Task-induced Changes in Idiopathic Infantile Nystagmus Vary with Gaze

Measurement of visual function in infantile nystagmus: a systematic review

BACKGROUND/AIMS

Recent work has called into question the ability of visual acuity (VA) to accurately represent changes in visual function in infantile nystagmus (IN). This systematic review investigated factors affecting visual performance in IN, to guide development of suitable alternatives to VA.

METHODS

Included studies used an experimental manipulation to assess changes in visual function in people with IN. Interventional studies, case series and case studies were excluded. Six databases were searched in August 2023. Selection, detection, attrition and measurement bias were assessed. Due to heterogeneous methodologies, narrative synthesis was undertaken.

RESULTS

Eighteen relevant papers were identified, 11 of which complied with the review criteria. Articles were grouped according to the factor manipulated to evoke within-participant changes in performance (motion blur, psychological state, gaze angle or visual crowding). Optotype, image, grating and moving stimuli have been employed under varying lighting conditions and exposure duration.

CONCLUSION

Several factors affecting visual performance should be considered when assessing visual function in IN. While maximum VA is a useful metric, its measurement deliberately minimises nystagmus-specific factors such as changes in visual performance with gaze angle and the 'slow to see' phenomenon. Maximum VA can be measured using the null zone, providing unlimited viewing time, reducing stress/mental load and minimising visual crowding. Gaze-dependent functional vision space is a promising measure which quantifies the impact of the null zone but does not consider temporal vision. Although no complete measurement technique has yet been proven, this review provides insights to guide future work towards development of appropriate methods.

Visual search in infantile nystagmus syndrome

CLINICAL RELEVANCE

Research on infantile nystagmus syndrome (INS) and visual search is limited. Conducting this research could assist practitioners in understanding how INS affects the real-life visual activities of patients and aid in developing new clinical visual function assessments for INS.

BACKGROUND

The aim of this work is to investigate how subjects with INS perform visual search tasks, and, particularly, to assess how INS subjects perform when targets are located at their null position or away from it, and when under additional cognitive demands.

METHODS

INS subjects (N = 15) and controls (N = 20) performed conjunction and feature search tasks, both with and without mental arithmetic. Search performance was assessed using log-transformed total search time, gaze-dependent search time, and accuracy. Cognitive demand was quantified by pupil size and the NASA task-load index score.

RESULTS

INS subjects showed longer search times compared to controls in conjunction search (P < 0.01), but not in feature search. Within INS and control subjects, the total search times were significantly increased by the addition of mental arithmetic (P < 0.0001). There was no difference in gaze-dependent search times between null target position and 15° away from null target position of subjects in conjunction search (P > 0.05). Accuracies were 100% for both control and INS subjects in both conjunction and feature search.

CONCLUSION

Conjunction visual search was impaired in adult INS subjects, and further worsened under increased cognitive demand. The null position did not affect the visual search performance in INS.

Effect of Cognitive Mental Load on Attended and Nonattended Visual Stimuli

SIGNIFICANCE

In the real word, visual tasks may be concurrent with other activity that imposes mental load. Although the brain's capacity to process information is limited, attention can improve visual performance by selectively allocating processing resources. Therefore, measuring visual performance under such circumstances can reflect patients' vision more accurately.

PURPOSE

The aim of this study was to evaluate the effect of nonvisual task-induced mental load on visual performance at both attended and unattended locations in stimulus-driven captured attention.

METHODS

Visual function was measured with an orientation discrimination task for Gabor patches with contrasts of 10, 15, 30, 50, and 80%. Three attentional conditions (valid-cue, invalid-cue, and neutral-cue) were randomly interleaved within runs. To modulate mental load, the visual task was performed either with or without a simultaneous auditory n-back task (two-back for maximum mental load and zero-back to control for the effect of having to perform a simultaneous task).

RESULTS

Our result showed that the effect of mental load on correct responses was significant ( P = .02). Correct responses decreased significantly during the two-back task when compared with the baseline condition ( P = .03), but there was no significant difference between baseline and zero-back conditions ( P = .06). The effect of attention and spatial frequencies on the percentage of correct responses was significant ( P < .001). There was no significant interaction between mental load and spatial frequency, contrast level, or attention ( P > .05).

CONCLUSIONS

Mental load had a similar decreasing effect on attended and unattended visual stimuli. This may be due to a generalized effect on processing resources upstream to where spatial attention is allocated.

Robust tests for multivariate repeated measures with small samples

Multivariate repeated measures data naturally arise in clinical trials and other fields such as biomedical science, public health, agriculture, social science and so on. For data of this type, the classical approach is to conduct multivariate analysis of variance (MANOVA) based on Wilks' Lambda and other multivariate statistics, which require the assumptions of multivariate normality and homogeneity of within-cell covariance matrices. However, data being analyzed nowadays show marked departure from multivariate normality and homogeneity. This paper proposes a finite-sample test by modifying the sums of squares matrices to make them insensitive to the heterogeneity in MANOVA. The proposed test is invariant to affine transformation and robust against nonnormality. The proposed method can be used in various experimental designs, for example, factorial design and crossover design. Under various simulation settings, the proposed method outperforms the classical Doubly Multivariate Model and Multivariate Mixed Model proposed elsewhere, especially for unbalanced sample sizes with heteroscedasticity. The applications of the proposed method are illustrated with ophthalmology data in factorial and crossover designs. The proposed method successfully identified and validated a significant main effect and demonstrated that univariate analysis could be oversensitive to small but clinically unimportant interactions.

The effect of mental load on psychophysical and visual evoked potential visual acuity

PURPOSE

Under real-world conditions, tasks dependent on visual acuity may need to be performed in the presence of a mental load arising from concurrent, non-visual tasks. Therefore, measuring visual acuity concurrently with mentally demanding tasks may reflect a patient's vision more accurately. This study was designed to evaluate the impact of task-induced mental load on high contrast visual acuity, as measured using a letter chart and estimated via sweep visual evoked potentials (sweep VEP).

METHODS

Visual acuity was determined using the Freiburg Vision Test, and also using sweep VEP tested stepwise, from coarse to fine, over 13 spatial frequencies, in 31 healthy participants (aged 22.4 ± 3.6 years). Recordings were repeated while participants concurrently performed an auditory 2-back task. Mental load of the n-back task was confirmed through subjective ratings.

RESULTS

Visual acuity determined with the Freiburg Vision Test worsened from -0.02 ± 0.12 to 0.04 ± 0.15 logMAR under mental load (p = 0.03). Visual acuities estimated by sweep VEPs worsened from 0.38 ± 0.1 to 0.47 ± 0.1 logMAR (p < 0.001). While the slope of the VEP amplitude versus spatial frequency function steepened significantly with mental load (p = 0.01), VEP noise levels were not significantly affected (p = 0.07).

CONCLUSION

Visual acuity reduces significantly with a concurrent task that produces mental load. At least part of this reduction appears to be related to alterations in responses within the visual cortex, rather than being purely attributable to higher-level distraction effects.

Perception of Coherent Motion in Infantile Nystagmus Syndrome

Purpose

Research on infantile nystagmus syndrome (INS) and motion perception is limited. We investigated how individuals with INS perform coherent motion tasks. Particularly, we assessed how the null position affects their performance.

Methods

Subjects with INS and controls identified the direction of coherent motion stimuli (22 subjects with INS and 13 controls) in a two-alternative forced-choice design. For subjects with INS, testing was done at the null position and 15 degrees away from it. If there was no null, testing was done at primary gaze position and 15 degrees away from primary. For controls, testing was done at primary gaze position and 20 degrees away from primary. Horizontal and vertical motion coherence thresholds were determined.

Results

Subjects with INS showed significantly higher horizontal and vertical motion coherence thresholds compared with controls at both gaze positions (P < 0.001). Within the INS group, for 12 subjects with INS who had an identified null position, no differences in coherence thresholds were found between their null and 15 degrees away from it (P > 0.05).

Conclusions

Coherent motion perception was impaired in subjects with INS. The null position did not significantly influence motion coherence thresholds for either horizontal or vertical motion.

Velocity Discrimination in Infantile Nystagmus Syndrome

Purpose

Research on infantile nystagmus syndrome (INS) and velocity discrimination is limited, and no research has examined velocity discrimination in subjects with INS at their null position and away from it. This study aims to investigate how individuals with INS perform, compared with controls, when carrying out velocity discrimination tasks. Particularly, the study aims to assess how the null position affects their performance.

Methods

INS subjects (N = 21, mean age 24 years; age range, 15–34 years) and controls (N = 16, mean age 26 years; age range, 22–39 years) performed horizontal and vertical velocity discrimination tasks at two gaze positions. Eighteen INS subjects were classified as idiopathic INS and three had associated visual disorders (two had oculocutaneous albinism, and one had congenital cataract). For INS subjects, testing was done at the null position and 15° away from it. If there was no null, testing was done at primary gaze position and 15° away from primary. For controls, testing was done at primary gaze position and 20° away from primary. Horizontal and vertical velocity discrimination thresholds were determined and analyzed.

Results

INS subjects showed significantly higher horizontal and vertical velocity discrimination thresholds compared with controls at both gaze positions (P < 0.001). Horizontal thresholds for INS subjects were elevated more than vertical thresholds (P < 0.0001) for INS subjects but not for controls. Within the INS group, 12 INS subjects who had an identified null position showed significantly lower horizontal and vertical thresholds at the null than at 15° away from it (P < 0.05).

Conclusions

Velocity discrimination was impaired in INS subjects, with better performance at the null. These findings could assist in understanding how INS affects the daily activities of patients in tasks involving moving objects, and aid in developing new clinical visual function assessments for INS.

Saccades under Mental Load in Infantile Nystagmus Syndrome and Controls

SIGNIFICANCE

This study compares saccades and visual task performance in patients with infantile nystagmus syndrome (INS) with that in normally sighted individuals under mental load. The results highlighted that to more completely evaluate INS therapies recognition time should also be measured with mental load, resembling real-world conditions.

PURPOSE

Patients with INS may complain of "being slow to see." Stress is reported to worsen nystagmus and to prolong visual recognition time. We hypothesized that the effects of mental load on timing indices of visual recognition, for example, saccade latency, target acquisition time, target viewing time, and subjects' reaction time, differ between the INS and control groups.

METHODS

Eye movements were recorded when participants (INS group, n = 15; controls, n = 25) reported the direction of tumbling-E targets presented randomly across ±25°. The task was repeated with both mental arithmetic and time restriction to impose high mental load, confirmed through subjective ratings and heart rate measurement.

RESULTS

Mental load increased saccade latency (mean, 32.69 milliseconds; 95% confidence interval [CI], 21.17 to 44.20 milliseconds; P < .001) and target acquisition time (57.00 milliseconds; 95% CI, 34 to 81 milliseconds; P < .001). Patients with INS showed longer saccade latency (39.79 milliseconds; 95% CI, 23.98 to 55.62 milliseconds; P < .001) and target acquisition time (134.00 milliseconds; 95% CI, 96 to 172 milliseconds; P < .001) compared with controls. The interaction between task and group was significant for saccade gain (0.11; 95% CI, 0.02 to 0.19; P = .015), target acquisition time (37.93 milliseconds; 95% CI, 36.91 to 38.96 milliseconds; P = .011), and subjects' reaction time (95.37 milliseconds; 95% CI, 65.91 to 124.84 milliseconds; P = .043). There was an inverse correlation between the changes in subjects' response errors and target viewing time with mental load only for controls (r = -0.484, P = .014). Total foveation exposure time and target viewing time remained unchanged.

CONCLUSIONS

Mental load worsens "being slow to see" in INS because of delayed target acquisition and possibly because efficiency of visual processing decreases more in patients with INS compared with controls. To investigate outcomes of INS therapies, visual recognition time should be also measured with mental load.

Reading Individual Words Within Sentences in Infantile Nystagmus

Purpose

Normal readers make immediate and precise adjustments in eye movements during sentence reading in response to individual word features, such as lexical difficulty (e.g., common or uncommon words) or word length. Our purpose was to assess the effect of infantile nystagmus (IN) on these adaptive mechanisms.

Methods

Eye movements were recorded from 29 participants with IN (14 albinism, 12 idiopathic, and 3 congenital stationary night blindness) and 15 controls when reading sentences containing either common/uncommon words or long/short target words. Parameters assessed included: duration of first foveation/fixation, number of first-pass and percentage second-pass foveations/fixations, percentage words skipped, gaze duration, acquisition time (gaze + nongaze duration), landing site locations, clinical and experimental reading speeds.

Results

Participants with IN could not modify first foveation durations in contrast to controls who made longer first fixations on uncommon words (P < 0.001). Participants with IN made more first-pass foveations on uncommon and long words (P < 0.001) to increase gaze durations. However, this also increased nongaze durations (P < 0.001) delaying acquisition times. Participants with IN reread shorter words more often (P < 0.005). Similar to controls, participants with IN landed more first foveations between the start and center of long words. Reading speeds during experiments were lower in IN participants compared to controls (P < 0.01).

Conclusions

People with IN make more first-pass foveations on uncommon and long words influencing reading speeds. This demonstrates that the "slow to see" phenomenon occurs during word reading in IN. These deficits are not captured by clinical reading charts.