We don't all look the same; detailed examination of peripheral looking strategies after simulated central vision loss

Real-time assessment of eye movements during reading in individuals with central vision loss using eye-tracking technology: A pilot study

PURPOSE

To assess eye movements during reading in individuals with central vision loss using eye-tracking technology and an ad-hoc calibration method.

MATERIALS AND METHODS

This pilot case control study included 17 participants (61.7 ± 8.8 years), 12 women and 5 men) and 17 controls, matched for age and sex. Two ad hoc computer-based tests were administered to analyze eye movements during a single-letter reading task and continuous reading task, measured using a 60 Hz eye-tracking device.

RESULTS

Individuals with central vision loss showed differences from the control group, with an increase in the number of fixations, saccadic movements, and regressions, whereas the amplitude and speed of saccades were lower. This resulted in longer reading times in the study group.

CONCLUSION

The results revealed lower performance in eye movements skills during reading tasks in patients with central vision loss. Eye-tracking devices allow the objective binocular assessment of eye movements during reading tasks. Our ad-hoc calibration method ensured minimal data loss and high validity, enhancing the reliability of the assessments. This information can be used to develop optimal and personalized functional and visual rehabilitation programs.

Saccadic re-referencing training with gaze-contingent FRL-'fixation': Effects of scotoma type and size adaptation

Foveal vision loss makes the fovea as saccadic reference point maladaptive. Training programs have been proposed that shift the saccadic reference point from the fovea to an extrafoveal location, just outside the area of vision loss. We used a visual search task to train normal-sighted participants to fixate target items with a predetermined 'forced retinal location' (FRL) adjacent to a simulated central scotoma. We found that training was comparatively successful for scotomata that had either a sharp or blurry demarcation from the background. Completing the task with sharp-edged scotoma resulted in overall higher training gains. Training with blurry-edged scotoma, however, yielded overall better results when scotoma size was increased after training and participants needed to adapt to a more eccentric FRL, as may be necessary in patients with progressive degenerative eye diseases.

Efficient versus inefficient visual search as training for saccadic re-referencing to an extrafoveal location

Central vision loss is one of the leading causes of visual impairment in the elderly and its frequency is increasing. Without formal training, patients adopt an unaffected region of the retina as a new fixation location, a preferred retinal locus (PRL). However, learning to use the PRL as a reference location for saccades, that is, saccadic re-referencing, is protracted and time-consuming. Recent studies showed that training with visual search tasks can expedite this process. However, visual search can be driven by salient external features - leading to efficient search, or by internal goals, usually leading to inefficient, attention-demanding search. We compared saccadic re-referencing training in the presence of a simulated central scotoma with either an efficient or an inefficient visual search task. Participants had to respond by fixating the target with an experimenter-defined retinal location in the lower visual field. We observed that comparable relative training gains were obtained in both tasks for a number of behavioral parameters, with higher training gains for the trained task, compared to the untrained task. The transfer to the untrained task was only observed for some parameters. Our findings thus confirm and extend previous research showing comparable efficiency for exogenously and endogenously driven visual search tasks for saccadic re-referencing training. Our results also show that transfer of training gains to related tasks may be limited and needs to be tested for saccadic re-referencing-training paradigms to assess its suitability as a training tool for patients.

Consistency of preferred retinal locus across tasks and participants trained with a simulated scotoma

After loss of central vision following retinal pathologies such as macular degeneration (MD), patients often adopt compensatory strategies including developing a "preferred retinal locus" (PRL) to replace the fovea in tasks involving fixation. A key question is whether patients develop multi-purpose PRLs or whether their oculomotor strategies adapt to the demands of the task. While most MD patients develop a PRL, clinical evidence suggests that patients may develop multiple PRLs and switch between them according to the task at hand. To understand this, we examined a model of central vision loss in normally seeing individuals and tested whether they used the same or different PRLs across tasks after training. Nineteen participants trained for 10 sessions on contrast detection while in conditions of gaze-contingent, simulated central vision loss. Before and after training, peripheral looking strategies were evaluated during tasks measuring visual acuity, reading abilities and visual search. To quantify strategies in these disparate, naturalistic tasks, we measured and compared the amount of task-relevant information at each of 8 equally spaced, peripheral locations, while participants performed the tasks. Results showed that some participants used consistent viewing strategies across tasks whereas other participants' strategies differed depending on task. This novel method allows quantification of peripheral vision use even in relatively ecological tasks. These results represent one of the first examinations of peripheral viewing strategies across tasks in simulated vision loss. Results suggest that individual differences in peripheral looking strategies following simulated central vision loss may model those developed in pathological vision loss.

A gaze-contingent saccadic re-referencing training with simulated central vision loss

Patients with central vision loss (CVL) adopt an eccentric retinal location for fixation, a preferred retinal location (PRL), to compensate for vision loss at the fovea. Although most patients with CVL are able to rapidly use a PRL instead of the fovea, saccadic re-referencing to a PRL develops slowly. Without re-referencing, saccades land the saccade target in the scotoma. This results in corrective saccades and leads to inefficient visual exploration. Here, we tested a new method to train saccadic re-referencing. Healthy participants performed gaze-contingent visual search tasks with simulated central scotoma in which participants had to fixate targets with an experimenter-defined forced retinal location (FRL). In experiment 1, we compared single-target search and foraging search tasks in the course of five training sessions. Results showed that both tasks improved the efficiency of gaze sequences and led to saccadic re-referencing to the FRL. In experiment 2, we trained participants extensively for 25 sessions, both with and without a gaze-contingent FRL-marker visible during training. After extensive training, observers' performance approached that of foveal vision. Thus, gaze-contingent FRL-fixation may become an efficient tool for saccadic re-referencing training in patients with central vision loss.

Training With Simulated Scotoma Leads to Behavioral Improvements Through at Least Two Distinct Mechanisms

Purpose

Individuals with central vision loss due to macular degeneration (MD) often spontaneously develop a preferred retinal locus (PRL) outside the area of retinal damage, which they use instead of the fovea. Those who develop a stable PRL are more successful at coping with their vision loss. However, it is unclear whether improvements in visual performance at the PRL are specific to that retinal location or are also observed in other parts of the retina. Perceptual learning literature suggests that the retinal specificity of these effects provides insight about the mechanisms involved. Better understanding of these mechanisms is necessary for the next generation of interventions and improved patient outcomes.

Methods

To address this, we trained participants with healthy vision to develop a trained retinal locus (TRL), analogous to the PRL in patients. We trained 24 participants on a visual search task using a gaze-contingent display to simulate a central scotoma.

Results

Results showed retinotopically specific improvements in visual crowding only at the TRL; however, visual acuity improved in both the TRL and in an untrained retinal locus.

Conclusions

These results suggest that training with an artificial scotoma involves multiple mechanistic levels, some location-specific and some not, and that simulated scotoma training paradigms likely influence multiple mechanisms simultaneously. Eye movement analysis suggests that the non-retinotopic learning effects may be related to improvements in the capability to maintain a stable gaze during stimulus presentation. This work suggests that effective interventions promoting peripheral viewing may influence multiple mechanisms simultaneously.

Oculomotor changes following learned use of an eccentric retinal locus

People with bilateral central vision loss sometimes develop a new point of oculomotor reference called a preferred retinal locus (PRL) that is used for fixating and planning saccadic eye movements. How individuals develop and learn to effectively use a PRL is still debated; in particular, the time course of learning to plan saccades using a PRL and learning to stabilize peripheral fixation at the desired location. Here we address knowledge limitations through research describing how eye movements change as a person learns to adopt an eccentric retinal locus. Using a gaze-contingent, eye tracking-guided paradigm to simulate central vision loss, 40 participants developed a PRL by engaging in an oculomotor and visual recognition task. After 12 training sessions, significant improvements were observed in six eye movement metrics addressing different aspects involved in learning to use a PRL: first saccade landing dispersion, saccadic re-referencing, saccadic precision, saccadic latency, percentage of useful trials, and fixation stability. Importantly, our analyses allowed separate examination of the stability of target fixation separately from the dispersion and precision of the landing location of saccades. These measures explained 50% of the across-subject variance in accuracy. Fixation stability and saccadic precision showed a strong, positive correlation. Although there was no statistically significant difference in rate of learning, individuals did tend to learn saccadic precision faster than fixation stability. Saccadic precision was also more associated with accuracy than fixation stability for the behavioral task. This suggests effective intervention strategies in low vision should address both fixation stability and saccadic precision.

How central and peripheral vision influence focal and ambient processing during scene viewing

Central and peripheral vision carry out different functions during scene processing. The ambient mode of visual processing is more likely to involve peripheral visual processes, whereas the focal mode of visual processing is more likely to involve central visual processes. Although the ambient mode is responsible for navigating space and comprehending scene layout, the focal mode gathers detailed information as central vision is oriented to salient areas of the visual field. Previous work suggests that during the time course of scene viewing, there is a transition from ambient processing during the first few seconds to focal processing during later time intervals, characterized by longer fixations and shorter saccades. In this study, we identify the influence of central and peripheral vision on changes in eye movements and the transition from ambient to focal processing during the time course of scene processing. Using a gaze-contingent protocol, we restricted the visual field to central or peripheral vision while participants freely viewed scenes for 20 seconds. Results indicated that fixation durations are shorter when vision is restricted to central vision compared to normal vision. During late visual processing, fixations in peripheral vision were longer than those in central vision. We show that a transition from more ambient to more focal processing during scene viewing will occur even when vision is restricted to only central vision or peripheral vision.

Assessing the contrast sensitivity function in myopic parafovea: A quick contrast sensitivity functions study

Purpose

Compare peripheral contrast sensitivity functions (CSF) between myopes and emmetropes to reveal potential myogenic risks during emmetropization.

Materials and methods

This observational, cross-sectional, non-consecutive case study included data from 19 myopes (23.42 ± 4.03 years old) and 12 emmetropes (22.93 ± 2.91 years old) who underwent central and peripheral quick CSF (qCSF) measurements. Summary CSF metrics including the cut-off spatial frequency (cut-off SF), area under log CSF (AULCSF), low-, intermediate-, and high-spatial-frequency AULCSFs (l-, i-, and h-SF AULCSFs), and log CS at 19 SFs in the fovea and 15 peripheral locations (superior, inferior, temporal, and nasal quadrants at 6, 12, 18, and 24° eccentricities, excluding the physiological scotoma at 18°) were analyzed with 3-way and 4-way between-subjects analysis of variance (ANOVA) (α = 0.05).

Results

Three-way ANOVA showed that myopes had significantly increased AULCSF at 6° (mean difference, 0.08; 95% CI, 0.02–0.13; P = 0.007) and 12° (mean difference, 0.09; 95% CI, 0.03–0.14; P = 0.003). Log CS at all 19 SFs were higher in the myopia group compared to the normal group (mean differencesuperior, 0.02; 95% CI, 0.01–0.20; P = 0.02 and mean differenceinferior, 0.11; 95% CI, 0.02–0.21; P = 0.01) at 12°. The h-SF AULCSF at 6° (mean differenceinferior, 1.27; 95% CI, 0.32–2.22; P = 0.009) and i-SF AULCSF at 12° (mean differencesuperior, 5.31; 95% CI, 4.35–6.27; P < 0.001; mean differenceinferior, 1.14; 95% CI, 0.19–2.10; P = 0.02) were higher in myopia vs. normal group.

Conclusion

We found myopia increased contrast sensitivity in superior and inferior visual field locations at 6° parafoveal and 12° perifoveal regions of the retina. The observation of increased contrast sensitivities within the macula visual field in myopia might provide important insights for myopia control during emmetropization.

Oculomotor responses of the visual system to an artificial central scotoma may not represent genuine visuomotor adaptation

Patients with central vision loss often adopt a location outside their scotoma as the new reference for vision, the preferred retinal locus (PRL). The development of a PRL is important not only for the rehabilitation of patients with central vision loss, but also helps us better understand how the brain adapts to the lack of visual input. Many investigators studied this question using a gaze-contingent display paradigm by imposing an artificial scotoma to simulate central vision loss for normally sighted subjects, with an important assumption that the "PRL" thus developed is the result of visuomotor adaptation, as is the case for people with a real scotoma. In this study, we tested the validity of this assumption. We used a gaze-contingent display combined with an artificial scotoma to first train normally sighted subjects to develop a "PRL" for saccade eye movements. Then, we compared the properties of saccades when the artificial scotoma was randomly turned off or on. When the artificial scotoma was absent, subjects automatically reverted to using their fovea, with a shorter saccade latency. Our findings suggest that the development of a "PRL" in response to an artificial scotoma may represent a strategy, instead of a genuine visuomotor adaptation.

Perspectives on the Combined Use of Electric Brain Stimulation and Perceptual Learning in Vision

A growing body of literature offers exciting perspectives on the use of brain stimulation to boost training-related perceptual improvements in humans. Recent studies suggest that combining visual perceptual learning (VPL) training with concomitant transcranial electric stimulation (tES) leads to learning rate and generalization effects larger than each technique used individually. Both VPL and tES have been used to induce neural plasticity in brain regions involved in visual perception, leading to long-lasting visual function improvements. Despite being more than a century old, only recently have these techniques been combined in the same paradigm to further improve visual performance in humans. Nonetheless, promising evidence in healthy participants and in clinical population suggests that the best could still be yet to come for the combined use of VPL and tES. In the first part of this perspective piece, we briefly discuss the history, the characteristics, the results and the possible mechanisms behind each technique and their combined effect. In the second part, we discuss relevant aspects concerning the use of these techniques and propose a perspective concerning the combined use of electric brain stimulation and perceptual learning in the visual system, closing with some open questions on the topic.

Perspective on Vision Science-Informed Interventions for Central Vision Loss

Pathologies affecting central vision, and macular degeneration (MD) in particular, represent a growing health concern worldwide, and the leading cause of blindness in the Western World. To cope with the loss of central vision, MD patients often develop compensatory strategies, such as the adoption of a Preferred Retinal Locus (PRL), which they use as a substitute fovea. However, visual acuity and fixation stability in the visual periphery are poorer, leaving many MD patients struggling with tasks such as reading and recognizing faces. Current non-invasive rehabilitative interventions are usually of two types: oculomotor, aiming at training eye movements or teaching patients to use or develop a PRL, or perceptual, with the goal of improving visual abilities in the PRL. These training protocols are usually tested over a series of outcome assessments mainly measuring low-level visual abilities (visual acuity, contrast sensitivity) and reading. However, extant approaches lead to mixed success, and in general have exhibited large individual differences. Recent breakthroughs in vision science have shown that loss of central vision affects not only low-level visual abilities and oculomotor mechanisms, but also higher-level attentional and cognitive processes. We suggest that effective interventions for rehabilitation after central vision loss should then not only integrate low-level vision and oculomotor training, but also take into account higher level attentional and cognitive mechanisms.

A comparison of reading, in people with simulated and actual central vision loss, with static text, horizontally scrolling text, and rapid serial visual presentation

Reading with central vision loss (CVL), as caused by macular disease, may be enhanced by presenting text using dynamic formats such as horizontally scrolling text or rapid serial visual presentation (RSVP). The rationale for these dynamic text formats is that they can be read while holding gaze away from the text, potentially supporting reading while using the eccentric viewing strategy. This study was designed to evaluate the practice of reading with CVL, with passages of text presented as static sentences, with horizontal scrolling sentences, or as single-word RSVP. In separate studies, normally sighted participants with a simulated (artificial) central scotoma, controlled by an eye-tracker, or participants with CVL resulting from macular degeneration read passages of text using the eccentric viewing technique. Comprehension was better overall with scrolling text when reading with a simulated CVL, whereas RSVP produced lower overall comprehension and high error rates. Analysis of eye movement behavior showed that participants consistently adopted a strategy of making multiple horizontal saccades on the text itself. Adherence to using eccentric viewing was better with RSVP, but this did not translate into better reading performance. Participants with macular degeneration and an actual CVL also showed the highest comprehension and lowest error rates with scrolling text and the lowest comprehension and highest errors with RSVP. We conclude that scrolling text can support effective reading in people with CVL and has potential as a reading aid.

Simulating Macular Degeneration to Investigate Activities of Daily Living: A Systematic Review

Purpose: Investigating difficulties during activities of daily living is a fundamental first step for the development of vision-related intervention and rehabilitation strategies. One way to do this is through visual impairment simulations. The aim of this review is to synthesize and assess the types of simulation methods that have been used to simulate age-related macular degeneration (AMD) in normally sighted participants, during activities of daily living (e.g., reading, cleaning, and cooking).

Methods: We conducted a systematic literature search in five databases and a critical analysis of the advantages and disadvantages of various AMD simulation methods (following PRISMA guidelines). The review focuses on the suitability of each method for investigating activities of daily living, an assessment of clinical validation procedures, and an evaluation of the adaptation periods for participants.

Results: Nineteen studies met the criteria for inclusion. Contact lenses, computer manipulations, gaze contingent displays, and simulation glasses were the main forms of AMD simulation identified. The use of validation and adaptation procedures were reported in approximately two-thirds and half of studies, respectively.

Conclusions: Synthesis of the methodology demonstrated that the choice of simulation has been, and should continue to be, guided by the nature of the study. While simulations may never completely replicate vision loss experienced during AMD, consistency in simulation methodology is critical for generating realistic behavioral responses under vision impairment simulation and limiting the influence of confounding factors. Researchers could also come to a consensus regarding the length and form of adaptation by exploring what is an adequate amount of time and type of training required to acclimatize participants to vision impairment simulations.

Is Peripheral Motion Detection Affected by Myopia?

Purpose

The current study was to investigate whether myopia affected peripheral motion detection and whether the potential effect interacted with spatial frequency, motion speed, or eccentricity.

Methods

Seventeen young adults aged 22–26 years participated in the study. They were six low to medium myopes [spherical equivalent refractions −1.0 to −5.0 D (diopter)], five high myopes (<-5.5 D) and six emmetropes (+0.5 to −0.5 D). All myopes were corrected by self-prepared, habitual soft contact lenses. A four-alternative forced-choice task in which the subject was to determine the location of the phase-shifting Gabor from the four quadrants (superior, inferior, nasal, and temporal) of the visual field, was employed. The experiment was blocked by eccentricity (20° and 27°), spatial frequency (0.6, 1.2, 2.4, and 4.0 cycles per degree (c/d) for 20° eccentricity, and 0.6, 1.2, 2.0, and 3.2 c/d for 27° eccentricity), as well as the motion speed [2 and 6 degree per second (d/s)].

Results

Mixed-model analysis of variances showed no significant difference in the thresholds of peripheral motion detection between three refractive groups at either 20° (F[2,14] = 0.145, p = 0.866) or 27° (F[2,14] = 0.475, p = 0.632). At 20°, lower motion detection thresholds were associated with higher myopia (p < 0.05) mostly for low spatial frequency and high-speed targets in the nasal and superior quadrants, and for high spatial frequency and high-speed targets in the temporal quadrant in myopic viewers. Whereas at 27°, no significant correlation was found between the spherical equivalent and the peripheral motion detection threshold under all conditions (all p > 0.1). Spatial frequency, speed, and quadrant of the visual field all showed significant effect on the peripheral motion detection threshold.

Conclusion

There was no significant difference between the three refractive groups in peripheral motion detection. However, lower motion detection thresholds were associated with higher myopia, mostly for low spatial frequency targets, at 20° in myopic viewers.