Reading speed does not benefit from increased line spacing in AMD patients

Luciole, a new font for people with low vision

Low vision affects the ability to read and can be a major barrier to educational success and insertion into the workplace. We designed a new font (Luciole) to improve the readability and comfort for people with low vision. In this study, we analyze the effect of the font type on readability. Luciole was compared to five other fonts (Arial, OpenDyslexic, Verdana, Eido and Frutiger) in 145 French readers (73 with low vision, and 72 normal sighted), aged 6 to 35 years old and divided into four reading expertise groups. Participants completed two tasks, first reading texts on paper and then reading false-words on screen using eye tracking. About half of the participants with low vision had a subjective preference for Luciole when reading on paper and on the screen; lower preference is noted for participants with normal vision. Other readability criteria show a slight advantage of the Luciole font over some fonts (e.g., Eido and OpenDyslexic) in both groups. The results obtained when taking into consideration the level of reading expertise confirm this trend.

Design and Validation of a New Smartphone-Based Reading Speed App (GDRS-Test) for the Greek Speaking Population

PURPOSE

To present a novel smartphone-based application (GDRS-test, Greek Digital Reading Speed - test) for the assessment of reading speed, to evaluate, whether this test could be easily and reliably used by patients with visual impairment and normal individuals serving as an adjunctive tool for their visual examination.

PATIENTS AND METHODS

One hundred and five visually impaired and 32 normal eyes were examined. Depending on existing active ocular pathology, patients were divided into a non-macular and a macular group, We examined the reading performance for continuous text (MNREAD chart) and random unrelated words of the new smartphone-based reading speed app, monocularly. The patients' best-corrected visual acuity ranged from 1.3 to 0.2 logMAR. Examinees were asked to read aloud (at a 40 cm distance) a series of 30 random two-syllable and then 30 three-syllable Greek words, without semantic connection. Reading speed was measured as correct words per minute for critical print size. The individuals were examined twice within 2 weeks for test-retest reliability. Correlations and comparisons concerning each group adjusted for age and visual acuity were performed.

RESULTS

There was moderate correlation between MNREAD and 2SYL SPEED (Reading speed for 2-syllable) (Pearson's rho = 0.589, p < 0.001) and 3SYL SPEED (Reading speed for 3-syllable) (Pearson's rho = 0.617, p < 0.001) for healthy individuals. The mean 2SYL SPEED and 3SYL SPEED for Individuals of the maculopathies group or non-maculopathies group were significantly lower compared to normal individuals adjusted for age and visual acuity [B (95% CI): -93.077 (-104.165, -81.98), p < 0.001] and [B (95% CI): -92.254 (-104.196, -80.312), p < 0.001], respectively. The test-retest analysis showed a good agreement for patients and healthy individuals.

CONCLUSION

The novel-reading speed application for the Greek-speaking population was found to accurately detect differences between patients with visual impairment and healthy individuals. It was designed and constructed with the intention to ease and improve the ophthalmic examination allowing individuals to self-evaluate reading speed by transmitting the result to their physician.

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.

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.

The influence of word frequency on word reading speed when individuals with macular diseases read text

People with central field loss (CFL) use peripheral vision to identify words. Eccentric vision provides ambiguous visual inputs to the processes leading to lexical access. Our purpose was to explore the hypothesis that this ambiguity leads to strong influences of inferential processes, our prediction being that increasing word frequency would decrease word reading time. Individuals with bilateral CFL induced by macular diseases read French sentences displayed with a self-paced reading method. Reading time of the last word of each sentence (target word) was recorded. Each target word (in sentence n) was matched with a synonym word (in sentence n+1) of the same length. When using absolute frequency value (Analysis 1), we found that reading time of target words decreased when word frequency increases, even when controlling for word length. The amplitude of this effect is larger than reported in previous investigations of reading with normal subjects. When comparing the effect of relative frequency (low vs. high) within each pair of synonyms (Analysis 2), results show the same pattern as the one observed in Analysis 1. Our results demonstrate clear-cut frequency effects on word reading time and suggest that inferential processes are stronger in CFL readers than in normally sighted observers. These results might also help design text simplification tools tailored for low-vision 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.

Object crowding in age-related macular degeneration

Crowding, the phenomenon of impeded object identification due to clutter, is believed to be a key limiting factor of form vision in the peripheral visual field. The present study provides a characterization of object crowding in age-related macular degeneration (AMD) measured at the participants' respective preferred retinal loci with binocular viewing. Crowding was also measured in young and age-matched controls at the same retinal locations, using a fixation-contingent display paradigm to allow unlimited stimulus duration. With objects, the critical spacing of crowding for AMD participants was not substantially different from controls. However, baseline contrast energy thresholds in the noncrowded condition were four times that of the controls. Crowding further exacerbated deficits in contrast sensitivity to three times the normal crowding-induced contrast energy threshold elevation. These findings indicate that contrast-sensitivity deficit is a major limiting factor of object recognition for individuals with AMD, in addition to crowding. Focusing on this more tractable deficit of AMD may lead to more effective remediation and technological assistance.

Reading Digital with Low Vision

Reading difficulty is a major consequence of vision loss for more than four million Americans with low vision. Difficulty in accessing print imposes obstacles to education, employment, social interaction and recreation. In recent years, research in vision science has made major strides in understanding the impact of low vision on reading, and the dependence of reading performance on text properties. The ongoing transition to the production and distribution of digital documents brings about new opportunities for people with visual impairment. Digital documents on computers and mobile devices permit customization of print size, spacing, font style, contrast polarity and page layout to optimize reading displays for people with low vision. As a result, we now have unprecedented opportunities to adapt text format to meet the needs of visually impaired readers.

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.

Impact of Wet Macular Degeneration on the Execution of Natural Actions

PURPOSE

To use eye movements to investigate how people with a central scotoma might be impaired in the execution of natural actions and whether task familiarity affects performance.

METHODS

Sixteen participants with AMD and 16 age-matched controls performed two natural actions: (1) a familiar sandwich-making task and (2) a less familiar model-building task. In each action, task-relevant and task-irrelevant objects were placed on a table, covering 90°. The participants were asked to execute the actions without a time constraint. Eye movements were recorded.

RESULTS

The people with AMD were significantly slower than the controls, both in the exploration phase (before the first reaching movement) and in the working phase (execution of action), especially in the unfamiliar task. Gaze duration was longer on relevant than irrelevant objects in both groups and tasks, as might be expected. However, for the participants with AMD, gaze durations were longer on all of the objects, whether relevant or irrelevant, except in the more familiar task. This suggests that participants with AMD take longer to extract the information they need but that this can be counteracted when the task items are familiar. The number of saccades/min of the task was significantly greater for the people with AMD than for the controls.

CONCLUSIONS

The present results show that people with AMD can accomplish natural actions efficiently, but need longer gaze durations and more eye movements than normally sighted people. This effect can be reduced when executing a familiar task.

Integrating oculomotor and perceptual training to induce a pseudofovea: A model system for studying central vision loss

People with a central scotoma often adopt an eccentric retinal location (Preferred Retinal Locus, PRL) for fixation. Here, we proposed a novel training paradigm as a model system to study the nature of the PRL formation and its impacts on visual function. The training paradigm was designed to effectively induce a PRL at any intended retinal location by integrating oculomotor control and pattern recognition. Using a gaze-contingent display, a simulated central scotoma was induced in eight normally sighted subjects. A subject's entire peripheral visual field was blurred, except for a small circular aperture with location randomly assigned to each subject (to the left, right, above, or below the scotoma). Under this viewing condition, subjects performed a demanding oculomotor and visual recognition task. Various visual functions were tested before and after training at both PRL and nonPRL locations. After 6-10 hr of the training, all subjects formed their PRL within the clear window. Both oculomotor control and visual recognition performance significantly improved. Moreover, there was considerable improvement at PRL location in high-level function, such as trigram letter-recognition, reading, and spatial attention, but not in low-level function, such as acuity and contrast sensitivity. Our results demonstrated that within a relatively short time, a PRL could be induced at any intended retinal location in normally-sighted subjects with a simulated scotoma. Our training paradigm might not only hold promise as a model system to study the dynamic nature of the PRL formation, but also serve as a rehabilitation regimen for individuals with central vision loss.

Misidentifying a tennis racket as keys: object identification in people with age-related macular degeneration

PURPOSE

Previous studies showed that people with age-related macular degeneration (AMD) can categorise a pre-defined target object or scene with high accuracy (above 80%). In these studies participants were asked to detect the target (e.g. an animal) in serial visual presentation. People with AMD must rely on peripheral vision which is more adapted to the low resolution required for detection than for the higher resolution required to identify a specific exemplar. We investigated the ability of people with central vision loss to identify photographs of objects and scenes.

METHODS

Photographs of isolated objects, natural scenes and objects in scenes were centrally displayed for 2 s each. Participants were asked to name the stimuli. We measured accuracy and naming times in 20 patients with AMD, 15 age-matched and 12 young controls.

RESULTS

Accuracy was lower (by about 30%) and naming times were longer (by about 300 ms) in people with AMD than in age-matched controls in the three categories of images. Correct identification occurred in 62-66% of the stimuli for patients. More than 20% of the misidentifications resulted from a structural and/or semantic similarity between the object and the name (e.g. spectacles for dog plates or dolphin for shark). Accuracy and naming times did not differ significantly between young and older normally sighted participants indicating that the deficits resulted from pathology rather than to normal ageing.

CONCLUSIONS

These results show that, in contrast to performance for categorisation of a single pre-defined target, people with central vision loss are impaired at identifying various objects and scenes. The decrease in accuracy and the increase in response times in patients with AMD indicate that peripheral vision might be sufficient for object and scene categorisation but not for precise scene or object identification.

Size or spacing: which limits letter recognition in people with age-related macular degeneration?

Recent evidence suggests a double dissociation of size and spacing limit on letter recognition-it is limited by size in the fovea and critical spacing in the normal periphery. Here, we evaluated whether size or spacing limits letter recognition in people with age-related macular degeneration (AMD) who must use their peripheral vision. We measured the size threshold for recognizing lowercase letters presented alone, or flanked by two letters at various center-to-center nominal letter spacings (multiples of letter size) for 11 observers with AMD. For comparison, similar measurements were obtained at 5° and 10° eccentricity in the nasal and lower visual fields in three older adults with normal vision. Single-letter size thresholds were worse for observers with AMD than at comparable retinal locations in the normal periphery. For flanked letters, size threshold improved with larger nominal spacing up to the critical spacing, beyond which size threshold was unaffected by the flankers. Seven AMD observers had a nominal critical spacing between 1.25× and 1.80×, values close to those in the normal fovea, suggesting that their letter recognition is size-limited; two had a nominal critical spacing of 3-4×, values close to those in the normal periphery, implying that their letter recognition is limited by spacing; and another two had a nominal critical spacing of ∼2.3×, implying that their letter recognition is limited by both size and spacing. The wide range of nominal critical spacings observed in our AMD observers may reflect the degree of completeness of their adaptation process to vision loss.

Enhanced text spacing improves reading performance in individuals with macular disease

The search by many investigators for a solution to the reading problems encountered by individuals with no central vision has been long and, to date, not very fruitful. Most textual manipulations, including font size, have led to only modest gains in reading speed. Previous work on spatial integrative properties of peripheral retina suggests that ‘visual crowding’ may be a major factor contributing to inefficient reading. Crowding refers to the fact that juxtaposed targets viewed eccentrically may be difficult to identify. The purpose of this study was to assess the combined effects of line spacing and word spacing on the ability of individuals with age-related macular degeneration (ARMD) to read short passages of text that were printed with either high (87.5%) or low contrast (17.5%) letters. Low contrast text was used to avoid potential ceiling effects and to mimic a possible reduction in letter contrast with light scatter from media opacities. For both low and high contrast text, the fastest reading speeds we measured were for passages of text with double line and double word spacing. In comparison with standard single spacing, double word/line spacing increased reading speed by approximately 26% with high contrast text (p < 0.001), and by 46% with low contrast text (p < 0.001). In addition, double line/word spacing more than halved the number of reading errors obtained with single spaced text. We compare our results with previous reading studies on ARMD patients, and conclude that crowding is detrimental to reading and that its effects can be reduced with enhanced text spacing. Spacing is particularly important when the contrast of the text is reduced, as may occur with intraocular light scatter or poor viewing conditions. We recommend that macular disease patients should employ double line spacing and double-character word spacing to maximize their reading efficiency.

Sensory and cognitive influences on the training-related improvement of reading speed in peripheral vision

Reading speed in normal peripheral vision is slow but can be increased through training on a letter-recognition task. The aim of the present study is to investigate the sensory and cognitive factors responsible for this improvement. The visual span is hypothesized to be a sensory bottleneck limiting reading speed. Three sensory factors-letter acuity, crowding, and mislocations (errors in the spatial order of letters)-may limit the size of the visual span. Reading speed is also influenced by cognitive factors including the utilization of information from sentence context. We conducted a perceptual training experiment to investigate the roles of these factors. Training consisted of four daily sessions of trigram letter-recognition trials at 10° in the lower visual field. Subjects' visual-span profiles and reading speeds were measured in pre- and posttests. Effects of the three sensory factors were isolated through a decomposition analysis of the visual span profiles. The impact of sentence context was indexed by context gain, the ratio of reading speeds for ordered and unordered text. Following training, visual spans increased in size by 5.4 bits of information transmitted, and reading speeds increased by 45%. Training induced a substantial reduction in the magnitude of crowding (4.8 bits) and a smaller reduction for mislocations (0.7 bits), but no change in letter acuity or context gain. These results indicate that the basis of the training-related improvement in reading speed is a large reduction in the interfering effect of crowding and a small reduction of mislocation errors.

Dependence of reading speed on letter spacing in central vision loss

PURPOSE

Crowding, the difficulty in recognizing a letter in close proximity with other letters, has been suggested as an explanation for slow reading in people with central vision loss. The goals of this study were (1) to examine whether increased letter spacing in words, which presumably reduces crowding among letters, would benefit reading for people with central vision loss and (2) to relate our finding to the current account of faulty feature integration of crowding.

METHODS

Fourteen observers with central vision loss read aloud single sentences, one word at a time, using rapid serial visual presentation. Reading speeds were calculated based on the rapid serial visual presentation exposure durations yielding 80% accuracy. Letters were rendered in Courier, a fixed-width font. Observers were tested at 1.4× the critical print size (CPS), three were also tested at 0.8× CPS. Reading speed was measured for five center-to-center letter spacings (range: 0.5-2× the standard spacing). The preferred retinal locus for fixation was determined for nine of the observers, from which we calculated the horizontal dimension of the integration field for crowding.

RESULTS

All observers showed increased reading speed with letter spacing for small spacings, until an optimal spacing, beyond which reading speed either showed a plateau, or dropped as letter spacing further increased. The optimal spacing averaged 0.95 ± 0.06× [±95% confidence interval] the standard spacing for 1.4× CPS (similar for 0.8× CPS), which was not different from the standard. When converted to angular size, the measured values of the optimal letter spacing for reading show a good relationship with the calculated horizontal dimension of the integration field.

CONCLUSIONS

Increased letter spacing beyond the standard size, which presumably reduces crowding among letters in text, does not improve reading speed for people with central vision loss. The optimal letter spacing for reading can be predicted based on the preferred retinal locus.

How do flanking objects affect reaching and grasping behavior in participants with macular disorders?

PURPOSE

To investigate how objects (flankers) placed on either side of a target affect reaching and grasping behavior in visually impaired (VI) subjects due to macular disorders compared with age-matched normals.

METHODS

Subjects reached out to grasp a cylindrical target placed on its own and when it had two identical objects (flankers) placed either half or one target diameter away on each side of the target. A motion analysis system (Vicon 460) recorded and reconstructed the 3-dimemsional (3D) hand and finger movements. Kinematic data for transport and grasping mechanisms were measured.

RESULTS

In subjects with VI, crowding effected the overall movement duration, time after maximum velocity, and maximum grip aperture. Maximum effect was shown when the flankers were placed close to the target (high-level crowding) with a decreased effect shown for flankers placed farther away (medium-level crowding). Compared with normals, subjects with VI generally took longer to initiate the hand movement and to complete the movement. Time after maximum velocity and time after maximum grip aperture were also longer in subjects with VI. No interaction effects were found for any of the indices for the different levels of crowding in the two visual groups.

CONCLUSIONS

Reaching and grasping behavior is compromised in subjects with VI due to macular disorders compared with normals, and crowding affected performance for both normal subjects and those with VI. Flankers placed half an object diameter away showed greater deterioration than those placed further away.

[Perception of objects and scenes in age-related macular degeneration]

Vision related quality of life questionnaires suggest that patients with AMD exhibit difficulties in finding objects and in mobility. In the natural environment, objects seldom appear in isolation. They appear in a spatial context which may obscure them in part or place obstacles in the patient's path. Furthermore, the luminance of a natural scene varies as a function of the hour of the day and the light source, which can alter perception. This study aims to evaluate recognition of objects and natural scenes by patients with AMD, by using photographs of such scenes. Studies demonstrate that AMD patients are able to categorize scenes as nature scenes or urban scenes and to discriminate indoor from outdoor scenes with a high degree of precision. They detect objects better in isolation, in color, or against a white background than in their natural contexts. These patients encounter more difficulties than normally sighted individuals in detecting objects in a low-contrast, black-and-white scene. These results may have implications for rehabilitation, for layout of texts and magazines for the reading-impaired and for the rearrangement of the spatial environment of older AMD patients in order to facilitate mobility, finding objects and reducing the risk of falls.

Improving reading speed for people with central vision loss through perceptual learning

PURPOSE

Perceptual learning has been shown to be effective in improving visual functions in the normal adult visual system, as well as in adults with amblyopia. In this study, the feasibility of applying perceptual learning to enhance reading speed in people with long-standing central vision loss was evaluated.

METHODS

Six observers (mean age, 73.8) with long-standing central vision loss practiced an oral sentence-reading task, with words presented sequentially using rapid serial visual presentation (RSVP). A pre-test consisted of measurements of visual acuities, RSVP reading speeds for six print sizes, the location of the preferred retinal locus for fixation (fPRL), and fixation stability. Training consisted of six weekly sessions of RSVP reading, with 300 sentences presented per session. A post-test, identical with the pre-test, followed the training.

RESULTS

All observers showed improved RSVP reading speed after training. The improvement averaged 53% (range, 34-70%). Comparisons of pre- and post-test measurements revealed little changes in visual acuity, critical print size, location of the fPRL, and fixation stability.

CONCLUSIONS

The specificity of the learning effect, and the lack of changes to the fPRL location and fixation stability suggest that the improvements are not due to observers adopting a retinal location with better visual capability, or an improvement in fixation. Rather, the improvements are likely to represent genuine plasticity of the visual system despite the older ages of the observers, coupled with long-standing sensory deficits. Perceptual learning might be an effective way of enhancing visual performance for people with central vision loss.

Enhancing visual performance for people with central vision loss

People with central vision loss must use peripheral vision for visual tasks. It is well known that performance for almost all spatial tasks is worse in the normal periphery than in the normal fovea. The primary goal of my ongoing research is to understand the limiting factors and the potential for enhancing vision for people with central vision loss. Here I review my previous work related to understanding the limiting factors on reading, a task that is the primary complaint of many patients with age-related macular degeneration, the leading cause of visual impairment in the elderly. I also review my work related to enhancing visual functions in the normal periphery and how it may be applied to people with central vision loss.