Differences in the legibility of letters at contrast threshold using the Pelli-Robson chart

EasyEyes: Crowded Dynamic Fixation for Online Psychophysics

Online vision testing enables efficient data collection from diverse participants but often requires accurate fixation. When needed, fixation accuracy is traditionally ensured by using a camera to track gaze. That works well in the lab, but tracking during online testing with a built-in webcam is not yet sufficiently precise. Kurzawski, Pombo, et al. (2023) introduced a fixation task that improves fixation through hand-eye coordination, requiring participants to track a moving crosshair with a mouse-controlled cursor. This dynamic fixation task greatly reduces peeking at peripheral targets relative to a stationary fixation task, but does not eliminate it. Here, we introduce a crowded dynamic fixation task that further enhances fixation by adding clutter around the fixation mark to leverage crowding. We assessed fixation accuracy during peripheral threshold measurement. Relative to the RMS gaze error during the stationary fixation task, dynamic fixation error was 61%, while crowded dynamic fixation error was only 47%. With a 1.5° tolerance, peeking occurred on 9% of trials with stationary fixation, 4% with dynamic fixation, and 0% with crowded dynamic fixation. This improvement eliminated implausibly low peripheral thresholds, likely by preventing peeking. We conclude that crowded dynamic fixation provides accurate gaze control for online testing.

Obstacle contrast modulates gait behavior in younger and older adults

PURPOSE

This study investigated how obstacle contrast altered gait behavior of healthy younger and older adults.

METHODS

Twenty normally sighted adults, 11 older (mean [standard deviation] age, 68.1 [5.1] years) and 9 younger (mean [standard deviation] age, 21.1 [2.1] years), walked along a 6-m, black carpeted walkway and stepped over a single obstacle positioned 4 m from the start. The obstacle varied in height (0 [no obstacle], 1, and 19 cm) and contrast (6% ["low"] and 90% ["high"] Michelson contrast). Each subject completed 10 trials for each of the 5 conditions in an unblocked, random order. Lower limb kinematics were recorded using 13 motion capture cameras. Visual acuity and contrast sensitivity were measured. A repeated-measures analysis of variance was used to assess age group differences in trail toe position before crossing, lead and trail foot clearance over the obstacle, lead heel position after crossing, and obstacle crossing speed. Planned comparisons were done with Bonferroni correction. Independent t tests were used to compare vision and survey variables between groups.

RESULTS

Visual acuity was similar in both groups (p=0.17), although contrast sensitivity was better in the younger than older adults (p=0.001). Main effects were found for age: compared with younger adults, older adults showed a farther back trail foot position, greater trail foot clearance, closer lead heel position, and slower obstacle crossing speed (p<0.001 for all effects). Main effects were found for obstacle contrast: compared with low-contrast obstacles, for high-contrast obstacles, the trail foot position was farther back, both lead and trail foot clearance were greater, and lead heel position was closer (p<0.024 for all effects).

CONCLUSIONS

Obstacle contrast impacts gait behavior for younger and older adults. It is possible that the visual characteristics of an obstacle are enhanced for high-contrast obstacles, causing changes to gait behavior that may increase safety.

The impact of vision loss on attitudes toward autonomous vehicles: A vision-centric analysis

SIGNIFICANCE

Autonomous vehicles (AVs) have the promise to be an alternative transportation solution for those with vision loss. However, the impact of vision loss on the perceptions and concerns of AVs is unknown. This study therefore examined whether AVs are perceived differently by blind, visually impaired (VI), and normally sighted people.

PURPOSE

This study compared the perceptions of AVs among the blind, VI, and normally sighted.

METHODS

Participants' opinions on four perception measures (general opinion, trust, impact on quality of life, and intention to use AVs) and nine concerns regarding AVs were measured. The survey was administered to 51 normally sighted, 68 VI, and 65 blind participants. Analyses of covariance assessed whether the four perception measures and nine concerns varied by vision status (normal vision, VI, blind) and driving status (driver, nondriver). Univariate correlations and multiple regression analyses identified associations and predictors of AV perceptions and concerns from demographic, mood, cognition, travel behavior, and vision measures, which included visual acuity, contrast sensitivity, and visual field.

RESULTS

The blind (p<0.001), VI (p<0.001), and nondrivers (p<0.001) showed a greater intention to use AVs compared with those with normal vision and drivers. Similar findings were found for the other perception measures. As visual acuity, contrast sensitivity, and visual field extent declined, positivity toward AVs increased (p<0.001). Visual field extent best predicted general opinion and trust in AVs, whereas driving measures were the best predictors of impact on quality of life and intention to use AVs. Concerns about AVs showed no differences based on vision (p=0.94) or driving (p=0.63) status.

CONCLUSIONS

Individuals with vision loss expressed more acceptance of AVs despite their concerns. How positive someone is toward AVs appears to be dependent on their visual field extent and driving status.

Papadopoulou E, Almpanidou S, Karamitopoulos L, Almaliotis D. Evaluation of contrast sensitivity in visually impaired individuals using K-CS test. A novel smartphone-based contrast sensitivity test-Design and validation

BACKGROUND

To describe the development and investigate the accuracy of a novel smartphone-based Contrast Sensitivity (CS) application, the K-CS test.

METHODS

A total of 67 visually impaired and 50 normal participants were examined monocularly using the novel digital K-CS test and the Pelli-Robson (PR) chart. The K-CS test examines letter contrast sensitivity in logarithmic units, using eight levels of contrast from logCS = ~0,1 to logCS = ~2,1 at two spatial frequencies of 1.5 and 3 cycles per degree (cpd). The K-CS test was compared to the gold standard, PR test and intra-session test repeatability was also examined.

RESULTS

The K-CS test in normally sighted was found to agree well with the PR, providing comparable mean scores in logCS (±SD) (K-CS = 1.908 ± 0.06 versus PR = 1.93 ± 0.05) at 1.5 cpd and mean (± SD) logCS at 3 cpd (K-CS = 1.83 ± 0.13 versus PR = 1.86 ± 0.07). The mean best corrected visual acuity of visually impaired participants was 0.67 LogMAR (SD = 0.21) and the K-CS was also found to agree well with the Pelli-Robson in this group, with an equivalent mean (±SD) logCS at 1.5 cpd: (K-CS = 1.19 ± 0.27, PR = 1.15 ± 0.31), 3 cpd: K-CS = 1.01 ± 0.33, PR = 0.94 ± 0.34. Regarding the intra-session test repeatability, both the K-CS test and the PR test showed good repeatability in terms of the 95% limits of agreement (LoA): K-CS = ±0.112 at 1.5 cpd and ±0.133 at 3 cpd, PR = ±0.143 at 1.5 cpd and ±0.183 in 3 cpd in visually impaired individuals.

CONCLUSION

The K-CS test provides a quick assessment of the CS both in normally sighted and visually impaired individuals. The K-CS could serve as an alternative tool to assess contrast sensitivity function using a smartphone and provides results that agree well with the commonly used PR test.

EasyEyes - A new method for accurate fixation in online vision testing

Online methods allow testing of larger, more diverse populations, with much less effort than in-lab testing. However, many psychophysical measurements, including visual crowding, require accurate eye fixation, which is classically achieved by testing only experienced observers who have learned to fixate reliably, or by using a gaze tracker to restrict testing to moments when fixation is accurate. Alas, both approaches are impractical online as online observers tend to be inexperienced, and online gaze tracking, using the built-in webcam, has a low precision (±4 deg). EasyEyes open-source software reliably measures peripheral thresholds online with accurate fixation achieved in a novel way, without gaze tracking. It tells observers to use the cursor to track a moving crosshair. At a random time during successful tracking, a brief target is presented in the periphery. The observer responds by identifying the target. To evaluate EasyEyes fixation accuracy and thresholds, we tested 12 naive observers in three ways in a counterbalanced order: first, in the laboratory, using gaze-contingent stimulus presentation; second, in the laboratory, using EasyEyes while independently monitoring gaze using EyeLink 1000; third, online at home, using EasyEyes. We find that crowding thresholds are consistent and individual differences are conserved. The small root mean square (RMS) fixation error (0.6 deg) during target presentation eliminates the need for gaze tracking. Thus, this method enables fixation-dependent measurements online, for easy testing of larger and more diverse populations.

Comparison of current paediatric contrast sensitivity assessments using simulated reduced contrast thresholds

PURPOSE

There are limited tests of contrast sensitivity (CS) for use in children. The Hiding Heidi (HH) is suitable for all cognitive abilities, but has a ceiling effect. The Double Happy (DH) test has comparable thresholds to the Pelli Robson (PR), however the ability to detect changes in contrast has not been established. This study aims to compare contrast thresholds and agreement between HH and the DH, comparing to the PR chart in normal conditions and under reduced visual and lighting conditions.

METHODS

Tests were repeated under different conditions to reduce the contrast. Room illumination was 20,900{plus minus}2% lux in bright conditions and 2,000{plus minus}2% lux in dim conditions, both conditions were repeated with the addition of simulation spectacles to reduce the clarity of vision. Participants' CS was measured uniocularly using the PR, HH and DH tests.

RESULTS

50 participants, age 18-62 years (mean{plus minus}standard deviation: 24.5{plus minus}7.98), were assessed. On HH 94% (n = 47) reached the maximum score, with the DH it was 18% (n = 9). The difference in reduction between conditions was smaller with HH in comparison to PR and DH, but significantly different from baseline conditions. Under dim conditions the reduction in PR and DH was -0.21 logCS units, but only -0.04 logCS for HH.

CONCLUSION

The DH test has better agreement with PR than HH and is better at detecting CS changes, highlighting the advantages of use in clinical practice.

The Bouma law accounts for crowding in 50 observers

Crowding is the failure to recognize an object due to surrounding clutter. Our visual crowding survey measured 13 crowding distances (or "critical spacings") twice in each of 50 observers. The survey includes three eccentricities (0, 5, and 10 deg), four cardinal meridians, two orientations (radial and tangential), and two fonts (Sloan and Pelli). The survey also tested foveal acuity, twice. Remarkably, fitting a two-parameter model-the well-known Bouma law, where crowding distance grows linearly with eccentricity-explains 82% of the variance for all 13 × 50 measured log crowding distances, cross-validated. An enhanced Bouma law, with factors for meridian, crowding orientation, target kind, and observer, explains 94% of the variance, again cross-validated. These additional factors reveal several asymmetries, consistent with previous reports, which can be expressed as crowding-distance ratios: 0.62 horizontal:vertical, 0.79 lower:upper, 0.78 right:left, 0.55 tangential:radial, and 0.78 Sloan-font:Pelli-font. Across our observers, peripheral crowding is independent of foveal crowding and acuity. Evaluation of the Bouma factor, b (the slope of the Bouma law), as a biomarker of visual health would be easier if there were a way to compare results across crowding studies that use different methods. We define a standardized Bouma factor b' that corrects for differences from Bouma's 25 choice alternatives, 75% threshold criterion, and linearly symmetric flanker placement. For radial crowding on the right meridian, the standardized Bouma factor b' is 0.24 for this study, 0.35 for Bouma (1970), and 0.30 for the geometric mean across five representative modern studies, including this one, showing good agreement across labs, including Bouma's. Simulations, confirmed by data, show that peeking can skew estimates of crowding (e.g., greatly decreasing the mean or doubling the SD of log b). Using gaze tracking to prevent peeking, individual differences are robust, as evidenced by the much larger 0.08 SD of log b across observers than the mere 0.03 test-retest SD of log b measured in half an hour. The ease of measurement of crowding enhances its promise as a biomarker for dyslexia and visual health.

EasyEyes - Accurate fixation for online vision testing of crowding and beyond

Online methods allow testing of larger, more diverse populations, with much less effort than in-lab testing. However, many psychophysical measurements, including visual crowding, require accurate eye fixation, which is classically achieved by testing only experienced observers who have learned to fixate reliably, or by using a gaze tracker to restrict testing to moments when fixation is accurate. Alas, both approaches are impractical online since online observers tend to be inexperienced, and online gaze tracking, using the built-in webcam, has a low precision (±4 deg, Papoutsaki et al., 2016). The EasyEyes open-source software reliably measures peripheral thresholds online with accurate fixation achieved in a novel way, without gaze tracking. EasyEyes tells observers to use the cursor to track a moving crosshair. At a random time during successful tracking, a brief target is presented in the periphery. The observer responds by identifying the target. To evaluate EasyEyes fixation accuracy and thresholds, we tested 12 naive observers in three ways in a counterbalanced order: first, in the lab, using gaze-contingent stimulus presentation (Kurzawski et al., 2023; Pelli et al., 2016); second, in the lab, using EasyEyes while independently monitoring gaze; third, online at home, using EasyEyes. We find that crowding thresholds are consistent (no significant differences in mean and variance of thresholds across ways) and individual differences are conserved. The small root mean square (RMS) fixation error (0.6 deg) during target presentation eliminates the need for gaze tracking. Thus, EasyEyes enables fixation-dependent measurements online, for easy testing of larger and more diverse populations.

Characterizing the in-out asymmetry in visual crowding

An object's processing is impaired by the presence of nearby clutter. Several distinct mechanisms, such as masking and visual crowding, are thought to contribute to such flanker-induced interference. It is therefore important to determine which mechanism is operational in any given situation. Previous studies have proposed that the in-out asymmetry (IOA), where a peripheral flanker interferes with the target more than a foveal flanker, is diagnostic of crowding. However, several studies have documented inconsistencies in the occurrence of this asymmetry, particularly at locations beyond the horizontal meridian, casting doubt on its ability to delineate crowding. In this study, to determine if IOA is diagnostic of crowding, we extensively charted its properties. We asked a relatively large set of participants (n = 38) to identify a briefly presented peripheral letter flanked by a single inward or outward letter at one of four locations. We also manipulated target location uncertainty and attentional allocation by blocking, randomizing or pre-cueing the target location. Using multilevel Bayesian regression analysis, we found robust IOA at all locations, although its strength was modulated by target location, location uncertainty, and attentional allocation. Our findings suggest that IOA can be an excellent marker of crowding, to the extent that it is not observed in other flanker-interference mechanisms, such as masking.

Novel computer-based assessments of everyday visual function in people with age-related macular degeneration

PURPOSE

To test the hypothesis that the performance in novel computer-based tasks of everyday visual function worsens with disease severity in people with non-neovascular age-related macular degeneration.

METHODS

Participants with and without non-neovascular age-related macular degeneration (≥60 years, minimum logMAR binocular visual acuity 0.7) performed a series of standard visual function tests and two novel computer-based tasks. In a visual search task, participants had to locate an image of a single real-world object within an array of 49 distractor images. Next, in a series of simulated dynamic driving scenes, participants were asked to identify one or two approaching real-world road signs and then select these road signs from four options. Outcome measures were median response times and total correct responses.

RESULTS

Forty-nine participants had no macular disease (n = 11), early/intermediate age-related macular degeneration (n = 16) or geographic atrophy (n = 22). Groups were age-similar with median (interquartile range) logMAR visual acuity of 0.00 (-0.08,0.12), 0.13 (-0.08,0.70) and 0.32 (0.12,0.70) respectively. Median (interquartile range) visual search response times were 1.9 (1.0,2.4), 1.8 (1.1,3.7) and 2.4 (1.2,6.0) seconds respectively. Median (interquartile range) road sign response times (single road signs) were 1.2 (0.4,1.7), 1.5 (0.9,2.8) and 1.8 (1.0,5.5) seconds respectively. Median (interquartile range) road sign response times (double road signs) were 1.7 (0.7,2.4), 2.3 (1.2,3.1) and 2.5 (1.7,6) seconds respectively. Participants with geographic atrophy recorded slower response times in all tasks and over 50% performed outside the normative limit for task performance. There were no significant differences between groups in total correct responses across all tasks.

CONCLUSIONS

In a novel computer-based assessment, people with increasing severity of age-related macular degeneration take longer to perform visual search of everyday objects and take longer to identify road signs than those with no age-related macular degeneration. These novel assessments could be useful as patient-relevant, secondary outcomes for clinical trials.

The Mind Cannot Go Blind: Effects of Central Vision Loss on Judging One's Crossing Time

SIGNIFICANCE

This study explored whether people with AMD can accurately judge the time they need to cross the street. The results suggest that AMD-related vision loss does not affect a person's ability to estimate his/her own street-crossing time, whereas familiarity with the street does.

PURPOSE

The purpose of this study was to assess whether people with AMD could judge accurately their street-crossing time.

METHODS

Fifty-one AMD subjects and 47 age-matched normally sighted subjects (controls) estimated their time to cross a single-lane, one-way street four times (pre-estimate). Then, subjects actually crossed the street four times and subsequently estimated their crossing time four additional times (post-estimate). A linear mixed model with repeated measures for subject was used to determine if the ratio between subjects' estimated and actual crossing times changed as a function of subject group (AMD vs. control) and whether estimates changed before and after actually crossing the street. Univariate correlations and multiple regression analyses were also performed to determine which of the measured experimental variables were the best predictors of a subject's ability to estimate his/her crossing time.

RESULTS

No significant difference in crossing ratios were found between the AMD (average, 1.05) and control (average, 1.16) subjects (P = .11). This was true for both the pre-crossing (AMD, 1.09; controls, 1.23; P = .11) and post-crossing ratios (AMD, 1.01; controls, 1.09; P = .17). Both subject groups' crossing ratios, however, decreased significantly going from pre to post (P < .0001). Increased age, longer actual crossing time, and experience gained from previously crossing the street resulted in less overestimation of one's crossing time.

CONCLUSIONS

Our data suggest that familiarity with the street as opposed to central vision loss from AMD affects a person's ability to estimate his/her crossing time.

The Effect of Simulated Central Field Loss on Street-crossing Decision-Making in Young Adult Pedestrians

SIGNIFICANCE

This study explored the street-crossing decision-making performance of young normally sighted subjects with simulated central field loss (CFL). The results suggest that using eccentric viewing enables a person to make safe and reliable street-crossing decisions.

PURPOSE

This study tested the hypothesis that, as the diameter of an experimentally induced central scotoma increases, the accuracy and reliability of street-crossing decisions worsen.

METHODS

Street-crossing decisions were measured in 20 young subjects aged between 23 and 31 years while monocularly viewing a nonsignalized, one-way street for different vehicular arrival times. Using a 5-point rating scale, subjects judged whether they could cross the street before vehicular arrival with habitual vision and simulated CFL with eccentric viewing. The CFL was induced using soft contact lenses with different central opaque diameters. Using receiver operating characteristic curve analysis, we obtained subjects' accuracy (amount of time in seconds where subjects either overestimated or underestimated vehicular arrival time relative to their actual crossing time) and reliability (how quickly subjects transitioned from judging insufficient to sufficient time to cross relative to their actual crossing time).

RESULTS

The centrally opaque contact lenses induced central scotomata with a mean (standard deviation) diameter of 17.12° (5.83°). No significant difference in street-crossing accuracy (P = .35) or reliability (P = .09) was found between the normal, habitual vision and simulated CFL conditions. No statistically significant correlations were found between scotoma diameter and the accuracy and reliability of subjects' street-crossing decisions (P = .83 and P = .95, respectively).

CONCLUSIONS

The findings of this study suggest that adopting eccentric viewing enables a person to successfully mitigate the negative effects of an absolute central scotoma on the accuracy and reliability of their street-crossing decisions.

Legibility Assessment of Visual Word Form Symbols for Visual Tests

For a reliable visual test, it is important to evaluate the legibility of the symbols, which depends on several factors. Previous studies have compared the legibility of Latin optotypes. This study developed a visual function test based on identification visual capacity for a Chinese reading population. The legibility of word symbols was assessed with three methods: (1) Identification of the contrast thresholds of the character sets, (2) patterns of confusion matrices obtained from analysis of the frequency of incorrect stimulus/response pairs, and (3) pixel ratios of bitmap images of Chinese characters. Then characters of similar legibility in each character set were selected. The contrast thresholds of the final five character sets and the Tumbling E and Landolt C optotypes were evaluated. No significant differences in contrast threshold were found among the five selected character sets (p > 0.05), but the contrast thresholds were significantly higher than those of the E and C optotypes. Our results indicate that combining multiple methods to include the influences of the properties of visual stimuli would be useful in investigating the legibility of visual word symbols.

Undermining a common language: smartphone applications for eye emergencies

Background

Emergency room physicians are frequently called upon to assess eye injuries and vision problems in the absence of specialized ophthalmologic equipment. Technological applications that can be used on mobile devices are only now becoming available.

Objective

To review the literature on the evidence of clinical effectiveness of smartphone applications for visual acuity assessment marketed by two providers (Google Play and iTunes).

Methods

The websites of two mobile technology vendors (iTunes and Google Play) in Canada and Ireland were searched on three separate occasions using the terms “eye”, “ocular”, “ophthalmology”, “optometry”, “vision”, and “visual assessment” to determine what applications were currently available. Four medical databases (Cochrane, Embase, PubMed, Medline) were subsequently searched with the same terms AND mobile OR smart phone for papers in English published in years 2010–2017.

Results

A total of 5,024 Canadian and 2,571 Irish applications were initially identified. After screening, 44 were retained. Twelve relevant articles were identified from the health literature. After screening, only one validation study referred to one of our identified applications, and this one only partially validated the application as being useful for clinical purposes.

Conclusion

Mobile device applications in their current state are not suitable for emergency room ophthalmologic assessment, because systematic validation is lacking.

Spatial-frequency dependent binocular imbalance in amblyopia

While amblyopia involves both binocular imbalance and deficits in processing high spatial frequency information, little is known about the spatial-frequency dependence of binocular imbalance. Here we examined binocular imbalance as a function of spatial frequency in amblyopia using a novel computer-based method. Binocular imbalance at four spatial frequencies was measured with a novel dichoptic letter chart in individuals with amblyopia, or normal vision. Our dichoptic letter chart was composed of band-pass filtered letters arranged in a layout similar to the ETDRS acuity chart. A different chart was presented to each eye of the observer via stereo-shutter glasses. The relative contrast of the corresponding letter in each eye was adjusted by a computer staircase to determine a binocular Balance Point at which the observer reports the letter presented to either eye with equal probability. Amblyopes showed pronounced binocular imbalance across all spatial frequencies, with greater imbalance at high compared to low spatial frequencies (an average increase of 19%, p < 0.01). Good test-retest reliability of the method was demonstrated by the Bland-Altman plot. Our findings suggest that spatial-frequency dependent binocular imbalance may be useful for diagnosing amblyopia and as an outcome measure for recovery of binocular vision following therapy.

Individual Letter Contrast Thresholds: Effect of Object Frequency and Noise

PURPOSE

To compare differences in contrast threshold among individual Sloan letters presented in additive white luminance noise and in the absence of noise.

METHODS

Contrast threshold for letter identification was measured for three visually normal subjects (aged 22, 25, and 34 years) using letters from the Sloan set (C, D, H, K, N, O, R, S, V, and Z). The letter size was equivalent to 1.5 logMAR (logarithm of the minimum angle of resolution), and the letters were either unfiltered or band-pass filtered to limit the object frequency content (cycles per letter) to a one-octave wide band centered at 1.25, 2.5, 5, and 10 cycles per letter. Letters were presented for an unlimited duration against a uniform adapting field or in the presence of additive white luminance noise. Contrast threshold for each letter was determined using a 10-alternative forced-choice interleaved staircase procedure.

RESULTS

For standard unfiltered Sloan letters presented against a uniform field, contrast threshold for individual letters differed by as much as a factor of 1.5, consistent with a previous report. When measured in luminance noise, the individual letters differed by as much as a factor of 1.8. Band-pass filtering the letters to include only low object frequencies increased the differences in contrast threshold among the individual letters (about a factor of 3) compared with unfiltered letters and letters filtered into high object frequency bands.

CONCLUSIONS

The addition of white luminance noise had relatively small effects on interletter contrast threshold differences, whereas band-pass filtering had large effects on interletter threshold differences, greatly increasing variation among the letters that contained only low object frequencies. Letters that contain only high object frequencies may be useful in the design of letter charts because the interletter threshold differences are relatively small for these optotypes and the object frequency information mediating identification is known.

Measuring Visual Function Using the MultiQuity System: Comparison with an Established Device

Purpose. To compare measures of visual acuity (VA) and contrast sensitivity (CS) from the Thompson Xpert 2000 and MultiQuity (MiQ) devices. Methods. Corrected distance VA (CDVA) and CS were measured in the right eye of 73 subjects, on an established system (Thompson Xpert) and a novel system (MiQ 720). Regression was used to convert MiQ scores into the Thompson scale. Agreement between the converted MiQ and Thompson scores was investigated using standard agreement indices. Test-retest variability for both devices was also investigated, for a separate sample of 24 subjects. Results. For CDVA, agreement was strong between the MiQ and Thomson devices (accuracy = 0.993, precision = 0.889, CCC = 0.883). For CS, agreement was also strong (accuracy = 0.996, precision = 0.911, CCC = 0.907). Agreement was unaffected by demographic variables or by presence/absence of ocular pathology. Test-retest agreement indices for both devices were excellent: in the range 0.88–0.96 for CDVA and in the range 0.90–0.98 for CS. Conclusion. MiQ measurements exhibit strong agreement with corresponding Thomson measurements, and test-retest results are good for both devices. Agreement between the two devices is unaffected by age or ocular pathology.

An individually-tailored multifactorial intervention program for older fallers in a middle-income developing country: Malaysian Falls Assessment and Intervention Trial (MyFAIT)

Background

In line with a rapidly ageing global population, the rise in the frequency of falls will lead to increased healthcare and social care costs. This study will be one of the few randomized controlled trials evaluating a multifaceted falls intervention in a low-middle income, culturally-diverse older Asian community. The primary objective of our paper is to evaluate whether individually tailored multifactorial interventions will successfully reduce the number of falls among older adults.

Methods

Three hundred community-dwelling older Malaysian adults with a history of (i) two or more falls, or (ii) one injurious fall in the past 12 months will be recruited. Baseline assessment will include cardiovascular, frailty, fracture risk, psychological factors, gait and balance, activities of daily living and visual assessments. Fallers will be randomized into 2 groups: to receive tailored multifactorial interventions (intervention group); or given lifestyle advice with continued conventional care (control group). Multifactorial interventions will target 6 specific risk factors. All participants will be re-assessed after 12 months. The primary outcome measure will be fall recurrence, measured with monthly falls diaries. Secondary outcomes include falls risk factors; and psychological measures including fear of falling, and quality of life.

Discussion

Previous studies evaluating multifactorial interventions in falls have reported variable outcomes. Given likely cultural, personal, lifestyle and health service differences in Asian countries, it is vital that individually-tailored multifaceted interventions are evaluated in an Asian population to determine applicability of these interventions in our setting. If successful, these approaches have the potential for widespread application in geriatric healthcare services, will reduce the projected escalation of falls and fall-related injuries, and improve the quality of life of our older community.

Trial registration

ISRCTN11674947

A double dissociation of the acuity and crowding limits to letter identification, and the promise of improved visual screening

Here, we systematically explore the size and spacing requirements for identifying a letter among other letters. We measure acuity for flanked and unflanked letters, centrally and peripherally, in normals and amblyopes. We find that acuity, overlap masking, and crowding each demand a minimum size or spacing for readable text. Just measuring flanked and unflanked acuity is enough for our proposed model to predict the observer's threshold size and spacing for letters at any eccentricity. We also find that amblyopia in adults retains the character of the childhood condition that caused it. Amblyopia is a developmental neural deficit that can occur as a result of either strabismus or anisometropia in childhood. Peripheral viewing during childhood due to strabismus results in amblyopia that is crowding limited, like peripheral vision. Optical blur of one eye during childhood due to anisometropia without strabismus results in amblyopia that is acuity limited, like blurred vision. Furthermore, we find that the spacing:acuity ratio of flanked and unflanked acuity can distinguish strabismic amblyopia from purely anisometropic amblyopia in nearly perfect agreement with lack of stereopsis. A scatter diagram of threshold spacing versus acuity, one point per patient, for several diagnostic groups, reveals the diagnostic power of flanked acuity testing. These results and two demonstrations indicate that the sensitivity of visual screening tests can be improved by using flankers that are more tightly spaced and letter like. Finally, in concert with Strappini, Pelli, Di Pace, and Martelli (submitted), we jointly report a double dissociation between acuity and crowding. Two clinical conditions-anisometropic amblyopia and apperceptive agnosia-each selectively impair either acuity A or the spacing:acuity ratio S/A, not both. Furthermore, when we specifically estimate crowding, we find a double dissociation between acuity and crowding. Models of human object recognition will need to accommodate this newly discovered independence of acuity and crowding.

Older drivers and rapid deceleration events: Salisbury Eye Evaluation Driving Study

Drivers who rapidly change speed while driving may be more at risk for a crash. We sought to determine the relationship of demographic, vision, and cognitive variables with episodes of rapid decelerations during five days of normal driving in a cohort of older drivers. In the Salisbury Eye Evaluation Driving Study, 1425 older drivers aged 67-87 were recruited from the Maryland Motor Vehicle Administration's rolls for licensees in Salisbury, Maryland. Participants had several measures of vision tested: visual acuity, contrast sensitivity, visual fields, and the attentional visual field. Participants were also tested for various domains of cognitive function including executive function, attention, psychomotor speed, and visual search. A custom created driving monitoring system (DMS) was used to capture rapid deceleration events (RDEs), defined as at least 350 milli-g deceleration, during a five day period of monitoring. The rate of RDE per mile driven was modeled using a negative binomial regression model with an offset of the logarithm of the number of miles driven. We found that 30% of older drivers had one or more RDE during a five day period, and of those, about 1/3 had four or more. The rate of RDE per mile driven was highest for those drivers driving<59 miles during the 5-day period of monitoring. However, older drivers with RDE's were more likely to have better scores in cognitive tests of psychomotor speed and visual search, and have faster brake reaction time. Further, greater average speed and maximum speed per driving segment was protective against RDE events. In conclusion, contrary to our hypothesis, older drivers who perform rapid decelerations tend to be more "fit", with better measures of vision and cognition compared to those who do not have events of rapid deceleration.

Measurements of street-crossing decision-making in pedestrians with low vision

PURPOSE

Crossing the street is an important but risky activity of daily living. If a pedestrian makes a poor street-crossing decision, the consequence could be serious injury or death. In order to advance our understanding of how visual and auditory information is sampled and processed to make street-crossing decisions, an accurate, reliable, and sensitive psychophysical and/or psychometric method of measurement of the street-crossing decision variable must first be developed and validated. The aim of this paper is to develop and validate a new metric for this variable.

METHODS

Using a 5 point rating scale, safety ratings for eight different vehicular gap times of different durations were recorded along an unsignalized, two-lane street of one-way traffic. Safety ratings were collected from 12 normally sighted and 10 visually impaired subjects. Receiver Operating Characteristic (ROC) curves were estimated for all possible gap pairs and the discriminability (d') of the street-crossing decision variable for all gap pairs was estimated from the area under the ROC curve.

RESULTS

We found that our data conform with the assumptions that the underlying distributions of the decision variable are continuous, monotonic and unbounded. Using the dissimilarity matrix of d' values for each person (which were computed for all pairings of gap times) in a one-dimensional scaling model, we estimated the means of each distribution of the decision variable relative to a center of gravity (COG) for the person. When plotting the means of the distributions against vehicular gap time, the data are best described as a non-linear function symmetric about the COG. We showed that the x-intercept (t(COG)) and slope from the non-linear function can be used to assess a person's street-crossing decision-making performance for different amounts of sensory information. Using our newly developed metrics, we found no significant difference in t(COG) (p=0.30) and in the slopes of the model (p=0.85) between normally sighted and visually impaired subjects. In addition, both subject groups centered their t(COG) close to their actual crossing time.

CONCLUSIONS

A newly developed model for measuring a street-crossing decision variable functions as a valid metric that can be used to quantify street-crossing decision-making performance in pedestrians. Using this new metric, we observed that visually impaired subjects who travel independently are able to make street-crossing judgments that are comparable to those of normally sighted subjects.

Street-crossing decision-making: a comparison between patients with age-related macular degeneration and normal vision

PURPOSE

We determined whether the street-crossing decisions of subjects with age-related macular degeneration (AMD) were as accurate and precise as those made by young and older subjects with normal vision.

METHODS

Street-crossing decisions in 13 AMD subjects, and 20 young and 20 older control subjects with normal vision were measured along an un-signalized street for nine different gap times. After calculating the discriminability (d') of the street-crossing decision variable for all gap pairs and entering these d' values into a one-dimensional scaling model, the means of each distribution of the decision variable relative to a "center of gravity" were estimated and plotted against gap time. The resultant plot was a nonlinear function. Street-crossing decision accuracy was computed for each subject as the difference between the x-intercept of the nonlinear function (t(COG)) and subjects' measured street-crossing time. Street-crossing decision-making precision was computed as the value of the slope of the nonlinear function at t(COG).

RESULTS

We found that all subjects were precise in their street-crossing decisions (P = 0.55). Significant differences in street-crossing accuracy were found as a function of age (P = 0.003). Compared to either the older normally-sighted (P = 0.018) or AMD (P = 0.019) subjects, the young normally-sighted subjects made the least accurate street-crossing decisions. No significant difference in accuracy was found between the AMD and age-matched normally-sighted subjects (P = 0.90).

CONCLUSIONS

Our data suggested that age and mild central vision loss did not affect significantly a subject's precision in their street-crossing decisions. Age, but not mild central vision loss, significantly affected a subject's accuracy in their street-crossing decisions.

Are normally sighted, visually impaired, and blind pedestrians accurate and reliable at making street crossing decisions?

PURPOSE

The purpose of this study is to measure the accuracy and reliability of normally sighted, visually impaired, and blind pedestrians at making street crossing decisions using visual and/or auditory information.

METHODS

Using a 5-point rating scale, safety ratings for vehicular gaps of different durations were measured along a two-lane street of one-way traffic without a traffic signal. Safety ratings were collected from 12 normally sighted, 10 visually impaired, and 10 blind subjects for eight different gap times under three sensory conditions: (1) visual plus auditory information, (2) visual information only, and (3) auditory information only. Accuracy and reliability in street crossing decision-making were calculated for each subject under each sensory condition.

RESULTS

We found that normally sighted and visually impaired pedestrians were accurate and reliable in their street crossing decision-making ability when using either vision plus hearing or vision only (P > 0.05). Under the hearing only condition, all subjects were reliable (P > 0.05) but inaccurate with their street crossing decisions (P < 0.05). Compared to either the normally sighted (P = 0.018) or visually impaired subjects (P = 0.019), blind subjects were the least accurate with their street crossing decisions under the hearing only condition.

CONCLUSIONS

Our data suggested that visually impaired pedestrians can make accurate and reliable street crossing decisions like those of normally sighted pedestrians. When using auditory information only, all subjects significantly overestimated the vehicular gap time. Our finding that blind pedestrians performed significantly worse than either the normally sighted or visually impaired subjects under the hearing only condition suggested that they may benefit from training to improve their detection ability and/or interpretation of vehicular gap times.

Adaptive gait changes in long-term wearers of contact lens monovision correction

INTRODUCTION

The aim of the present study was to determine adaptive gait changes in long-term wearers of monovision correction contact lenses by comparing gait parameters when wearing monovision correction to those observed when wearing binocular distance correction contact lenses.

METHODS

Gait and toe clearance parameters were measured in eleven participants (53.5 +/- 4.6 years, median monovision wearing time 5 years) as they repeatedly walked up to and onto a raised surface with either monovision or distance correction.

RESULTS

Compared to distance correction, monovision resulted in a large reduction in stereoacuity from 17'' to 87'', a slower walking velocity (p = 0.001), a reduced horizontal toe clearance of the step edge (p = 0.035) and, for trials when monovision correction occurred first, a 33% greater variability in vertical toe clearance (p = 0.021). Variability in some gait data was large due to certain study design features and learning effects.

CONCLUSION

A slower walking velocity with monovision correction suggests participants became more cautious, likely as a result of the significantly reduced stereoacuity. The decreased horizontal toe clearance and increased vertical toe clearance variability suggests that monovision correction may cause a greater likelihood of hitting step edges and tripping during everyday gait. Recommended study design features are suggested for future adaptive gait studies to increase the precision of the data and to attempt to minimize the effects of learning from somatosensory feedback.

Predictors of lane-change errors in older drivers

OBJECTIVES

To determine the factors that predict errors in executing proper lane changes among older drivers.

DESIGN

Cross-sectional analysis of data from a longitudinal study.

SETTING

Maryland's Eastern Shore.

PARTICIPANTS

One thousand eighty drivers aged 67 to 87 enrolled in the Salisbury Eye Evaluation Driving Study.

MEASUREMENTS

Tests of vision, cognition, health status, and self-reported distress and a driving monitoring system in each participant's car, used to quantify lane-change errors.

RESULTS

In regression models, measures of neither vision nor perceived stress were related to lane-change errors after controlling for age, sex, race, and residence location. In contrast, cognitive variables, specifically performance on the Brief Test of Attention and the Beery-Buktenicka Test of Visual-Motor Integration, were related to lane-change errors.

CONCLUSION

The current findings underscore the importance of specific cognitive skills, particularly auditory attention and visual perception, in the execution of driving maneuvers in older individuals.

Urban and rural differences in older drivers' failure to stop at stop signs

Our purpose was to determine visual and cognitive predictors for older drivers' failure to stop at stop signs. 1425 drivers aged between ages 67 and 87 residing in Salisbury Maryland were enrolled in a longitudinal study of driving. At baseline, the participants were administered a battery of vision and cognition tests, and demographic and health questionnaires. Five days of driving data were collected with a Driving Monitoring System (DMS), which obtained data on stop signs encountered and failure to stop at stop signs. Driving data were also collected 1 year later (round two). The outcome, number of times a participant failed to stop at a stop sign at round two, was modeled using vision and cognitive variables as predictors. A negative binomial regression model was used to model the failure rate. Of the 1241 who returned for round two, 1167 drivers had adequate driving data for analyses and 52 did not encounter a stop sign. In the remaining 1115, 15.8% failed at least once to stop at stop signs, and 7.1% failed to stop more than once. Rural drivers had 1.7 times the likelihood of not stopping compared to urban drivers. Amongst the urban participants, the number of points missing in the bilateral visual field was significantly associated with a lower failure rate. In this cohort, older drivers residing in rural areas were less likely to stop at stop-sign intersections than those in urban areas. It is possible that rural drivers frequent areas with less traffic and better visibility, and may be more likely to take the calculated risk of not stopping. In this cohort failure to stop at stop signs was not explained by poor vision or cognition. Conversely in urban areas, those who have visual field loss appear to be more cautious at stop signs.

Visual and cognitive deficits predict stopping or restricting driving: the Salisbury Eye Evaluation Driving Study (SEEDS)

PURPOSE

To determine the visual and other factors that predict stopping or restricting driving in older drivers.

METHODS

A group of 1425 licensed drivers aged 67 to 87 years, who were residents of greater Salisbury, participated. At 1 year after enrollment, this group was categorized into those who had stopped driving, drove only within their neighborhood, or continued to drive beyond their neighborhood. At baseline, a battery of structured questionnaires, vision, and cognitive tests were administered. Multivariate analysis determined the factors predictive of stopping or restricting driving 12 months later.

RESULTS

Of the 1425 enrolled, 1237 (87%) were followed up at 1 year. Excluding those who were already limiting their driving at baseline (n = 35), 1.5% (18/1202) had stopped and 3.4% (41/1202) had restricted their driving. The women (odds ratio [OR], 4.01; 95% confidence interval [CI], 2.05-8.20) and those who prefer to be driven (OR, 3.91; 95% CI, 1.91-8.00) were more likely to stop or restrict driving. Depressive symptoms increased likelihood of restricting or stopping driving (OR, 1.08; 95% CI, 1.009-1.16 per point Geriatric Depression Scale). Slow visual scanning and psychomotor speed (Trail Making Test, Part A: OR, 1.02; 95% CI, 1.01-1.03), poor visuoconstructional skills (Beery-Buktenica Test of Visual Motor Integration: OR, 1.14; 95% CI, 1.05-1.25), and reduced contrast sensitivity (OR, 1.15; 95% CI, 1.03-1.28) predicted stopping or reducing driving. Visual field loss and visual attention were not associated. The effect of vision on changing driving behavior was partially mediated by cognition, depression, and baseline driving preferences.

CONCLUSIONS

In this cohort, contrast sensitivity and cognitive function were independently associated with incident cessation or restriction of driving space. These data suggest drivers with functional deficits make difficult decisions to restrict or stop driving.

A Modified ETDRS Visual Acuity Chart for European-Wide Use

PURPOSE

The log MAR visual acuity (VA) chart developed for use in the Early Treatment Diabetic Retinopathy Study (ETDRS) is composed of 10 Sloan letters, which are not used in the Greek, Cyrillic, and Central European alphabets. In this study we evaluate a modified ETDRS chart, the University of Crete (UoC) chart, which contains a set of letters readable by all European citizens.

METHODS

In the UoC charts, the letters C, D, R, N, V, S, and Z were substituted with E, P, B, X, Y, A, and T, respectively. The similarity between the modified and the standard acuity charts was evaluated using two procedures. First, VA of 227 secondary school children (454 eyes) was evaluated using both sets of charts. Second, the relative difficulty for the identification of individual Sloan letters used in both charts, as well as letter M, was assessed from psychometric functions for five subjects.

RESULTS

Bland-Altman plots revealed no statistical significant differences in the value of VA between the standard and the UoC set of charts. Although, estimates of identification log MAR threshold showed relatively significant interletter variability, in total, the new set of Sloan letters was equally identifiable with the original set.

CONCLUSIONS

The overall pattern of results suggests that the modified log MAR UoC charts forms a valid alternative to the ETDRS for assessing VA in multinational clinical trials, offering the advantage of containing letters recognizable by a wider population basis, such as European citizens, as well as subjects from countries using the Cyrillic alphabet.

What is the minimum field of view required for efficient navigation?

Critical points were computed to determine the minimum field of view (FOV) size required for efficient navigation. Navigation performance in 20 normally sighted subjects was assessed using an immersive virtual environment. Subjects were instructed to walk through a virtual forest to a target tree as quickly as possible without hitting any obstacles (trees, boulders, and holes). The navigation task was performed in three FOV and image contrast conditions under binocular, monocular, chromatic and achromatic viewing conditions. FOV was constricted to 10 degrees , 20 degrees and 40 degrees diameter and average image contrast was nominally high (11%), medium (6%) and low (3%). Navigation performance was scored as latency in walk initiation, walk time to reach goal and the number of obstacle contacts. The results revealed a linear relationship between log FOV and the two time measures, log latency and log walk time. The slopes of the linear regressions for log latency and log walk time ranged between -0.11 and -0.41. Critical points were computed from the non-linear relationships found between the number of obstacle contacts and FOV. The critical points for efficient navigation were FOVs of 32.1 degrees , 18.4 degrees and 10.9 degrees (diam.) for low, medium and high image contrast levels, respectively, highlighting the importance of contrast on the size of the FOV required for efficient navigation. Neither binocularity nor image chromaticity significantly affected navigation performance. The findings of this study have important implications in the design and prescription of head mounted displays intended to augment navigation performance.

Dynamics of Retinal Function after Multiple Photodynamic Therapies in Age-Related Macular Degeneration: A Report of Cases

PURPOSE

To monitor retinal function after multiple laser treatments by photodynamic therapy (PDT) with the multifocal electroretinogram (mfERG) in age-related macular degeneration (AMD).

METHODS

Five eyes of five subjects with AMD were investigated before the first and 1 month after each of three PDT treatments. Function was assessed using the cone- and rod-mediated mfERG, high-contrast distance visual acuity, central visual fields and contrast sensitivity. For each subject the local first-order mfERG results before treatment were used as a template and fitted against the local post-treatment results (Matlab, Mathworks).

RESULTS

We found transient reduction of the cone- and rod-mediated amplitudes between the first and second treatments but stable or improved mfERG function in four of five eyes for the cone-mediated mfERG and in all eyes for the rod-mediated mfERG after three treatments. Visual acuities and contrast sensitivities remained stable between treatments in four and two eyes respectively, whereas visual fields showed substantially higher mean defects in two subjects after all treatments.

CONCLUSION

As found in previous studies of the cone-mediated mfERG after one PDT treatment, objective function was stabilized after multiple treatments in this case report. Similarly, although poor at baseline, rod-mediated function was not further compromised. Transiently reduced amplitudes after 1 month possibly reflected choroidal hypoperfusion. A larger sample size is needed to confirm if additional evaluation using electrophysiological criteria might be helpful in re-treatment decisions during PDT.

Intermediate spatial frequency letter contrast sensitivity: its relation to visual resolution before and during amblyopia treatment

We examined the loss of letter contrast sensitivity (LCS) measured using the Pelli-Robson chart, and the extent to which any such loss was modulated by spectacle wear and occlusion therapy in children participating in an amblyopia treatment trial. Their initial mean interocular difference in logMAR acuity was approximately three times that of their LCS (0.45 vs 0.14 log units). Log LCS was weakly though significantly correlated with logMAR visual acuity (VA) for all VAs better than 0.90 (r = -0.19, 95% CI: -0.28 to -0.10) whereas for all VAs of 0.90 or poorer, log LCS was markedly and significantly correlated with VA (r = -0.72, 95% CI: -0.83 to -0.53). LCS in those children with a > or =0.1 log unit interocular difference on this test improved commensurately with VA during treatment. We conjecture that the spatial visual loss in all but the most severe amblyopes occurs in an area of resolution and contrast space that lies beyond that sampled by the Pelli-Robson chart.

An evaluation of the Mars Letter Contrast Sensitivity Test

PURPOSE

The Mars Letter Contrast Sensitivity Test (initially known as the Lighthouse Letter Contrast Sensitivity Test) is similar in design to the Pelli-Robson Test but may offer several advantages. This study evaluates the repeatability of the Mars test and its agreement with the Pelli-Robson test in normal and low-vision subjects.

METHODS

Fifty-four subjects were tested (age 22-86 years), including 20 normally sighted young adults, 17 normally sighted older adults, and 17 adults with low vision (20/16 to 20/250). Subjects were tested with both contrast sensitivity tests and with the ETDRS visual acuity chart. After a short break, subjects were retested with an alternate form of each contrast sensitivity test. The chart forms used (two Pelli-Robson and three Mars) and the order of testing were varied systematically. Testing was monocular with habitual correction and, for subjects over 40 years of age, included appropriate near add. Letter-by-letter scoring was used for both tests. Repeatability and agreement were assessed by determining the 95% limits of agreement (LoA): +/- 1.96 standard deviations of the differences between administrations or tests.

RESULTS

The Mars test showed excellent agreement with the Pelli-Robson test, with 95% LoA of +/- 0.21 log units for all subjects. The Mars test was similarly repeatable (95% LoA = +/-0.20 log units) to the Pelli-Robson test (95% LoA = +/-0.20 log units) among all subjects.

CONCLUSION

The new Mars Letter Contrast Sensitivity Test shows excellent agreement with the Pelli-Robson test and has similar repeatability. There are subtle differences in the actual contrast levels on different forms of the Mars test, and adjusting for these differences leads to superior repeatability of the Mars test. Thus, the Mars test may be a useful alternative to the Pelli-Robson test offering several advantages, including smaller size, improved durability, and ease of use.

Monitoring retinal function in early age-related maculopathy: visual performance after 1 year

PURPOSE

To monitor visual performance in early age-related maculopathy (ARM).

METHODS

We measured monocular visual function-high-contrast visual acuity (HC-VA), central visual fields (mean sensitivity, MS), colour vision (desaturated Panel D-15), Pelli-Robson (P-R), and cone- and rod-mediated multifocal electroretinograms (mfERG) in 13 ARM subjects and 13 age-matched control subjects with normal fundi at baseline and after 1 year. All had visual acuity of 6/12 or better. The mfERG data were compared to templates derived from the control group at baseline. We analysed the mfERG results by averaging the central and peripheral fields and the superior and inferior fields (CP and SI methods) and by calculating the local responses.

RESULTS

The mean rod-mediated responses were significantly delayed in the ARM group for the CP (P=0.04) and the SI methods (P=0.03) at baseline compared to the control group. This did not change significantly after 1 year, whereas the mean cone-mediated responses were within the normal range at both times. Although the local analysis revealed lower amplitudes for the cone- and rod-mediated responses at baseline this was not found after 1 year and only the local rod-mediated latencies were delayed at both times (P<0.01). HC-VA, desaturated Panel D-15 and P-R were significantly worse in the ARM group (P< or =0.01) at baseline but did not show further significant deterioration. Progressive fundus changes were found in only two subjects (18%).

CONCLUSION

Although there was significant impairment of retinal function in early ARM at baseline no further deterioration was evident after 1 year.

Reliability and Validity of the Melbourne Edge Test and High/Low Contrast Visual Acuity Chart

PURPOSE

The purposes of the study were to investigate the test-retest reliability and the validity of new versions of the Melbourne Edge Test (MET) and the High/Low Contrast Visual Acuity (H/LCVA) chart and to investigate the agreement between the original and new versions.

METHODS

The MET original photographic version, MET new light box version, H/LCVA Chart original photographic version, H/LCVA Chart new printed version, and the Pelli-Robson chart were administered twice to one eye of 22 subjects with low vision and 20 soft contact lenses wearers.

RESULTS

For the low vision group, the test-retest 95% limits of agreement were +/- 5.2 dB for the MET new light box version and +/- 0.39 logarithm of the minimum angle of resolution (logMAR) for the LCVA component of the H/LCVA new printed version. For the soft contact lens group, the test-retest 95% limits of agreement were +/- 2.1 dB for the MET new light box version and +/- 0.26 logMAR for the LCVA component of the H/LCVA new printed version. Moderate to high correlations were obtained between contrast sensitivity tests, thus providing evidence of validity. Scores obtained for the new test versions were significantly higher than the original versions (p < 0.01).

CONCLUSIONS

Of all the tests administered, the MET original photographic version and the Pelli-Robson Chart had the highest test-retest reliability for the low vision group. For the soft contact lens group, the H/LCVA original version (low contrast letters, 18% Weber) and the Pelli-Robson Chart had the highest reliability.

Clinical Testing of Contrast Sensitivity in Children: Age-related Norms and Validity

PURPOSE

The Hiding Heidi (HH) test and the LEA low-contrast symbols are two commercially available charts of contrast sensitivity (CS) for children. However, there are no published normal data and no indication of how CS measured by these charts relates to other measures of CS. In this study, normal age-related data for both tests are reported, and validity against the Pelli-Robson (PR) chart is measured.

METHODS

Eighty-eight normally sighted children were divided into four age groups: 1 to <2.5 years, 2.5 to <4 years, 4 to <6 years, and 6 to <8 years. An adult group with normal vision and with low vision also took part. CS was measured with the HH test, the LEA symbols at 1 m and 28 cm, and the PR chart, as the child's ability permitted. Because there were obvious differences between the contrast levels of the PR chart and the nominal contrast for the children's charts, each contrast level for the children's tests was recalibrated.

RESULTS

The HH test and the LEA symbols at 28 cm and 1 m all showed a floor effect; that is, most children of all ages correctly responded to the lowest contrast. The median CS for the LEA symbols at 28 cm and 1 m was 2.22 log CS, which was 1.65 when recalibrated. There was a significant difference of PR CS between the 6- to <8-year-olds and adults (p < 0.001). Of the children's charts, the LEA symbols at 28 cm, once recalibrated for contrast, had the best agreement with the PR chart.

CONCLUSION

The LEA and HH charts cannot measure a true contrast threshold for children with normal vision because of the floor effect. The LEA symbols at 28 cm gave the most useful information, once recalibrated for contrast, and may be useful to predict performance of children with low vision, when CS is likely to be compromised.

Normal Values for Photopic and Mesopic Letter Contrast Sensitivity

PURPOSE

The exponential increase of patients having refractive surgery has increased the number of patients with night vision disturbances, such as decreased contrast sensitivity. However, there are no standard contrast sensitivity scales in normal persons in the mesopic range. We describe Pelli-Robson contrast sensitivity under photopic and mesopic luminance conditions in a large Spanish population over a wide range of age groups to provide normal values. A further aim was to evaluate the effect of photopic visual acuity on photopic and mesopic contrast sensitivity.

METHODS

A cross-sectional study was performed on 292 participants stratified by age into six groups. Binocular contrast sensitivity was determined with best spectacle correction using the Pelli-Robson letter chart at 1 m under photopic (85 cd/m2) and mesopic (0.15 cd/m2) luminance conditions.

RESULTS

Phototopic letter contrast sensitivity began to decrease gradually from the 61 to 70-year-old age group onward, and for mesopic conditions, from the 51 to 60-year-old age group onward. The reduction in mean contrast sensitivity between the oldest and the youngest age groups was 0.20 log units (photopic) and 0.33 log units (mesopic). Loss in contrast sensitivity due to luminance (two successive triplets) increased slightly with age. Both photopic and mesopic letter contrast sensitivity significantly improved as photopic visual acuity increased.

CONCLUSIONS

Under mesopic conditions, Pelli-Robson contrast sensitivity began to decline 1 decade earlier than under photopic conditions and was affected by visual acuity. Normal values for mesopic contrast sensitivity could be of help in deciding whether mesopic function is normal or a decrease in contrast sensitivity is pathologic in nature.

The midget pathways of the primate retina

Midget ganglion cells in the foveal slope, parafovea, near periphery and far periphery of human and monkey retinas have been studied by electron microscopy (EM). Five human foveal ganglion cells were reconstructed and found to share input from seven midget bipolar cells. The OFF center ganglion cells were in a one to one relationship with their midget bipolar cells. But the ON center cells received input from two to three midget bipolar cells, of which one was dominant in terms of numbers of ribbon synapses directed at the midget ganglion cell dendrites. In the human parafovea every midget ganglion cell received input from only one midget bipolar cell (previously published, Kolb and DeKorver, 1991). At 4 mm of eccentricity, the near peripheral ON midget ganglion cell received input from three midget bipolar cells and thus from three cones. In far peripheral retina (12 mm) the ON midget ganglion cell received input from three to four midget bipolar cells. The peripheral midget bipolar cells probably contacted three cones each: therefore between nine and 12 cones could have input to such midget ganglion cell. The relationship of the increasing dendritic field size and increasing convergence of cones to the midget ganglion cells with eccentricity from the fovea is discussed in terms of color processing and resolution.

Vision and mobility performance of subjects with age-related macular degeneration

PURPOSE

To investigate the effects of age-related macular degeneration (ARMD) on mobility performance and to identify the vision determinants of mobility in subjects with ARMD.

METHODS

Walking speed and the number of obstacle contacts made on a 79-m indoor mobility course were measured in 21 subjects with ARMD and 11 age-matched subjects with normal vision. The mobility measures were transformed to percentage preferred walking speed and contacts score. The vision functions assessed included binocular visual acuity, contrast sensitivity, and visual field.

RESULTS

In this study, subjects with ARMD did not walk significantly slower or make significantly more obstacle contacts on the mobility course than the normally sighted subjects of similar age. Between 29% and 35% of the variance in the ARMD mobility performance was accounted for by visual field and contrast sensitivity measures. The most significant predictor of mobility performance scored as percentage preferred walking speed was the size of a binocular central scotoma.

CONCLUSION

As the size of a binocular central scotoma increases, mobility performance decreases.

Face recognition in age related macular degeneration: perceived disability, measured disability, and performance with a bioptic device

AIMS

(1) To explore the relation between performance on tasks of familiar face recognition (FFR) and face expression difference discrimination (FED) with both perceived disability in face recognition and clinical measures of visual function in subjects with age related macular degeneration (AMD). (2) To quantify the gain in performance for face recognition tasks when subjects use a bioptic telescopic low vision device.

METHODS

30 subjects with AMD (age range 66-90 years; visual acuity 0.4-1.4 logMAR) were recruited for the study. Perceived (self rated) disability in face recognition was assessed by an eight item questionnaire covering a range of issues relating to face recognition. Visual functions measured were distance visual acuity (ETDRS logMAR charts), continuous text reading acuity (MNRead charts), contrast sensitivity (Pelli-Robson chart), and colour vision (large panel D-15). In the FFR task, images of famous people had to be identified. FED was assessed by a forced choice test where subjects had to decide which one of four images showed a different facial expression. These tasks were repeated with subjects using a bioptic device.

RESULTS

Overall perceived disability in face recognition did not correlate with performance on either task, although a specific item on difficulty recognising familiar faces did correlate with FFR (r = 0.49, p<0.05). FFR performance was most closely related to distance acuity (r = -0.69, p<0.001), while FED performance was most closely related to continuous text reading acuity (r = -0.79, p<0.001). In multiple regression, neither contrast sensitivity nor colour vision significantly increased the explained variance. When using a bioptic telescope, FFR performance improved in 86% of subjects (median gain = 49%; p<0.001), while FED performance increased in 79% of subjects (median gain = 50%; p<0.01).

CONCLUSION

Distance and reading visual acuity are closely associated with measured task performance in FFR and FED. A bioptic low vision device can offer a significant improvement in performance for face recognition tasks, and may be useful in reducing the handicap associated with this disability. There is, however, little evidence for a correlation between self rated difficulty in face recognition and measured performance for either task. Further work is needed to explore the complex relation between the perception of disability and measured performance.

Does mobility performance of visually impaired adults improve immediately after orientation and mobility training?

BACKGROUND

Previous studies that have attempted to determine the effect of orientation and mobility training on mobility performance of visually impaired adults have had a number of limitations. With the inclusion of a control group of subjects, this study investigated the effect of orientation and mobility training on mobility performance of a group of visually impaired adults.

METHODS

Vision was measured binocularly as high- and low-contrast visual acuity, letter and edge contrast sensitivity, and Humphrey kinetic visual fields. The subjects' mobility performance was assessed as percentage preferred walking speed (PPWS) and error score before and after mobility training.

RESULTS

Orientation and mobility training did not enhance mobility performance compared with the control group, who did not receive training, when performance was measured immediately after training. PPWS improved for both groups with short-term practice only, but there was no improvement in error score due to either practice or training.

CONCLUSIONS

There was no immediate improvement in mobility performance of visually impaired adults after orientation and mobility training. Familiarity with the route may play an important role in measured improvement of mobility performance after orientation and mobility training.

A weighted version of the Melbourne Low-Vision ADL Index: a measure of disability impact

OBJECTIVE

To develop a version of the Melbourne Low-Vision ADL Index that measures the personal impact of disability in activities of daily living (ADL's). Also, to determine the relationship between clinical measures of vision impairment and disability impact.

METHODS

The Melbourne Low-Vision ADL Index (MLVAI) is a desk-based clinical assessment of disability in ADL's. Ability to perform each item is rated on a five-level descriptive scale from zero to four. In this study, the original version of the MLVAI was modified to measure disability impact. The simple modification involved weighting each item by the importance of that item to the person being tested. Importance was also rated on a five-level scale from zero to four. The validity and reliability of the Weighted Melbourne Low-Vision ADL Index (MLVAI(W)) was determined for 97 vision-impaired subjects in a cross-sectional study.

RESULTS

Cronbach's alpha coefficient indicated an internal reliability of 0.94, and an intraclass correlation coefficient indicated an overall reliability of 0.88. The standard error of measurement was 24.7 points (out of a possible score of 400). There was a statistically significant difference in test scores between normal subjects and vision-impaired subjects. All vision measures had a high, statistically significant correlation with MLVAI(W) score. Near-word acuity had the strongest correlation (r(s) = 0.78, p < 0.001), followed by Melbourne Edge Test contrast sensitivity (r(s) = -0.72, p < 0.001). Visual field had the weakest correlation (r(s) = -0.52, p < 0.001). The best predictive model of MLVAI(W) score incorporated the variables age, near-word acuity, and visual field. Together, these variables accounted for 65.1% of the variance in MLVAI(W) score.

CONCLUSIONS

The MLVAI is highly valid and reliable when weighted by a scale that reflects the personal importance of ADL's. The MLVAI(W) can provide information over and above that obtained with the usual clinical vision measures and may be used to assess low-vision patients and to measure low-vision rehabilitation outcomes. It is suggested that the assessment of disability using the original MLVAI and the assessment of the impact of disability using the MLVAI(W) should be kept separate to facilitate the clear interpretation of the outcomes of low-vision rehabilitation.

Reading performance in children with low vision

PURPOSE: While educators and optometrists are concerned with reading efficiency in children with low vision, in most low vision assessments, children's reading performance is assessed only by a brief evaluation of reading fluency. We examined the relationships between clinical vision measures and reading performance in children with low vision. METHODS: Subjects were 71 students with low vision, aged seven to 18 years. The vision and reading performance measures were: high contrast distance visual acuity, contrast sensitivity using both the Pelli-Robson and LH symbol charts, near text visual acuity and reading rates on a range of print sizes. RESULTS: Most children achieved maximum reading rate at print sizes between 2.5 and seven times larger than threshold print size. Maximum reading rate increased significantly with age and near visual acuity. There was no significant relationship between reading rate and contrast sensitivity. CONCLUSIONS: The majority of children with low vision can achieve near normal reading rates with magnification. Age is the strongest predictor of reading rate in children with low vision. They need print sizes well above threshold to achieve maximum reading rate. Routine contrast sensitivity testing of visually impaired students is not indicated for reading assessment.

Normal values for the Pelli-Robson contrast sensitivity test

PURPOSE

To define normal values for the Pelli-Robson contrast sensitivity test in different age groups.

SETTING

University Eye Clinic of Kuopio, Kuopio, Finland.

METHODS

Contrast sensitivity was measured with the Pelli-Robson contrast sensitivity test in 87 persons (60 women and 27 men) with a mean age of 34.5 years +/- 20.8 (SD) (range 6 to 75 years). Results were studied by age group (years): 6 to 9, 10 to 19, 20 to 29, 30 to 39, 40 to 49, 50 to 59, and 60 and older. Of 163 eyes, both were healthy in 76 persons and 1 was healthy in 11. Study participants consisted of members of the staff of the Kuopio University Hospital Eye Clinic, medical students at the Kuopio University, and patients of the Strabismus and General Ophthalmology Units of the Eye Clinic and their accompanying persons. Two test distances were used: 1 m and 3 m. Eyes were tested individually; thereafter, the test was done binocularly.

RESULTS

There were significant differences in logarithmic contrast sensitivity values among the age groups except on the test of the left eye at 1 m. The P values for the right eye at 1 m and 3 m, left eye at 1 m and 3 m, and both eyes at 1 m and 3 m were 0.003, 0.002, 0.19, 0.043, 0.037, and 0.003, respectively. The mean test results in 1 eye varied from 1.68 in the 60 year and older group to 1.84 in the 20 to 29 and 30 to 39 year groups. Binocularly, the variation was from 1.73 in the 40 year group to 1.99 in the 30 year group.

CONCLUSIONS

The Pelli-Robson contrast sensitivity test is a quick and reliable method in a clinical setting. Normal values of the test can be of help in evaluating cataract patients or patients having refractive surgery.

Repeatability and intercorrelations of standard vision tests as a function of age

PURPOSE

We assessed repeatability and intercorrelations of five standard vision tests in subjects with normal vision.

METHODS

Seventy-eight subjects (aged 21 to 68 years) completed five measurements each of high- and low-contrast visual acuity, near visual acuity and contrast sensitivity (Pelli-Robson chart).

RESULTS

Except for correlations between high- and low-contrast visual acuity (r = 0.78), intercorrelations between tests were low to moderate (r < 0.5). For each measure, variability for the group was about one line on the chart (one triplet for the Pelli-Robson chart) and the minimum variability for an individual subject was about one third of this. On average, 1 to 2 lines can be expected to be lost over the normal lifespan on each test. Variability in responses did not increase significantly with age for any test.

CONCLUSIONS

The criterion for judging change on commonly used clinical vision tests is about one line for subjects over a wide age range.