Can fixation instability improve text perception during eccentric fixation in patients with central scotomas?

Development and Validation of Performance-Based Assessment of Daily Living Tasks in Age-Related Macular Degeneration

Purpose

To establish the reliability and validity of five performance-based activities of daily living task tests (ADLTT), to correlate structure to function, to evaluate the impact of visual impairment (VI) on age-related macular degeneration (AMD), and to develop new outcome measures.

Methods

A multidisciplinary team developed five ADLTTs: (1) reading test (RT); (2) facial expression (FE) recognition; (3) item search (IS) task; (4) money counting (MC) task; and (5) making a drink (MD), tested with binocular and monocular vision. ADLTTs were tested for known-group (i.e., difference between AMD group and controls) and convergent (i.e., correlation to other measures of visual function), validity metrics, and test-retest reliability in 36 patients with VI (visual acuity (logMAR VA > 0.4) in at least one eye caused by AMD versus 36 healthy controls without VI.

Results

Compared to controls, AMD patients had a slower reading speed (-77.41 words/min; P < 0.001); took longer to complete MC using monocular worse eye and binocular vision (15.13 seconds and 4.06 seconds longer compared to controls, respectively; P < 0.001); and MD using monocular worse eye vision (9.37 sec; P = 0.033), demonstrating known-group validity. Only RT and MC demonstrated convergent validity, showing correlations with VA, contrast sensitivity, and microperimetry testing. Moderate to good test-retest reliability was observed for MC and MD (interclass correlation coefficient = 0.55 and 0.77; P < 0.001) using monocular worse eye vision.

Conclusions

Real-world ADL functioning associated with VI-related AMD can be assessed with our validated ADLTTs, particularly MC and MD.

Translational Relevance

This study validates visual function outcome measures that are developed for use in future clinical practice and clinical trials.

tRNS boosts visual perceptual learning in participants with bilateral macular degeneration

Perceptual learning (PL) has shown promise in enhancing residual visual functions in patients with age-related macular degeneration (MD), however it requires prolonged training and evidence of generalization to untrained visual functions is limited. Recent studies suggest that combining transcranial random noise stimulation (tRNS) with perceptual learning produces faster and larger visual improvements in participants with normal vision. Thus, this approach might hold the key to improve PL effects in MD. To test this, we trained two groups of MD participants on a contrast detection task with (n = 5) or without (n = 7) concomitant occipital tRNS. The training consisted of a lateral masking paradigm in which the participant had to detect a central low contrast Gabor target. Transfer tasks, including contrast sensitivity, near and far visual acuity, and visual crowding, were measured at pre-, mid and post-tests. Combining tRNS and perceptual learning led to greater improvements in the trained task, evidenced by a larger increment in contrast sensitivity and reduced inhibition at the shortest target to flankers' distance. The overall amount of transfer was similar between the two groups. These results suggest that coupling tRNS and perceptual learning has promising potential applications as a clinical rehabilitation strategy to improve vision in MD patients.

Changes in eye movement parameters in the presence of an artificial central scotoma

BACKGROUND

Central vision loss, such as in the case of age-related macular degeneration (AMD), has a a major negative impact on patients' quality of life. However, some patients have shown spontaneous adaptive strategies development, mostly relying on their peripheral vision.

OBJECTIVE

This study assesses eye movement and eccentric visual function adaptive behaviors of a healthy population in the presence of simulated central vision loss. We wished to determine how central vision loss affects eye movements, specifically the foveal-target alignment.

METHODS

Fifteen healthy participants (7 females, M = 21.69, SD = 2.13) discriminated the orientation of a Gabor relative to the vertical located at 12 deg of eccentricity to the right of fixation, in the presence of a gaze-contingent artificial central scotoma either visible or invisible. The artificial central scotoma was 4° diameter in order to simulate an earlier stage of degenerative disease while still impairing foveal vision. The target's orientation varied between 10° counter-clockwise and 10° clockwise. Each participant performed four blocks of 75 trials each per day over 10 days, the first day being a baseline without scotoma.

RESULTS

We found changes in the endpoints of the 1st saccade over the practice days. The most common pattern was a gradual upward shift. We also observed a significant increase in discrimination performance over the 9 days of practice. We did not find any difference linked to the scotoma types.

CONCLUSIONS

These findings suggest that the presence of an artificial central scotoma combined with a challenging discrimination task induces both changes in saccade planning mechanisms, resulting in a new eccentric-target alignment, and improvements in eccentric visual functions. This demonstrates the potential of this research paradigm to understand and potentially improve visual function in patients with central vision loss.

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.

Decreased fixation stability of the preferred retinal location in juvenile macular degeneration

Macular degeneration is the main cause for diminished visual acuity in the elderly. The juvenile form of macular degeneration has equally detrimental consequences on foveal vision. To compensate for loss of foveal vision most patients with macular degeneration adopt an eccentric preferred retinal location that takes over tasks normally performed by the healthy fovea. It is unclear however, whether the preferred retinal locus also develops properties typical for foveal vision. Here, we investigated whether the fixation characteristics of the preferred retinal locus resemble those of the healthy fovea. For this purpose, we used the fixation-offset paradigm and tracked eye-position using a high spatial and temporal resolution infrared eye-tracker. The fixation-offset paradigm measures release from fixation under different fixation conditions and has been shown useful to distinguish between foveal and non-foveal fixation. We measured eye-movements in nine healthy age-matched controls and five patients with juvenile macular degeneration. In addition, we performed a simulation with the same task in a group of five healthy controls. Our results show that the preferred retinal locus does not adopt a foveal type of fixation but instead drifts further away from its original fixation and has overall increased fixation instability. Furthermore, the fixation instability is most pronounced in low frequency eye-movements representing a slow drift from fixation. We argue that the increased fixation instability cannot be attributed to fixation under an unnatural angle. Instead, diminished visual acuity in the periphery causes reduced oculomotor control and results in increased fixation instability.

Image jitter enhances visual performance when spatial resolution is impaired

PURPOSE

Visibility of low-spatial frequency stimuli improves when their contrast is modulated at 5 to 10 Hz compared with stationary stimuli. Therefore, temporal modulations of visual objects could enhance the performance of low vision patients who primarily perceive images of low-spatial frequency content. We investigated the effect of retinal-image jitter on word recognition speed and facial emotion recognition in subjects with central visual impairment.

METHODS

Word recognition speed and accuracy of facial emotion discrimination were measured in volunteers with AMD under stationary and jittering conditions. Computer-driven and optoelectronic approaches were used to induce retinal-image jitter with duration of 100 or 166 ms and amplitude within the range of 0.5 to 2.6° visual angle. Word recognition speed was also measured for participants with simulated (Bangerter filters) visual impairment.

RESULTS

Text jittering markedly enhanced word recognition speed for people with severe visual loss (101 ± 25%), while for those with moderate visual impairment, this effect was weaker (19 ± 9%). The ability of low vision patients to discriminate the facial emotions of jittering images improved by a factor of 2. A prototype of optoelectronic jitter goggles produced similar improvement in facial emotion discrimination. Word recognition speed in participants with simulated visual impairment was enhanced for interjitter intervals over 100 ms and reduced for shorter intervals.

CONCLUSIONS

Results suggest that retinal-image jitter with optimal frequency and amplitude is an effective strategy for enhancing visual information processing in the absence of spatial detail. These findings will enable the development of novel tools to improve the quality of life of low vision patients.

Quantifying Eye Stability During a Fixation Task: A Review of Definitions and Methods

Several definitions, measurements, and implicit meanings of ‘fixation stability’ have been used in clinical vision research, leading to some confusion. One definition concerns eye movements observed within fixations (i.e., within periods separated by saccades) when observing a point target: drift, microsaccades and physiological tremor all lead to some degree of within-fixation instability. A second definition relates to eye position during multiple fixations (and saccades) when patients fixate a point target. Increased between-fixation variability, combined with within-fixation instability, is known to be associated with poorer visual function in people with retinal disease such as age-related macular degeneration. In this review article, methods of eye stability measurement and quantification are summarised. Two common measures are described in detail: the bivariate contour ellipse area (BCEA) and the within-isolines area. The first measure assumes normality of the underlying positions distribution whereas the second does not. Each of these measures can be applied to two fundamentally different kinds of eye position data collected during a period of target observation. In the first case, mean positions of eye fixations are used to obtain an estimate of between-fixation variability. In the second case, often used in clinical vision research, eye position samples recorded by the eyetracker are used to obtain an estimate that confounds within- and between-fixation variability.

We show that these two methods can produce significantly different values of eye stability, especially when reported as BCEA values. Statistical techniques for describing eye stability when the distribution of eye positions is multimodal and not normally distributed are also reviewed.

Reading performance and central field loss

Age-related macular degeneration is a major cause of blindness in Europe and the U.S. and a leading cause of significant loss of visual acuity in elderly patients. Reading is a key visual task in everyday living involving a synthesis of a number of different motor, sensory and cognitive functions. When the centre of a reader's visual field is obscured, reading speed declines and oculomotor pattern differs, compared to normal reading. Improvement in the generation of visual stimuli using computer-generated images and projection/display systems as well as advances in eye movement recording techniques, including infrared pupil tracking and magnetic search coils, have contributed greatly to our understanding of these sensorimotor abnormalities. The developed reading strategies have been thoroughly investigated in individuals with central field loss either induced artificially or related to eye pathology.The following review aims at presenting the contemporary literature regarding the sensory and oculomotor deficits in reading ability, resulting from central field loss and should contribute to a greater understanding of the functional visual deficit caused by this visual impairment.

Retinal sensitivity and fixation changes 1 year after triamcinolone acetonide assisted internal limiting membrane peeling for macular hole surgery--a MP-1 microperimetric study

PURPOSE

To evaluate microperimetric changes 1year after macular hole surgery with triamcinolone acetonide assisted internal limiting membrane (ILM) peeling.

METHODS

Twenty-two eyes of 22 patients with stage 3 and 4 idiopathic macular holes of <6months' duration underwent vitrectomy with triamcinolone acetonide assisted ILM peeling. Best corrected visual acuity (BCVA) (logarithm of the minimum angle of resolution), and central retinal sensitivity were documented before and 1, 3, 6, and 12months after surgery. Macular sensitivity (mean sensitivity in decibels -dB), and stability and location of fixation (preferred retinal locus) were determined using MP-1 microperimetry (Nidek). The MP-1 microperimetry sensitivity map was overlaid onto infrared images recorded on a Heidelberg scanning laser ophthalmoscope using dedicated MP-1 software to evaluate the fixation location before surgery. Anatomical success was evaluated with optical coherence tomography (OCT). Optical coherence tomography scans were recorded on an OCT 3000 scanner.

RESULTS

Anatomical success was achieved in all 22 eyes. All patients completed 1year follow-up. No recurrence of macular hole was seen in any patients in the follow-up period. The mean BCVA improved from 0.75±0.2 before surgery to 0.31±0.1 logMAR at the last visit (p<0.001). Mean sensitivity improved from 3.7±0.6 to 5.3±1.0dB at the last visit (p<0.001). Before surgery, the preferred retinal locus was located on the margin of the hole in all, in 18 eyes on its upper part and in four eyes to the side or on its lower part. Preoperatively, 12 eyes were stable and 10 were relatively unstable, but 12month after surgery, fixation stability had improved, and 20 eyes were stable and two were relatively unstable.

CONCLUSIONS

  MP-1 microperimetry sensitivity map overlaid onto an infrared image using dedicated MP-1 software can be used successfully to evaluate fixation location in patients with a macular hole before surgery. With microperimetry findings, we can also measure functional macular changes more precisely than using BCVA alone after macular hole surgery. Our results also showed that retinal sensitivity and fixation properties were improved after vitrectomy with triamcinolone acetonide assisted ILM peeling in patients with idiopathic macular hole.

Relationship between slow visual processing and reading speed in people with macular degeneration

PURPOSE

People with macular degeneration (MD) often read slowly even with adequate magnification to compensate for acuity loss. Oculomotor deficits may affect reading in MD, but cannot fully explain the substantial reduction in reading speed. Central-field loss (CFL) is often a consequence of macular degeneration, necessitating the use of peripheral vision for reading. We hypothesized that slower temporal processing of visual patterns in peripheral vision is a factor contributing to slow reading performance in MD patients.

METHODS

Fifteen subjects with MD, including 12 with CFL, and five age-matched control subjects were recruited. Maximum reading speed and critical print size were measured with rapid serial visual presentation (RSVP). Temporal processing speed was studied by measuring letter-recognition accuracy for strings of three randomly selected letters centered at fixation for a range of exposure times. Temporal threshold was defined as the exposure time yielding 80% recognition accuracy for the central letter.

RESULTS

Temporal thresholds for the MD subjects ranged from 159 to 5881 ms, much longer than values for age-matched controls in central vision (13 ms, p<0.01). The mean temporal threshold for the 11 MD subjects who used eccentric fixation (1555.8 +/- 1708.4 ms) was much longer than the mean temporal threshold (97.0 +/- 34.2 ms, p<0.01) for the age-matched controls at 10 degrees in the lower visual field. Individual temporal thresholds accounted for 30% of the variance in reading speed (p<0.05).

CONCLUSION

The significant association between increased temporal threshold for letter recognition and reduced reading speed is consistent with the hypothesis that slower visual processing of letter recognition is one of the factors limiting reading speed in MD subjects.

Fixation in Patients with Juvenile Macular Disease

PURPOSE

The instability of fixation with central scotoma has been mainly studied in patients with age-related macular diseases (MDs). However, early macular lesions can lead to different characteristics of fixation. The aim of this work was to study fixation in patients with juvenile MD.

METHODS

Eye movements of 10 patients and 10 controls were monitored during fixation. Visual fields were assessed by static perimetry to determine the extent of the field defects. Eye movements were separated into saccades and drifts, with fixation stability assessed by bivariate contour ellipse area (BCEA). To quantify the number and location of preferred retinal loci (PRL), the kernel density estimator and expectation maximization for mixtures of gaussians were used.

RESULTS

Patients have worse fixation stability than controls and large BCEAs resulted in more than one PRL. It was found that central field defects (10 degrees) have negative correlation with the size of BCEA. In addition, the meridian of saccades during fixation was correlated with the meridian inter-PRL.

CONCLUSIONS

Patients with juvenile MDs have large BCEAs, frequently associated with two PRL. Similar results had been found for patients with age-related MDs. Also, the meridian of involuntary saccades during fixation was found to be correlated with the location of PRLs, suggesting a useful role of these movements in alternating between them.

Functional and cortical adaptations to central vision loss

Age-related macular degeneration (AMD), affecting the retina, afflicts one out of ten people aged 80 years or older in the United States. AMD often results in vision loss to the central 15-20 deg of the visual field (i.e. central scotoma), and frequently afflicts both eyes. In most cases, when the central scotoma includes the fovea, patients will adopt an eccentric preferred retinal locus (PRL) for fixation. The onset of a central scotoma results in the absence of retinal inputs to corresponding regions of retinotopically mapped visual cortex. Animal studies have shown evidence for reorganization in adult mammals for such cortical areas following experimentally induced central scotomata. However, it is still unknown whether reorganization occurs in primary visual cortex (V1) of AMD patients. Nor is it known whether the adoption of a PRL corresponds to changes to the retinotopic mapping of V1. Two recent advances hold out the promise for addressing these issues and for contributing to the rehabilitation of AMD patients: improved methods for assessing visual function across the fields of AMD patients using the scanning laser ophthalmoscope, and the advent of brain-imaging methods for studying retinotopic mapping in humans. For the most part, specialists in these two areas come from different disciplines and communities, with few opportunities to interact. The purpose of this review is to summarize key findings on both the clinical and neuroscience issues related to questions about visual adaptation in AMD patients.