1

Matt Abruzzo, Joshua Kurman, Ruby Lee, Patrick Tice-Carroll

Dr. Peter Lelkes
Honors Bionic Human
December 12, 2018

Final Paper: The Future of Retinal Implants and the Bionic Eye

Abstract:

This paper focuses primarily on the current state of research and implementation of retinal
prosthesis and implants in combating diseases that destroy function of the retina, such as retinitis
pigmentosa. Past and current developments of this technology within the context of bionic prosthesis are
discussed, with specific attention to key strengths and weaknesses of retinal implants as well as the ethical
questions and concerns associated with the general concept of bionic vision. In addition, other avenues of
technological advancement in this field are looked at, exploring the most promising opportunities and
challenging threats facing current projects and technologies under development today. Ultimately, this
paper aims to extrapolate what the future of retinal implants and bionic vision might mean for those
affected with vision-reducing diseases long-term, also attempting to predict the potential economic and
ethical implications that might arise from the research that is currently available to us.
___________________________________________________________________________________

The history of bionics and experimentation with “spare parts” traces back as early as the fourth
century BCE. The earliest rudimentary prosthetic limbs and devices date back to Egyptians who were
responsible for the spread of this information. The construction of metal and wooden hands, legs, and
other appendages became more common to places like Italy, Rome, and beyond. Now millennia later, the
field of bionic research and experimentation with prosthetic devices erupted into something of a modern
phenomenon and has become an increasingly important and relevant topic within the larger context of
contemporary science. The progression of scientific developments is typically dictated by the need of that
particular solution in a society, and one particular malady that still has no cure or restorative treatment is
the disease known as retinitis pigmentosa (RP), also called rod cone dystrophy. The treatment of this
disease through bionic prostheses in the retina has become a field of much study, development, and
practical application within the last decade, leading to exciting advances in not just retinal prosthetics, but
bionics as a whole.
Retinitis pigmentosa is a condition caused from a genetic mutation that results in the gradual
deterioration of the patient’s photoreceptors over time. The photoreceptors, located in the retina, are
responsible for providing color and are essential to the neural connections associated with translating and
decoding vision (National Eye Institute). Photoreceptors are comprised of two main structures: the rods
and the cones. The rods are responsible for grayscale color and light detection, especially at lower light
intensities, although they have limited visual acuity. It is these rods that also give us a natural “night
vision,” as the rods are able to adapt to and interpret dimly lit surroundings. Cones, on the other hand, are
the particular photoreceptors that handle the processing of color in brighter visual spaces. They also
provide higher visual acuity, which is why are able to see more crisp and clear visual images when our
environment is well-lit, rather than the blurry, almost black and white images we see in darker spaces.
In the progression of RP in a patient, the rods are the first to begin losing function. This loss of
photoreceptors causes night blindness and a reduction in the patient’s visual field, as the rods are also
responsible for the majority of our peripheral vision. As the disease progresses in the patient, the cones
are the next to experience considerable damage. This leads to further reduction of the visual field and can
even cause what is known as tunnel vision. Once affected by RP, the photoreceptors, one by one, cease to
function and, in more extreme cases, lead to total loss of vision.
The image to the left illustrates this idea of
tunnel vision. The patient loses much of his/her field of
 2

vision and as the disease continues to cause joint

degeneration of the rods and and the cones in the
eye(s). The loss of vision becomes more and more
detrimental to the patient’s perception of different
scenes and images as the disease continues to render
the integral cells in the retina unresponsive. (The
Scientist Magazine).
National Eye Institute

According to the National Eye Institute, it is estimated that one in four thousand people carry the
genetic mutation suspected of precipitating RP. The disease leads to partial or full vision loss depending
on the patient’s level of severity. More often than not, the natural progression of the disease will see the
eventual outcome of total and complete blindness (National Eye Institute). People who end up suffering
from RP will experience an increasing amount of difficulty with important tasks like reading, driving,
walking without outside assistance, and recognizing or detecting familiar faces. These problematic
conditions, in conjunction with the previously scant regard for those affected by them, can be credited as
the primary catalyst for many of the projects and initiatives we see in the field of bionic vision today.
Current research and experimentation efforts surrounding retinal implants in particular extends
worldwide. The basic premise of approaching retinal degeneration with a bionic prosthesis is, in effect,
replacing the failing photoreceptors with digital alternatives that then stimulate the retina. These digital
alternatives are typically externally mounted cameras that then send electrical stimuli to an implant
mounted in the patient’s eye.
There are three commonly studied types of
retinal implants (see Figures 1 and 2), all of which are
based on and dictated by physical location of the implant
within the eye: suprachoroidal, subretinal, and epiretinal.
Suprachoroidal implants would be inserted between the
sclera (the white, outer layer of the eye) and the choroid
(the inner membrane responsible for providing oxygen
and other nourishment to the outer eye). Subretinal
implants are located between the retina and the retinal
pigment epithelium (RPE), a single layer of cells above
the retina that nourishes the retina. Epiretinal implants
are attached anywhere outside of the retina.
Figure 1

Figure 2

Significant amounts of research and experimentation have been done on those three main types of
retinal implants, although only implants created using the epiretinal approach have received official
approval from both the FDA and Canada Health. The most well-known and widely applied epiretinal
 3

device to date is the Argus II (see Figure 3). The Argus I was put through extensive testing and
experimentation upon its release in 2002, running clinical trials with six patients. It was not until a decade
later in 2011 that the redesigned Argus II was approved for release in certain European countries. Two
years later in 2013, it went on to be approved for release in the United State. Between these two major
regions, 190 patients have received surgical implantation of the device as of 2016 (Retina Specialist).
Figure 3
The Argus II device is reliant on an externally mounted camera
attached to the glasses. The video camera in the glasses captures a scene or
image. In real time, the footage is processed into electrical impulses by a small
computer worn on the waist. These electrical signals are then sent wirelessly to
an electrode array within the retinal implant (Figure 3A). The impulses bypass
the RP-damaged photoreceptors and stimulate the retina’s remaining, active
inner-retinal cells. At that point, these cells become capable of creating
perceptions of light and generating other visual information to send along the
optic nerve to the visual cortex in the brain (Madan). This technology, while
incomparable to human vision, is considered the most successful and abling
epiretinal implant in the field of bionic vision so far.

Figure 3A
Another strength in this field lies in the recent advancements made to address certain
technological difficulties. As of 2011, five companies (see Figure 4) had carried out Phase 1 clinical trials
for various devices, all of which employed electrical stimulation to mimic the impulses that functioning
photoreceptors would normally be in charge of sending out. Figure 4
The Boston Retinal
Implant Group in particular
has arguably done the most
out of these companies to
work around the technical
issues associated with retinal
implants. Founded in the late 1980s, the Boston Retinal Implant Project (BRIP) was originally geared
towards raising greater awareness and interest in the field of bionic vision and generating more funding
for research. Since then, their mission has evolved into the goal of developing a more efficient and
effective retinal implant. In working to achieve this goal, the BRIP has made major strides in the realm of
retinal implant research and experimentation.
Figure 5
 4

One challenge the BRIP has successfully addressed is that of

having to align the electrode array with the retinal surface. In the
past, many implants have relied on the use of tacks (see Figure 5) to
secure the array at the site of insertion (Retina Prosthesis), but the
overuse of tacks has been proven to cause gliosis, a condition which
can make the retina completely resistant to any further electrical
stimulation. The issue of the appropriate number of tacks used has
become one of great contention in the field of bionic vision, seeing
that even the slightest elevation or miscalculation can inflict
permanent damage unto the retina. To work around this problem, the
BRIP decided to switch from an epiretinal to a subretinal approach.
As a result, the surgical process of implantation for the newest
version of their device has become significantly less invasive - only one slit is required in the very back of
the eye and no tacks are necessary. The avoidance of tacks in this new and innovative approach has been
attributed plainly to the fact that “stability is achieved in the absence of significant fibrosis around the
arrays” (Journal of Neuro-Ophthalmology).
Another issue the BRIP has managed to address are the risks of
damage to the host tissue that seemed to be so threatening yet
unavoidable with retinal implants - until now. After experimenting with
different engineering methods, the BRIP settled on using
microfabrication technology to embed the microwires of their device in
a way that makes the device lighter and easier on the retina. In
addition, the BRIP was able to use titanium for the enclosure of the
device’s stimulating chip and the flexibility of the polyimide has in
theory, improved the overall function of the implant by enabling it to
“bend to match the curvature of the delicate retina without generating a
spring-like restorative force” (Journal of Neuro-Ophthalmology).
The image to the right illustrates the changes in appearance
that the BRIP has seen with its now epi-turned-subretinal implant.
In spite of the many strengths we can identify in the field of
retinal implants, there are certain weaknesses we must acknowledge as
well. One subject of great controversy among researchers is that of the
optimal number of stimulating electrodes when it comes to bionic vision. The Argus II uses 60, while the
BRIP has settled on 200. The disparity between these two numbers is indicative of the important yet
unresolved issue of how many electrodes would be ideal for a retinal implant or related device. Just like
the aforementioned overuse of tacks, the use of too many stimulating electrodes can be detrimental to the
function and ability of the retina. What further complicates this issue is the idea that the “optimal number”
of electrodes may very well differ from patient to patient; those who are “less blind” or “more blind” than
others will most likely require different numbers of stimulating electrodes to produce optimal outcomes,
respectively. The question of how to find those numbers has yet to be answered among scientists.
Another prevalent issue facing the field of retinal implants would be the concept of commercial
backing. From an economic standpoint, this issue could greatly impact the field, and any emerging
technology from it. As of right now, only one device has received approval from the FDA for commercial
use, meaning the current market is miniscule. With this lack of accessibility, the price range for both the
device and implementation would be impractically high. If the field is to continue to grow and improve, it
will need to find funding to both lower the cost, and allow for a more practical implementation of the
technology. Otherwise the field could very well end up stagnant, with only one or two astronomically
priced units available.
In addition to these economic issues facing the field, there are ethical concerns that come with the
advancement of this technology. While the idea that such a device could cure certain forms of blindness
may seem ideal to a sighted individual, it shows an extremely negative, diseased view on the blind
 5

community. At its base, the bionic eye is used as a treatment for someone who has lost their vision to
disease or individuals who were born blind, with this latter group making up the main focus of the ethical
dilemma. In modern society, a large portion of the blind community have built up their identity as being a
blind individual. To suddenly have treatment presented to you that would utterly remove the entire basis
of your identity is quite a large imposition for someone in that situation. The fact that they are blind has
become such an ingrained part of themselves that to say they should alter their condition so as to fit in
with societal norms both disrespects and deeply offends that individual.
Beyond the issue of personal ethics, the technology possess the potential to delve into more
problematic ethical concerns. As mentioned before, one of the issues facing the technology is the concept
of how many electrodes should be used in order to produce the best results. While these decisions are
making strides to provide any form of sight to an individual, it still only works out to the equivalent of
being able to see 50 or 60 pixels on a screen, instead of the natural human eye, which in comparison
would be magnitudes more powerful than the most high definition screens we have today. With this
drastic difference from one to the other, a potential concern is the misinterpretation of information when
processed through retinal prosthesis. The potential for misunderstanding is relatively great, as the lack of
color and finer detail could pose potential problems in analyzing visual information and making decisions
based on that. However, advances in the field continue to work towards fixing these potential ethical
concerns.
Despite these ethical and technological challenges, the field of retinal implants and vision
restoration shows a promising future. One exciting new technology is the exploration Figure 7
of gene therapy. Gene therapy is done when a virus has its
genetic information replaced with the desired DNA. The virus is then
injected into the area to which the DNA must be delivered, and the
viruses infiltrate the surrounding cells. They replace the mutated
DNA of that cell with the corrected version of the DNA (see Figure
7). The cells then reproduce the new, correct genes. This method is
currently not as effective as desired, but further developments with
gene editing technologies, such as CRISPR, show further feasibility
for this technology down the line. The primary concern is that, since
the retina is so proportionally larger than the viruses, several
injections must be made to fully treat the retina. This increases the cost as well as the risks, as multiple
retinal surgeries increase the chance of complications or mistakes. Additionally, the viruses cannot be
injected directly onto the retina, as the surrounding membrane is difficult to break through, meaning that
the needle must be directed to the subretina, lessening the effectiveness of the therapy. Gene therapy is a
growing field, which means that as more research is put into it, more efficient and safer methods will be
found, leading to an increased effectiveness of the gene therapy on combating Retinitis Pigmentosa.
A second future technique for retinal implants are the use of Near-Infrared Optogenetic Sensors.
The current electrode technology involves the use of bright flashes of light to stimulate vision. This
method works when the retinal cells are damaged and are no longer light sensitive, but often it is the case
that some areas of the retina will remain light sensitive. The bright flashes cause damage to the healthy
cells over time, leading to their degradation. Additionally, the current electrode technology is not as
sensitive to motion as the human eye is. This means that with devices like the Argus II cannot display
moving objects in exact real time, leading to a reduced framerate. One way to lessen the impact of both of
these problems is to use Near-Infrared Optogenetic Sensors. These sensors use infrared light to stimulate
retinal activity instead of visible light. This means that any healthy retinal cells will not be damaged by
bright flashes of visible light, and the sensitivity to motion will be increased. While this is still not near
the sensitivity of the eye under healthy conditions, it is an improvement from the visible light electrodes.
This technology is still in its infancy, but as the field grows, so too do the advancements in Near-Infrared
Optogenetic Sensors.
The challenges faced by the patients of retinitis pigmentosa and other vision-impairing diseases
are many, but a solution is forming. Devices such as the Argus II and research done by institutions, such
 6

as the BRIP, are charting a pathway to being able to restore vision in impaired patients. The current
retinal devices use a video camera that transmits electrical signals to an array of electrodes, which light up
to activate the damaged retinal cells. However, these advancements are not without their drawbacks. The
matter of how many electrodes to use is still under debate, as ideally the more electrodes there are, the
greater the sensitivity and the clearer the image. With the use of more electrodes, however, there lies the
risk of further damaging the retina and other healthy retinal cells still functioning. Additionally, the extent
of the damage varies from patient to patient on account of the disease being the result of genetic mutation,
and thus is different for each hereditary family of genes. Along with the technological concerns are the
ethical concerns of such devices. A large portion of the blind community have built identities around their
condition, and wearing a device that could restore vision could cause a rift between themselves and their
community of people who are still blind. Another issue is that, since the disease affects each patient
differently, a device that works well on one patient might not work as well or at all on another patient.
Despite these concerns, there is a promising future in the field of optical bionics. With methods such as
gene therapy and Near-Infrared Optogenetic Sensors being explored and improved upon, the future of
vision repair is bright and full of optimism.
 7

Works Cited

“Argus II Available for CHM Patients.” History | Choroideremia Research Foundation,

www.curechm.org/blog/argus-ii-available-for-chm-patients.

Cohen, Ethan D. “Retinal Prostheses.” Current Neurology and Neuroscience Reports., U.S.
National Library of Medicine, 19 Mar. 2018, www.ncbi.nlm.nih.gov/books/NBK493746/.

“Facts About Retinitis Pigmentosa.” National Eye Institute, U.S. Department of Health and Human
Services, 1 May 2014, nei.nih.gov/health/pigmentosa/pigmentosa_facts.

Hornig, Ralf, et al. “A Method and Technical Equipment for an Acute Human Trial to Evaluate Retinal
Implant Technology.” Journal of Neural Engineering, 18 Jan. 2005,
iopscience.iop.org.libproxy.temple.edu/article/10.1088/1741-2560/2/1/014/pdf.

Kim, Leo A, et al. “Retina Prosthesis.” Retina Prosthesis - EyeWiki, 26 Sept. 2017,
eyewiki.aao.org/Retina_Prosthesis.

Maldonado, Ramiro S. “Real-Life Story of the 'Bionic Eye,' the Argus II.” Retina Specialist, 16 Mar.
2015, www.retina-specialist.com/article/reallife-story-of-the-bionic-eye-the-argus-iia.

Mann, Collette, et al. “The Bionic Eye.” The Scientist Magazine®, 1 Oct. 2014,
www.the-scientist.com/features/the-bionic-eye-36747.

Roska, Botond, and José-Alain Sahel. “Restoring Vision.” Nature News, Nature Publishing Group, 16
May 2018, www.nature.com/articles/s41586-018-0076-4#Sec8.

Rizzo, Joseph F. “Update on Retinal Prosthetic Research: The Boston Retinal Implant Project: Journal of
Neuro-Ophthalmology.” LWW, June 2011,
journals.lww.com/jneuro-
ophthalmology/Fulltext/2011/06000/Update_on_Retinal_Prosthetic_Research__The_Boston.14.a
spx#O2-14.

“Second Sight Argus II.” Madan, 3 Jan. 2014, madan.org.il/en/news/second-sight-argus-ii.

Slattery, Max. “The Ethical Future of Bionic Vision.” Pursuit, The University of Melbourne, 22 Oct.
2018, pursuit.unimelb.edu.au/articles/the-ethical-future-of-bionic-vision.