Binocular interactions in patients with age-related macular degeneration: Acuity summation and rivalry

Biofeedback rehabilitation in patients with binocular inhibition due to macular disease

BACKGROUND

To investigate whether patients with binocular reading inhibition due to central vision loss benefit from a new biofeedback (BF) rehabilitation method that aimed at improving fixation stability and at establishing a correspondence between the monocular preferred retinal loci (PRLs) on functioning retina in both eyes.

METHODS

Thirty-three patients with bilateral macular disease and with binocular reading inhibition participated in 10 training sessions consisting of 10-min visual stimulation for each eye to stabilize fixation and relocate the PRL (if needed) using the BF module of the MP-1 microperimeter (Nidek Technologies Srl., Vigonza, PD, Italy). Binocular and monocular reading performance, contrast sensitivity, and visual acuity were evaluated pre and post training. Binocular summation/inhibition was evaluated with binocular ratio (BR).

RESULTS

Fixation stability improved significantly post training in both eyes. Maximum reading speed during binocular viewing increased from 57 ± 24wpm pre training to 67 ± 24wpm post training. BR increased for all parameters of reading, visual acuity, and contrast sensitivity. Training resulted in a complete reversal of binocular reading inhibition in 30% of patients.

CONCLUSIONS

For patients with binocular inhibition due to central vision loss, BF training to stabilize fixation and to bring the monocular PRLs into correspondence on functioning retina in both eyes is an efficient rehabilitation method to improve binocular performance.

Binocular rivalry reveals differential face processing in congenital prosopagnosia

Congenital Prosopagnosia (CP) is an innate impairment in face perception with heterogeneous characteristics. It is still unclear if and to what degree holistic processing of faces is disrupted in CP. Such disruption would be expected to lead to a focus on local features of the face. In this study, we used binocular rivalry (BR) to implicitly measure face perception in conditions that favour holistic or local processing. The underlying assumption is that if stimulus saliency affects the perceptual dominance of a given stimulus in BR, one can deduce how salient a stimulus is for a given group (here: participants with and without CP) based on the measured perceptual dominance. A further open question is whether the deficit in face processing in CP extends to the processing of the facial display of emotions. In experiment 1, we compared predominance of upright and inverted faces displaying different emotions (fearful, happy, neutral) vs. houses between participants with CP (N = 21) and with normal face perception (N = 21). The results suggest that CP observers process emotions in faces automatically but rely more on local features than controls. The inversion of faces, which is supposed to disturb holistic processing, affected controls in a more pronounced way than participants with CP. In experiment 2, we introduced the Thatcher effect in BR by inverting the eye and mouth regions of the presented faces in the hope of further increasing the effect of face inversion. However, our expectations were not borne out by the results. Critically, both experiments showed that inversion effects were more pronounced in controls than in CP, suggesting that holistic face processing is less relevant in CP. We find BR to be a useful implicit test for assessing visual processing specificities in neurological participants.

Monocular and Binocular Visual Function Assessments and Activities of Daily Living Performance in Age-Related Macular Degeneration

PURPOSE

To evaluate the relationship between specific monocular and binocular visual function (VF) assessments with binocularly performed activities of daily living task tests (ADLTTs) in patients with age-related macular degeneration (AMD) and healthy controls.

DESIGN

Prospective case-control cohort study.

SUBJECTS

Thirty-six AMD patients and 36 controls.

METHOD

Visual field assessments included monocular and binocular best-corrected visual acuity (BCVA), contrast sensitivity (CS), and monocular microperimetry testing for mean macula sensitivity, mean retina sensitivity (MRS), fixation area, and fixation distance from fovea (FDF). Age-related macular degeneration lesion area and sensitivity were measured on OCT and microperimetry, respectively. Participants performed 4 validated ADLTTs with binocular BCVA: (1) reading; (2) item-search; (3) money-counting; and (4) multi-step drink-making tasks.

MAIN OUTCOME MEASURES

Spearman correlations and multivariate regression analysis, adjusted for age, sex, and potential correlation between the 2 eyes, were used to assess the relationship between monocular and binocular VF assessments, and ADLTT performance in both groups.

RESULTS

Age-related macular degeneration patients had poorer VF (BCVA, CS, mean macula sensitivity, and MRS) compared with healthy controls. Monocular BCVA in both better- and worse-vision eyes was moderately correlated with the binocular reading speed and money-counting tasks in participants with AMD. In AMD, monocular worse eye CS, MRS, AMD lesion area on OCT, and lesion sensitivity on microperimetry showed moderate correlations to various ADLTTs, such as reading, money-counting, and drink-making. Similar findings were found in our AMD cohort on multivariate regression analysis. Fewer significant correlations were observed for the better-vision eye, whereas no correlations were observed for healthy controls between VF parameters and ADLTTs. In contrast, significant associations were observed between binocular BCVA and CS with binocular ADLTTs (reading and item-search tasks) but not in AMD patients.

CONCLUSION

Although monocular BCVA remains the most common measure of VF, CS and microperimetry testing also show significant correlations with ADLTTs performance in AMD patients, and should be considered as complimentary VF-outcome measures in both clinical and research settings. Unlike healthy subjects, AMD patients do not rely on binocular VF for ADLTT function, with the worse-vision eye impacting binocular ADLTT function more than the better-vision eye. Therefore, the worse-vision eye should not be neglected during the management of AMD.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

What Is a Preferred Retinal Locus?

This review examines the concept of the preferred retinal locus (PRL) in patients with macular diseases. Considering monocular and binocular viewing, we (a) explain how to identify the PRL and discuss the pitfalls associated with its measurement, (b) review the current hypotheses for PRL development, (c) assess whether the PRL is the new reference point of the ocular motor system, and discuss (d) the functional and (e) the clinical implications of the PRL. We conclude that the current definition of the PRL is probably incomplete and should incorporate the need to evaluate the PRL in the framework of binocular viewing. We emphasize the need for more research.

Reading Vision in Adults With Early and Intermediate Age-Related Macular Degeneration Under Mesopic and Photopic Conditions

Purpose

Reading is involved in various daily activities that operate under a wide range of luminance levels. Rod- and cone-mediated mesopic visual function is known to be impaired even in early/intermediate age-related macular degeneration (AMD). It remains unclear whether and to what extent mesopic reading is impaired in early/intermediate AMD. Here, we assessed differences in reading vision between photopic and mesopic conditions in early/intermediate AMD and compared their performance to those in older adults with normal macular health.

Methods

The study included 30 patients with early/intermediate AMD and 30 healthy controls. Reading performance was tested on the MNREAD iPad app under mesopic (2 cd/m2 with a neural-density filter) and photopic (220 cd/m2) conditions. Four reading indices-maximum reading speed (MRS), critical print size (CPS), reading acuity (RA), and reading accessibility index (ACC)-were obtained from the MNREAD test, yielding a function representing reading speed versus print size.

Results

Compared to photopic conditions, patients with AMD and healthy controls both exhibited noticeable decreases in reading vision under mesopic conditions (P < 0.001) despite normal photopic visual acuity. This decrease was more pronounced in AMD even after adjusting for age (P < 0.001): Under mesopic conditions, MRS and ACC decreased by 8 words per minute and 0.1, respectively; CPS and RA were enlarged by 0.27 and 0.24 logMAR, respectively.

Conclusions

Reading vision deteriorates under mesopic conditions compared to photopic conditions in early/intermediate AMD and is accentuated compared to this difference in healthy controls.

Translational Relevance

A mesopic reading test may provide a more sensitive and comprehensive assessment of a patient's reading impairment.

Binocularity Principles of PRL Development in Patients With Macular Disease

Purpose

We tested the hypothesis that binocularity requirements for correspondence play a role in establishing the preferred retinal locus (PRL) in macular degeneration.

Methods

Monocular PRL locations in 202 eyes of 101 patients with macular degeneration (79 ± 10 years) were recorded with the MP1 microperimeter. Corresponding PRLs were those with similar polar angle and distance from former fovea in the better eye (BE) and the worse eye (WE).

Results

On average, the PRL in the BE was in the foveal proximity at 1.1 ± 0.99 degrees for 55 patients (foveal-driven PRL) and eccentrically at 6.9 ± 3.4 degrees for 46 patients with central lesions involving the fovea (peripheral-driven PRL). For the foveal-driven PRL group, the PRL in the BE was not affected by the status of the WE. In 100% of cases, the monocular PRL in the WE was in a corresponding location either on functioning retina or onto the lesion, or would fall onto the lesion during binocular viewing. For the peripheral-driven PRL group, the PRL location depended on the lesion size in both eyes to maximize correspondence and/or the function of peripheral vision during binocular viewing. In this group, PRL correspondence status was different for those with equal, unequal, or extensive lesions in both eyes.

Conclusions

Binocularity requirements for correspondence play an important role in determining the PRL location. We formulated two principles based on whether the BE has foveal sparing (foveal-driven PRL) or central lesions affecting the fovea (peripheral-driven PRL). The PRL should be evaluated in the framework of binocular viewing.

Binocular visual function and fixational control in patients with macular disease: A review

For normally sighted observers, the centre of the macula—the fovea—provides the sharpest vision and serves as the reference point for the oculomotor system. Typically, healthy observers have precise oculomotor control and binocular visual performance that is superior to monocular performance. These functions are disturbed in patients with macular disease who lose foveal vision. An adaptation to central vision loss is the development of a preferred retinal locus (PRL) in the functional eccentric retina, which is determined with a fixation task during monocular viewing. Macular disease often affects the two eyes unequally, but its impact on binocular function and fixational control is poorly understood. Given that patients’ natural viewing condition is binocular, the aim of this article was to review current research on binocular visual function and fixational oculomotor control in macular disease. Our findings reveal that there is no overall binocular gain across a range of visual functions, although clear evidence exists for subgroups of patients who exhibit binocular summation or binocular inhibition, depending on the clinical characteristics of their two eyes. The monocular PRL of the better eye has different characteristics from that of the worse eye, but during binocular viewing the PRL of the better eye drives fixational control and may serve as the new reference position for the oculomotor system. We conclude that evaluating binocular function in patients with macular disease reveals important clinical aspects that otherwise cannot be determined solely from examining monocular functions, and can lead to better disease management and interventions.

A Unified Rule for Binocular Contrast Summation Applies to Normal Vision and Common Eye Diseases

Purpose

Binocular summation refers to better visual performance with two eyes than with one eye. Little is known about the mechanism underlying binocular contrast summation in patients with common eye diseases who often exhibit binocularly asymmetric vision loss and structural changes along the visual pathway. Here we asked whether the mechanism of binocular contrast summation remains preserved in eye disease.

Methods

This study included 1035 subjects with normal ocular health, cataract, age-related macular degeneration, glaucoma, and retinitis pigmentosa. Monocular and binocular contrast sensitivity were measured by the Pelli-Robson contrast sensitivity chart. Interocular ratio (IOR) was quantified as the ratio between the poorer and better eye contrast sensitivity. Binocular summation ratio (BSR) was quantified as the ratio between binocular and better eye contrast sensitivity.

Results

All groups showed statistically significant binocular summation, with the BSR ranging from 1.25 [1.20, 1.30] in the glaucoma group to 1.31 [1.27, 1.36] in the normal vision group. There was no significant group difference in the BSR, after accounting for IOR. By fitting a binocular summation model Binocular = (Leftm + Rightm)1/m to the contrast sensitivity data, we found that the same binocular summation rule, reflected by the parameter m, applies across the five groups.

Conclusions

Cortical binocular contrast summation appears to be preserved in spite of eye diseases that can affect the two eyes differently. This finding supports the importance of assessing both monocular and binocular functions, rather than relying on a monocular assessment in the better eye as a potentially inaccurate surrogate measure.

Role of improved distance and near visual acuity with low vision aids to enhance stereopsis in retinal diseases

Purpose:

The purpose of this study was to examine role of improved distance and near best-corrected visual acuity (DBCVA and NBCVA) with use of magnification devices to enhance stereopsis in low vision (LV) subjects having retinal diseases.

Methods:

In a cross-sectional observational study without control, 84 subjects having LV due to retinal diseases were examined for an improvement of BCVA with use of magnifying low vision aids (LVAs) (2X for DBCVA and 3X for NBCVA). The stereopsis scores on titmus fly test were recorded with near refractive correction “on” and then with 3X magnification. The improvement in stereopsis for distance was however estimated through statistical correlation values.

Results:

The DBCVA (P < 0.001), NBCVA (P < 0.001) and stereopsis (P < 0.001) improved statistically significantly (SS) following magnifying LVA. There was no correlation between pre-LVA stereopsis and pre-LVA DBCVA (r = 0.059; P = 0.444;NSS) and post-LVA DBCVA (r = 0.054; P = 0.487;NSS); and no correlation between post-LVA stereopsis and pre-LVA DBCVA (r = 0.042; P = 0.592;NSS) and post-LVA DBCVA (r = 0.08; P = 0.920;NSS). There was no correlation between pre-LVA stereopsis and pre-LVA NBCVA (r = 0.044; P = 0.572;NSS) and no correlation between post-LVA stereopsis and pre-LVA NBCVA (r = 0.108; P = 0.165;NSS). But positive correlation between pre-LVA stereopsis and post-LVA NBCVA (r = 0.347; P < 0.001) and between post-LVA stereopsis and post-LVA NBCVA (r = 0.445; P < 0.001) was SS.

Conclusion:

The use of magnification as LVA improves both the BCVA and stereopsis. The increase in DBCVA with LVA improves the stereopsis for distance though it may not be SS while improvement in NBCVA with LVA enhances stereopsis for near objects in SS manner.

Topical Review: Assessment of Binocular Sensory Processes in Low Vision

SIGNIFICANCE

This article summarizes the evidence for a higher prevalence of binocular vision dysfunctions in individuals with vision impairment. Assessment for and identification of binocular vision dysfunctions can detect individuals experiencing difficulties in activities including reading, object placement tasks, and mobility.Comprehensive vision assessment in low vision populations is necessary to identify the extent of remaining vision and to enable directed rehabilitation efforts. In patients with vision impairment, little attention is typically paid to assessments of binocular vision, including ocular vergence, stereopsis, and binocular summation characteristics. In addition, binocular measurements of threshold automated visual fields are not routinely performed in clinical practice, leading to an incomplete understanding of individuals' binocular visual field and may affect rehabilitation outcomes.First, this review summarizes the prevalence of dysfunctions in ocular vergence, stereopsis, and binocular summation characteristics across a variety of ocular pathologies causing vision impairment. Second, this review examines the links between clinical measurements of binocular visual functions and outcome measures including quality of life and performance in functional tasks. There is an increased prevalence of dysfunctions in ocular alignment, stereopsis, and binocular summation across low vision cohorts compared with those with normal vision. The identification of binocular vision dysfunctions during routine low vision assessments is especially important in patients experiencing difficulties in activities of daily living, including but not limited to reading, object placement tasks, and mobility. However, further research is required to determine whether addressing the identified deficits in binocular vision in low vision rehabilitative efforts directly impacts patient outcomes.

Reading with central vision loss: binocular summation and inhibition

Purpose

There are conflicting reports as to whether there is a binocular advantage or disadvantage when reading with central vision loss. This study examined binocular reading summation in patients with macular degeneration.

Methods

Seventy‐one patients with bilateral central vision loss [mean age: 63 (S.D. = 21) years] participated. Reading performances during binocular and monocular viewing with the better eye (i.e., the eye with the best monocular visual acuity) were evaluated using different versions of the Italian MNREAD reading chart (www.precision‐vision.com). Fixation stability and preferred retinal loci (PRLs) were recorded monocularly for each eye. The overall sample was split into inhibition, equality, and summation groups based on the binocular ratio (i.e., binocular/monocular) of the maximum reading speed.

Results

41% of patients experienced binocular inhibition, 42% summation, and 17% equality. Binocular reading speed of the inhibition group was approximately 30 words per minute slower than those of the equality and summation groups, although the inhibition group had the best visual acuity. These patients generally had monocular PRLs in non‐corresponding locations temporal or nasal to the scotoma, had the largest interocular acuity difference and lacked residual stereopsis. The three groups did not differ in fixational control, contrast sensitivity or critical print size.

Conclusions

Equal proportions of patients with central vision loss show binocular reading summation and inhibition. Patients with binocular reading inhibition have poorer reading performance and different clinical characteristics than those with binocular reading summation and equality.

Vision-Related Quality of Life, Anxiety and Depression in Congolese Patients with Polypoidal Choroidal Vasculopathy

OBJECTIVE

To assess the impact of polypoidal choroidal vasculopathy (PCV) on quality of life (QoL) and mental health in a cohort of Congolese patients.

METHODS

Fifteen PCV patients and 26 age-matched controls completed the National Eye Institute Visual Function Questionnaire (NEI VFQ-25) and the Hospital Anxiety and Depression Scale (HADS) questionnaire. Outcome measures were QoL and HADS scores, frequency of anxiety and depression, correlations between best-corrected distance visual acuity (BCDVA) and QoL and HADS scores. Risk factors for anxiety and depression were also determined.

RESULTS

The QoL composite score was (54.9 ± 24.2) in patients and (94.5 ± 4.5) in controls, p <.001. Patients scored higher on HADS-A (9.5 ± 3.4) and HADS-D (6.7 ± 4.7) than controls (3.0 ± 2.7 and 1.5 ± 2.6), all p <.001. Anxiety and depression were present in 73.3% and 46.7% of patients, respectively, versus 1% each of controls (p <.001). Every unit improvement in best eye's BCDVA increased QoL composite score by 24.3, but decreased HADS-D by 5.9. Macular lesions decreased QoL by 34.5 while increasing HADS-A and HADS-D scores by 4.2 and 4.4, respectively. A history of stroke also increased the HADS-A score by 5.9.

CONCLUSIONS

PCV impairs the QoL and induces both anxiety and depression in Congolese PCV patients. Screening for QoL, anxiety and depression in PCV patients at first presentation will help detect those in need of psychological support.

Effect of Visual Feedback on the Eye Position Stability of Patients with AMD

The sources of the reduced fixation stability exhibited by patients with central vision loss in the light are relatively well understood, but we have no information on how they control eye position in complete darkness, in the absence of visual error signals. We therefore explored the effect of visual feedback on eye position stability by testing patients with age-related macular degeneration (AMD) and controls with normal vision in the light and in complete darkness. Nine patients (ages 67 to 92 years) and 16 controls (ages 16 to 74 years) were tested binocularly in the light and in complete darkness while remembering the location of a now invisible target. Binocular eye position was recorded with a video-based eye tracker. Results show that eye position stability both in the light and in the dark is worse for patients than for controls and that, for the two groups, eye position stability in the dark is, on average, 5.9 times worse than in the light. Large instability of fixation in patients with AMD was found even in absolute darkness when the scotoma cannot impair vision. These data reflect permanent changes in the oculomotor reference of patients with AMD.

Low Vision Enhancement with Head-mounted Video Display Systems: Are We There Yet?

SIGNIFICANCE

Head-mounted video display systems and image processing as a means of enhancing low vision are ideas that have been around for more than 20 years. Recent developments in virtual and augmented reality technology and software have opened up new research opportunities that will lead to benefits for low vision patients. Since the Visionics low vision enhancement system (LVES), the first head-mounted video display LVES, was engineered 20 years ago, various other devices have come and gone with a recent resurgence of the technology over the past few years. In this article, we discuss the history of the development of LVESs, describe the current state of available technology by outlining existing systems, and explore future innovation and research in this area. Although LVESs have now been around for more than two decades, there is still much that remains to be explored. With the growing popularity and availability of virtual reality and augmented reality technologies, we can now integrate these methods within low vision rehabilitation to conduct more research on customized contrast-enhancement strategies, image motion compensation, image-remapping strategies, and binocular disparity, all while incorporating eye-tracking capabilities. Future research should use this available technology and knowledge to learn more about the visual system in the low vision patient and extract this new information to create prescribable vision enhancement solutions for the visually impaired individual.

Binocular contrast summation and inhibition depends on spatial frequency, eccentricity and binocular disparity

PURPOSE

When central vision is compromised, visually-guided behaviour becomes dependent on peripheral retina, often at a preferred retinal locus (PRL). Previous studies have examined adaptation to central vision loss with monocular 2D paradigms, whereas in real tasks, patients make binocular eye movements to targets of various sizes and depth in 3D environments.

METHODS

We therefore examined monocular and binocular contrast sensitivity functions with a 26-AFC (alternate forced choice) band-pass filtered letter identification task at 2° or 6° eccentricity in observers with simulated central vision loss. Binocular stimuli were presented in corresponding or non-corresponding stereoscopic retinal locations. Gaze-contingent scotomas (0.5° radius disks of pink noise) were simulated independently in each eye with a 1000 Hz eye tracker and 120 Hz dichoptic shutter glasses.

RESULTS

Contrast sensitivity was higher for binocular than monocular conditions, but only exceeded probability summation at low-mid spatial frequencies in corresponding retinal locations. At high spatial frequencies or non-corresponding retinal locations, binocular contrast sensitivity showed evidence of interocular suppression.

CONCLUSIONS

These results suggest that binocular vision deficits may be underestimated by monocular vision tests and identify a method that can be used to select a PRL based on binocular contrast summation.

The reading accessibility index and quality of reading grid of patients with central vision loss

PURPOSE

In this study we evaluated the reading accessibility index (ACC) and a quality of reading grid as assessment tools for reading and as outcome measures for reading rehabilitation of patients with central vision loss.

METHODS

Reading performances on the MNRead chart (www.precision-vision.com) were reviewed from our research database. Participants were 24 controls with normal vision [mean age: 34 (SD, 14) years] and 61 patients with bilateral central vision loss [mean age: 81 (SD, 9) years] among which a subgroup of 18 patients [mean age, 76 (SD, 13) years] had undergone perceptual learning training for reading rehabilitation. The outcome measures were maximum reading speed, reading acuity, critical print size, ACC, and the reading quality. A reading quality grid that classified reading speed as spot, slow, functional, or fluent and print size as small, regular, medium, or large was used. All reading speed values were normalised (i.e., divided by 200, the average reading speed in young adults with normal vision measured with the MNRead).

RESULTS

The ACC was associated perfectly with the maximum reading speed in the control group (r₂₂  = 0.99, P < 0.001) and strongly with all parameters of reading in the patient group (smallest r value: r₅₉  = -0.66, P < 0.001). For patients with central vision loss, reading was functional for large print, but slow for medium print and spot for regular print. For some patients with the same ACC values, the quality of reading grid revealed important performance differences. For the subgroup (n = 18) of patients who were trained, the ACC revealed a greater effect of training than the other three parameters of reading, and although there were statistically significant improvements across all print size categories, a qualitative improvement in reading was noticed only for the medium print sizes.

CONCLUSIONS

The ACC is a good measure of reading performance in patients with central vision loss. Examining reading quality for different print size categories can provide a more detailed picture of reading impairment and should be considered as an outcome for rehabilitation in addition to the ACC.

Mechanisms of Image Stabilization in Central Vision Loss: Smooth Pursuit

SIGNIFICANCE

In addition to understanding the adaptive mechanisms of eccentric viewing during smooth pursuit, the ocular motor adaptations of patients with central vision loss give us a better understanding of the basic mechanisms of smooth pursuit in the healthy visual system.

PURPOSE

For patients with age-related macular degeneration and controls with normal vision, we examined the closed-loop gain of horizontal and vertical smooth pursuit eye movements as a function of stimulus speed and direction. We hypothesized that pursuit gain functions would be affected by stimulus speed and the location of the preferred retinal locus (PRL) in relation to the scotoma as determined by a fixation stability task using a microperimeter. Specifically, that a PRL on the left of the scotoma in the visual field would decrease the rightward gain relative to the leftward gain and a PRL below the scotoma in the visual field would decrease the upward gain.

METHODS

Ten patients and 15 controls were tested in a step-ramp procedure with direction (left/right for horizontal motion; up/down for vertical motion), speed (5, 10, 15, 20, and 30 deg/s), and five replication conditions randomized and blocked by orientation (horizontal vs. vertical).

RESULTS

Horizontal pursuit had a higher gain than vertical pursuit. The two eyes of the patients moved conjugately with similar smooth pursuit gains. For horizontal pursuit, all patients, regardless of PRL location, showed significantly better pursuit of leftward motion. For vertical pursuit, downward pursuit had a higher gain than upward pursuit for most patients.

CONCLUSIONS

PRL location was not predictive of the directional preponderance of pursuit performance. These results imply that patients may not use the PRL that was initially found during a static fixation task; they may adapt to the task by using a PRL that appears more suitable.

Visual processing in patients with age-related macular degeneration performing a face detection test

PURPOSE

People with age-related macular degeneration (AMD) have difficulties in familiar face recognition and facial expression discrimination. Our aim was to evaluate the visual processing of faces in AMD patients and whether this would be improved by anti-vascular endothelial growth factor therapy. This was a prospective interventional cohort study.

PATIENTS

Twelve patients with monocular wet AMD and 6 control subjects were recruited. Face detection processes were studied using cortical event-related potentials (ERPs). Patients received 3 bevacizumab intravitreal injections to the single affected eye. At baseline and 4-6 weeks after the last injection, clinical presentation and ERPs of the face task were evaluated. Face pictures were shown as targets (16.7%) among standard pictures of pixelated faces in an oddball-type paradigm.

RESULTS

Face pictures elicited well-defined electrical components in occipital and parieto-occipital cortical areas at baseline and after treatment. The face-specific N170 component was evident in all subjects with longer peak latency in patients than in controls (170±13 vs 155±14, P=0.032). Unexpectedly, an early component reflecting unintentional prediction of perceiving a face, that is, deviance-related negativity, was present in patients and controls. Visual acuity of the affected eye seemed improved in patients from logarithm of the minimum angle of resolution 0.71 (±0.33) to 0.52 (±0.39) by 119 (±23) days without accompanying significant change in face-specific ERPs.

CONCLUSIONS

Monocular wet AMD distinctly influenced face-specific brain electrophysiological components. However, the anti-vascular endothelial growth factor treatment did not improve the binocular face detection ability. The EudraCT number of this study is 2012-000765-20.

Normal Aging Slows Spontaneous Switching in Auditory and Visual Bistability

Age-related changes in auditory and visual perception have an impact on the quality of life. It has been debated how perceptual organization is influenced by advancing age. From the neurochemical perspective, we investigated age effects on auditory and visual bistability. In perceptual bistability, a sequence of sensory inputs induces spontaneous switching between different perceptual objects. We used different modality tasks of auditory streaming and visual plaids. Young and middle-aged participants (20-60years) were instructed to indicate by a button press whenever their perception changed from one stable state to the other. The number of perceptual switches decreased with participants' ages. We employed magnetic resonance spectroscopy to measure non-invasively concentrations of the inhibitory neurotransmitter (γ-aminobutyric acid, GABA) in the brain regions of interest. When participants were asked to voluntarily modulate their perception, the amount of effective volitional control was positively correlated with the GABA concentration in the auditory and motion-sensitive areas corresponding to each sensory modality. However, no correlation was found in the prefrontal cortex and anterior cingulate cortex. In addition, effective volitional control was reduced with advancing age. Our results suggest that sequential scene analysis in auditory and visual domains is influenced by both age-related and neurochemical factors.

Monocular and binocular smooth pursuit in central field loss

Macular degeneration results in heterogeneous central field loss (CFL) and often has asymmetrical effects in the two eyes. As such, it is not clear to what degree the movements of the two eyes are coordinated. To address this issue, we examined smooth pursuit quantitatively in CFL participants during binocular viewing and compared it to the monocular viewing case. We also examined coordination of the two eyes during smooth pursuit and how this coordination was affected by interocular ratios of acuity and contrast, as well as CFL-specific interocular differences, such as scotoma sizes and degree of binocular overlap. We hypothesized that the coordination of eye movements would depend on the binocularity of the two eyes. To test our hypotheses, we used a modified step-ramp paradigm, and measured pursuit in both eyes while viewing was binocular, or monocular with the dominant or non-dominant eye. Data for CFL participants and age-matched controls were examined at the group, within-group, and individual levels. We found that CFL participants had a broader range of smooth pursuit gains and a significantly lower correlation between the two eyes, as compared to controls. Across both CFL and control groups, smooth pursuit gain and correlation between the eyes are best predicted by the ratio of contrast sensitivity between the eyes. For the subgroup of participants with measurable stereopsis, both smooth pursuit gain and correlation are best predicted by stereoacuity. Therefore, our results suggest that coordination between the eyes during smooth pursuit depends on binocular cooperation between the eyes.

Bilateral symmetry in vision and influence of ocular surgical procedures on binocular vision: A topical review

We analyze the role of bilateral symmetry in enhancing binocular visual ability in human eyes, and further explore how efficiently bilateral symmetry is preserved in different ocular surgical procedures. The inclusion criterion for this review was strict relevance to the clinical questions under research. Enantiomorphism has been reported in lower order aberrations, higher order aberrations and cone directionality. When contrast differs in the two eyes, binocular acuity is better than monocular acuity of the eye that receives higher contrast. Anisometropia has an uncommon occurrence in large populations. Anisometropia seen in infancy and childhood is transitory and of little consequence for the visual acuity. Binocular summation of contrast signals declines with age, independent of inter-ocular differences. The symmetric associations between the right and left eye could be explained by the symmetry in pupil offset and visual axis which is always nasal in both eyes. Binocular summation mitigates poor visual performance under low luminance conditions and strong inter-ocular disparity detrimentally affects binocular summation. Considerable symmetry of response exists in fellow eyes of patients undergoing myopic PRK and LASIK, however the method to determine whether or not symmetry is maintained consist of comparing individual terms in a variety of ad hoc ways both before and after the refractive surgery, ignoring the fact that retinal image quality for any individual is based on the sum of all terms. The analysis of bilateral symmetry should be related to the patients' binocular vision status. The role of aberrations in monocular and binocular vision needs further investigation.

Depth Perception and Grasp in Central Field Loss

Purpose

We set out to determine whether individuals with central field loss benefit from using two eyes to perform a grasping task. Specifically, we tested the hypothesis that this advantage is correlated with coarse stereopsis, in addition to binocular summation indices of visual acuity, contrast sensitivity, and binocular visual field.

Methods

Sixteen participants with macular degeneration and nine age-matched controls placed pegs on a pegboard, while their eye and hand movements were recorded. Importantly, the pegboard was placed near eye height, to minimize the contribution of monocular cues to peg position. All participants performed this task binocularly and monocularly. Before the experiment, we performed microperimetry to determine the profile of field loss in each eye and the locations of eccentric fixation (if applicable). In addition, we measured both acuity and contrast sensitivity monocularly and binocularly, and stereopsis by using both a RanDot test and a custom stereo test.

Results

Peg-placement time was significantly shorter and participants made significantly fewer errors with binocular than with monocular viewing in both the patient and control groups. Among participants with measurable stereopsis, binocular advantage in peg-placement time was significantly correlated with stereoacuity (ρ = −0.78; P = 0.003). In patients without measurable stereopsis, the binocular advantage was related significantly to the overlap in the scotoma between the two eyes (ρ = −0.81; P = 0.032).

Conclusions

The high correlation between grasp performance and stereoacuity indicates that coarse stereopsis may benefit tasks of daily living for individuals with central field loss.

Reading training with threshold stimuli in people with central vision loss: a feasibility study

PURPOSE

To evaluate the effectiveness of a perceptual learning technique for improving reading performance of patients with central vision loss and to explore whether this learning generalizes to other visual functions.

METHODS

Ten patients with central vision loss were trained binocularly, in four consecutive sessions, with serially presented words printed at each patient's reading acuity limit. Patients read 10 blocks of 100 words in each session. They were encouraged to read the whole word and were discouraged to read letter by letter. Assessment sessions before and after training measured fixation stability, monocular and binocular visual acuity, as well as reading acuity, critical print size, and maximum reading speed with continuous text. Another six patients with central vision loss were included in a test-retest control group and were tested twice, 1 week apart, with no intervention.

RESULTS

The average time required to read a block of trials decreased significantly with each training session. After training, continuous text reading improved in terms of reading acuity (p = 0.017) and maximum reading speed (p = 0.01), but critical print size did not change. Binocular acuity improved significantly from an average of 0.54 logMAR before training to 0.44 logMAR after training. Binocular ratio (better eye acuity/binocular acuity) increased from an average of 1.0 before training to 1.17 after training. There was a 62% improvement in fixation stability in the better eye and 58% in the worse eye. There were no changes in the outcome measures for the test-retest control group.

CONCLUSIONS

The technique described in this article can be used for vision rehabilitation of patients with central vision loss. When training is done with size threshold stimuli, learning generalizes to visual acuity, continuous text reading, and fixation stability.

Residual stereopsis in age-related macular degeneration patients and its impact on vision-related abilities: a pilot study

OBJECTIVE

To determine the effect of residual stereopsis on vision-related abilities of low vision (LV) patients with age-related macular degeneration (AMD).

METHODS

Prospective non-randomized observational case series. Inclusion criteria included documented AMD, LV with best corrected visual acuity (BCVA) of 20/50-20/400 in the better eye, and ages between 50 and 90 years. Stereoacuity was measured using the near Frisby Stereotest. Vision related abilities were documented with the VA LV VFQ-48 questionnaire.

RESULTS

Twenty-seven subjects with mean age of 84±6 years old were recruited, of which 59.3% (16/27) were female. 59.3% (16/27) of the subjects were not able to see any stereoacuity plate, 25.9% (7/27) had stereoacuity of 340s of arc (SOA), 11.1% (3/27) had stereoacuity of 170 SOA and 3.7% (1/27) had stereoacuity of 85 SOA. The mean Overall Functional Visual Abilities (OFVA) score was significantly higher in those with stereopsis (2.25±0.99) than those without stereopsis (1.50±0.92) (P=0.028).

CONCLUSIONS

LV patients with stereopsis have better OFVA than those without. Stereopsis should be considered as a component of LV rehabilitation and considered as an outcome measure in research and clinical practice.

Principles of modern low vision rehabilitation

Low vision rehabilitation is a new emerging subspecialty drawing from the traditional fields of ophthalmology, optometry, occupational therapy, and sociology, with an ever-increasing impact on our customary concepts of research, education, and services for the visually impaired patient. A multidisciplinary approach and coordinated effort are necessary to take advantage of new scientific advances and achieve optimal results for the patient. Accordingly, the intent of this paper is to outline the principles and details of a modern low vision rehabilitation service. All rehabilitation attempts must start with a first hand interview (the intake) for assessing functionality and priority tasks for rehabilitation, as well as assessing the patient's all-important cognitive skills. The assessment of residual visual functions follows the intake and offers a unique opportunity to measure, evaluate, and document accurately the extent of functional loss sustained by the patient from disease. An accurate assessment of residual visual functions includes assessment of visual acuity, contrast sensitivity, binocularity, refractive errors, perimetry, oculomotor functions, cortical visual integration, and light characteristics affecting visual functions. Functional vision assessment in low vision rehabilitation measures how well one uses residual visual functions to perform routine tasks, using different items under various conditions, throughout the day. Of the many functional vision skills known, reading skills is an obligatory item for all low vision rehabilitation assessments. Results of assessment guide rehabilitation professionals in developing rehabilitation plans for the individual and recommending appropriate low vision devices. The outcome from assessing residual visual functions is detection of visual functions that can be improved with the use of optical devices. Methods for prescribing devices such as image relocation with prisms to a preferred retinal locus, field displacement to primary gaze position, field expansion, and manipulation of light are practiced today in addition to, or instead of, magnification. Correction of refractive errors, occlusion therapy, enhancement of oculomotor skills, and field restitution are additional methods now available for prescribing devices leading to rehabilitation of visual functions. The outcome from assessing residual functional vision is detection of functional vision that can be improved with the use of vision therapy training. After restoration of optimal residual visual functions is achieved with optical devices, one can follow with training programs for restoration of lost vision-related skills. If an optical dispensary is available where prescribing of low vision devices routinely take place, this will help ensure familiarity and specialization of the dispensary and staff with low vision devices and their special dispensing requirements. The dispensing of low vision devices is an opportunity to introduce the device to the patient, train the patient in the correct use of the device for the task selected, and create a direct and continuous connection with the patient until the next encounter. Following assessment, prescribing, and dispensing of devices, a low vision practitioner, ophthalmologist or optometrist, is responsible for recommending and prescribing vision therapy training to improve residual functional vision. An attempt to present a template for a comprehensive modern low vision rehabilitation practice is made here by summarizing scientific developments in the field and stressing the multidisciplinary involvement required for this kind of practice. It is hoped that this paper and other initiatives from colleagues, the public, and government will promote and raise awareness of modern low vision rehabilitation for the benefit of all.

Binocular function in patients with age-related macular degeneration: a review

Normally sighted observers typically benefit from binocular viewing when monocular sensitivities are equivalent. Age-related macular degeneration (AMD) not only destroys the foveal vision, however, but it also affects the 2 eyes unequally, providing grounds for impairment of binocular function. The aim of the present article is to provide a review of the current research on the effect of AMD on binocular vision. The main findings to date reveal that a high proportion of patients show characteristics of binocular contrast inhibition at low and medium spatial frequencies. Yet binocular acuity gain is not different from that of age-matched control participants without AMD. Additional findings show that rivalry processes are severely disrupted in patients with AMD. The effects of the disease on other binocular functions have yet to be explored. Knowledge of binocular function in AMD may one day help clinicians decide on the most appropriate management and rehabilitation techniques.