There are two main types of<unk> s by placement. Epiretinal<unk> s are placed in the internal surface of the<unk>  while subretinal<unk> s are placed between the outer<unk>  layer and the<unk>  pigment epithelium. Epiretinal<unk> s Design principles Epiretinal<unk> s are placed on top of the<unk>  surface, above the nerve fiber layer, directly stimulating ganglion cells and bypassing all other<unk>  layers. Array of electrodes is stabilized on the<unk> using micro tacks which penetrate into the sclera. Typically, external video camera on eyeglasses acquires images and transmits processed video information to the stimulating electrodes via wireless telemetry. An external transmitter is also required to provide power to the<unk>  via radio-frequency induction coils or infrared lasers. The real-time image processing involves reducing the resolution, enhancing contrast, detecting the edges in the image and converting it into a spatio-temporal pattern of stimulation delivered to the electrode array on the<unk>  The majority of electronics can be incorporated into the associated external components, allowing for a smaller<unk>  and simpler upgrades without additional surgery. The external electronics provides full control over the image processing for each patient. Advantages Epiretinal<unk> s directly stimulate the<unk>  ganglion cells, thereby bypassing all other<unk>  layers. Therefore, in principle, epiretinal<unk> s could provide visual perception to individuals even if all other<unk>  layers have been damaged. Disadvantages Since the nerve fiber layer has similar stimulation threshold to that of the<unk>  ganglion cells, axons passing under the epiretinal electrodes are stimulated, creating arcuate percepts, and thereby distorting the retinotopic map. So far, none of the epiretinal<unk> s had light-sensitive pixels, and hence they rely on external camera for capturing the visual information. Therefore, unlike natural vision, eye movements do not shift the transmitted image on the<unk>  which creates a perception of the moving object when person with such an<unk>  changes the direction of gaze. Therefore, patients with such<unk> s are asked to not move their eyes, but rather scan the visual field with their head. Additionally, encoding visual information at the ganglion cell layer requires very sophisticated image processing techniques in order to account for various types of the<unk>  ganglion cells encoding different features of the image. Clinical study The first epiretinal<unk> , the ARGUS device, included a silicon platinum array with 16 electrodes. The Phase I clinical trial of ARGUS began in 2002 by<unk> ing six participants with the device. All patients reported gaining a perception of light and discrete phosphenes, with the visual function of some patients improving significantly over time. Future versions of the ARGUS device are being developed with increasingly dense electrode arrays, allowing for improved spatial resolution. The most recent ARGUS II device contains 60 electrodes, and a 200 electrode device is under development by ophthalmologists and engineers at the USC Eye Institute. The ARGUS II device received marketing approval in February 2011 (CE Mark demonstrating safety and performance), and it is available in Germany, France, Italy, and UK. Interim results on 30 patients long term trials were published in Ophthalmology in 2012. Argus II received approval from the US FDA on April 14, 2013 FDA Approval. Another epiretinal device, the Learning<unk> , has been developed by IIP technologies GmbH, and has begun to be evaluated in clinical trials. A third epiretinal device, EPI-RET, has been developed and progressed to clinical testing in six patients. The EPI-RET device contains 25 electrodes and requires the crystalline lens to be replaced with a receiver chip. All subjects have demonstrated the ability to discriminate between different spatial and temporal patterns of stimulation. Subretinal<unk> s Design principles Subretinal<unk> s sit on the outer surface of the<unk>  between the photoreceptor layer and the<unk>  pigment epithelium, directly stimulating<unk>  cells and relying on the normal processing of the inner and middle<unk>  layers. Adhering a subretinal<unk>  in place is relatively simple, as the<unk>  is mechanically constrained by the minimal distance between the outer<unk> and the<unk>  pigment epithelium. A subretinal<unk>  consists of a silicon wafer containing light sensitive microphotodiodes, which generate signals directly from the incoming light. Incident light passing through the<unk> generates currents within the microphotodiodes, which directly inject the resultant current into the underlying<unk>  cells via arrays of microelectrodes. The pattern of microphotodiodes activated by incident light therefore stimulates a pattern of bipolar, horizontal, amacrine, and ganglion cells, leading to a visual perception representative of the original incident image. In principle, subretinal<unk> s do not require any external hardware beyond the<unk> ed microphotodiodes array. However, some subretinal<unk> s require power from external circuitry to enhance the image signal. Advantages A subretinal<unk>  is advantageous over an epiretinal<unk>  in part because of its simpler design. The light acquisition, processing, and stimulation are all carried out by microphotodiodes mounted onto a single chip, as opposed to the external camera, processing chip, and<unk> ed electrode array associated with an epiretinal<unk> . The subretinal placement is also more straightforward, as it places the stimulating array directly adjacent to the damaged photoreceptors. By relying on the function of the remaining<unk>  layers, subretinal<unk> s allow for normal inner<unk>  processing, including amplification, thus resulting in an overall lower threshold for a visual response. Additionally, subretinal<unk> s enable subjects to use normal eye movements to shift their gaze. The retinotopic stimulation from subretinal<unk> s is inherently more accurate, as the pattern of incident light on the microphotodiodes is a direct reflection of the desired image. Subretinal<unk> s require minimal fixation, as the subretinal space is mechanically constrained and the<unk>  pigment epithelium creates negative pressure within the subretinal space. Disadvantages The main disadvantage of subretinal<unk> s is the lack of sufficient incident light to enable the microphotodiodes to generate adequate current. Thus, subretinal<unk> s often incorporate an external power source to amplify the effect of incident light. The compact nature of the subretinal space imposes significant size constraints on the<unk> . The close proximity between the<unk>  and the<unk> also increases the possibility of thermal damage to the<unk> from heat generated by the<unk> . Subretinal<unk> s require intact inner and middle<unk>  layers, and therefore are not beneficial for<unk>  diseases extending beyond the outer photoreceptor layer. Additionally, photoreceptor loss can result in the formation of a membrane at the boundary of the damaged photoreceptors, which can impede stimulation and increase the stimulation threshold. Clinical studies Optobionics was the first company to develop a subretinal<unk>  and evaluate the design in a clinical trial. Initial reports indicated that the<unk> ation procedure was safe, and all subjects reported some perception of light and mild improvement in visual function. The current version of this device has been<unk> ed in 10 patients, who have each reported improvements in the perception of visual details, including contrast, shape, and movement.<unk>  AG in Germany has also developed a subretinal<unk> , which has undergone clinical testing in nine patients. Trial was put on hold due to repeated failures. The<unk>  AG device contains 1500 microphotodiodes, allowing for increased spatial resolution, but requires an external power source.<unk>  AG reported 12 months results on the Alpha IMS study in February 2013 showing that six out of nine patients had a device failure in the nine months post<unk>  Proceedings of the royal society B, and that five of the eight subjects reported various<unk> -mediated visual perceptions in daily life. One had optic nerve damage and did not perceive stimulation. The Boston Subretinal<unk>  Project has also developed several iterations of a functional subretinal<unk> , and focused on short term analysis of<unk>  function. Results from all clinical trials to date indicate that patients receiving subretinal<unk> s report perception of phosphenes, with some gaining the ability to perform basic visual tasks, such as shape recognition and motion detection.
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