roland Consult Stasche & Finger Gmbh, Brandenburg an der Havel, Germany) according to the ISCEV standards, with the modification of the standard 0.8-degree check pattern size in the case of PERG. This difference from the standard ISCEV protocol was applied to stimulate the same retinal ganglion cells as stimulated by the PVEPs. Briefly, PERG was recorded with the correction of refractive errors to the viewing distance of the display by binocular stimulation under ambient light conditions (the room illuminance was 10 to 30 lux) with nondilated pupils. The active electrode (a DTL electrode) was placed in the lower conjunctival fold, the reference electrode (a gold cup skin electrode) was attached to the skin near the ipsilateral outer canthus, and the ground electrode (a gold cup skin electrode) was placed at the middle of the forehead (Fpz point).2 For stimulation, a black-and-white checkerboard pattern reversal (1.8 Hz) was used with a check size of 0.5 degrees. Contrast was determined at a level of 97%. Active and bandpass voltages were set at T100 KV and 5 to 50 Hz, respectively. On evaluation, 200 responses were averaged; peak time and P50 and N95 peakto-peak amplitudes were analyzed (i.e., the P50 amplitude is the peak of N35 to the peak of P50, etc.). The PVEPs were also recorded with nondilated pupils by monocular stimulation under ambient light conditions. The right eye was always tested first to avoid any confusion caused by compliance. According to the ISCEV standards, the active electrode was placed in the midlineV2.5 cm above the external
473
occipital protuberance (Oz), the reference electrode was in the Fz, and the ground electrode was attached to the Cz localization.3 The stimulation size and pattern, contrast, reversal rate, and active voltage were the same as in the case of PERG. The bandpass was 1 to 100 Hz. The averages of 100 responses were analyzed. Peak times and P100 and N135 peak-to-peak amplitudes were assessed. In both PERG and PVEPs, the luminance of the screen was set to 59 cd/m2.
Statistical Analysis Statistical analysis was carried out with the SigmaStat 3.5 statistical software (Statcon Software Ltd., Witzenhausen, Germany). On determination of the side differences, the statistical grouping was as follows: comparison of the responses of the right eyes and the left eyes and comparison as groups of higher and lower amplitudes or longer and shorter peak times with the Wilcoxon signed rank test, as the normality of the samples failed. The correlation between the amplitudes and the peak times of PERG and PVEPs was calculated with the Spearman test. The absolute values of the side (eye) differences were determined, and the percentage of the difference between the right and the left eyes was calculated for each subject by using the absolute difference (higher minus lower amplitude) divided by the higher amplitude or, in the case of the peak times, the longer minus the shorter peak time divided by the longer peak time. Intersubject coefficients of variability (CVs) were calculated as SD divided by the mean. Results are given as median (5 to 95%) CV or percentage, as appropriate. The association of laterality between the amplitudes and the P50 and P100 peak times of PERG and the latency of PVEPs was calculated with the W2 test. Differences in the values of the right and left eyes were calculated and analyzed as nonparametric variables.
RESULTS No significant differences were found between the averaged amplitudes and peak times of the responses of the right and left eyes either in PERG or in PVEP. Side differences in the functions of the two eyes of the individual subjects disappeared on averaging, as some of them exhibited higher amplitude in the right and some in the left eye. In contrast, on comparison of the higher and lower response amplitudes for both the PERG and the PVEP parameters with the Wilcoxon signed rank test, side differences were significant (p G 0.001). The P50 and N95 peak times and the P50 and N95 amplitudes of the PERG are shown in Table 1. The
TABLE 1.
Medians (5Y95%) (intersubject CVs) of the P50 and N95 peak times, the P50 and N95 amplitudes of the PERG for the right and left eyes, the higher and lower values, and the absolute side difference
PERG right eye PERG left eye Absolute side difference of PERG Higher PERG parameter Lower PERG parameter
P50 peak time, ms
P50 amplitude, KV
N95 peak time, ms
N95 amplitude, KV
52 (49Y56) (0.04) 52 (50Y55.2) (0.04) 1 (0Y3) (1.07) 52 (50Y56)* (0.04) 52 (49Y56)* (0.04)
8.01 (4.8Y11.34) (0.27) 7.51 (4.98Y10.84) (0.26) 0.9 (0.1Y2.93) (0.85) 8.49 (5.3Y11.44)* (0.25) 7.56 (4.7Y10.32)* (0.26)
95 (83.8Y100) (0.06) 94 (83Y101.2) (0.06) 2 (0Y13.2) (1.2) 96 (86.8Y102.2)* (0.05) 95 (83.8Y100)* (0.06)
10.9 (7.03Y15.38) (0.27) 10.5 (7.21Y13.92) (0.23) 1.03 (0.12Y4.18) (1.04) 11.4 (7.49Y15.54)* (0.25) 9.21 (5.97Y13.26)* (0.3)
*Significant differences were found between the higher and lower values with the Wilcoxon signed rank test (p G 0.001). Optometry and Vision Science, Vol. 91, No. 4, April 2014
Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
474 Pattern ERG and VEP Interocular DifferencesVFejes et al. TABLE 2.
Medians (5Y95%) (intersubject CVs) of the P100 and N135 peak times, the P100 and N135 amplitudes of the 0.5-degree PVEP for the right and left eyes, the higher and lower values, and the absolute side difference
VEP 0.5 degrees right eye VEP 0.5 degrees left eye Absolute side difference of PVEP Higher PVEP parameter Lower PVEP parameter
P100 peak time, ms
P100 amplitude, KV
N135 peak time, ms
102 (93Y107) (0.04) 103 (93.8Y108.2) (0.04) 1 (0Y4.2) (0.89)
11.4 (6.18Y23.32) (0.44) 11.8 (6.45Y21.26) (0.4) 1.2 (0.11Y4.8) (0.95)
143 (121.8Y155.8) (0.08) 142 (124.6Y159.2) (0.08) 3 (0Y18.2) (1.28)
N135 amplitude, KV 12.6 (8Y24.88) (0.41) 13.3 (6.65Y24.3) (0.38) 1.6 (0.1Y5.36) (0.89)
103 (93.8Y108.2)* (0.04) 12.1 (6.61Y23.32)* (0.41) 146 (126.6Y160.2)* (0.08) 13.5 (8.06Y25.36)* (0.39) 102 (93Y106.2)* (0.04) 10.3 (3.12Y20.24)* (0.42) 139 (120Y151.4)* (0.08) 11.5 (6.65Y22.16)* (0.39)
*Significant differences were found between the higher and lower values with the Wilcoxon signed rank test (p G 0.001).
P100 and N135 latencies and P100 and N135 amplitudes of the PVEPs are presented in Table 2. The intersubject CVs of the peak times and amplitudes did not differ when the parameters were grouped by side or by higher and lower values for both the PERG and the PVEPs (Tables 1, 2). Mean (TSD); CV; 5, 25, 50 (median); 75 and 95 percentiles; and maximum values of percentage differences are shown in Table 3. For the PVEP P100 and PERG P50 peak times, the maximum percentage interocular differences were less than 7%. The percentage side differences of the PERG P50 and N95 and the PVEP P100 and N135 amplitudes were as high as 50%, but in more than 95% of the cases (regarded as a cutoff point), the interocular amplitude differences were less than 30.5%. The latter can be used as the threshold of the normal interocular difference in clinical practice. The usefulness of interocular differences is supported by its lower variability than that of the monocular responses (Table 4). The lateral correspondence of the longer and shorter peak times of P50 and P100 with the W2 test was 0.015 (p = 0.9), and the power of the test was 0.049. The differences in the PERG and PVEP amplitudes of right and left eyes were not related. For the PERG P50 and PVEP P100 amplitudes, the W2 value was 0.008 (p = 0.93), with the power of the test 0.048; whereas for the PERG P50 and PVEP N135 amplitudes, the W2 value was 0.236 (p = 0.63), with the power of the test 0.073. For the PERG N95 and PVEP P100 amplitudes, the W2 value was 0.686 (p = 0.41), with the power of the test 0.122; and for the PERG N95
and PVEP P100 amplitudes, the W2 value was less than 0.001 (p = 0.98), with the power of the test 0.047.
DISCUSSION Determination of the interocular differences in the PERG and PVEP parameters in normal subjects may be useful in the evaluation of monocular macular pathologies or asymmetric macular ganglion cell or optic nerve diseases. Clinically, PERG can be used in a patient with an abnormal VEP to establish whether a retinal (macular) disorder is present and, therefore, to differentiate between a macular and an optic nerve dysfunction as a cause of the VEP abnormality. It can also directly demonstrate retinal ganglion cell dysfunction.2 In the event of a high interocular difference, the side difference may be interpreted as abnormal. Previous histological and imaging studies revealed an interocular difference as high as 8% in the foveolar cone density.12 Asymmetry in macular thickness was detected by optical coherence tomography as 6.4 T 14.7 Km (average foveal thickness, 207 T 24 Km vs. 200 T 23 Km).13 With regard to the normal retinal nerve fiber layer thickness measured by optical coherence tomography, the side difference was approximately 9 to 12 Km, depending on the scanning algorithm applied.14 These data may explain the visual acuity differences determined by psychophysical methods and the PERG and PVEP amplitude differences. The retinal blood flow of the macula has been shown to display no interocular difference in the absence of light stimulation of the
TABLE 3.
Interocular percentage (%) side differences of the PERG P50 peak time and P50 and N95 amplitudes and the PVEP P100 and N135 peak times and P100 and N135 amplitudes
Mean SD CV 5% Percentile 25% Percentile 50% percentile (median) 75% Percentile 95% Percentile Maximum
PERG P50 peak time
PERG P50 amplitude
PERG N95 peak time
PERG N95 amplitude
PVEP P100 peak time
PVEP P100 amplitude
PVEP N135 peak time
PVEP N135 amplitude
1.92 2.05 1.07 0 0 1.92
13.0 9.45 0.73 1.32 5.95 11.82
3.86 4.6 1.19 0 1.01 2.06
11.7 9.97 0.85 1.19 3.33 9.45
1.51 1.33 0.88 0 0 1.04
11.93 9.12 0.76 1.26 5.7 9.86
3.58 4.42 1.24 0 0.77 1.96
13.33 9.13 0.69 1.18 7.57 11.19
3.64 5.48 10
18.06 29.93 48
5.21 13.95 18.56
15.25 30.38 49.86
2.04 4.15 4.95
15.35 29.76 45.79
4.17 12.36 20
17.75 29.99 39.05
The percentage difference was calculated as the interocular difference divided by the higher value. Optometry and Vision Science, Vol. 91, No. 4, April 2014
Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
Pattern ERG and VEP Interocular DifferencesVFejes et al.
475
TABLE 4.
Comparison of the confidence intervals of the means PERG peak time Right eye Left eye Longer peak time Shorter peak time Absolute difference
PVEP peak time
P50
N95
P100
N135
0.49 0.43 0.44 0.49 0.25
1.22 1.29 1.08 1.22 1.02
0.96 1.03 1.00 0.96 0.32
2.59 2.54 2.49 2.50 1.52
Right eye Left eye Higher amplitude Lower amplitude Absolute difference
PERG amplitude
PVEP amplitude
P50
N95
P100
N135
0.48 0.46 0.48 0.43 0.22
0.68 0.58 0.65 0.64 0.34
1.26 1.14 1.25 0.12 0.35
1.31 1.2 1.32 1.14 0.41
The variability of the side difference is less than the variability of the monocular responses in every case. Consideration of the side difference might improve the electrophysiological diagnosis.
eyes.15,16 We found no previously published studies involving light stimulation. A recent article on hemispheric asymmetry from the aspect of lateralization of the visual evoked response revealed a general dominance of the right occipital lobe in the visual process. In addition, functional transcranial Doppler demonstrated a higher blood flow velocity in the right posterior cerebral arteries in response to white light stimuli.17 The occipital blood flow (visual evoked flow responses) was found to correlate with the VEP N145 amplitude of the PVEP on hemifield visual stimulation and showed a side difference.18 In this study, there was a tendency to an increase in the N145 amplitude on the dominant side in young subjects. Other groups have shown that pattern stimulation can cause amplitude and latency disparities of VEP between the dominant and nondominant eyes, providing electrophysiological evidence of lateralization in the nervous system at a cortical level.19 The PERG side difference was independent of the eye dominance.20 Our study was not aimed at finding dependences on eye dominance. An interocular difference of the full-field ERG was described earlier.21 In 95% of that cohort, the interocular difference in the five standard ISCEV stimuli was in the range 27 to 36%, which is similar to the interocular difference of the PERG and PVEP parameters in our study (the amplitude difference was approximately 30%). We have previously reported an interocular difference of multifocal ERG of 21.55% on binocular stimulation and of 18.69% on monocular stimulation.22 Our present study revealed interocular side differences in both the PERG and PVEP parameters. If retinal anatomical differences were responsible for the lateralization, for example, differences in retinal ganglion cell density and the corresponding area of the visual cortex, the PERG and PVEP parameters would correlate, or the side correspondence would be higher. These two examinations test the consecutive elements of the visual pathway. If the PERG of one eye is influenced by a pathological or anatomical cause, the subsequent PVEP on stimulation of the same eye would be influenced in a similar way. The side differences we observed are therefore presumed to be independent of the electrophysiological method used and to be attributable to normal variability. It is possible that artifacts, such as biological or technical noise, may contribute to side differences. Although it was beyond the scope of this report, biological noise could be examined by the repeated testing of subjects on separate visits. Technical noise could be caused by differences in electrode characteristics or amplifier characteristics. This possibility could be assessed by
reversing the electrodes and recording channels between the eyes on retesting within a session. We used the same electrodes as in the daily routine, in which such technical noise is not observed (unpublished data). On the other hand, for PVEPs, the electrodes were placed in the midline, and technical noise was therefore unlikely to cause any side difference. On determination of the normative values, an interocular difference should be considered regardless of its cause. If the differences previously described are neglected, misinterpretation of the results might occur in the event of the existence of some monocular pathology.
ACKNOWLEDGMENTS This study was supported by grant K83810 OTKA/Hungary. We thank Dr. Goran Petrovski and David Durham for proofreading this manuscript. We are also grateful to Ms. Kati Majer for her kind technical help. Received June 8, 2013; accepted December 12, 2013.
REFERENCES 1. Holder GE. Pattern electroretinography (PERG) and an integrated approach to visual pathway diagnosis. Prog Retin Eye Res 2001;20: 531Y61. 2. Holder GE, Brigell MG, Hawlina M, Meigen T, Vaegan, Bach M. ISCEV standard for clinical pattern electroretinographyV2007 update. Doc Ophthalmol 2007;114:111Y6. 3. Odom JV, Bach M, Barber C, Brigell M, Marmor MF, Tormene AP, Holder GE, Vaegan. Visual evoked potentials standard (2004). Doc Ophthalmol 2004;108:115Y23. 4. Froehlich J, Kaufman DI. Improving the reliability of pattern electroretinogram recording. Electroencephalogr Clin Neurophysiol 1992;84:394Y9. 5. Jacobi PC, Walter P, Brunner R, Krieglstein GK. Reproducibility and intraindividual variability of the pattern electroretinogram. Ger J Ophthalmol 1994;3:216Y9. 6. Shors TJ, Ary JP, Eriksen KJ, Wright KW. P100 amplitude variability of the pattern visual evoked potential. Electroencephalogr Clin Neurophysiol 1986;65:316Y9. 7. Abe Y, Kuroiwa Y. Amplitude asymmetry of hemifield pattern reversal VEPs in healthy subjects. Electroencephalogr Clin Neurophysiol 1990;77:81Y5. 8. Mellow TB, Liasis A, Lyons R, Thompson D. When do asymmetrical full-field pattern reversal visual evoked potentials indicate visual pathway dysfunction in children? Doc Ophthalmol 2011;122:9Y18.
Optometry and Vision Science, Vol. 91, No. 4, April 2014
Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
476 Pattern ERG and VEP Interocular DifferencesVFejes et al. 9. Nightingale S, Mitchell KW, Howe JW. Visual evoked cortical potentials and pattern electroretinograms in Parkinson’s disease and control subjects. J Neurol Neurosurg Psychiatry 1986;49:1280Y7. 10. Porciatti V, Ventura LM. Normative data for a user-friendly paradigm for pattern electroretinogram recording. Ophthalmology 2004;111:161Y8. 11. Vaegan, Anderton PJ, Millar TJ. Multifocal, pattern and full field electroretinograms in cats with unilateral optic nerve section. Doc Ophthalmol 2000;100:207Y29. 12. Curcio CA, Sloan KR, Kalina RE, Hendrickson AE. Human photoreceptor topography. J Comp Neurol 1990;292:497Y523. 13. El-Ashry M, Hegde V, James P, Pagliarini S. Analysis of macular thickness in British population using optical coherence tomography (OCT): an emphasis on interocular symmetry. Curr Eye Res 2008;33:693Y9. 14. Budenz DL. Symmetry between the right and left eyes of the normal retinal nerve fiber layer measured with optical coherence tomography (an AOS thesis). Trans Am Ophthalmol Soc 2008;106:252Y75. 15. Kimura I, Shinoda K, Tanino T, Ohtake Y, Mashima Y, Oguchi Y. Scanning laser Doppler flowmeter study of retinal blood flow in macular area of healthy volunteers. Br J Ophthalmol 2003;87: 1469Y73. 16. Rawji MH, Flanagan JG. Intraocular and interocular symmetry in normal retinal capillary perfusion. J Glaucoma 2001;10:4Y12. 17. Roje-Bedekovi( M, Lovrencˇi(-Huzjan A, Bosnar-Pureti( M, Seri( V, Demarin V. Hemispheric asymmetry of visual cortical response by means of functional transcranial Doppler. Stroke Res Treat 2012;2012:615406.
18. Topcuoglu MA, Aydin H, Saka E. Occipital cortex activation studied with simultaneous recordings of functional transcranial Doppler ultrasound (fTCD) and visual evoked potential (VEP) in cognitively normal human subjects: effect of healthy aging. Neurosci Lett 2009; 452:17Y22. 19. Seyal M, Sato S, White BG, Porter RJ. Visual evoked potentials and eye dominance. Electroencephalogr Clin Neurophysiol 1981; 52:424Y8. 20. Kamis U, Gunduz K, Okudan N, Gokbel H, Bodur S, Tan U. Relationship between eye dominance and pattern electroretinograms in normal human subjects. Int J Neurosci 2005;115:185Y92. 21. Rotenstreich Y, Fishman GA, Anderson RJ, Birch DG. Interocular amplitude differences of the full field electroretinogram in normal subjects. Br J Ophthalmol 2003;87:1268Y71. 22. Palffy A, Janaky M, Fejes I, Horvath G, Benedek G. Interocular amplitude differences of multifocal electroretinograms obtained under monocular and binocular stimulation conditions. Acta Physiol Hung 2010;97:326Y31.
Imre Fejes Department of Ophthalmology Albert Szent-Gyo¨rgyi Clinical Center University of Szeged H-6720, Szeged Kora´nyi Fasor 10-11 Hungary e-mail: [email protected]
Optometry and Vision Science, Vol. 91, No. 4, April 2014
Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
ORIGINAL ARTICLE
Interocular Amplitude and Latency Differences of Pattern ERG and Pattern VEP Parameters Imre Fejes*, Pe´ter Bala´zs Kocsis†, Gyo¨rgy Benedek‡, and Ma´rta Jana´ky*
ABSTRACT Purpose. To determine the normal interocular differences in amplitudes and peak times of the pattern electroretinograms (PERGs) and pattern visual evoked potentials (PVEPs) and to investigate whether the PERG and PVEP parameters correspond in lateral dominance or whether the eye-side distributions of the functional parameters are similar. Methods. The PERGs and PVEPs were recorded in healthy subjects (N = 77) according to the standards of the International Society for Clinical Electrophysiology of Vision, with the modification of the check size of the PERG to 0.5 degrees. This allows stimulation of the macular ganglion cells and their corresponding visual pathways in healthy subjects. Results. Comparison of the averaged higher and lower response amplitudes and the shorter and longer response peak times showed significant differences (p G 0.001) in both the PERG and the PVEP parameters (median [5 to 95%]): the P50 (1.92% [0 to 5.48%]) and N95 (2.06% [0 to 13.95%]) peak times and the P50 (11.82% [1.32 to 29.93%) and N95 (9.45% [1.17 to 30.38%]) amplitudes of the PERGs and the P100 (1.04% [0 to 4.15%]) and N135 (1.96% [0 to 12.36%]) peak times and the P100 (9.86% [1.26 to 29.76%]) and N135 (11.19% [1.18 to 29.99%]) amplitudes of the PVEPs. No significant correlation was found concerning the eye dominance of the PERG and PVEP parameters. Conclusions. Our results reveal a significant interocular difference on PERG and PVEP recording, but this could not be ascribed to the anatomy of the retina and related visual pathways. If the difference between the eyes is not taken into account, misinterpretation may occur in a pathological process. (Optom Vis Sci 2014;91:472Y476) Key Words: pattern electroretinography, visual evoked potential, interocular difference
T
he objective assessment of the macular function and subsequent visual pathways can be carried out by using pattern electroretinography (PERG) and pattern visual evoked potentials (PVEPs).1 Parameters measured by PERG and PVEPs are compared with normative data determined by each laboratory for their own individual population according to the standards of the International Society for Clinical Electrophysiology of Vision (ISCEV).2,3 Normal responses are reproducible, and their coefficients of variability have been determined.4Y6 Some data have been reported on histological and functional interocular differences,7Y11 but PERG and PVEP results on the same subjects have not been reported to date, although testing of the whole visual pathway from the retina to the visual cortex may be important in evaluating monocular pathologies. Both PERG *MD, PhD † MD ‡ MD, DSc Department of Ophthalmology, Albert Szent-Gyo¨rgyi Clinical Center, Faculty of Medicine, University of Szeged, Szeged, Hungary (IF, PBK, MJ); and Department of Physiology, Faculty of Medicine, University of Szeged, Szeged, Hungary (GB).
and PVEPs are applied to test central vision: PERG is recorded to examine the function of the macular area, whereas PVEPs reflect the function of the consecutive retinal ganglion cells, the optic nerve, and the visual pathway up to the visual cortex. We set out to determine whether interocular differences can serve as an important parameter for evaluation of the asymmetric macular and optic nerve functions, because their variability may also be of value in pathological follow-ups. Furthermore, the correspondence of the amplitude values of the two tests within each eye might be important. A strong correlation would imply an anatomical or physiological reason for the individual lateralization at the level of the retina, as the responses of the consequent structures of the visual pathway depend on the function of the structures situated before them. A difference in the retinal response between eyes would affect the response of the visual pathway and the visual cortex. To the best of our knowledge, no previous study has compared the lateralization (correspondence within but not between eyes) of PERG and PVEP responses and, therefore, an additional aim of this study was to determine its possible existence.
Optometry and Vision Science, Vol. 91, No. 4, April 2014
Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
Pattern ERG and VEP Interocular DifferencesVFejes et al.
METHODS Participants A total of 77 subjects free of any ophthalmologic pathology (men, n =16; women, n = 61; mean age, 35.6 T 12.9 years) were tested. The subjects gave their written consent for the anonymous analysis of their test results in harmony with the institutional ethical rules. On ophthalmologic examination, no alteration of the refractive media or fundus was detected, and the best corrected visual acuity was 20/20. Subjects were selected from a group of normal control patients free of any systemic disease (n = 32) and from among patients referred for PVEP examination because of a suspicion of multiple sclerosis, which was excluded by subsequent cerebrospinal fluid and magnetic resonance imaging diagnostics (n = 45).
Electrophysiological Examinations Electrophysiological examinations were performed with the RetiPort Science 4.9.8.9. program (Roland Consult Stasche & Finger Gmbh, Brandenburg an der Havel, Germany) according to the ISCEV standards, with the modification of the standard 0.8-degree check pattern size in the case of PERG. This difference from the standard ISCEV protocol was applied to stimulate the same retinal ganglion cells as stimulated by the PVEPs. Briefly, PERG was recorded with the correction of refractive errors to the viewing distance of the display by binocular stimulation under ambient light conditions (the room illuminance was 10 to 30 lux) with nondilated pupils. The active electrode (a DTL electrode) was placed in the lower conjunctival fold, the reference electrode (a gold cup skin electrode) was attached to the skin near the ipsilateral outer canthus, and the ground electrode (a gold cup skin electrode) was placed at the middle of the forehead (Fpz point).2 For stimulation, a black-and-white checkerboard pattern reversal (1.8 Hz) was used with a check size of 0.5 degrees. Contrast was determined at a level of 97%. Active and bandpass voltages were set at T100 KV and 5 to 50 Hz, respectively. On evaluation, 200 responses were averaged; peak time and P50 and N95 peakto-peak amplitudes were analyzed (i.e., the P50 amplitude is the peak of N35 to the peak of P50, etc.). The PVEPs were also recorded with nondilated pupils by monocular stimulation under ambient light conditions. The right eye was always tested first to avoid any confusion caused by compliance. According to the ISCEV standards, the active electrode was placed in the midlineV2.5 cm above the external
473
occipital protuberance (Oz), the reference electrode was in the Fz, and the ground electrode was attached to the Cz localization.3 The stimulation size and pattern, contrast, reversal rate, and active voltage were the same as in the case of PERG. The bandpass was 1 to 100 Hz. The averages of 100 responses were analyzed. Peak times and P100 and N135 peak-to-peak amplitudes were assessed. In both PERG and PVEPs, the luminance of the screen was set to 59 cd/m2.
Statistical Analysis Statistical analysis was carried out with the SigmaStat 3.5 statistical software (Statcon Software Ltd., Witzenhausen, Germany). On determination of the side differences, the statistical grouping was as follows: comparison of the responses of the right eyes and the left eyes and comparison as groups of higher and lower amplitudes or longer and shorter peak times with the Wilcoxon signed rank test, as the normality of the samples failed. The correlation between the amplitudes and the peak times of PERG and PVEPs was calculated with the Spearman test. The absolute values of the side (eye) differences were determined, and the percentage of the difference between the right and the left eyes was calculated for each subject by using the absolute difference (higher minus lower amplitude) divided by the higher amplitude or, in the case of the peak times, the longer minus the shorter peak time divided by the longer peak time. Intersubject coefficients of variability (CVs) were calculated as SD divided by the mean. Results are given as median (5 to 95%) CV or percentage, as appropriate. The association of laterality between the amplitudes and the P50 and P100 peak times of PERG and the latency of PVEPs was calculated with the W2 test. Differences in the values of the right and left eyes were calculated and analyzed as nonparametric variables.
RESULTS No significant differences were found between the averaged amplitudes and peak times of the responses of the right and left eyes either in PERG or in PVEP. Side differences in the functions of the two eyes of the individual subjects disappeared on averaging, as some of them exhibited higher amplitude in the right and some in the left eye. In contrast, on comparison of the higher and lower response amplitudes for both the PERG and the PVEP parameters with the Wilcoxon signed rank test, side differences were significant (p G 0.001). The P50 and N95 peak times and the P50 and N95 amplitudes of the PERG are shown in Table 1. The
TABLE 1.
Medians (5Y95%) (intersubject CVs) of the P50 and N95 peak times, the P50 and N95 amplitudes of the PERG for the right and left eyes, the higher and lower values, and the absolute side difference
PERG right eye PERG left eye Absolute side difference of PERG Higher PERG parameter Lower PERG parameter
P50 peak time, ms
P50 amplitude, KV
N95 peak time, ms
N95 amplitude, KV
52 (49Y56) (0.04) 52 (50Y55.2) (0.04) 1 (0Y3) (1.07) 52 (50Y56)* (0.04) 52 (49Y56)* (0.04)
8.01 (4.8Y11.34) (0.27) 7.51 (4.98Y10.84) (0.26) 0.9 (0.1Y2.93) (0.85) 8.49 (5.3Y11.44)* (0.25) 7.56 (4.7Y10.32)* (0.26)
95 (83.8Y100) (0.06) 94 (83Y101.2) (0.06) 2 (0Y13.2) (1.2) 96 (86.8Y102.2)* (0.05) 95 (83.8Y100)* (0.06)
10.9 (7.03Y15.38) (0.27) 10.5 (7.21Y13.92) (0.23) 1.03 (0.12Y4.18) (1.04) 11.4 (7.49Y15.54)* (0.25) 9.21 (5.97Y13.26)* (0.3)
*Significant differences were found between the higher and lower values with the Wilcoxon signed rank test (p G 0.001). Optometry and Vision Science, Vol. 91, No. 4, April 2014
Copyright © American Academy of Optometry. Unauthorized reproduction of this article is prohibited.
474 Pattern ERG and VEP Interocular DifferencesVFejes et al. TABLE 2.
Medians (5Y95%) (intersubject CVs) of the P100 and N135 peak times, the P100 and N135 amplitudes of the 0.5-degree PVEP for the right and left eyes, the higher and lower values, and the absolute side difference
VEP 0.5 degrees right eye VEP 0.5 degrees left eye Absolute side difference of PVEP Higher PVEP parameter Lower PVEP parameter
P100 peak time, ms
P100 amplitude, KV
N135 peak time, ms
102 (93Y107) (0.04) 103 (93.8Y108.2) (0.04) 1 (0Y4.2) (0.89)
11.4 (6.18Y23.32) (0.44) 11.8 (6.45Y21.26) (0.4) 1.2 (0.11Y4.8) (0.95)
143 (121.8Y155.8) (0.08) 142 (124.6Y159.2) (0.08) 3 (0Y18.2) (1.28)
N135 amplitude, KV 12.6 (8Y24.88) (0.41) 13.3 (6.65Y24.3) (0.38) 1.6 (0.1Y5.36) (0.89)
103 (93.8Y108.2)* (0.04) 12.1 (6.61Y23.32)* (0.41) 146 (126.6Y160.2)* (0.08) 13.5 (8.06Y25.36)* (0.39) 102 (93Y106.2)* (0.04) 10.3 (3.12Y20.24)* (0.42) 139 (120Y151.4)* (0.08) 11.5 (6.65Y22.16)* (0.39)
*Significant differences were found between the higher and lower values with the Wilcoxon signed rank test (p G 0.001).
P100 and N135 latencies and P100 and N135 amplitudes of the PVEPs are presented in Table 2. The intersubject CVs of the peak times and amplitudes did not differ when the parameters were grouped by side or by higher and lower values for both the PERG and the PVEPs (Tables 1, 2). Mean (TSD); CV; 5, 25, 50 (median); 75 and 95 percentiles; and maximum values of percentage differences are shown in Table 3. For the PVEP P100 and PERG P50 peak times, the maximum percentage interocular differences were less than 7%. The percentage side differences of the PERG P50 and N95 and the PVEP P100 and N135 amplitudes were as high as 50%, but in more than 95% of the cases (regarded as a cutoff point), the interocular amplitude differences were less than 30.5%. The latter can be used as the threshold of the normal interocular difference in clinical practice. The usefulness of interocular differences is supported by its lower variability than that of the monocular responses (Table 4). The lateral correspondence of the longer and shorter peak times of P50 and P100 with the W2 test was 0.015 (p = 0.9), and the power of the test was 0.049. The differences in the PERG and PVEP amplitudes of right and left eyes were not related. For the PERG P50 and PVEP P100 amplitudes, the W2 value was 0.008 (p = 0.93), with the power of the test 0.048; whereas for the PERG P50 and PVEP N135 amplitudes, the W2 value was 0.236 (p = 0.63), with the power of the test 0.073. For the PERG N95 and PVEP P100 amplitudes, the W2 value was 0.686 (p = 0.41), with the power of the test 0.122; and for the PERG N95
and PVEP P100 amplitudes, the W2 value was less than 0.001 (p = 0.98), with the power of the test 0.047.
DISCUSSION Determination of the interocular differences in the PERG and PVEP parameters in normal subjects may be useful in the evaluation of monocular macular pathologies or asymmetric macular ganglion cell or optic nerve diseases. Clinically, PERG can be used in a patient with an abnormal VEP to establish whether a retinal (macular) disorder is present and, therefore, to differentiate between a macular and an optic nerve dysfunction as a cause of the VEP abnormality. It can also directly demonstrate retinal ganglion cell dysfunction.2 In the event of a high interocular difference, the side difference may be interpreted as abnormal. Previous histological and imaging studies revealed an interocular difference as high as 8% in the foveolar cone density.12 Asymmetry in macular thickness was detected by optical coherence tomography as 6.4 T 14.7 Km (average foveal thickness, 207 T 24 Km vs. 200 T 23 Km).13 With regard to the normal retinal nerve fiber layer thickness measured by optical coherence tomography, the side difference was approximately 9 to 12 Km, depending on the scanning algorithm applied.14 These data may explain the visual acuity differences determined by psychophysical methods and the PERG and PVEP amplitude differences. The retinal blood flow of the macula has been shown to display no interocular difference in the absence of light stimulation of the
TABLE 3.
Interocular percentage (%) side differences of the PERG P50 peak time and P50 and N95 amplitudes and the PVEP P100 and N135 peak times and P100 and N135 amplitudes
Mean SD CV 5% Percentile 25% Percentile 50% percentile (median) 75% Percentile 95% Percentile Maximum
PERG P50 peak time
PERG P50 amplitude
PERG N95 peak time
PERG N95 amplitude
PVEP P100 peak time
PVEP P100 amplitude
PVEP N135 peak time
PVEP N135 amplitude
1.92 2.05 1.07 0 0 1.92
13.0 9.45 0.73 1.32 5.95 11.82
3.86 4.6 1.19 0 1.01 2.06
11.7 9.97 0.85 1.19 3.33 9.45
1.51 1.33 0.88 0 0 1.04
11.93 9.12 0.76 1.26 5.7 9.86
3.58 4.42 1.24 0 0.77 1.96
13.33 9.13 0.69 1.18 7.57 11.19
3.64 5.48 10
18.06 29.93 48
5.21 13.95 18.56
15.25 30.38 49.86
2.04 4.15 4.95
15.35 29.76 45.79
4.17 12.36 20
17.75 29.99 39.05
The percentage difference was calculated as the interocular difference divided by the higher value. Optometry and Vision Science, Vol. 91, No. 4, April 2014
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Pattern ERG and VEP Interocular DifferencesVFejes et al.
475
TABLE 4.
Comparison of the confidence intervals of the means PERG peak time Right eye Left eye Longer peak time Shorter peak time Absolute difference
PVEP peak time
P50
N95
P100
N135
0.49 0.43 0.44 0.49 0.25
1.22 1.29 1.08 1.22 1.02
0.96 1.03 1.00 0.96 0.32
2.59 2.54 2.49 2.50 1.52
Right eye Left eye Higher amplitude Lower amplitude Absolute difference
PERG amplitude
PVEP amplitude
P50
N95
P100
N135
0.48 0.46 0.48 0.43 0.22
0.68 0.58 0.65 0.64 0.34
1.26 1.14 1.25 0.12 0.35
1.31 1.2 1.32 1.14 0.41
The variability of the side difference is less than the variability of the monocular responses in every case. Consideration of the side difference might improve the electrophysiological diagnosis.
eyes.15,16 We found no previously published studies involving light stimulation. A recent article on hemispheric asymmetry from the aspect of lateralization of the visual evoked response revealed a general dominance of the right occipital lobe in the visual process. In addition, functional transcranial Doppler demonstrated a higher blood flow velocity in the right posterior cerebral arteries in response to white light stimuli.17 The occipital blood flow (visual evoked flow responses) was found to correlate with the VEP N145 amplitude of the PVEP on hemifield visual stimulation and showed a side difference.18 In this study, there was a tendency to an increase in the N145 amplitude on the dominant side in young subjects. Other groups have shown that pattern stimulation can cause amplitude and latency disparities of VEP between the dominant and nondominant eyes, providing electrophysiological evidence of lateralization in the nervous system at a cortical level.19 The PERG side difference was independent of the eye dominance.20 Our study was not aimed at finding dependences on eye dominance. An interocular difference of the full-field ERG was described earlier.21 In 95% of that cohort, the interocular difference in the five standard ISCEV stimuli was in the range 27 to 36%, which is similar to the interocular difference of the PERG and PVEP parameters in our study (the amplitude difference was approximately 30%). We have previously reported an interocular difference of multifocal ERG of 21.55% on binocular stimulation and of 18.69% on monocular stimulation.22 Our present study revealed interocular side differences in both the PERG and PVEP parameters. If retinal anatomical differences were responsible for the lateralization, for example, differences in retinal ganglion cell density and the corresponding area of the visual cortex, the PERG and PVEP parameters would correlate, or the side correspondence would be higher. These two examinations test the consecutive elements of the visual pathway. If the PERG of one eye is influenced by a pathological or anatomical cause, the subsequent PVEP on stimulation of the same eye would be influenced in a similar way. The side differences we observed are therefore presumed to be independent of the electrophysiological method used and to be attributable to normal variability. It is possible that artifacts, such as biological or technical noise, may contribute to side differences. Although it was beyond the scope of this report, biological noise could be examined by the repeated testing of subjects on separate visits. Technical noise could be caused by differences in electrode characteristics or amplifier characteristics. This possibility could be assessed by
reversing the electrodes and recording channels between the eyes on retesting within a session. We used the same electrodes as in the daily routine, in which such technical noise is not observed (unpublished data). On the other hand, for PVEPs, the electrodes were placed in the midline, and technical noise was therefore unlikely to cause any side difference. On determination of the normative values, an interocular difference should be considered regardless of its cause. If the differences previously described are neglected, misinterpretation of the results might occur in the event of the existence of some monocular pathology.
ACKNOWLEDGMENTS This study was supported by grant K83810 OTKA/Hungary. We thank Dr. Goran Petrovski and David Durham for proofreading this manuscript. We are also grateful to Ms. Kati Majer for her kind technical help. Received June 8, 2013; accepted December 12, 2013.
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Imre Fejes Department of Ophthalmology Albert Szent-Gyo¨rgyi Clinical Center University of Szeged H-6720, Szeged Kora´nyi Fasor 10-11 Hungary e-mail: [email protected]
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