Os antimaláricos, cloroquina e hidroxicloroquina, têm sido usados há décadas com bons resultados terapêuticos para o tratamento do lupus eritematoso e são considerados medicações seguras, muito embora, haja preocupação em relação à retinotoxicidade, notadamente com a cloroquina. O objetivo deste trabalho foi avaliar a ocorrência dos efeitos adversos desencadeados pelo tratamento com 250mg/d de difosfato de cloroquina em doentes com lupus eritematoso, dando ênfase à retinotoxicidade. Foram estudados 350 doentes e reavaliados seus respectivos prontuários, que datavam de 1980 a 2003. Os doentes foram acompanhados no ambulatório de colagenoses da Divisão de Dermatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. A ocorrência dos efeitos adversos foi de 35,7%, sendo que 17,4% decorreram de alterações oculares. Em 12% dos doentes ocorreu pigmentação retiniana sugestiva de retinopatia antimalárica, em 3,1% depósitos corneanos e, em 2,3%, sintomas visuais agudos. Em 10% dos doentes houve alterações gastrointestinais: epigastralgia (6%), náuseas e vômitos (3,7%) e diarréia (0,3%). Alterações dermatológicas ocorreram em 3,4% dos doentes: rash cutâneo no início do tratamento (2%), exacerbação de quadro de psoríase pré-existente (0,3%) e pigmentação cutânea (1,1%). Ocorreram ainda cefaléia (2,9%), alterações neuromusculares (1,7%) com quadro gripal símile no início do tratamento (1,1%), neuropatia sensitiva (0,3%) e miopatia compatível com miastenia (0,3%) e, sintomas neuropsiquiátricos (0,3%). A droga foi suspensa devido aos efeitos adversos em 22,9% dos doentes, principalmente, em decorrência de alterações oculares, gastrointestinais e dermatológicas. A reavaliação oftalmológica de 12% dos doentes com pigmentação retiniana, confirmou a retinopatia antimalárica em apenas 2,6%, o que demonstrou uma tendência à valorização de alterações retinianas inespecíficas, discretas e unilaterais, com indicação desnecessária da suspensão da droga em 9,4% dos doentes. Não ocorreram casos de retinopatia antimalárica avançada com lesão do tipo bull-eye. Não houve associação estatisticamente significativa entre a ocorrência de efeitos adversos e alterações retinianas com dose diária de difosfato de cloroquina por quilo de peso e com o tipo clínico do lupus eritematoso. As alterações retinianas foram estatisticamente significativas nos doentes acima de cinqüenta anos quando comparado ao grupo abaixo dos cinqüenta anos, possivelmente pela dificuldade em diferenciar as alterações iniciais da retinopatia antimlárica daquelas decorrentes da degeneração macular senil. O controle oftalmológico foi realizado em intervalo médio de 10,5 meses, demonstrando que o controle anual foi eficaz para o acompanhamento dos doentes. Nove doentes foram expostas durante o primeiro trimestre gestacional, não ocorrendo casos de mal formação fetal / Antimalarial agents, chloroquine and hydroxichloroquine, have been used for decades leading to good therapeutic outcomes at treatment approach for lupus erythematosus and are considered safe medication; however, the main concern is retina toxicity, especially with chloroquine. The purpose of the present study was to conduct analysis of the occurrence of adverse effects, triggered by use of 250 mg/d of chloroquine diphosphate at treatment for lupus erythematosus, especially retina toxicity. We analyzed 350 patients and reviewed their medical charts, from 1980 to 2003. The patients were followed up by the outpatient unit of collagenosis, Division of Dermatology, Hospital das Clinicas, Medical School, University of São Paulo. The occurrence of adverse effects was 35.7%, and eye affections were detected in 17.4% of patients. Impairment of retina pigmentation suggestive of antimalarial retinopathy occurred in 12%, cornea deposits in 3,1%, and acute visual symptoms in 2.3%. Gastrointestinal affections were detected in 10% of patients: epigastralgia (6%), nausea and vomiting (3.7%) and diarrhea (0.3%). Dermatological affections occurred in 3.4% of patients: skin rash in the beginning of treatment (2%), exacerbation of preexisting psoriasis (0.3%) and skin pigmentation (1.1%). We also detected headache (2.9%), neuromuscular disorders (1.7%) with flu-like episode at the beginning of treatment (1,1%), sensitive neuropathy (0,3%) and myopathy compatible with myasthenia (0.3%) and neuropsychiatric symptoms (0.3%). Discontinuation of drugs owing to side effects occurred in 22.9% of the patients, being that the main affections were eye, gastrointestinal and dermatological occurrences. Ophthalmologic reevaluation of retina pigmentation affections occurred in 12% of the patients, but we confirmed antimalarial retinopathy only in 2.6%, detecting a tendency to value nonspecific, discreet and unilateral affections, which generated unnecessary recommendations for discontinuation of drug in 9.4% of the patients. There were no cases of advanced retinopathy with bull-eye type lesion. There was no statistically significant association between occurrence of adverse effects and retina affections with daily dose per kg of chloroquine diphosphate and the differents types of lupus erythematosus. In patients over the age of 50, there was statistically significant increase in number of retina affections when compared to the group aged below 50 years, possibly owing to difficulty to differentiate between initial affections in antimalarial retinopathy from those resultant from senile macular degeneration. Ophthalmologic control was conducted on average after 10.5 months, showing that annual follow-up was effective to keep track of patients. Nine of the patients were exposed during the first gestational trimester and there were no cases of fetal malformations

O disco intervertebral é uma estrutura cuja função é receber, amortecer e distribuir o impacto das cargas impostas sobre a coluna vertebral. O aumento da idade e a postura adotada pelo indivíduo podem levar à degeneração do disco intervertebral. Atualmente, a Ressonância Magnética (RM) é considerada o melhor e mais sensível método não invasivo de avaliação por imagem do disco intervertebral. Neste trabalho foram desenvolvidos métodos quantitativos computadorizados para auxílio ao diagnóstico da degeneração do disco intervertebral em imagens de ressonância magnética ponderadas em T2 da coluna lombar, de acordo com a escala de Pfirrmann, uma escala semi-quantitativa, com cinco graus de degeneração. Os algoritmos computacionais foram testados em um conjunto de dados que consiste de imagens de 300 discos, obtidos de 102 indivíduos, com diferentes graus de degeneração. Máscaras binárias de discos segmentados manualmente foram utilizadas para calcular seus centroides, visando criar um ponto de referência para possibilitar a extração de atributos. Uma análise de textura foi realizada utilizando a abordagem proposta por Haralick. Para caracterização de forma, também foram calculados os momentos invariantes definidos por Hu e os momentos centrais para cada disco. A classificação do grau de degeneração foi realizada utilizando uma rede neural artificial e o conjunto de atributos extraídos de cada disco. Uma taxa média de acerto na classificação de 87%, com erro padrão de 6,59% e uma área média sob a curva ROC (Receiver Operating Characteristic) de 0,92 indicam o potencial de aplicação dos algoritmos desenvolvidos como ferramenta de apoio ao diagnóstico da degeneração do disco intervertebral. / The intervertebral disc is a structure whose function is to receive, absorb and transmit the impact loads imposed on the spine. Increasing age and the posture adopted by the individual can lead to degeneration of the intervertebral disc. Currently, Magnetic Resonance Imaging (MRI) is considered the best and most sensitive noninvasive method to imaging evaluation of the intervertebral disc. In this work were developed methods for quantitative computer-aided diagnosis of the intervertebral disc degeneration in MRI T2 weighted images of the lumbar column according to Pfirrmann scale, a semi-quantitative scale with five degrees of degeneration. The algorithms were tested on a dataset of 300 images obtained from 102 subjects with varying degrees of degeneration. Binary masks manually segmented of the discs were used to calculate their centroids, to create a reference point to enable extraction of attributes. A texture analysis was performed using the approach proposed by Haralick. For the shape characterization, invariant moments defined by Hu and central moments were also calculated for each disc. The rating of the degree of degeneration was performed using an artificial neural network and the set of extracted attributes of each disk. An average rate of correct classification of 87%, with standard error 6.59% and an average area under the ROC curve (Receiver Operating Characteristic) of 0.92 indicates the potential application of the algorithms developed as a diagnostic support tool to the degeneration of the intervertebral disc.

A tese propõem uma metodologia, em nível de pesquisa, por intermédio do desenvolvimento e da adaptação de ferramentas de apoio computadorizado, capaz de realizar a segmentação da imagem dos discos intervertebrais da região lombar da coluna vertebral humana, de maneira semiautomática reduzindo drasticamente o tempo gasto manualmente neste procedimento, sem perder sua acurácia e, ainda, garantindo maior reprodutibilidade em seus resultados. Foram utilizadas imagens sagitais de ressonância magnética ponderadas em T2 de 285 discos intervertebrais de 70 pacientes, classificados segundo o grau de severidade da degeneração discal definido pelo critério proposto por Pfirrmann. A classificação computacional dos discos foi realizada com base em atributos quantitativos extraídos dos histogramas de níveis de cinza e de informações de textura das imagens. O desempenho dos métodos computacionais de segmentação foi avaliado com base no Coeficiente de Jaccard, na distância de Hausdorff e no Erro Médio Quadrático. O desempenho dos métodos computacionais de classificação foi também avaliado com base em medidas similares à aplicação da sensibilidade, da especificidade e da área sob a curva ROC. A segmentação manual e a classificação por inspeção visual dos discos realizadas por três profissionais experientes foram utilizadas como padrão ouro para a comparação. Os principais resultados indicaram a médio de 63,22% para o Coeficiente de Jaccard, as médias de 0,044 das distâncias de Hausdoff e de 0,014 para o EMQ na comparação entre as imagens. Além disso, a segmentação semiautomatizada diferiu em uma taxa média de 30% em relação à segmentação manual e a classificação da degeneração discal, por redes neurais artificiais difere em menos de 2%, ao ser comparada ao procedimento de classificação manual realizado pelos especialistas. / The thesis proposes a methodology at the level of research through the development and adaptation of computerized support tools, able to perform the image segmentation of the intervertebral discs of the lumbar region of the human spine, semiautomatic way dramatically reducing time spent manually in this procedure, without losing its accuracy and also ensuring more reproducible in their results. Were used sagittal MRI T2- weighted of 285 intervertebral discs from 70 patients, classified according to the severity of disc degeneration defined by the criteria proposed by Pfirrmann. The computational classification of disks was based on quantitative attributes extracted from histograms of gray level images and the texture information. The performance of computational segmentation methods was evaluated based on Jaccard coefficient, Hausdorff distance and Mean Square Error. The performance of the computational classification methods was evaluated based on measures of sensitivity, specificity and the area under the ROC curve. The manual segmentation and visual inspection classification of the discs made by three experienced professionals were used as the gold standard for comparison. The main results showed an average Jaccard coefficient of 63.22%, the average Hausdoff of distances was 0.044 and 0.014 Mean Square Error average when comparing the images from both segmentation targets. Additionally, the targeting semiautomatic differed by an average of 30% compared with manual segmentation and classification of disc degeneration provided from an artificial neural networks differs by less than 2% when compared to manual sorting procedure performed by experts.

Diss. (sammanfattning) Umeå : Umeå universitet, 2009. / Härtill 4 uppsatser. Även tryckt utgåva.

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Objectif: Nous avons effectué une étude chez 135 patients ayant subis une chirurgie lombo-sacrée avec vissage pédiculaire sous navigation par tomographie axiale. Nous avons évalué la précision des vis pédiculaires et les résultats cliniques. Méthodes: Cette étude comporte 44 hommes et 91 femmes (âge moyen=61, intervalle 24-90 ans). Les diamètres, longueurs et trajectoires des 836 vis ont été planifiés en préopératoire avec un système de navigation (SNN, Surgical Navigation Network, Mississauga). Les patients ont subi une fusion lombaire (55), lombo-sacrée (73) et thoraco-lombo-sacrée (7). La perforation pédiculaire, la longueur des vis et les spondylolisthesis sont évalués par tomographies axiales postopératoires. Le niveau de douleur est mesuré par autoévaluations, échelles visuelles analogues et questionnaires (Oswestry et SF-36). La fusion osseuse a été évaluée par l’examen des radiographies postopératoires. Résultats: Une perforation des pédicules est présente pour 49/836 (5.9%) des vis (2.4% latéral, 1.7% inférieur, 1.1% supérieur, 0.7% médial). Les erreurs ont été mineures (0.1-2mm, 46/49) ou intermédiaires (2.1 - 4mm, 3/49 en latéral). Il y a aucune erreur majeure (≥ 4.1mm). Certaines vis ont été jugées trop longues (66/836, 8%). Le temps moyen pour insérer une vis en navigation a été de 19.1 minutes de l΄application au retrait du cadre de référence. Un an postopératoire on note une amélioration de la douleur des jambes et lombaire de 72% et 48% en moyenne respectivement. L’amélioration reste stable après 2 ans. La dégénérescence radiologique au dessus et sous la fusion a été retrouvée chez 44 patients (33%) and 3 patients respectivement (2%). Elle est survenue en moyenne 22.2 ± 2.6 mois après la chirurgie. Les fusions se terminant à L2 ont été associées à plus de dégénération (14/25, 56%). Conclusion: La navigation spinale basée sur des images tomographiques préopératoires est une technique sécuritaire et précise. Elle donne de bons résultats à court terme justifiant l’investissement de temps chirurgical. La dégénérescence segmentaire peut avoir un impact négatif sur les résultats radiologique et cliniques. / Objective: The authors studied 135 consecutive patients following a lumbo-sacral fixation using pedicle screws and CT-based navigation to evaluate pedicle screw accuracy and clinical outcomes. Methods: The series included 44 men and 91 women (mean age 61 years, range 24-90 years). All 836 screws were planned with pre-operative CT-Scans in a navigation system (SNN, Surgical Navigation Network, Mississauga, Ontario, Canada) for diameter, length and direction. Fixation included the lumbar spines only (55), the lumbo-sacral spine (73) or the thoraco-lumbo-sacral spine (7). Pedicle perforation, screw length and spondylolisthesis were assessed on post-operative CT-Scan. Pain was surveyed using self-rated scales, visual analogue scales, Oswestry and SF-36 questionnaires. Bony union was assessed on post-operative follow-up radiographs. Results: Pedicle perforation was found in 49/836 (5.9%) screws (2.4% laterally, 1.7% inferiorly, 1.1% superiorly, 0.7% medially). The errors were minor (0.1-2mm, 46/49) or intermediate (2.1 – 4 mm, 3/49). All intermediate errors were lateral. There were no major errors (≥ 4.1mm). Some screws were judged too long (66/836, 8%). The average time to insert one screw with navigation was 19.1 minutes from application to removal of the reference frame. The amount of improvement at one year post-operation for self-rated leg and back pain were 72% and 48% respectively. The improvement was stable over 2 years. Above-level and below-level radiological degenerations were found in 44 patients (33%) and 3 patients respectively (2%) and occurred on average 22.2 ± 2.6 months after the surgery. Fusions ending at L2 had the most degenerations (14/25, 56%). Conclusion: CT-based preoperative navigation for lumbo-sacral pedicle screw insertion is accurate and associated with a good short term outcome, making it worth the investment of the additional time required. Segmental degeneration may have a negative effect on radiological and clinical outcomes.

Vision impairment and blindness are in industrialized countries primarily caused by the degeneration of the retina, the light sensing tissue inside the eye. The degeneration, occurring in diseases like age-related macular degeneration (AMD) or retinitis pigmentosa (RP), can be caused by environmental factors as well as genetic defects and thus shows diverse pathologies. In all conditions, the light detecting photoreceptors (rods and/or cones) are dying caused by either direct photoreceptor damage or as a secondary effect following degeneration of supporting cells. Although promising treatment approaches are currently under investigation, up to date it is not possible to cure these diseases. Amongst these therapeutic strategies, pre-clinical studies evaluating the replacement of degenerated cells by transplantation of new photoreceptors demonstrated promising results. First studies conducted the specific enrichment and transplantation of primary photoreceptors derived from postnatal mice and their sufficient integration and differentiation into mature photoreceptors in wild-type as well as degenerated mouse retinae. Recent experiments additionally proved the recovery of some dim-light vision after transplantation in mice lacking night sight. The in vitro differentiation of whole eye cups containing photoreceptors, out of human or mouse ES or iPS cells, peaked in the transplantation of ES-derived photoreceptors into wild-type as well as degenerated mice and the integration and maturation of these cells. These observations are encouraging, but prior to a save implementation of this strategy into a clinical routine, several further hurdles need to be challenged. Collection of photoreceptors out of whole retinal tissues prior to transplantation was shown to be an important step to reach high integration rates. Additionally, transplantation of photoreceptors derived from stem cells comprises the risk of tumor formation after transplantation and thus also requires depletion of inadvertent cells. Therefore, we established the enrichment of photoreceptors using the cell surface marker dependent method magnetic-activated cell sorting (MACS). For identification of suitable target-specific surface markers, we characterized young transplantable mouse photoreceptors using microarray analysis and screened their transcriptome. Amongst others, ecto-5´nucleotidase (Nt5e, termed CD73) was identified being a rod photoreceptor specific cell surface protein. Thus, we enriched young photoreceptors with CD73-dependent MACS with sufficient purity and transplanted these cells into the subretinal space of wild-type mice. In contrast to unsorted retinal cells, enriched photoreceptors integrated in significantly higher number into the host retina, proving that MACS is a suitable alternative for specific photoreceptor enrichment. Testing other proteins, identified as photoreceptor specific, for MACS suitability and the translation of this approach to photoreceptors, derived from mouse as well as human iPS or ES cells, should be the focus of consecutive investigations. The integration of grafted cells into the retina is a complex process dependent on a variety of influencing factors. Transplantation experiments in aging wild-type mice and a rod-depleted mouse model, containing a retina composed of cone and cone-like photoreceptors, indicated that the activation of Müller glia cells facilitates integration of transplanted photoreceptors. Besides that, reduced outer limiting membrane (OLM) integrity, increased subretinal graft distribution or reduced retinal cell density are further suggested as potential cell engraftment enhancers. These factors might open up important possibilities of host retina manipulation to increase cell integration rates. Although retinal transplantation experiments were in addition to mice also performed using pigs or rats as hosts, the transplantation of enriched single photoreceptors, following the protocols successfully established in mice, has not been performed in other species. Nevertheless, transferring this technique is important and would allow better predictions for future application in human patients. Therefore, we transferred our protocol, using CD73 based MACS, to the rat and successfully enriched rat photoreceptors with sufficient purity. We subsequently transplanted these cells into the subretinal space of rats as well as mice and observed limited integration capacity of grafted cells. Only few transplanted rat photoreceptors were localized in the rat retina, lacking proper photoreceptor morphology. Especially regarding a perspective clinical application in humans, these data are remarkable. They imply the question, whether low integration in rat represents a general problem and might thus also be relevant for treatment in humans, or whether the rat retina forms just an exception. Thus, further detailed analysis of the cellular and molecular mechanisms underlying the integration process of transplanted photoreceptors represent an essential prerequisite for the development of a safe and efficient therapy, aiming to treat retinal degenerative diseases characterized by photoreceptor loss. / Degenerationserkrankungen der Netzhaut (Retina) sind in Industrieländern die Hauptursache für verminderte Sehfähigkeit und Blindheit. Sowohl Umweltfaktoren als auch vererbte Mutationen können Defekte wie altersbedingte Makuladegeneration (AMD) oder Retinitis pigmentosa (RP) auslösen und führen zu einem sehr variablen Krankheitsbild. Eine Gemeinsamkeit aller Formen ist das Absterben der lichtdetektierenden Fotorezeptoren (Stäbchen und/oder Zapfen). Dieses kann entweder durch direkte Schädigung, oder als Sekundäreffekt nach Degeneration der unterstützenden Zellen erfolgen. Obwohl im Moment vielversprechende Behandlungsansätze untersucht werden, ist es zurzeit nicht möglich, retinale Degenerationserkrankungen dieser Art zu heilen. Ein erfolgversprechender Ansatz könnte jedoch der Ersatz der degenerierten Zellen durch transplantierte Fotorezeptoren sein. Erste Studien demonstrierten die spezifische Anreicherung von primären Fotorezeptoren aus der Netzhaut neugeborener Mäuse und deren subretinale Transplantation in Wildtyp-Mäuse und Mausmodelle mit retinaler Degeneration. Die transplantierten Zellen integrierten in die Empfängernetzhaut und entwickelten sich in ausgereifte Fotorezeptoren und konnten unter anderem bei nachtblinden Mäusen die Sehfähigkeit bei Dunkelheit verbessern. Die Differenzierung von humanen oder murinen ES- und iPS-Zellen in vitro in vollständige Retinae und die Transplantation daraus gewonnener Fotorezeptoren in Mäuse, bilden vorläufig den Höhepunkt dieser Entwicklung. Obwohl die Fortschritte der jüngsten Vergangenheit beeindruckend sind, sollten vor der sicheren und effektiven Anwendung einer retinalen Zellersatztherapie als therapeutische Maßnahme beim Menschen noch einige wissenschaftliche Fragestellungen beantwortet werden. Studien zeigen, dass Zellpopulationen, die direkt aus der Spendernetzhaut entnommen und transplantiert wurden, auf Grund ihrer Heterogenität in geringeren Zahlen in die Empfängerretina einwandern als angereicherte Fotorezeptoren. Zusätzlich besteht bei unsortierten Zellen, die aus Stammzellpopulationen gewonnen wurden, das Risiko einer Tumorbildung. Daher haben wir die magnetisch-aktivierte Zellsortierung (MACS) zur Anreicherung junger Fotorezeptoren etabliert. Die dabei benötigten, für Fotorezeptoren spezifischen, Oberflächenproteine wurden mit Hilfe von Microarray-Analysen des Transkriptoms junger Stäbchen von Mäusen identifiziert. Dabei wurde unter anderem die 5\'-Nukleotidase (Nt5e, CD73) entdeckt, die uns die erfolgreiche Anreicherung junger Mausfotorezeptoren mit Hilfe von CD73-vermitteltem MACS erlaubte. Die Transplantation dieser angereicherten Zellpopulation in die Netzhaut von Empfängertieren resultierte in einer signifikant erhöhten Integrationsrate im Vergleich zu nicht-angereicherten retinalen Zellen. Die Überprüfung der Nutzbarkeit weiterer identifizierter Oberflächenproteine zur Zellanreicherung bzw. die Übertragung der etablierten Protokolle zur Zellsortierung und Transplantation auf Fotorezeptoren aus ES- und iPS-Zellkulturen, sollten im Fokus nachfolgender Experimente stehen. Die Integration transplantierter Zellen in die Empfängernetzhaut ist ein komplexer Prozess und von unterschiedlichen Einflussfaktoren abhängig. Durch Transplantationsexperimente in alternden Wildtyp-Mäusen und einem Mausmodell, dessen Fotorezeptorschicht keine Stäbchen und stattdessen nur Zapfen und zapfenähnlichen Fotorezeptoren aufweist, konnte gezeigt werden, dass vor allem die Aktivierung von Müllerzellen die Integrationsrate der Fotorezeptoren erhöht. Neben dieser sogenannten Gliose werden weitere Faktoren, wie die reduzierte Stabilität der äußeren Grenzmembran, die flächenmäßig größere Verteilung der transplantierten Zellen im subretinalen Raum oder die reduzierte Dichte der Zellen in der äußeren Körnerschicht, als potentielle integrationsfördernde Komponenten in Betracht gezogen. Diese bilden interessante Schwerpunkte für weitere Forschungen, um eine ausreichende Zellintegration durch Manipulation der Empfängernetzhaut, auch in der klinischen Anwendung, zu erreichen. Obwohl Transplantationsexperimente zusätzlich zur Maus auch in anderen Empfängerspezies, wie Ratten und Schweinen, durchgeführt wurden, liegen bis jetzt keine Studien vor, die die in der Maus erfolgreich etablierten Protokolle der Zellanreicherung und Transplantation von Fotorezeptor-Suspensionen in diesen Spezies reproduzierte. Der Transfer dieser Technik und eine Generalisierung der Anwendbarkeit eines Fotorezeptorersatzes durch Transplantation in verschiedenen Säugetierarten geben jedoch wichtige Hinweise für eine mögliche Translation dieser Technologie für klinische Anwendungen. Deshalb haben wir unser bereits an der Maus getestetes Protokoll auf die Ratte übertragen und erfolgreich Fotorezeptoren der Ratte mit Hilfe von CD73-vermitteltem MACS angereichert. Nach deren Transplantation in die Netzhaut von Ratten und Mäusen zeigten die Rattenfotorezeptoren aber eine stark verminderte Integrationsfähigkeit und das Fehlen einer reifen Fotorezeptormorphologie. Speziell in Hinsicht auf eine zukünftige klinische Anwendung sind diese Ergebnisse relevant, da sie die Frage aufwerfen, ob die mangelnde Integration in der Ratte ein generelles Problem darstellt und daher auch beim Menschen zu erwarten ist, oder ob sie nur eine Ausnahme im Rattenmodell bildet. Aus diesem Grund bildet die weitere Erforschung der zellulären und molekularen Mechanismen der Integration transplantierter Fotorezeptoren eine wichtige Grundlage für die Entwicklung einer sicheren und effizienten Therapie mit dem Ziel, degenerative Netzhauterkrankungen zu heilen.

Age-related maculopathy (ARM) is a central retinal disease with unclear pathogenesis. It is the major cause of permanent vision loss in adults over 50 years and is increasing in prevalence and incidence, faster than the aging population would suggest. Early in the disease process (early ARM) there is little or no vision loss and there are only slight retinal changes with abnormal deposits within Bruch's membrane. As the disease progresses (late ARM or age-related macular degeneration, AMD) vision loss may be quite severe due to atrophy (dry AMD) or the development of chorioretinal neovascularisation (CNV, wet AMD). It is hard to predict from conventional eye examinations and clinical vision tests which cases will progress to the severe, dry or wet forms of the disease. Moreover, most of the conventional clinical tests are based upon subjective vision measures. Objective tests which detect ARM earlier would be a useful aid to diagnosis and to monitoring progression. The multifocal electroretinogram (mfERG) is a relatively new clinical tool which enables the recording of electrical potentials from multiple, small areas of the central retina and thus assesses function from specific retinal locations. It is therefore useful in detecting focal retinal diseases such as hereditary or acquired maculopathies or in monitoring retinal laser or surgical treatment effects. There is cone and rod impairment in ARM and histopathological and psychophysical evidence for a preferential vulnerability of rods compared to cones. This research project investigated if an objective tool such as the mfERG could detect early ARM,its progression and the treatment effects of multiple photodynamic therapies (PDT) on retinal function in late ARM, prior to a battery of subjective vision measures. For comparison purposes a subjective assessment of central retinal function was performed using high and low contrast distance visual acuities (VA), near VA, low luminance VA (SKILL cards), contrast sensitivity (Pelli-Robson, P-R), saturated and desaturated Panel D-15 (sat Panel D-15, desat Panel D-15) and central visual fields (Humphrey 10-2, mean sensitivity, MS and mean defects, MD). As an objective assessment of central retinal function the cone- and rod-mediated multifocal electroretinograms were recorded. Subjective and objective tests of retinal function were compared in early ARM and an age-matched control group (chapter 3). Seventeen eyes of seventeen subjects with early ARM and twenty control subjects with normal vision were measured. For the cone-mediated mfERG responses conventional averaging methods were used and results were correlated with subjective vision tests. The conventional cone-mediated mfERG failed to distinguish between the early ARM and control subjects whereas subjective vision measures such as HC- and LC-VA, desat Panel D-15, MS, P-R were significantly reduced in the ARM group. However, there were significant correlations between the cone-mediated mfERG and the desat Panel D-15 results in the ARM group. This suggests that the mfERG measures similar retinal processes that detect colour vision deficiency under desaturated conditions. There was no significant correlation between cone-mediated mfERG measures and funduscopic changes. The conclusion from this study was that the subjective vision tests detected early ARM better than the objective cone-mediated mfERG. Thus the aim of detecting early ARM objectively was not met by the cone-mediated mfERG suggesting the need to develop other objective tests such as a rod-mediated mfERG. Whether the preferential rod vulnerability others have reported in early ARM could be detected by the rod-mediated mfERG was determined in the next study (chapter 4). A protocol for recording rod-mediated mfERG responses was developed by determining the optimal testing luminance to reduce the effect of stray light and elicit maximal rod-mediated responses. Sixteen of the seventeen ARM subjects and seventeen control subjects from the previous study were tested. For analysis, a customized computer template fitting method was developed in MATLAB (Mathworks, Natick, MA, USA). This method has been shown to be useful for low signal-to-noise ratio responses that characterize the rod-mediated mfERG. Significantly delayed rod-mediated mfERG responses were found whereas cone-mediated mfERG responses were within the normal range. This suggested that the effect of ARM on the rod system could be detected objectively with the rod-mediated mfERG before changes in the cone-mediated mfERG. Which of the tests best detected progression of vision loss was investigated in chapter 5. Visual function of 26 (13 ARM and 13 control subjects) of the original 37 subjects (17 ARM and 20 control subjects) had cone- and rod-mediated mfERG and the subjective vision measures repeated after one year. The main purpose was to determine which of the tests best detected progression of vision loss. The mfERG results were analysed by using both averaged and local responses and by using the computer template fitting procedure. On average no significant worsening of either objective or subjective function measures was evident after one year. These results reinforce the slow progression of the disease. With a longer follow-up period progression of ARM may translate into measurable changes in the mfERG and the other visual function tests. The effect of multiple photodynamic therapies (PDT) on cone- and rod-mediated function was assessed with the mfERG in the last study (chapter 6). The cumulative treatment effects of PDT in five subjects with late ARM were determined. Having demonstrated that the rod-mediated mfERG was applicable in early ARM, this study also aimed to investigate how useful it was in late ARM where there is substantially greater rod loss. Cone- and rod-mediated mfERGs, visual acuities, contrast sensitivities and central visual fields were investigated a week before treatment began and then one month after each PDT treatment. The subjects received three treatments each over an average period of five and a half months. In some subjects there were significant transient reductions in cone- and rod-mediated amplitudes possibly reflecting alterations in choroidal hypoperfusion dynamics one month after treatment. Further, b-wave component of the mfERG became increasingly misshapen after each PDT treatment suggesting an ischemic insult mainly targeting post-receptoral sites. However, objective and subjective function was stabilized after multiple PDT treatments in most of the subjects. This pilot study of five cases showed that there was no additional damage to cone- and rod-mediated outer retinal function after three PDT treatments. One of the novel findings of this research was that the rod-mediated function measured with the mfERG was impaired in early ARM. This finding supports histopathological and psychophysical evidence of rod vulnerability in early ARM. The results of these studies also suggest that early ARM affects different aspects of visual function which is reflected by different outcomes from objective and subjective vision tests. A model (chapter 7) based upon the results was developed proposing a hypoxic insult with a preferential alteration of post-receptoral sites in early ARM. The cone-mediated mfERG documented the retinal damage and possible treatment effects on outer retinal function of the multiple PDTs which did not further deteriorate. Thus, this technique might assist in the development of optimal treatment modalities for ARM, especially in retreatment regimes. Greater variability was found for the rod-mediated mfERG and its clinical use in PDT treatment regimes still needs to be investigated. In conclusion, this research has provided a better understanding of the disease process and treatment effects in ARM and might contribute to improvements in diagnosis and treatment of ARM.