Comparison of unifocal, flicker, and multifocal pupil perimetry methods in healthy adults

Does pseudoneglect influence pupillary light or dark response?

Pupillary light response (PLR) is modulated by the allocation of spatial attention. Larger pupil constrictions for bright stimuli presented on the left side are considered indicative of pseudoneglect, a subtle attentional bias observed in neurotypical populations. This study aimed to replicate this effect using the split-screen method-a newly introduced measure of spatial attentional bias-while accounting for factors such as contraction anisocoria by recording from both pupils. Additionally, we introduced conditions with and without competing stimuli (a black patch on the opposite side to the original white patch that is supposed to elicit pupil contraction) to investigate the role of visual competition in PLR modulation and explored the pupillary dark response (PDR) to assess whether attentional biases affect pupil dilation. Contrary to our hypothesis, we did not observe a significant pseudoneglect effect, as pupil constriction was not consistently greater for left-sided stimuli. We found clear evidence for contraction anisocoria, whereby ipsilateral stimuli produce stronger constrictions than contralateral stimuli, thus highlighting the need to account for this physiological effect in future studies. Regarding PDR, we did not find significant attentional modulation or evidence of dilation anisocoria as pupil dilation amplitudes were similar across both hemifields. These findings suggest that although the split-screen method may reveal physiological asymmetries like anisocoria, its sensitivity to attentional biases in neurotypical populations still requires further investigation.

Diagnostic performance of pupil perimetry in detecting hemianopia under standard and virtual reality viewing conditions

PURPOSE

To determine the diagnostic performance and reliability of two pupil perimetry (PP) methods in homonymous hemianopia.

METHODS

This cross-sectional monocenter cohort study performed gaze-contingent flicker PP (gcFPP) and a virtual reality version of gcFPP (VRgcFPP) twice on separate occasions in all patients suffering from homonymous hemianopia due to neurological impairment. The main outcomes were (1) test accuracy and (2) test-retest reliability: (1) was measured through area under the receiver operating characteristics curve (AUC) calculation of (VR)gcFPP results with comparators being SAP and healthy controls, respectively; (2) was evaluated by comparing tests 1 and 2 of both methods within patients.

RESULTS

Both gcFPP and VRgcFPP were performed in 15 patients (12 males, MAge = 57, SDAge = 15) and 17 controls (6 males, MAge = 53, SDAge = 12). Mean test accuracy was good in separating damaged from intact visual field regions (gcFPP: Mauc = 0.83, SDauc = 0.09; VRgcFPP: Mauc = 0.69, SDauc = 0.13) and in separating patients from controls (gcFPP: Mauc = 0.92, SDauc = 0.13; VRgcFPP: Mauc = 0.96, SDauc = 0.15). A high test-retest reliability was found for the proportion intact versus damaged visual field (gcFPP: r = 0.95, P < .001, VRgcFPP: r = 1.00, P < .001).

CONCLUSIONS

Overall, these results can be summarized as follows: (1) the comparison of pupil response amplitudes between intact versus damaged regions per patient indicate that gcFPP allows for cleaner imaging of intact versus damaged visual field regions than VRgcFPP, (2) the comparisons of average differences in intact versus damaged amplitudes between patients and controls demonstrate high diagnostic performance of both gcFPP and VRgcFPP, and (3) the test-retest reliabilities confirm that both gcFPP and VRgcFPP reliably and consistently measure defects in homonymous hemianopia. KEY  MESSAGES: What is known Standard automated perimetry is the current gold standard for visual field examination, but not always suited for the evaluation of the VF in neurologically impaired patients. Pupil perimetry consists of the measurement of pupillary responses to light stimuli as a measure of visual sensitivity. What is new This study reports the highest diagnostic accuracy of pupil perimetry so far in patients with homonymous hemianopia. Gaze-contingent flicker pupil perimetry reliably and consistently measures defects in homonymous hemianopia under standard and virtual reality viewing conditions.

Mapping simulated visual field defects with movie-viewing pupil perimetry

PURPOSE

Assessing the quality of the visual field is important for the diagnosis of ophthalmic and neurological diseases and, consequently, for rehabilitation. Visual field defects (VFDs) are typically assessed using standard automated perimetry (SAP). However, SAP requires participants to understand instructions, maintain fixation and sustained attention, and provide overt responses. These aspects make SAP less suitable for very young or cognitively impaired populations. Here we investigate the feasibility of a new and less demanding form of perimetry. This method assesses visual sensitivity based on pupil responses while performing the perhaps simplest task imaginable: watching movies.

METHOD

We analyzed an existing dataset, with healthy participants (n = 70) freely watching movies with or without gaze-contingent simulated VFDs, either hemianopia (left- or right-sided) or glaucoma (large nasal arc, small nasal arc, and tunnel vision). Meanwhile, their gaze and pupil size were recorded. Using a recently published toolbox (Open-DPSM), we modeled the relative contribution of visual events to the pupil responses to indicate relative visual sensitivity across the visual field and to dissociate between conditions with and without simulated VFDs.

RESULT

Conditions with and without simulated VFDs could be dissociated, with an AUC ranging from 0.85 to 0.97, depending on the specific simulated VFD condition. In addition, the dissociation was better when including more movies in the modeling but the model with as few movies as 10 movies was sufficient for a good classification (AUC ranging from 0.84 to 0.96).

CONCLUSION

Movie-viewing pupil perimetry is promising in providing complementary information for the diagnosis of VFDs, especially for those who are unable to perform conventional perimetry.

Method to Quickly Map Multifocal Pupillary Response Fields (mPRF) Using Frequency Tagging

We present a method for mapping multifocal Pupillary Response Fields in a short amount of time using a visual stimulus covering 40° of the visual angle divided into nine contiguous sectors simultaneously modulated in luminance at specific, incommensurate, temporal frequencies. We test this multifocal Pupillary Frequency Tagging (mPFT) approach with young healthy participants (N = 36) and show that the spectral power of the sustained pupillary response elicited by 45 s of fixation of this multipartite stimulus reflects the relative contribution of each sector/frequency to the overall pupillary response. We further analyze the phase lag for each temporal frequency as well as several global features related to pupil state. Test/retest performed on a subset of participants indicates good repeatability. We also investigate the existence of structural (RNFL)/functional (mPFT) relationships. We then summarize the results of clinical studies conducted with mPFT on patients with neuropathies and retinopathies and show that the features derived from pupillary signal analyses, the distribution of spectral power in particular, are homologous to disease characteristics and allow for sorting patients from healthy participants with excellent sensitivity and specificity. This method thus appears as a convenient, objective, and fast tool for assessing the integrity of retino-pupillary circuits as well as idiosyncrasies and permits to objectively assess and follow-up retinopathies or neuropathies in a short amount of time.

Effects of Stimulus Luminance, Stimulus Color and Intra-Stimulus Color Contrast on Visual Field Mapping in Neurologically Impaired Adults Using Flicker Pupil Perimetry

Purpose

We improve pupillary responses and diagnostic performance of flicker pupil perimetry through alterations in global and local color contrast and luminance contrast in adult patients suffering from visual field defects due to cerebral visual impairment (CVI).

Methods

Two experiments were conducted on patients with CVI (Experiment 1: 19 subjects, age M and SD 57.9 ± 14.0; Experiment 2: 16 subjects, age M and SD 57.3 ± 14.7) suffering from absolute homonymous visual field (VF) defects. We altered global color contrast (stimuli consisted of white, yellow, cyan and yellow-equiluminant-to-cyan colored wedges) in Experiment 1, and we manipulated luminance and local color contrast with bright and dark yellow and multicolor wedges in a 2-by-2 design in Experiment 2. Stimuli consecutively flickered across 44 stimulus locations within the inner 60 degrees of the VF and were offset to a contrasting (opponency colored) dark background. Pupil perimetry results were compared to standard automated perimetry (SAP) to assess diagnostic accuracy.

Results

A bright stimulus with global color contrast using yellow (p= 0.009) or white (p= 0.006) evoked strongest pupillary responses as opposed to stimuli containing local color contrast and lower brightness. Diagnostic accuracy, however, was similar across global color contrast conditions in Experiment 1 (p= 0.27) and decreased when local color contrast and less luminance contrast was introduced in Experiment 2 (p= 0.02). The bright yellow condition resulted in highest performance (AUC M = 0.85 ± 0.10, Mdn = 0.85).

Conclusion

Pupillary responses and pupil perimetry's diagnostic accuracy both benefit from high luminance contrast and global but not local color contrast.

The Trade-Off Between Luminance and Color Contrast Assessed With Pupil Responses

Purpose

A scene consisting of a white stimulus on a black background incorporates strong luminance contrast. When both stimulus and background receive different colors, luminance contrast decreases but color contrast increases. Here, we sought to characterize the pattern of stimulus salience across varying trade-offs of color and luminance contrasts by using the pupil light response.

Methods

Three experiments were conducted with 17, 16, and 17 healthy adults. For all experiments, a flickering stimulus (2 Hz; alternating color to black) was presented superimposed on a background with a complementary color to the stimulus (i.e., opponency colors in human color perception: blue and yellow for Experiment 1, red and green for Experiment 2, and equiluminant red and green for Experiment 3). Background luminance varied between 0% and 45% to trade off luminance and color contrast with the stimulus. By comparing the locus of the optimal trade-off between color and luminance across different color axes, we explored the generality of the trade-off.

Results

The strongest pupil responses were found when a substantial amount of color contrast was present (at the expense of luminance contrast). Pupil response amplitudes increased by 15% to 30% after the addition of color contrast. An optimal pupillary responsiveness was reached at a background luminance setting of 20% to 35% color contrast across several color axes.

Conclusions

These findings suggest that a substantial component of pupil light responses incorporates color processing. More sensitive pupil responses and more salient stimulus designs can be achieved by adding subtle levels of color contrast between stimulus and background.

Translational Relevance

More robust pupil responses will enhance tests of the visual field with pupil perimetry.