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

Efficacy of perceptual learning in low vision: A systematic review and meta-analysis

BACKGROUND

Visual perceptual learning (PL) shows promise for enhancing visual functions in individuals with visual impairment.

OBJECTIVE

This systematic review aimed to evaluate the effectiveness of PL in improving visual function.

STUDY ELIGIBILITY

Eligible studies were those examining the efficacy of PL in individuals with low vision.

STUDY APPRAISAL AND SYNTHESIS METHODS

The review protocol was registered with the international Prospective Register of Systematic Reviews (ID CRD42022327545) and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Screened studies were synthesized using random-effects meta-analysis and narrative synthesis following Synthesis Without Meta-analysis guidelines. The quality of the evidence was assessed using the Cochrane risk-of-bias tool and the JBI Critical Appraisal Tool for Quasi-Experimental studies.

RESULTS

Fifty studies were included, covering various visual impairments and employing different PL interventions. Most studies had low risk of bias. Meta-analysis showed significant improvement in visual search for individuals with cortical blindness (Hedges' g = 0.71; 95% confidence interval, 0.48 to 0.93; p=0.002); all other analyses did not show significant improvements-reading in central vision loss and cortical blindness, and visual field in peripheral vision loss and cortical blindness. However, the narrative synthesis provided evidence showing effectiveness, particularly in individuals with central vision loss and cortical blindness, demonstrating positive effects on reading, contrast sensitivity, visual field, and motion perception.

LIMITATIONS

Variations in study design, PL protocols, outcome measures, and measurement methods introduced heterogeneity, limiting the analysis.

CONCLUSIONS

The efficacy of PL in vision rehabilitation remains uncertain. Although meta-analysis results were mostly inconclusive, the narrative synthesis indicated improved visual functions following PL, consistent with individual study findings.

IMPLICATIONS OF KEY FINDINGS

Future research should optimize intervention parameters, explore long-term effects, and assess generalizability across diverse populations and visual impairment etiologies. Larger randomized controlled trials using standardized outcome measures are needed to advance the field.

Enhancing the Functional Performance of Patients with Late-Stage Age-Related Macular Degeneration Implanted with a Miniature Telescope using Rehabilitation Training

INTRODUCTION

In this work, our aim is to report the functional outcomes of cataract surgery with smaller-incision new-generation miniature telescope (SING IMT) implantation followed by rehabilitation training in patients with central visual loss due to late-stage age-related macular degeneration (AMD).

METHODS

This retrospective study included patients who were monocularly implanted with SING IMT and then followed a rehabilitation program based on 6 biweekly sessions focused on visual abilities, reading, writing, visual motor integration and mobility. A total of 11 participants were included in this study. Reading acuity (RA), reading speed (RS), and fixation stability (FS) were assessed biweekly at 6-, 8-, 10-, 12-, 14-, and 16-week follow-up visits after SING IMT implantation and at a final assessment at 24 weeks. Best-corrected distance visual acuity (BCDVA) was also measured at baseline and at the same postoperative timepoints.

RESULTS

Mean baseline BCDVA was 12.5 ± 8.6 letter score. Both RA and RS were found to be significantly improved from the first rehabilitation session (6 weeks after surgery) to the last session (24 weeks after surgery). At the end of the rehabilitation program, mean RA was 0.45 ± 0.19 LogMAR and mean RS was 30.9 ± 17.6 words per minute. Moreover, all patients achieved a FS of 15 s or more after the last rehabilitation session. Most patients (55%) achieved an improvement of 15 letters in BCDVA at the end of the study.

CONCLUSIONS

This study suggests that rehabilitation training can improve visual functions of patients with late-stage AMD implanted with SING IMT in real-world tasks such as reading skills.

Altered eye movements during reading under degraded viewing conditions: Background luminance, text blur, and text contrast

Degraded viewing conditions caused by either natural environments or visual disorders lead to slow reading. Here, we systematically investigated how eye movement patterns during reading are affected by degraded viewing conditions in terms of spatial resolution, contrast, and background luminance. Using a high-speed eye tracker, binocular eye movements were obtained from 14 young normally sighted adults. Images of text passages were manipulated with varying degrees of background luminance (1.3-265 cd/m2), text blur (severe blur to no blur), or text contrast (2.6%-100%). We analyzed changes in key eye movement features, such as saccades, microsaccades, regressive saccades, fixations, and return-sweeps across different viewing conditions. No significant changes were observed for the range of tested background luminance values. However, with increasing text blur and decreasing text contrast, we observed a significant decrease in saccade amplitude and velocity, as well as a significant increase in fixation duration, number of fixations, proportion of regressive saccades, microsaccade rate, and duration of return-sweeps. Among all, saccade amplitude, fixation duration, and proportion of regressive saccades turned out to be the most significant contributors to reading speed, together accounting for 90% of variance in reading speed. Our results together showed that, when presented with degraded viewing conditions, the patterns of eye movements during reading were altered accordingly. These findings may suggest that the seemingly deviated eye movements observed in individuals with visual impairments may be in part resulting from active and optimal information acquisition strategies operated when visual sensory input becomes substantially deprived.

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

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

Training peripheral vision to read: Using stimulus exposure and identity priming

Reading in the periphery can be improved with perceptual learning. A conventional training paradigm involves repeated practice on a character-based task (e.g., recognizing random letters/words). While the training is effective, the hours of strenuous effort required from the trainees makes it difficult to implement the training in low-vision patients. Here, we developed a training paradigm utilizing stimulus exposure and identity priming to minimize training effort and improve training accessibility while maintaining the active engagement of observers through a stimulus visibility task. Twenty-one normally sighted young adults were randomly assigned to three groups: a control group, a with-repetition training group, and a without-repetition training group. All observers received a pre-test and a post-test scheduled 1 week apart. Each test consisted of measurements of reading speed, visual-span profile, the spatial extent of crowding, and isolated-letter profiles at 10° eccentricity in the lower visual field. Training consists of five daily sessions (a total of 7,150 trials) of viewing trigram stimuli (strings of three letters) with identity priming (prior knowledge of target letter identity). The with-repetition group was given the option to replay each stimulus (averaged 0.4 times). In comparison to the control group, both training groups showed significant improvements in all four performance measures. Stimulus replay did not yield a measurable benefit on learning. Learning transferred to various untrained tasks and conditions, such as the reading task and untrained letter size. Reduction in crowding was the main basis of the training-related improvement in reading. We also found that the learning can be partially retained for a minimum of 3 months and that complete retention is attainable with additional monthly training. Our findings suggest that conventional training task that requires recognizing random letters or words is dispensable for improving peripheral reading. Utilizing stimulus exposure and identity priming accompanied by a stimulus visibility task, our novel training procedure offers effective intervention, simple implementation, capability for remote and self-administration, and an easy translation into low-vision reading rehabilitation.

Perspective on Vision Science-Informed Interventions for Central Vision Loss

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

Training to improve temporal processing of letters benefits reading speed for people with central vision loss

Reading is slow and difficult for many people with central vision loss. A previous study showed that the temporal threshold for letter recognition is a major factor limiting reading speed for people with central vision loss. Here, we asked whether the temporal threshold for letter recognition for people with central vision loss could be improved through training and, if so, whether that would benefit reading. Training consisted of six sessions (3000 trials) of recognizing letter trigrams presented at fixation. Trigrams were initially presented at a baseline temporal threshold that was decreased by 0.1 log step when observers' letter recognition accuracies reached 80% or higher for four consecutive blocks. Before and after training, we measured observers' visual acuity, preferred retinal locus for fixation, fixation stability, reading speeds using the rapid serial visual presentation (RSVP) paradigm, the MNREAD Acuity Chart and 100-word passages, the baseline temporal threshold for letter recognition at 80% accuracy, and a visual-span profile. After training, the temporal threshold was decreased by 68%. This improvement was accompanied by a higher RSVP maximum reading speed (but no change in MNREAD and passage reading speeds) and a larger visual span. A mediation analysis showed that the relationship between the temporal threshold and RSVP maximum reading speed was mainly mediated by the information transfer rate (size of visual span/temporal duration). Our results showed that the temporal threshold for letter recognition is amenable to training and can improve RSVP reading speeds, offering a practical means to improve reading speed for people with central vision loss.

Combining fixation and lateral masking training enhances perceptual learning effects in patients with macular degeneration

Macular degeneration (MD), a retinal disease affecting central vision, represents the leading cause of visual impairment in the Western world, and MD patients face severe limitations in daily activities like reading and face recognition. A common compensation strategy adopted by these patients involves the use of a region in the spared peripheral retina as a new fixation spot and oculomotor reference (preferred retinal locus, or PRL). Still, peripheral vision is characterized by poorer visual acuity, fixation stability, and larger crowding zones that further hinder processes like object recognition, visual search, and reading. Perceptual learning (PL) has been successfully used to improve visual acuity in mild visual conditions (e.g., presbyopia, amblyopia and myopia), but results in MD are less clear, often showing limited generalization of learning, unlike what is observed in a healthy population. A possible reason is the suboptimal fixation in the PRL that might prevent patients from processing the briefly presented training stimuli. Following this hypothesis, we trained five MD patients and four age- and eccentricity-matched controls with a protocol that combined contrast detection and a task previously used to train fixation stability. Results showed transfer of learning to crowding reduction, reading speed, and visual acuity in both MD patients and controls. These results suggest that in the case of central vision loss, PL training might benefit from the integration of oculomotor components to optimize the effect of training and promote transfer of learning to other visual functions.

The Effect of Perceptual Learning on Face Recognition in Individuals with Central Vision Loss

Purpose

To examine whether perceptual learning can improve face discrimination and recognition in older adults with central vision loss.

Methods

Ten participants with age-related macular degeneration (ARMD) received 5 days of training on a face discrimination task (mean age, 78 ± 10 years). We measured the magnitude of improvements (i.e., a reduction in threshold size at which faces were able to be discriminated) and whether they generalized to an untrained face recognition task. Measurements of visual acuity, fixation stability, and preferred retinal locus were taken before and after training to contextualize learning-related effects. The performance of the ARMD training group was compared to nine untrained age-matched controls (8 = ARMD, 1 = juvenile macular degeneration; mean age, 77 ± 10 years).

Results

Perceptual learning on the face discrimination task reduced the threshold size for face discrimination performance in the trained group, with a mean change (SD) of –32.7% (+15.9%). The threshold for performance on the face recognition task was also reduced, with a mean change (SD) of –22.4% (+2.31%). These changes were independent of changes in visual acuity, fixation stability, or preferred retinal locus. Untrained participants showed no statistically significant reduction in threshold size for face discrimination, with a mean change (SD) of –8.3% (+10.1%), or face recognition, with a mean change (SD) of +2.36% (–5.12%).

Conclusions

This study shows that face discrimination and recognition can be reliably improved in ARMD using perceptual learning. The benefits point to considerable perceptual plasticity in higher-level cortical areas involved in face-processing. This novel finding highlights that a key visual difficulty in those suffering from ARMD is readily amenable to rehabilitation.

Reading in the presence of macular disease: a mini-review

Purpose

Reading is vital to full participation in modern society. To millions of people suffering from macular disease that results in a central scotoma, reading is difficult and inefficient, rendering reading as the primary goal for most patients seeking low vision rehabilitation. The goals of this review paper are to summarize the dependence of reading speed on several key visual and typographical factors and the current methods or technologies for improving reading performance for people with macular disease.

Important findings

In general, reading speed for people with macular disease depends on print size, text contrast, size of the visual span, temporal processing of letters and oculomotor control. Attempts at improving reading speed by reducing the crowding effect between letters, words or lines; or optimizing properties of typeface such as the presence of serifs or stroke‐width thickness proved to be futile, with any improvement being modest at best. Currently, the most promising method to improve reading speed for people with macular disease is training, including perceptual learning or oculomotor training.

Summary

The limitation on reading speed for people with macular disease is likely to be multi‐factorial. Future studies should try to understand how different factors interact to limit reading speed, and whether different methods could be combined to produce a much greater benefit.

Perceptual learning in patients with Stargardt disease

OBJECTIVE

To evaluate the efficacy of Perceptual Learning in improving the peripheral reading performance of patients with Stargardt disease (STGD).

DESIGN

Prospective observational randomized study.

PARTICIPANTS

Fourteen consecutive patients (7 females, 7 males; median age of 50.4 ± 12.8 years) with STGD were analyzed and divided into two groups: Group A received "Win-flash" as Perceptual Learning training and Group B was used as control.

METHODS

Subjects underwent an ophthalmic evaluation at baseline, after perceptual learning training and at 6 months of follow-up. Outcomes measured included reading speed, contrast sensitivity and fixation stability.

RESULTS

Reading speed improved of 51,7% after training in group A. Visual acuity, contrast sensitivity and fixation stability enhanced in group A after training from 0.89 (±0.09) LogMAR to 0.75 (±0.2) LogMAR (t(6)= 3.6, p= 0.001), from 0.8 (±0.3) LogC (0.6 - 0.9) to 1.3 (±0.3) LogC (t(13)=3.17, p= 0.003) and from 59.3 % (± 24.3) to 71.5 % (± 20.4) (t(13)=1.8 p= 0.04), respectively. No changes were found in group B. At 6-monts of follow-up, visual acuity and contrast sensitivity decreased in group A.

CONCLUSIONS

STGD patients receiving "Win-flash training", as PL technique, showed an improvement of reading performance on a real-world task. Early follow-up for perceptual learning re-intervention should be considered.

Impact of simulated micro-scotomas on reading performance in central and peripheral retina

Observers with central field loss typically fixate within a non-foveal region called the preferred retinal locus, which can include localized sensitivity losses, or micro-scotomas (Krishnan and Bedell, 2018). In this study, we simulated micro-scotomas at the fovea and in the peripheral retina to assess their impact on reading speed. Ten younger (<36 years old) and 8 older (>50 years old) naïve observers with normal vision monocularly read high and/or low contrast sentences, presented at or above the critical print size for young observers at the fovea and at 5 and 10 deg in the inferior visual field. Reading material comprised MNREAD sentences and sentences taken from novels that were presented in rapid serial visual presentation (RSVP) format. Randomly distributed 13 × 13 arc min blocks corresponding to 0-78% of the text area (corresponding to ∼0-17 micro-scotomas/deg2) were set to the background luminance to simulate micro-scotomas. A staircase algorithm estimated maximum reading speed from the threshold exposure duration for each combination of retinal eccentricity, contrast and micro-scotoma density in both age groups. Log10(RSVP reading speed) decreased significantly with simulated micro-scotoma density and eccentricity. Across conditions, reading speed was slower with low-compared to high-contrast text and was faster in younger than older normal observers. For a given eccentricity and contrast, a higher density of random element losses maximally affected older observers with normal vision. These outcomes may explain some of the reading deficits observed in older observers with central field loss.

Training peripheral vision to read: Boosting the speed of letter processing

Central-field loss necessitates the use of peripheral vision which makes reading slow and difficult. Slower temporal processing of letter recognition has been shown to be a limiting factor in peripheral letter recognition and reading. Previous studies showed that perceptual learning can increase the number of letters recognized on each fixation and is accompanied by an increase in reading speed. We hypothesized that improvement in temporal processing speed underlies the observed training effects. Here, we proposed an adaptive training procedure to focus on boosting the speed of letter recognition, and investigated whether peripheral reading would be enhanced by this training method. Seven normally-sighted subjects were trained with four daily one-hour sessions of a letter recognition task at 10° in the lower visual field in a pre/post design. During training, we adjusted stimulus duration on a block by block basis to maintain task difficulty near a pre-defined level of 80% performance accuracy. Stimulus duration progressively decreased with training, indicative of faster letter recognition at the 80% criterion. Following training, reading speed measured using a rapid serial visual presentation showed a substantial improvement in the trained (lower) field (41%) and the untrained (upper) field (27%), similar to the improvements observed from the training with a fixed stimulus duration. Despite being no more effective than the previous training, the adaptive temporal training method may allow individualized training, and may have advantages for clinical populations.

Smooth pursuit of amodally completed images

In order to evaluate the effect of the parafoveal area of the retina on smooth pursuit, we compared the horizontal smooth pursuit of visible and amodally completed stimuli in people with central vision loss and controls. In the amodally completed stimuli, a black mask covered the bottom vertex of a moving diamond which is the feature whose movement participants had to track. Both the visible and the amodally completed stimuli moved along regular and irregular sinusoidal motion paths. Our results show that people with central vision loss are able to track a perceptually completed moving stimulus albeit with lower gain, larger tracking errors, and more saccadic eye movements than people with normal vision. Just as the controls, however, people with central vision do better in the no mask condition showing that visual feedback from eccentric vision can improve performance.

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.

Perceptual learning leads to long lasting visual improvement in patients with central vision loss

BACKGROUND

Macular Degeneration (MD), a visual disease that produces central vision loss, is one of the main causes of visual disability in western countries. Patients with MD are forced to use a peripheral retinal locus (PRL) as a substitute of the fovea. However, the poor sensitivity of this region renders basic everyday tasks very hard for MD patients.

OBJECTIVE

We investigated whether perceptual learning (PL) with lateral masking in the PRL of MD patients, improved their residual visual functions.

METHOD

Observers were trained with two distinct contrast detection tasks: (i) a Yes/No task with no feedback (MD: N = 3; controls: N = 3), and (ii) a temporal two-alternative forced choice task with feedback on incorrect trials (i.e., temporal-2AFC; MD: N = 4; controls: N = 3). Observers had to detect a Gabor patch (target) flanked above and below by two high contrast patches (i.e., lateral masking). Stimulus presentation was monocular with durations varying between 133 and 250 ms. Participants underwent 24- 27 training sessions in total.

RESULTS

Both PL procedures produced significant improvements in the trained task and learning transferred to visual acuity. Besides, the amount of transfer was greater for the temporal-2AFC task that induced a significant improvement of the contrast sensitivity for untrained spatial frequencies. Most importantly, follow-up tests on MD patients trained with the temporal-2AFC task showed that PL effects were retained between four and six months, suggesting long-term neural plasticity changes in the visual cortex.

CONCLUSION

The results show for the first time that PL with a lateral masking configuration has strong, non-invasive and long lasting rehabilitative potential to improve residual vision in the PRL of patients with central vision loss.

Spontaneous and training-induced cortical plasticity in MD patients: Hints from lateral masking

Macular degeneration (MD) affects central vision and represents the leading cause of visual diseases in elderly population worldwide. As a consequence of central vision loss, MD patients develop a preferred retinal locus (PRL), an eccentric fixation point that replaces the fovea. Here, our aim was to determine whether and to what extent spontaneous plasticity takes place in the cortical regions formerly responding to central vision and whether a visual training based on perceptual learning (PL) can boost this plasticity within the PRL area. Spontaneous and PL-induced cortical plasticity were characterized by using lateral masking, a contrast sensitivity modulation induced by collinear flankers. This configuration is known to be sensitive to neural plasticity and underlies several rehabilitation trainings. Results in a group of 4 MD patients showed that collinear facilitation was similar to what observed in age- and eccentricity-matched controls. However, MD patients exhibited significantly reduced collinear inhibition, a sign of neural plasticity, consistent with the hypothesis of partial cortical reorganization. Three AMD patients from the same group showed a further reduction of inhibition after training, but not controls. This result suggests that PL might further boost neural plasticity, opening promising perspectives for the development of rehabilitation protocols for MD patients.

Evaluation of a gaze-controlled vision enhancement system for reading in visually impaired people

People with low vision, especially those with Central Field Loss (CFL), need magnification to read. The flexibility of Electronic Vision Enhancement Systems (EVES) offers several ways of magnifying text. Due to the restricted field of view of EVES, the need for magnification is conflicting with the need to navigate through text (panning). We have developed and implemented a real-time gaze-controlled system whose goal is to optimize the possibility of magnifying a portion of text while maintaining global viewing of the other portions of the text (condition 1). Two other conditions were implemented that mimicked commercially available advanced systems known as CCTV (closed-circuit television systems)—conditions 2 and 3. In these two conditions, magnification was uniformly applied to the whole text without any possibility to specifically select a region of interest. The three conditions were implemented on the same computer to remove differences that might have been induced by dissimilar equipment. A gaze-contingent artificial 10° scotoma (a mask continuously displayed in real time on the screen at the gaze location) was used in the three conditions in order to simulate macular degeneration. Ten healthy subjects with a gaze-contingent scotoma read aloud sentences from a French newspaper in nine experimental one-hour sessions. Reading speed was measured and constituted the main dependent variable to compare the three conditions. All subjects were able to use condition 1 and they found it slightly more comfortable to use than condition 2 (and similar to condition 3). Importantly, reading speed results did not show any significant difference between the three systems. In addition, learning curves were similar in the three conditions. This proof of concept study suggests that the principles underlying the gaze-controlled enhanced system might be further developed and fruitfully incorporated in different kinds of EVES for low vision reading.

Learning to recognize letters in the periphery: Effects of repeated exposure, letter frequency, and letter complexity

Patients with central vision loss must rely on their peripheral vision for reading. Unfortunately, limitations of peripheral vision, such as crowding, pose significant challenges to letter recognition. As a result, there is a need for developing effective training methods for improving crowded letter recognition in the periphery. Several studies have shown that extensive practice with letter stimuli is beneficial to peripheral letter recognition. Here, we explore stimulus-related factors that might influence the effectiveness of peripheral letter recognition training. Specifically, we examined letter exposure (number of letter occurrences), frequency of letter use in English print, and letter complexity and evaluated their contributions to the amount of improvement observed in crowded letter recognition following training. We analyzed data collected across a range of training protocols. Using linear regression, we identified the best-fitting model and observed that all three stimulus-related factors contributed to improvement in peripheral letter recognition with letter exposure being the most important factor. As an important explanatory variable, pretest accuracy was included in the model as well to avoid estimate biases and was shown to have influence on the relationship between training improvement and letter exposure. When developing training protocols for peripheral letter recognition, it may be beneficial to not only consider the overall length of training, but also to tailor the number of stimulus occurrences for each letter according to its initial performance level, frequency, and complexity.

Rehabilitation Approaches in Macular Degeneration Patients

Age related macular degeneration (AMD) is a visual disease that affects elderly population. It entails a progressive loss of central vision whose consequences are dramatic for the patient's quality of life. Current rehabilitation programs are restricted to technical aids based on visual devices. They only temporarily improve specific visual functions such as reading skills. Considering the rapid increase of the aging population worldwide, it is crucial to intensify clinical research on AMD in order to develop simple and efficient methods that improve the patient's visual performances in many different contexts. One very promising approach to face this challenge is based on perceptual learning (PL). Through intensive practice, PL can induce neural plasticity in sensory cortices and result in long-lasting enhancements for various perceptual tasks in both normal and visually impaired populations. A growing number of studies showed how appropriate PL protocols improve visual functions in visual disorders, namely amblyopia, presbyopia or myopia. In order to successfully apply these approaches to more severe conditions such as AMD, numerous challenges have to be overcome. Indeed, the overall elderly age of patients and the reduced cortical surface that is devoted to peripheral vision potentially limit neural plasticity in this population. In addition, ocular fixation becomes much less stable because patients have to rely on peripheral fixation spots outside the scotoma whose size keeps on evolving. The aim of this review article is to discuss the recent literature on this topic and to offer a unified approach for developing new rehabilitation programs of AMD using PL. We argue that with an appropriate experimental and training protocol that is adapted to each patient needs, PL can offer fascinating opportunities for the development of simple, non-expensive rehabilitation approaches a large spectrum of visual functions in AMD patients.

Low Vision and Plasticity: Implications for Rehabilitation

Low vision is any type of visual impairment that affects activities of daily living. In the context of low vision, we define plasticity as changes in brain or perceptual behavior that follow the onset of visual impairment and that are not directly due to the underlying pathology. An important goal of low-vision research is to determine how plasticity affects visual performance of everyday activities. In this review, we consider the levels of the visual system at which plasticity occurs, the impact of age and visual experience on plasticity, and whether plastic changes are spontaneous or require explicit training. We also discuss how plasticity may affect low-vision rehabilitation. Developments in retinal imaging, noninvasive brain imaging, and eye tracking have supplemented traditional clinical and psychophysical methods for assessing how the visual system adapts to visual impairment. Findings from contemporary research are providing tools to guide people with low vision in adopting appropriate rehabilitation strategies.

Changes across the psychometric function following perceptual learning of an RSVP reading task

Several recent studies have shown that perceptual learning can result in improvements in reading speed for people with macular disease (e.g., Chung, 2011; Tarita-Nistor et al., 2014). The improvements were reported as an increase in reading speed defined by specific criteria; however, little is known about how other properties of the reading performance or the participants' perceptual responses change as a consequence of learning. In this paper, we performed detailed analyses of data following perceptual learning using an RSVP (rapid serial visual presentation) reading task, looking beyond the change in reading speed defined by the threshold at a given accuracy on a psychometric function relating response accuracy with word exposure duration. Specifically, we explored the statistical characteristics of the response data to address two specific questions: was there a change in the slope of the psychometric function and did the improvements in performance occur consistently across different word exposure durations? Our results show that there is a general steepening of the slope of the psychometric function, leading to non-uniform improvements across stimulus levels.

The effect of normal aging and age-related macular degeneration on perceptual learning

We investigated whether perceptual learning could be used to improve peripheral word identification speed. The relationship between the magnitude of learning and age was established in normal participants to determine whether perceptual learning effects are age invariant. We then investigated whether training could lead to improvements in patients with age-related macular degeneration (AMD). Twenty-eight participants with normal vision and five participants with AMD trained on a word identification task. They were required to identify three-letter words, presented 10° from fixation. To standardize crowding across each of the letters that made up the word, words were flanked laterally by randomly chosen letters. Word identification performance was measured psychophysically using a staircase procedure. Significant improvements in peripheral word identification speed were demonstrated following training (71% ± 18%). Initial task performance was correlated with age, with older participants having poorer performance. However, older adults learned more rapidly such that, following training, they reached the same level of performance as their younger counterparts. As a function of number of trials completed, patients with AMD learned at an equivalent rate as age-matched participants with normal vision. Improvements in word identification speed were maintained at least 6 months after training. We have demonstrated that temporal aspects of word recognition can be improved in peripheral vision with training across a range of ages and these learned improvements are relatively enduring. However, training targeted at other bottlenecks to peripheral reading ability, such as visual crowding, may need to be incorporated to optimize this approach.