Comparison of measures of visual acuity in infants: Teller acuity cards and sweep visual evoked potentials

Rhythmic visual stimulation as a window into early brain development: A systematic review

Rhythmic visual stimulation (RVS), the periodic presentation of visual stimuli to elicit a rhythmic brain response, is increasingly applied to reveal insights into early neurocognitive development. Our systematic review identified 69 studies applying RVS in 0- to 6-year-olds. RVS has long been used to study the development of the visual system and applications have more recently been expanded to uncover higher cognitive functions in the developing brain, including overt and covert attention, face and object perception, numeral cognition, and predictive processing. These insights are owed to the unique benefits of RVS, such as the targeted frequency and stimulus-specific neural responses, as well as a remarkable signal-to-noise ratio. Yet, neural mechanisms underlying the RVS response are still poorly understood. We discuss critical challenges and avenues for future research, and the unique potentials the method holds. With this review, we provide a resource for researchers interested in the breadth of developmental RVS research and hope to inspire the future use of this cutting-edge method in developmental cognitive neuroscience.

Development of the spatial contrast sensitivity function (CSF) during childhood: Analysis of previous findings and new psychophysical data

Although the contrast sensitivity function (CSF) changes markedly during infancy, there is no consensus regarding whether, how, and why it continues to develop in later childhood. Here, we analyzed previously published data (N = 1928 CSFs), and present new psychophysical findings from 98 children (4.7–14.8 years) and 50 adults (18.1–29.7 years), in order to answer the following questions: (1) Does the CSF change during childhood? (2) How large is the developmental effect size? (3) Are any changes uniform across the CSF, or frequency-specific? and (4) Can some or all of the changes be explained by “non-visual” (i.e. procedural/cognitive) factors, such as boredom or inattentiveness? The new data were collected using a four-alternative forced-choice (4AFC) Gabor-detection task, with two different psychophysical procedures (Weighted Staircase; QUEST+), and suprathreshold (false-negative) catch trials to quantify lapse rates. It is shown that from ages 4 to 18 years, the CSF improves (at an exponentially decaying rate) by approximately 0.3 log₁₀ units (a doubling of contrast sensitivity [CS]), with 90% of this change complete by 12 years of age. The size of the effect was small relative to individual variability, with age alone explaining less than one sixth of variability (16%), and most children performing as well as some adults (i.e. falling within the 90% population limits for adults). Development was frequency-specific, with changes occurring primarily around or below the CSF peak (≤ 4 cpd). At least half — and potentially all — of the changes observed could be explained by non-visual factors (e.g. lapses in concentration), although possible biological mechanisms are discussed.

Assessment of Human Visual Acuity Using Visual Evoked Potential: A Review

Visual evoked potential (VEP) has been used as an alternative method to assess visual acuity objectively, especially in non-verbal infants and adults with low intellectual abilities or malingering. By sweeping the spatial frequency of visual stimuli and recording the corresponding VEP, VEP acuity can be defined by analyzing electroencephalography (EEG) signals. This paper presents a review on the VEP-based visual acuity assessment technique, including a brief overview of the technique, the effects of the parameters of visual stimuli, and signal acquisition and analysis of the VEP acuity test, and a summary of the current clinical applications of the technique. Finally, we discuss the current problems in this research domain and potential future work, which may enable this technique to be used more widely and quickly, deepening the VEP and even electrophysiology research on the detection and diagnosis of visual function.

VEP estimation of visual acuity: a systematic review

Purpose

Visual evoked potentials (VEPs) can be used to measure visual resolution via a spatial frequency (SF) limit as an objective estimate of visual acuity. The aim of this systematic review is to collate descriptions of the VEP SF limit in humans, healthy and disordered, and to assess how accurately and precisely VEP SF limits reflect visual acuity.

Methods

The protocol methodology followed the PRISMA statement. Multiple databases were searched using “VEP” and “acuity” and associated terms, plus hand search: titles, abstracts or full text were reviewed for eligibility. Data extracted included VEP SF limits, stimulus protocols, VEP recording and analysis techniques and correspondence with behavioural acuity for normally sighted healthy adults, typically developing infants and children, healthy adults with artificially degraded vision and patients with ophthalmic or neurological conditions.

Results

A total of 155 studies are included. Commonly used stimulus, recording and analysis techniques are summarised. Average healthy adult VEP SF limits vary from 15 to 40 cpd, depend on stimulus, recording and analysis techniques and are often, but not always, poorer than behavioural acuity measured either psychophysically with an identical stimulus or with a clinical acuity test. The difference between VEP SF limit and behavioural acuity is variable and strongly dependent on the VEP stimulus and choice of acuity test. VEP SF limits mature rapidly, from 1.5 to 9 cpd by the end of the first month of life to 12–20 cpd by 8–12 months, with slower improvement to 20–40 cpd by 3–5 years. VEP SF limits are much better than behavioural thresholds in the youngest, typically developing infants. This difference lessens with age and reaches equivalence between 1 and 2 years; from around 3–5 years, behavioural acuity is better than the VEP SF limit, as for adults. Healthy, artificially blurred adults had slightly better behavioural acuity than VEP SF limits across a wide range of acuities, while adults with heterogeneous ophthalmic or neurological pathologies causing reduced acuity showed a much wider and less consistent relationship. For refractive error, ocular media opacity or pathology primarily affecting the retina, VEP SF limits and behavioural acuity had a fairly consistent relationship across a wide range of acuity. This relationship was much less consistent or close for primarily macular, optic nerve or neurological conditions such as amblyopia. VEP SF limits were almost always normal in patients with non-organic visual acuity loss.

Conclusions

The VEP SF limit has great utility as an objective acuity estimator, especially in pre-verbal children or patients of any age with motor or learning impairments which prevent reliable measurement of behavioural acuity. Its diagnostic power depends heavily on adequate, age-stratified, reference data, age-stratified empirical calibration with behavioural acuity, and interpretation in the light of other electrophysiological and clinical findings. Future developments could encompass faster, more objective and robust techniques such as real-time, adaptive control.

Registration

International prospective register of systematic reviews PROSPERO (https://www.crd.york.ac.uk/PROSPERO/), registration number CRD42018085666.

Curveball: A tool for rapid measurement of contrast sensitivity based on smooth eye movements

The contrast sensitivity function (CSF) is an informative measure of visual function, but current tools for assessing it are limited by the attentional, motor, and communicative abilities of the participant. Impairments in these abilities can prevent participants from engaging with tasks or following an experimenter's instructions. Here, we describe an efficient new tool for measuring contrast sensitivity, Curveball, and empirically validate it with a sample of healthy adults. The Curveball algorithm continuously infers stimulus visibility through smooth eye tracking instead of perceptual report, and rapidly lowers stimulus contrast in real time until a threshold is found. The procedure requires minimal instruction to administer and takes only five minutes to estimate a full CSF, which is comparable to the best existing methods available for healthy adults. Task repeatability was high: the coefficients of repeatability were 0.275 (in log10 units of RMS contrast) within the same session and 0.227 across different days. We also present evidence that the task is robust across illumination changes, well correlated with results from conventional psychophysical methods, and highly sensitive to improvements in visual acuity from refractive correction. Our findings indicate that Curveball is a promising means of accurately assessing contrast sensitivity in previously neglected populations.

Searching for biomarkers of CDKL5 disorder: early-onset visual impairment in CDKL5 mutant mice

CDKL5 disorder is a neurodevelopmental disorder still without a cure. Murine models of CDKL5 disorder have been recently generated raising the possibility of preclinical testing of treatments. However, unbiased, quantitative biomarkers of high translational value to monitor brain function are still missing. Moreover, the analysis of treatment is hindered by the challenge of repeatedly and non-invasively testing neuronal function. We analyzed the development of visual responses in a mouse model of CDKL5 disorder to introduce visually evoked responses as a quantitative method to assess cortical circuit function. Cortical visual responses were assessed in CDKL5 null male mice, heterozygous females, and their respective control wild-type littermates by repeated transcranial optical imaging from P27 until P32. No difference between wild-type and mutant mice was present at P25-P26 whereas defective responses appeared from P27-P28 both in heterozygous and homozygous CDKL5 mutant mice. These results were confirmed by visually evoked potentials (VEPs) recorded from the visual cortex of a different cohort. The previously imaged mice were also analyzed at P60-80 using VEPs, revealing a persistent reduction of response amplitude, reduced visual acuity and defective contrast function. The level of adult impairment was significantly correlated with the reduction in visual responses observed during development. Support vector machine showed that multi-dimensional visual assessment can be used to automatically classify mutant and wt mice with high reliability. Thus, monitoring visual responses represents a promising biomarker for preclinical and clinical studies on CDKL5 disorder.

Similarities and differences between behavioral and electrophysiological visual acuity thresholds in healthy infants during the second half of the first year of life

PURPOSE

Behavioral and electrophysiological methods for visual acuity estimation typically correlate well in children and adult populations, but this relationship remains unclear in infants, particularly during the second half of the first year of life. It has been suggested that the agreement between both methods mostly relies on age and/or subjective acuity factors. The present study aimed at comparing acuity thresholds obtained with both approaches in a sample of healthy infants in a relatively narrow age range, that is 6-10 months old.

METHODS

Acuity thresholds were assessed in 61 healthy infants aged between 6 and 10 months using the Teller acuity cards (TAC) and sweep visual evoked potentials (sVEP). The TAC stimuli (stationary vertical gratings displayed on laminated cards) ranged from 0.31 to 38 cycles per degree (cpd). The TAC acuity threshold was estimated according to the highest spatial frequency scored by the experimenter as seen by the infant. The sVEP stimuli (high-contrast vertical gratings counter-phased at 12 reversals/s) ranged from 13.5 to 1 cpd. sVEP were recorded at Oz and acuity threshold was estimated using regression linear fitting.

RESULTS

Considering the entire sample, sVEP acuity thresholds (8.97 ± 2.52 cpd) were significantly better than TAC scores (5.58 ± 2.95 cpd), although the difference was within 1 octave for 64% of the infants. Neither Pearson nor intra-class correlations between the two methods were significant (0.18 and 0.03, respectively). While age at assessment was not related to any dependent variable (TAC, sVEP, sVEP-TAC difference score), subjective (behavioral) acuity was found to underlie the difference between the two methods. The difference between sVEP and TAC scores decreased as a function of subjective acuity, and at the highest subjective acuity level (>10 cpd), TAC acuity slightly exceeded sVEP acuity.

CONCLUSIONS

The superiority of sVEP acuity often reported in the literature was evident in our infant sample when subjective acuity (TAC) was low or moderate, but not when it was high (>10 cpd). The relationship between the two estimation methods was not dependent on age, but on subjective acuity.

Contribution of sVEP visual acuity testing in comparison with subjective visual acuity

AIMS

Visual acuity determination is an important task in ophthalmology and optometry practices. Visual acuity can be examined objectively or subjectively. The objective examination method, sVEP, allows for quick objective measurements of patient's visual acuity. Previous studies have not demonstrated the repeatability of this objective sVEP method. This study aims to evaluate the sVEP method and compare it to a subjective method.

METHODS AND RESULTS

The sample was divided into two groups. For the first group, visual acuity was measured with sVEP and Snellen methods on only one patient twelve times. In the second group, visual acuity was measured twice with sVEP followed twice with the Snellen method with Landolt's rings and logMAR modification on 32 non-pathological patients. Results showed significant differences between average values of visual acuity obtained with both methods (sVEP and Snellen) in both samples (T-test, P < 0.01; Wilcoxon test, P = 0.02 in second group). In the second group, significant correlations between repeated sVEP measurements (Spearman test, P < 0.05, r = 0.69) were found but no significant correlation between average sVEP measurement and average Snellen measurement (Spearman test, P > 0.05, r = 0.15) was found.

CONCLUSION

Objective measurement of visual acuity with sVEP is a valid and reliable method, but is recommended only when it is not possible to use a subjective method for measuring visual acuity, e.g. children, patients with mental retardation or simulating/dissimulating patients.

Comparing enfant and PowerDiva sweep visual evoked potential (sVEP) acuity estimates

PURPOSE

Many studies have examined different variables that affect the outcome of sVEP estimated acuity. However, no studies have compared the estimated sVEP acuity between different instruments. The primary purpose of this study was to compare sVEP acuity estimates obtained with two different sVEP systems: the Enfant and the PowerDiva.

METHODS

Twenty-five normal adults with monocular acuities of 0.10 logMAR or better took part in this study. The sVEP acuities were determined with the two instruments in a single visit with the same electrode placement. For both systems, the stimuli were horizontal sine wave gratings of 80 % contrast, counterphased at 7.5 Hz, with a screen mean luminance of 100 cd/m(2). The sweep presented spatial frequencies from 3 to 36 cpd with each spatial frequency presented for 1 s. Ten presentations of the stimuli were averaged together for one acuity measurement. The acuity estimate was made with the specific instruments standard software. Two acuity measurements were made for each system and averaged together for further comparison. The acuity estimates were compared using an ANOVA, paired t tests, and Bland-Altman plots.

RESULTS

The average estimated logMAR acuities with the Enfant (0.064 ± 0.069 logMAR) and PowerDiva (0.065 ± 0.115 logMAR) were not significantly different (t = 0.04, p = 0.97). Consistent with previous studies, the logMAR chart acuity (-0.086 ± 0.089 logMAR) was significantly different from the Enfant (t = 8.10, p < 0.001) and PowerDiva (t = 5.77, p < 0.001) acuity estimates. The Bland-Altman analysis for the two instruments did not indicate a bias (-0.001), and the limit of agreement was 0.227 logMAR.

CONCLUSIONS

Acuity estimates with the Enfant and PowerDiva are not significantly different for patients with normal acuity. Thus, direct comparisons between the two instruments can be made for patients with normal acuity.

Meta-analysis of LCPUFA supplementation of infant formula and visual acuity

BACKGROUND AND OBJECTIVE

Long-chain polyunsaturated fatty acids (LCPUFAs) are hypothesized to affect visual acuity development in infants. Randomized controlled trials (RCTs) have been conducted to assess whether supplementation of LCPUFAs of infant formulas affects infant visual acuity. This meta-analysis was conducted to evaluate whether LCPUFA supplementation of infant formulas improves infants' visual acuity.

METHODS

PubMed and PsycInfo were searched for RCTs assessing the efficacy of LCPUFA supplementation of infant formulas on infant visual acuity. RCTs assessing the effects of LCPUFA supplementation on visual acuity (by using either visual evoked potential or behavioral methods) in the first year of life were included in this meta-analysis. Our primary outcome was the mean difference in visual resolution acuity (measured in logarithm of minimum angle of resolution [logMAR]) between supplemented and unsupplemented infants. We also conducted secondary subgroup analyses and meta-regression examining the effects of LCPUFA dose and timing, preterm versus term birth status, and trial methodologic quality.

RESULTS

Nineteen studies involving 1949 infants were included. We demonstrated a significant benefit of LCPUFA supplementation on infants' visual acuity at 2, 4, and 12 months of age when visual acuity was assessed by using visual evoked potential and at 2 months of age by using behavioral methods. There was significant heterogeneity between trials but no evidence of publication bias. Secondary analysis failed to show any moderating effects on the association between LCPUFA supplementation and visual acuity.

CONCLUSIONS

Current evidence suggests that LCPUFA supplementation of infant formulas improves infants' visual acuity up to 12 months of age.

Preverbal assessment for amblyopia

PURPOSE

To describe and compare the different methods of preverbal assessment of amblyopia.

RESULTS

Each method of visual assessment has its plusses and minuses.

CONCLUSION

There is no "best" method for assessment for amblyopia. The best method may be a combination of the various described tests.

Sweep pattern visual evoked potential acuity in children during their periods of visual development

PURPOSE

To study the clinical usage of sweep pattern visual evoked potential (SPVEP) acuity in children's visual development periods and compare the amplitude-spatial frequency (A-SP) function regression method with the amplitude-logarithm of the visual angle (A-logVA) function regression method in evaluating the SPVEP acuity of children, especially those who have poor visual acuities.

METHODS

Twenty-six eyes of 26 amblyopic children (ages ranged from 3 to 12 years; mean age±standard deviation 6.69±1.74 years) and 31 eyes of normal children whose ages were matched with the amblyopic group were involved in this study. SPVEP acuity was recorded with GT-2000 NV (Guote Medical Apparatus Ltd., China) using sinusoidally modulated horizontal gratings with 10 different spatial frequencies from 0.99 to 12.89 cycles per degree to stimulate the retina. The averaging responses were displayed with the discrete Fourier transformation method. SPVEP acuity was assessed by both the A-SP function regression method and the A-logVA function regression method. The logarithm of minimal angle of resolution (logMAR) chart was used to obtain logMAR visual acuity.

RESULTS

In the normal group, logMAR acuity calculated by both the A-SP and A-logVA function regression methods had a significant correlation with SPVEP acuity. The average value of SPVEP acuity (by A-logVA) was closer to logMAR acuity. The difference of mean values between logMAR acuity and SPVEP acuity was significant in both regression methods. In the amblyopic group, it was SPVEP acuity (by A-logVA) that had a significant correlation with logMAR acuity, whereas the result was not significant when calculated by the A-SP function regression method (p=0.515). The average value of SPVEP acuity (A-SP) was closer to logMAR acuity. The difference of mean values between logMAR acuity and SPVEP acuity (A-logVA) was significant; however, when compared with SPVEP acuity (A-SP), it was not significant (p=0.174). In addition, SPVEP acuity may be overestimated or underestimated when it is compared with different logMAR visual acuities.

CONCLUSION

SPVEP could be used to evaluate the visual acuity for normal children or those with poor visual acuity. Moreover, the A-logVA function regression method was more accurate than the A-SP function regression method in evaluating SPVEP acuity.

Threshold determination in sweep VEP and the effects of criterion

In order to develop criteria for the range of data points used for regression line fitting in sweep visually evoked potential (sVEP), which would be objective, clearly specified and give good repeatability and validity, and in order to investigate the effect of luminance on sVEP measurement, visual acuity (VA) and contrast sensitivity (CS) were measured with sVEP in adults aged 17-30 years and children aged 6-8 years. Six to ten participants took part in each experiment. Five criteria (C0-C4) for fitting the regression line were implemented. Test-retest repeatability and validity against psychophysical thresholds at three luminance levels were considered for thresholds and the number of acceptable readings. There were significant effects of criteria (repeated measures ANOVAs, P < 0.05). The criteria, C2 and C3 (based on the range over which the signal-to-noise ratio >or=1), consistently gave better VA and CS, more viable readings, better agreement with psychophysical thresholds in adults and better repeatability than the other criteria. In the case of adults, C2 gave thresholds that were not significantly different from the psychophysical thresholds (P > 0.05). There was little effect of luminance over the 25-100 cd/m(2) range used. Overall, C2 performed the best and would be the criterion of choice, giving better repeatability, better validity and more viable plots.

Evaluation of infant accommodation using retinoscopy and photoretinoscopy

PURPOSE

To compare PlusOptix PowerRefractor (PR) and Monocular Estimation Method (MEM) for measurement of infant accommodation and to assess the usefulness of applying individual calibration factors to PR data.

METHODS

Subjects were 41 infants aged 3 to 12 months. Accommodative response was measured by MEM and PR at 33 and 57 cm, acuity by Teller Acuity Cards, and cycloplegic refractive error (RE) (tropicamide 1%) by retinoscopy (Wet Ret) and PR (PR C). Monocular wear of a +2.00 diopter (D) and +4.00 D lens established a PR calibration factor for each subject.

RESULTS

The median individual calibration slope was significantly different from 1.0 (+0.91; Wilcoxon signed-rank test: p = 0.03), yet there was no correlation between individual calibration slopes and the difference in RE by Wet Ret and PR C (rs = 0.05, p = 0.76). For 19 infants with an accommodative response slope by PR of >0.50, the mean lag was not significantly different between methods (0.50 D PR, 0.48 D MEM; p = 0.92; 95% LoA = +/-1.78 D). Despite the improvement in acuity with age (rp = -0.56, p < 0.0001), neither age nor acuity had a significant effect on accommodative error. Lag was greater at 57 cm (0.69 D) than 33 cm (0.30 D, F1, 18 = 6.3, p = 0.022), but lag was unrelated to RE (F1, 17 = 3.3, p = 0.09). Accommodative response slopes for boys were larger (1.5) than for girls (1.0; F1, 17 = 9.5, p = 0.007).

CONCLUSION

MEM and PR provided similar estimates of RE and of accommodative lag once the PR data were screened for inattention using an accommodative response slope criterion. Adult-like accommodative responses between 3 and 12 months of age suggest that acuity at these ages is not limited by accommodative immaturity. Further, mature accommodation may attenuate RE-related defocus signals for emmetropization.

Development of Visual Acuity and Contrast Sensitivity in Children

Purpose

Most studies of visual development have concentrated on visual development of infants. Only a few studies have extended this to children and determined the point at which visual function becomes truly adult-like. Yet from a clinical and research perspective it is important to know this. This review paper is a discussion of the development of visual acuity and contrast sensitivity into childhood.

Methods

The literature on subjective (measured with preferential looking or psychophysical methods) and objective (visually-evoked potential) measures of visual acuity and contrast sensitivity was examined with particular emphasis on studies of children over the age of 5 years and those articles that compared different age groups and those that made a comparison with adults.

Results

Visual acuity was found to be fully mature between the ages of 5 and the mid teenage years, while contrast sensitivity was found to mature fully between the ages of 8 to 19 years. Thus, there is still no clear answer to the fundamental question of when these basic aspects of visual function mature, but it may be later than previously thought.

Conclusions

Further studies are needed to answer this basic question more precisely and objective measures, such as VEP, may be able to answer this question better than psychophysical methods.

The technique, validity and clinical use of the sweep VEP

Vision scientists have concentrated on studying two visual functions when it comes to assessing the sensory visual development in human: visual acuity and contrast sensitivity. The methods used to measure these visual functions can be either behavioral or electrophysiological. A relatively new technique for measuring the visual acuity and contrast sensitivity electrophysiologically is the sweep visual evoked potential (sVEP). This paper is a review of the literature on the sVEP technique: stimulus parameters, threshold determination, validity and reliability of sVEP are discussed. Different studies using the sVEP to study the development of visual acuity, contrast sensitivity, and vernier acuity are presented. Studies have demonstrated that the sVEP is a potentially important tool for assessing visual acuity and contrast sensitivity in non-verbal individuals with disorders affecting their visual system.

The assessment of visual acuity in children with periventricular damage: a comparison of behavioural and electrophysiological techniques

It has been controversial whether electrophysiology offers better precision than behavioural techniques in measuring visual acuity in children with brain damage. We investigated the concordance between sweep VEPs and Acuity Cards (AC) in 29 children with periventricular leukomalacia (PVL), the most common type of brain damage in preterm infants. An overall good correlation was shown but with relatively better behavioural acuity values. VEP/AC ratio was significantly correlated to corpus callosum posterior thinning. We propose that this result reflects the efficacy of the compensatory mechanisms following early brain damage which may differentially affect the two methods.

A new method of extrapolating the sweep pattern visual evoked potential acuity

PURPOSE

In order to compare the amplitude-spatial frequency (A-SP) regression method with amplitude-logVA (A-logVA) regression methods in extrapolating the sweep pattern visual evoked potential (SPVEP) acuity.

METHODS

We measured SPVEPs in 21 children and three adults using sinusoidally-modulated horizontal gratings as stimuli. The responses were averaged and displayed through discrete Fourier transformations. SPVER acuity was then estimated by using both the SPVEP amplitude- spatial frequency function (A-SP function regression method) and the SPVEP amplitude-log visual-angle function (A-logVA function regression method). Furthermore, the Bailey Lovie logMAR chart was employed to define visual acuity. Curve estimates were calculated to derive a correlation index (R) for each method.

RESULTS

There are significant differences (t = 2.71, P < 0.05) between the correlation indices of curves obtained using the A-logVA function (logarithmic model, 0.95 +/- 0.01) and that obtained by the A-SP function (inverse model, 0.92 +/- 0.02). The overall correlation coefficient (r) between logMAR acuity and acuity calculated by the A-logVA regression method was 0.32 (P < 0.05). The overall correlation coefficient (r) between logMAR acuity and acuity calculated by the A-SP regression method was 0.41 (P < 0.05). Paired t-tests show that SPVEP acuity from the A-logVA function was not significantly different from acuities of the logMAR function (t = 1.77, P = 0.09). The difference in their mean values is 0.14 +/- 0.08. However, SPVEP acuity calculated using the A-SP function regression method is significantly different from the acuity calculated from the logMAR function (t = 10.09, P < 0.01). The difference in their mean values is 0.41 +/- 0.04.

CONCLUSIONS

The amplitude-logVA function regression method is more accurate in estimating SPVEP acuity in normal subjects with good visual acuity.

Methods of visual acuity determination with the spatial frequency sweep visual evoked potential

PURPOSE

The spatial frequency sweep visual evoked potential (sVEP) is used to rapidly determine visual acuity in children or non-responsive patients. Two techniques have been used to separate signal from noise: (1) the 95% confidence interval for the signal amplitude (95% CI) or (2) the amplitude of a Fourier frequency adjacent to 2x the signal frequency (DFT). The purpose of this study is to determine if there is a significant difference in acuity estimates with these techniques.

METHODS

Ten normal subjects (approximately 0.00 logMAR acuity) and 11 patients with decreased visual acuity took part in this project. Stimulus production and data analysis were done with an Enfant 4010 (Neuroscientific Corp). Standard VEP recording techniques were employed. The stimulus was a horizontal-oriented, sine wave grating that swept up the spatial frequency spectrum (contrast 80%, temporal reversal rate 7.5 Hz). Sweeps were repeated until the confidence intervals for the data were no longer decreasing. The Bailey Lovie logMAR chart was used to determine visual acuity. A line was fit to the high spatial frequency data using either the 95% CI or the DFT as the noise estimate. By using these linear equations, acuity estimates were obtained at 0, 1, and 2 microV signal amplitudes.

RESULTS

The average logMAR acuity for the subjects with normal acuity was -0.06 +/- 0.070 (SD). The sVEP acuity estimates were 0.08 +/- 0.098, 0.18 +/- 0.092, and 0.33 +/- 0.195 (0, 1, and 2 microV extrapolations) with the 95% CI used as noise and 0.07 +/- 0.100, 0.18 +/- 0.103, and 0.33 +/- 0.202 (0, 1, and 2 microV extrapolations) with the DFT used as noise. By using the average noise from the Fourier frequency as the extrapolation level, the acuity was 0.10 +/- 0.098 logMAR. The average logMAR acuity for the subjects with decreased visual acuity was 0.67 +/- 0.306 (SD). The sVEP acuity estimates were 0.53 +/- 0.175, 0.66 +/- 0.171, and 0.88 +/- 0.295 (0, 1, and 2 microV extrapolations) with the 95% CI used as noise and 0.53 +/- 0.179, 0.65 +/- 0.176, and 0.86 +/- 0.268 (0, 1, and 2 microV extrapolations) with the DFT used as noise. By using the average noise from the Fourier frequency as the extrapolation level, the acuity was 0.57 +/- 0.186 logMAR. No significant difference was found between the two acuity estimate techniques for all of the subjects (repeated measures ANOVA, p = 0.16, F20 = 2.131). The sVEP estimates of acuity to the 0 microV and noise levels were not significantly different from the logMAR acuity (paired t-test, all p values > 0.05).

CONCLUSIONS

The results indicate that the sVEP acuity does not depend on the noise estimation technique. In agreement with prior studies, the sVEP acuity underestimates the logMAR acuity in normally sighted individuals by about an octave.

[Compared progression of visual-evoked potentials in preterm and term newborns]

PURPOSE

To compare the development of the visual pathway in healthy preterm and full-term newborns using flash and patterned (both transient and steady-state) visual-evoked potentials (fVEP, pVEP-t, pVEP-ss).

PATIENTS AND METHODS

Twenty-nine preterm newborns (28-35 weeks gestational age) were evaluated at four different times: at 3 months postnatal and corrected age, at 8 months postnatal and corrected age. They were matched with 92 term newborns tested at 3 and 8 months of life.

RESULTS

The maximal perceived spatial frequencies in the groups were: 2 C/d at 3 months postnatal age, >2 C/d at 3 months corrected age and at 3 months at term, between 3 and 5C/d, >=5C/d at 8 months corrected age and at 8 months of life, respectively. The latencies of the P1 and P100 waves for the flash and the transient stimulation were, respectively, 192 ms and 207.9 ms at 3 months postnatal age, 144 ms and 137.7 ms at 3 months corrected age, 126.3 ms and 124.1 ms at 8 months postnatal age, 112.7 ms and 112.5 ms at 8 months corrected age, 137.3 and 110.1 ms at 3 months of life; and 122.3 and 100.5 ms at 8 months of life.

DISCUSSION

In the preterm infants of 3 gestational months, the latencies of the fVEP are comparable to those of the 3-month-old full-term infants, although the pVEP-t latencies are still delayed at 8 months. In the fVEP; however, we noted a shorter latency in the preterm infants at 8 months corrected age compared to those of the full-term infants. This tendency inversion was also evidenced at the steady-state stimulation.

CONCLUSIONS

As evidenced by our results, at 8 months of corrected age the preterm infants recovered the fVEP and pVEP-ss, but not the pVEP-t. Different results obtained with different visual-evoked stimulations suggest that similar neural pools are developed in not completely equal amounts of time.

Test-retest reliability of swept visual evoked potential measurements of infant visual acuity and contrast sensitivity

The aim of the study was to describe variations in swept visual evoked potential (SWEEP-VEP) assessment of visual acuity and contrast sensitivity in infants and to evaluate the best way to estimate visual performance from obtained SWEEP-VEP data. The visual performance of 92 infants (6-40 wk of age) was measured in two separate visits. Results were verified with repeated tests in seven adults. There was a strong association between the two measurements of infant visual acuity (r = 0.91, p < 0.001), with no constant bias and an inter-assay coefficient of variation of 8.4%. The intra-assay coefficient of variation was 17% and in repeated sessions all obtained acuity measures were normally distributed, indicating that the mean and not the maximum threshold best estimates visual acuity. This estimate of visual acuity also had lower test-retest variability than those calculated from the maximum threshold or threshold from the average EEG signals (p = 0.001). Test-retest measures of infant contrast sensitivity had a correlation coefficient of 0.72 (p < 0.001) and an inter-assay coefficient of variation of 23%. With the observed test-retest variability, SWEEP-VEP is less valid for estimating the visual performance of individual subjects, but it can give reliable group means. This method was well suited to describe visual development in the infants, which for acuity as well as contrast sensitivity increased by 0.64 octave per doubling in age. However, the variability of the SWEEP-VEP method can be a limiting factor, for example, in the assessment of the potential effect of dietary docosahexaenoic acid in a homogeneous group of infants.

FPL and sweep VEP to tritan stimuli in young human infants

Young infants can distinguish red from green without brightness cues which shows that neural pathways processing color information (the 'red-green' color-opponent pathway) are functional early in life. There is some doubt over whether the 'blue-yellow' pathway is functional in young infants. Here, we show that infants behave like tritanopic adults until 2-3 months post-term age. By 3-4 months, infants distinguish tritan stimuli, and therefore, the 'blue-yellow' pathway must be functional by that age. Our sweep visual evoked potentials to identical stimuli, however, are not significantly above noise levels, in disagreement with the behavioral responses. We discuss several possible explanations for the discrepancy.

Visual acuity assessment in infants and young children

The accurate and reliable assessment of visual function in infants and young children is important for ensuring optimal management of those at risk of abnormal visual development. Visual acuity is the aspect of visual function most commonly assessed by optometrists and can be measured in infants and children using appropriate techniques. Acuity measurements obtained using different techniques may show considerable disagreement and may mislead the optometrist when monitoring acuity development. It is important for the practitioner to appreciate these differences so that reasonable comparisons may be made between acuity estimates made using different techniques. With this in mind, we discuss methodological differences between some of the techniques used in visual assessment of very young patients and the effects those differences may have on acuity estimates.