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ELECTRORETINOGRAM (ERG)

By,
G.Shirisha,
13IMMO20
ERG
• ERG is the corneal measure of an action potential
produced by the retina when it is stimulated by light of
adequate intensity.
• It is the composite of electrical activity from the
photoreceptors, Muller cells & RPE.
HISTORY
• 1865 : First known recording of an ERG (amphibian retina)
Swedish physiologist Alarik Frithiof
• 1877 : Holmgren, James Dewar of Scotland (humans)
• 1908 : Einthoven and Jolly separated the ERG response into
three components: a-wave, b-wave and c-wave
• 1941 : American psychologist Lorin Riggs introduced the
contact-lens electrode (clinical use)
• 1967 : Ragnar Granit Nobel Prize for Physiology and Medicine
(demonstrated the physiology of the receptor potential of each
component of the ERG)
• 1989 : ISCEV standards(International Society for Clinical
Electrophysiology of Vision)
• 1992 : Erich Sutter mfERG
PROCEDURE
According to ISCEV 2015 guidelines:
• Maximally dilate the pupils
• Before Dark adapted protocols- 20-30 min
of dark adaptation
• Before light adapted protocols- 10 min of
light adaptation
• Present low strength flashes before stronger
flashes- so that the partial light adaptation
due to bright light does not occur
• Insert corneal contact electrodes (when these are used) under
dim red light after dark adaptation period. Avoid strong red
light. Allow 5 min of extra dark adaptation after insertion of
contact lens electrode.
• Allow at least 30 min recovery time in ordinary room
illumination after use of strong light for retinal imaging
(fundus photography, fluorescein angiography and others).
• Request the patient to fix and not move eyes. Ocular
movements can change the positions of electrodes, can cause
blockage of light by eyelids or electrode and may induce
electrical artifacts.
ELECTRODES

• GROUND ELECTRODE – FOREHEAD


• REFERENCE ELECTRODE – OUTER
CANTHUS
• ACTIVE ELECTRODE -Cornea (contact
lens electrode) in flash ERG
Conjunctival sac – used in pattern ERG
TYPES OF ERG

• FULL FIELD ERG

• FOCAL ERG
• MULTIFOCAL ERG
• PATTERN ERG
Full-Field ERG
• The full-field ERG, also referred to as the standard or
flash ERG
• Retinal potential elicited by a brief flash of light,
recommended to be about 5 ms in duration, that evenly
illuminates the entire retina (Marmor and Zrenner, 1998).
FOCAL ERG
• Used for detecting small focal lesions or pathologies
which are missed by standard full field ERG.
• A small stimulus of 4⁰ size is projected on area of retina
to be tested.
• Due to light scattering & poor signal to noise ratio, this
technique is mostly used in research setting than in
clinical setting.
MULTIFOCAL ERG
• The stimuli consists densely arranged black
or white hexagonal elements displayed on
CRT monitor.
• These hexagonal elements change from
light to dark independently & this change
results into recording of mfERG.
PATTERN ERG
• It mainly represents inner retinal activity (especially
ganglion cell activity)
• Useful in differentiating optic nerve disorders from
macular disorders.
• Unlike flash ERG, pattern ERG is a very small response.
• Recorded with full correction of refractive errors as
visualization of stimulus for extended time is essential
for recording.
PERG WAVEFORMS
• P1 or P50 : Initial corneal positive response.

• N1 or N95 : Immediate cornea negative response.


• This 50 & 95 represents the time in milliseconds from the
onset of stimulus to peak of positive or negative response.
Indications & Clinical Uses of ERG
• Evaluation of visual function in infants & children.
• To determine presence or absence of retinal function.
• To evaluate progression of retinal degeneration.
• To confirm diagnosis of a particular disease (dystrophies).
• For early detection of toxic retinopathies.
• Assisting in diagnosing the retinal conditions in which
clinical findings don't match with visual complaints
(unexplained visual loss).
Components

• a-wave: initial corneal-negative deflection, derived from


the cones and rods of the outer photoreceptor layers
• b-wave: corneal-positive deflection; derived from the
inner retina, predominantly Muller and ON-bipolar cells
• c-wave: derived from the retinal pigment epithelium and
photoreceptors
• d-wave: off bipolar cells.
• Dark adapted Oscillatory potentials: Responses primarily
from the amacrine cells/inner retina.
• Latency of response refers to the onset of the stimulus to the
beginning of the a-wave.
• Implicit time or peak time is a measure of the time interval
from onset of the stimulus to the peak of the b-wave
Factors affecting the ERG
• Physiological : Pupil, Age, Sex, Ref. Error, Diurnal Variation,
Dark adaptation, anesthesia
• Instrumental : amplification, gain, stimulus, electrodes
• Artifacts : Blinking, tearing, eye movements, air bubbles
under electrode.
ISOLATED ROD RESPONSE

• Produced by dark adapting patient for


20-30 min. & then stimulating retina
with dim light flash(2.5 log
units/24db) which is below cone
threshold and the time interval is
2seconds.
• The resultant waveform has
‘prominent b (positive) wave ‘& no
detectable ‘a (negative) wave’.
MAXIMAL COMBINED RESPONSE

• It is a larger waveform generated by using bright flash


(10 seconds of interval)in dark adapted state(30 mins)
which maximally stimulates both rods & cones.
• It results in prominent ‘a (negative) wave & ‘b (positive)
wave’ with ‘oscillatory potentials’ which are
superimposed on ‘b wave’.
SINGLE FLASH CONE RESPONSES

• It is obtained by maintaining the


patient in light adapted state(10
mins) & stimulating the retina with
bright white flash(10 sec interval).
• The rods are suppressed by light
adaptation & donot contribute to the
waveform.
30 Hz Flicker Response
• With patient in light adapted state(10 mins), a flickering
stimulus at 30 Hz(30 stimuli/sec) can also be used to filter
rod response & measure cone response
Interpretation of ERG

• ERG is abnormal only if more than 30% to 40% of retina


is affected
• A clinical correlation is necessary
• Media opacities, non-dilating pupils & nystagmus can
cause an abnormal ERG
• ERG reaches its adult value after the age of 2yrs
• ERG size is slightly larger in women than men
Negative ERG
• Characterized by large a-wave.
Causes:
 X-linked retinoschisis
 Congenital stationary night blindness
 Quinine, vigabatrine toxicity, siderosis
 Melanoma associated retinopathy
INTERPRETATION
Non recording ERG Leber congenital Amaurosis,
Retinitis pigmentosa,
Total RD
Retinal Aplasia

Abnormal or non recordable photopic Cone degenerations


ERG Achromatopsia
(often mild rod ERG abnormalities) X-linked blue cone monochromatism
X-linked cone dystrophy

Non recordable Rod ERG Congenital stationary blindness


(abnormal dark adapted bright flash Early RP
ERG)
Normal to near normal
Barely or Non recordable Scotopic ERG Rod Cone Degenerations
(abnormal photopic B-Wave ERG) Night blindness
Normal MFERG

2D Map
3D Map
RETINITIS PIGMENTOSA
CONE DYSTROPHY
Chloroquine retinopathy
Macular Degeneration Stargardt’s Disease
Limitations of ERG

• Since the ERG measures only the mass response of the


retina, isolated lesions like a hole hemorrhage, a small
patch of chorioretinitis or localized area of retinal
detachment can not be detected by amplitude changes.
• Disorders involving ganglion cells (e.g. Tay sachs’
disease), optic nerve or striate cortex do not produce any
ERG abnormality
REFERENCES

• eyewiki.aao.org/Electroretinogram
• webvision.med.utah.edu/book/electrophysiology/the-
electroretinogram-clinical-applications
• electroretinographic-modifications-induced-by-agomelatine-a-novel-
aven-peer-reviewed-fulltext-article-NDT
• wonderbaby.org/articles/whats-erg
• slideshare.net/shenoyvignesh/electrophysiology-in-ophthalmology
• slideshare.net/susumarashdeh/erg-21541872
• intechopen.com/books/electroretinograms/electroretinogram-in-
hereditary-retinal-disorders