Psychophysical characterisation of early functional loss in glaucoma and ocular hypertension

Higher susceptibility to central crowding in glaucoma

CLINICAL RELEVANCE

Crowding limits many daily life activities, such as reading and the visual search for objects in cluttered environments. Excessive sensitivity to crowding, especially in central vision, may amplify the difficulties of patients with ocular pathologies. It is thus important to investigate what limits visual activities and how to improve it.

BACKGROUND

Numerous studies have reported reduced contrast sensitivity in central vision in patients with glaucoma. However, deficits have also been observed for letter recognition at high contrast, suggesting that contrast alone cannot completely account for impaired central perception.

METHOD

Seventeen patients and fifteen age-matched controls were randomly presented with letters in central or parafoveal vision at 5° eccentricity for 200 ms. They were asked to decide whether the central T was upright or inverted. The T was either presented in isolation (uncrowded) or flanked by two Hs (crowded) at various spacings. Contrast was manipulated: 60% and 5%.

RESULTS

Compared to controls, patients exhibited a significant effect of crowding in central vision, with higher accuracy for the isolated T than for HTH only at low contrast. In parafoveal vision, an effect of crowding was also observed only in patients. The spacing to escape crowding varied as a function of contrast. Larger spacing was required at low contrast than at high contrast. Susceptibility to crowding was related to central visual field defect for central presentations and to contrast sensitivity for parafoveal presentations, only at low contrast. Controls were at ceiling level both for central and parafoveal presentations.

CONCLUSION

Crowding limits visual perception, impeding reading and object recognition in cluttered environments. Visual field defects and lower contrast sensitivity in glaucoma can increase susceptibility to central and parafoveal crowding, the deleterious effect of which can be improved by manipulating contrast and spacing between elements.

Eye Movement Abnormalities in Glaucoma Patients: A Review

Glaucoma is a common condition that relies on careful clinical assessment to diagnose and determine disease progression. There is growing evidence that glaucoma is associated not only with loss of retinal ganglion cells but also with degeneration of cortical and subcortical brain structures associated with vision and eye movements. The effect of glaucoma pathophysiology on eye movements is not well understood. In this review, we examine the evidence surrounding altered eye movements in glaucoma patients compared to healthy controls, with a focus on quantitative eye tracking studies measuring saccades, fixation, and optokinetic nystagmus in a range of visual tasks. The evidence suggests that glaucoma patients have alterations in several eye movement domains. Patients exhibit longer saccade latencies, which worsen with increasing glaucoma severity. Other saccadic abnormalities include lower saccade amplitude and velocity, and difficulty inhibiting reflexive saccades. Fixation is pathologically altered in glaucoma with reduced stability. Optokinetic nystagmus measures have also been shown to be abnormal. Complex visual tasks (eg reading, driving, and navigating obstacles), integrate these eye movements and result in behavioral adaptations. The review concludes with a summary of the evidence and recommendations for future research in this emerging field.

Subtype-specific survival and regeneration of retinal ganglion cells in response to injury

Retinal ganglion cells (RGCs) are a heterogeneous population of neurons that function synchronously to convey visual information through the optic nerve to retinorecipient target areas in the brain. Injury or disease to the optic nerve results in RGC degeneration and loss of visual function, as few RGCs survive, and even fewer can be provoked to regenerate their axons. Despite causative insults being broadly shared, regeneration studies demonstrate that RGC types exhibit differential resilience to injury and undergo selective survival and regeneration of their axons. While most early studies have identified these RGC types based their morphological and physiological characteristics, recent advances in transgenic and gene sequencing technologies have further enabled type identification based on unique molecular features. In this review, we provide an overview of the well characterized RGC types and identify those shown to preferentially survive and regenerate in various regeneration models. Furthermore, we discuss cellular characteristics of both the resilient and susceptible RGC types including the combinatorial expression of different molecular markers that identify these specific populations. Lastly, we discuss potential molecular mechanisms and genes found to be selectively expressed by specific types that may contribute to their reparative capacity. Together, we describe the studies that lay the important groundwork for identifying factors that promote neural regeneration and help advance the development of targeted therapy for the treatment of RGC degeneration as well as neurodegenerative diseases in general.

Vision Impairment Provides New Insight Into Self-Motion Perception

Purpose

Leading causes of irreversible blindness such as age-related macular degeneration (AMD) and glaucoma can, respectively, lead to central or peripheral vision loss. The ability of sufferers to process visual motion information can be impacted even during early stages of eye disease. We used head-mounted display virtual reality as a tool to better understand how vision changes caused by eye diseases directly affect the processing of visual information critical for self-motion perception.

Methods

Participants with intermediate AMD or early manifest glaucoma with near-normal visual acuities and visual fields were recruited for this study. We examined their experiences of self-motion in depth (linear vection), spatial presence, and cybersickness when viewing radially expanding patterns of optic flow simulating different speeds of self-motion in depth. Viewing was performed with the head stationary (passive condition) or while making lateral-sway head movements (active conditions).

Results

Participants with AMD (i.e., central visual field loss) were found to have greater vection strength and spatial presence, compared to participants with normal visual fields. However, participants with glaucoma (i.e., peripheral visual field loss) were found to have lower vection strength and spatial presence, compared to participants with normal visual fields. Both AMD and glaucoma groups reported reduced severity in cybersickness compared to healthy normals.

Conclusions

These findings strongly support the view that perceived self-motion is differentially influenced by peripheral versus central vision loss, and that patients with different visual field defects are oppositely biased when processing visual cues to self-motion perception.

Summation of Temporal L-Cone- and M-Cone-Contrast in the Magno- and Parvocellular Retino-Geniculate Systems in Glaucoma

Purpose

The purpose of this study was to characterize summation of temporal L- and M-cone contrasts in the parvo- (P-) and magnocellular (M-) pathways in glaucoma and the relationship between the respective temporal contrast sensitivities (tCS) and clinical parameters.

Methods

Perifoveal tCS to isolated or combined L- and M-cone contrasts (with different contrast ratios, and therefore different luminance and chromatic components) were measured at different temporal frequencies (at 1 or 2 Hz and at 20 Hz) using triple silent substitution in 73 subjects (13 healthy, 25 with glaucoma, and 35 with perimetric glaucoma). A vector summation model was used to analyze whether perception was driven by the P-pathway, the M-pathway, or both. Using this model, L- and M-cone input strengths (A_L, A_M) and phase differences between L- and M-cone inputs were estimated.

Results

Perception was always mediated by the P-pathway at low frequencies, as indicated by a median phase angle of 179.84 degrees (cone opponency) and a median A_L/A_M ratio of 1.04 (balanced L- and M-cone input strengths). In contrast, perception was exclusively mediated by the M-pathway at higher frequencies (input strength not balanced: A_L/A_M = 2.94, median phase angles = 130.17 degrees). Differences in phase were not significant between diagnosis groups (Kruskal-Wallis = 0.092 for P- and 0.35 for M-pathway). We found differences between groups only for the M-pathway (L-cone tCS deviations at 20 Hz were significantly lower in the patients with glaucoma P = 0.014, with a strong tendency in M-cones P = 0.049). L-cone driven tCS deviations at 20 Hz were linearly correlated with perimetric mean defect (MD) and quadratically correlated with retinal nerve fiber layer (RNFL) thickness.

Conclusions

Unaltered phase angles between L- and M-cone inputs in glaucoma indicated intact temporal processing. Only in the M-pathway, contrast sensitivity deviations were closely related to diagnosis group, MD, and RNFL thickness, indicating M-pathway involvement.

Immediate Impact of Acute Elevation of Intraocular Pressure on Cortical Visual Motion Processing

Purpose

To physiologically examine the impairment of cortical sensitivity to visual motion during acute elevation of intraocular pressure (IOP).

Methods

Motion processing in the cat brain is well characterized, its X and Y cell visual pathways being functionally analogous to parvocellular and magnocellular pathways in primates. Using this model, we performed ocular anterior chamber perfusion to reversibly elevate IOP over a range from 30 to 90 mm Hg while monitoring cortical activity with intrinsic signal optical imaging. Drifting random-dot fields and gratings were used to characterize cortical population responses to motion direction and orientation in early visual areas 17 and 18.

Results

We found that acute IOP elevations at 50 mm Hg and above, which is often observed in acute glaucoma, suppressed cortical motion direction responses. This suppression was more profound in area 17 than in area 18, and more profound in central than peripheral visual field (eccentricities 0°–4° vs. 4°–8°) within area 17. In addition, orientation responses were more suppressed than motion direction responses for the same IOP modulation.

Conclusions

In contrast to human chronic glaucoma that may cause greater dysfunction in large-cell magnocellular than in small-cell parvocellular visual pathways, our direct measurement of cortical processing networks implies that the small X-cell pathway shows greater vulnerability to acute IOP elevation than the large Y-cell pathway in visual motion processing. The results demonstrate that fine discrimination mechanisms for motion in the central visual field are particularly impacted by acute IOP attacks, suggesting a neural basis for immediate visual deficits in the fine motion perception of acute glaucoma patients.

Evidence-based understanding of disc hemorrhage in glaucoma

Disc hemorrhage is a characteristic finding that is highly associated with glaucoma development or progression. Consequently, the literature commonly designates disc hemorrhage as a "risk factor" for glaucoma progression; however, the exact cause-and-effect relationship or mechanism remains unclear. In this review, we discuss the emerging evidence that disc hemorrhage is a secondary development that follows glaucomatous damage. As our understanding of disc hemorrhage has progressed in recent decades, we suggest the terminology be changed from "risk factor" to "indicator" of ongoing glaucomatous development or progression for a more accurate description, better indication of the clinical implications and, ultimately, a better guide for future research.

Increased Equivalent Input Noise in Glaucomatous Central Vision: Is it Due to Undersampling of Retinal Ganglion Cells?

Purpose

Recent evidence shows that macular damage is common even in early stages of glaucoma. Here we investigated whether contrast sensitivity loss in the central vision of glaucoma patients is due to an increase in equivalent input noise (Neq), a decrease in calculation efficiency, or both. We also examined how retinal undersampling resulting from loss of retinal ganglion cells (RGCs) may affect Neq and calculation efficiency.

Methods

This study included 21 glaucoma patients and 23 age-matched normally sighted individuals. Threshold contrast for orientation discrimination was measured with a sinewave grating embedded in varying levels of external noise. Data were fitted to the linear amplifier model (LAM) to factor contrast sensitivity into Neq and calculation efficiency. We also correlated macular RGC counts estimated from structural (spectral-domain optical coherence tomography) and functional (standard automated perimetry Swedish interactive thresholding algorithm 10-2) data with either Neq or efficiency. Furthermore, using analytical and computer simulation approach, the relative effect of retinal undersampling on Neq and efficiency was evaluated by adding the RGC sampling module into the LAM.

Results

Compared with normal controls, glaucoma patients exhibited a significantly larger Neq without significant difference in efficiency. Neq was significantly correlated with Pelli-Robson contrast sensitivity and macular RGC counts. The results from analytical derivation and model simulation further demonstrated that Neq can be expressed as a function of internal noise and retinal sampling.

Conclusions

Our results showed that equivalent input noise is significantly elevated in glaucomatous vision, thereby impairing foveal contrast sensitivity. Our findings further elucidated how undersampling at the retinal level may increase equivalent input noise.

Potential mechanisms of retinal ganglion cell type-specific vulnerability in glaucoma

Glaucoma is a neurodegenerative disease characterised by progressive damage to the retinal ganglion cells (RGCs), the output neurons of the retina. RGCs are a heterogenous class of retinal neurons which can be classified into multiple types based on morphological, functional and genetic characteristics. This review examines the body of evidence supporting type-specific vulnerability of RGCs in glaucoma and explores potential mechanisms by which this might come about. Studies of donor tissue from glaucoma patients have generally noted greater vulnerability of larger RGC types. Models of glaucoma induced in primates, cats and mice also show selective effects on RGC types - particularly OFF RGCs. Several mechanisms may contribute to type-specific vulnerability, including differences in the expression of calcium-permeable receptors (for example pannexin-1, P2X7, AMPA and transient receptor potential vanilloid receptors), the relative proximity of RGCs and their dendrites to blood supply in the inner plexiform layer, as well as differing metabolic requirements of RGC types. Such differences may make certain RGCs more sensitive to intraocular pressure elevation and its associated biomechanical and vascular stress. A greater understanding of selective RGC vulnerability and its underlying causes will likely reveal a rich area of investigation for potential treatment targets.

How do different lighting conditions affect the vision and quality of life of people with glaucoma? A systematic review

This article is a systematic review of evidence regarding the impact of different lighting conditions on the vision and quality of life (QoL) of people with primary open-angle glaucoma (POAG). A systematic literature search was carried out using CINAHL, MEDLINE, PsycARTICLES, PsycINFO, Embase, and Ovid Nursing Database for studies: published up to April 2019; including people diagnosed with POAG; and assessing visual function or QoL in response to changing lighting/luminance levels or glare. Two researchers independently screened studies for eligibility. Data were extracted from eligible studies regarding study design, participant characteristics, outcomes, and results. Quality of included studies was critically appraised. Of 8437 studies, 56 eligible studies were included. Studies investigated the effects of lighting on the following domains among people with POAG: QoL (18/56), psychophysical measures (16/56), functional vision (10/56), activities of daily living (10/56), and qualitative findings (2/56). POAG negatively affects low-luminance contrast sensitivity, glare symptoms, and dark adaptation time and extent. In vision-related QoL questionnaires, people with POAG report problems with lighting, glare, and dark adaptation more frequently than any other domain. These problems worsen with progressing visual field loss. Early-stage POAG patients experience significantly more difficulties in low-luminance or changing lighting conditions than age-matched controls (AMCs), challenging perceptions of early-stage POAG as asymptomatic. However, performance-based studies seldom show significant differences between POAG participants and AMCs on tasks simulating daily activities under non-optimal lighting conditions. Further research with larger samples is required to optimise ambient and task-oriented lighting that can support patients' adaptation to POAG.

Impact of acute intraocular pressure elevation on the visual acuity of non-human primates

Background

Glaucoma is the leading cause of irreversible blindness worldwide and elevated intraocular pressure (IOP) is an established risk factor. Visual acuity, the capacity for fine analysis of spatial frequency (SF) information, is relatively preserved in central vision until the later stages of chronic glaucoma. However, for acute glaucoma that is associated with sharp IOP elevation, how visual acuity is affected by acute IOP elevation remains unclear.

Methods

Using intrinsic-signal optical imaging of large areas of visual cortices V1 and V2 in seven rhesus macaques, visual acuity was directly examined during acute IOP elevation at 70 mmHg, a pressure often observed in acute angle-closure glaucoma. Acute IOP elevation was achieved by reversible monocular anterior chamber perfusions, and visual acuity was quantified by cortical population responses to various SFs ranging from 0.5–6 cycles/°.

Findings

Acute IOP elevation particularly depressed the ability of the visual cortex to register fine details (at high SFs referring to visual acuity), an effect that was progressively more severe toward the central visual field. These results completely contrast with long-term impairments present in chronic glaucoma.

Interpretation

Our results show that impairment of fine visual discrimination within the central visual field is the principal consequence of sharp IOP elevation, implicating relatively greater dysfunction in parvocellular pathways. This study provides direct cortical neural evidence for the immediate visual acuity impairment in acute glaucoma patients.

Fund

National Natural Science Foundation of China, Chinese Academy of Sciences, Shanghai Committee of Science and Technology, and Shanghai Municipal Health Commission.

Spatial contrast sensitivity from star- to sunlight in healthy subjects and patients with glaucoma

Glaucoma is traditionally considered an asymptomatic disease until later stages. However, questionnaire studies revealed visual complaints related to various tasks, especially under extreme luminance conditions (such as outdoor at night on an unlit road or outside in the sun). We measured contrast sensitivity (CS) over a luminance range of 6 log units spanning the scotopic to photopic range and we aimed (1) to determine whether Weber's law also holds under extremely high luminance conditions and (2) to compare CS as a function of spatial frequency and luminance between glaucoma patients and healthy subjects. We included 22 glaucoma patients and 51 controls, all with normal visual acuity. For the second aim, we used a subgroup of 22 age-similar controls. Vertically oriented sine-wave gratings were generated with a projector-based setup (stimulus size 8x5 degrees). CS was measured monocularly at 1, 3, and 10 cycles per degree (cpd); mean luminance ranged from 0.0085 to 8500 cd/m². ANOVA was used to analyze the effect of glaucoma, luminance, and spatial frequency on logCS. In controls, Weber's law held for 3 and 10 cpd; for 1 cpd, CS dropped above 1000 cd/m² (P = 0.003). The logCS versus log luminance curves did not differ grossly between patients and controls (P = 0.14; typically 0-0.2 log units); the difference became larger with decreasing luminance (P = 0.003) but did not depend clearly on spatial frequency (P = 0.27). We conclude that differences between glaucoma and healthy were relatively modest for the spatially redundant, static stimulus as used in the current study.

Audiovisual Temporal Perception in Aging: The Role of Multisensory Integration and Age-Related Sensory Loss

Within each sensory modality, age-related deficits in temporal perception contribute to the difficulties older adults experience when performing everyday tasks. Since perceptual experience is inherently multisensory, older adults also face the added challenge of appropriately integrating or segregating the auditory and visual cues present in our dynamic environment into coherent representations of distinct objects. As such, many studies have investigated how older adults perform when integrating temporal information across audition and vision. This review covers both direct judgments about temporal information (the sound-induced flash illusion, temporal order, perceived synchrony, and temporal rate discrimination) and judgments regarding stimuli containing temporal information (the audiovisual bounce effect and speech perception). Although an age-related increase in integration has been demonstrated on a variety of tasks, research specifically investigating the ability of older adults to integrate temporal auditory and visual cues has produced disparate results. In this short review, we explore what factors could underlie these divergent findings. We conclude that both task-specific differences and age-related sensory loss play a role in the reported disparity in age-related effects on the integration of auditory and visual temporal information.

The Effect of Cataract on Early Stage Glaucoma Detection Using Spatial and Temporal Contrast Sensitivity Tests

BACKGROUND

To investigate the effect of cataract on the ability of spatial and temporal contrast sensitivity tests used to detect early glaucoma.

METHODS

Twenty-seven glaucoma subjects with early cataract (mean age 60 ± 10.2 years) which constituted the test group were recruited together with twenty-seven controls (cataract only) matched for age and cataract type from a primary eye care setting. Contrast sensitivity to flickering gratings at 20 Hz and stationary gratings with and without glare, were measured for 0.5, 1.5 and 3 cycles per degree (cpd) in central vision. Perimetry and structural measurements with the Heidelberg Retinal Tomograph (HRT) were also performed.

RESULTS

After considering the effect of cataract, contrast sensitivity to stationary gratings was reduced in the test group compared with controls with a statistically significant mean difference of 0.2 log units independent of spatial frequency. The flicker test showed a significant difference between test and control group at 1.5 and 3 cpd (p = 0.019 and p = 0.011 respectively). The percentage of glaucoma patients who could not see the temporal modulation was much higher compared with their cataract only counterparts. A significant correlation was found between the reduction of contrast sensitivity caused by glare and the Glaucoma Probability Score (GPS) as measured with the HRT (p<0.005).

CONCLUSIONS

These findings indicate that both spatial and temporal contrast sensitivity tests are suitable for distinguishing between vision loss as a consequence of glaucoma and vision loss caused by cataract only. The correlation between glare factor and GPS suggests that there may be an increase in intraocular stray light in glaucoma.

Designing a new test for contrast sensitivity function measurement with iPad

PURPOSE

To introduce a new application (ClinicCSF) to measure Contrast Sensitivity Function (CSF) with tablet devices, and to compare it against the Functional Acuity Contrast Test (FACT).

METHODS

A total of 42 subjects were arranged in two groups of 21 individuals. Different versions of the ClinicCSF (.v1 and .v2) were used to measure the CSF of each group with the same iPad and the results were compared with those measured with the FACT. The agreements between ClinicCSF and FACT for spatial frequencies of 3, 6, 12 and 18 cycles per degree (cpd) were represented by Bland-Altman plots.

RESULTS

Statistically significant differences in CSF of both groups were found due to the change of the ClinicCSF version (p<0.05) while no differences were manifested with the use of the same FACT test. The best agreement with the FACT was found with the ClinicCSF.v2 with no significant differences in all the evaluated spatial frequencies. However, the 95% confidence intervals for mean differences between ClinicCSF and FACT were lower for the version which incorporated a staircase psychophysical method (ClinicCSF.v1), mainly for spatial frequencies of 6, 12 and 18 cpd.

CONCLUSIONS

The new ClinicCSF application for iPad retina showed no significant differences with FACT test when the same contrast sensitivity steps were used. In addition, it is shown that the accurateness of a vision screening could be improved with the use of an appropriate psychophysical method.

Dendritic changes in rat visual pathway associated with experimental ocular hypertension

PURPOSE

Increasing evidence shows that structural changes in dendrites play an important role in neuronal degenerative processes. The aims of this study were to characterize and delineate morphological changes of dendrites in retinal ganglion cells (RGCs) and their central target neurons in the superior colliculus (SC) and lateral geniculate nucleus (LGN) in experimental rat glaucoma.

METHODS

Chronic ocular hypertension (OHT) was surgically induced in rats and animals were sacrificed at 1, 4, 8, 16 and 32 weeks following IOP elevation. Animals without IOP elevation served as normal control. Dendritic morphology of neurons was visualized by ex vivo DiI labelling using confocal microscopy and dendritic length and number was quantified using Image J.

RESULTS

We found significant dendritic shrinkage (p < 0.001) and loss (p < 0.001) in RGCs and neurons in the SC and LGN in OHT animals compared to age-matched controls. Analysis of the temporal morphological profiles among them revealed the RGCs to have the earliest changes compared to the SC and LGN although the most prominent changes occurred in the SC.

CONCLUSION

Our study has demonstrated that OHT results in dendritic changes of the neurons throughout the visual pathways, from RGCs to SC cells and LGN cells, suggesting that both the retina and the brain should be targeted when considering diagnosis and therapeutic strategies for glaucoma.

Contrast sensitivity of thyroid associated ophthalmopathy patients without obvious optic neuropathy

Purpose. To compare the contrast sensitivity levels of thyroid associated ophthalmopathy (TAO) patients without obvious optic neuropathy with those of healthy people. Methods. Forty eyes of 20 TAO patients without dysthyroid optic neuropathy and 40 eyes of 20 healthy subjects were evaluated in this prospective case-controlled study. The contrast sensitivity functions (CSFs) of all subjects were measured by the functional acuity contrast test (FACT) in five frequencies which were 1,5 cpd (A), 3 cpd (B), 6 cpd (C), 12 cpd (D), and 18 cpd (E). Results were compared for both groups, and a correlation of CSF with Hertel and clinical activity scores was assessed. Results. There was no statistically significant difference between TAO patients and control groups for age and sex. TAO patients had lower levels than the control group in all the frequencies of CSFs (P < 0.05) and the difference in contrast sensitivity functions between the groups seems to be more significant in higher frequencies (B, C, D, and E) (P < 0.001). Conclusions. TAO patients without DON can have contrast sensitivity loss and this would probably imply subtle optic nerve dysfunction in early disease phase.

A novel high-content flow cytometric method for assessing the viability and damage of rat retinal ganglion cells

Purpose

The aim of the study was to develop a high-content flow cytometric method for assessing the viability and damage of small, medium, and large retinal ganglion cells (RGCs) in N-methyl-D-aspartic acid (NMDA)-injury model.

Methods/Results

Retinal toxicity was induced in rats by intravitreal injection of NMDA and RGCs were retrogradely labeled with Fluoro-Gold (FG). Seven days post-NMDA injection, flatmount and flow cytometric methods were used to evaluate RGCs. In addition, the RGC area diameter (D_(a)) obtained from retinal flatmount imaging were plotted versus apparent volume diameter (D_(v)) obtained from flow cytometry for the same cumulative cell number (sequentially from small to large RGCs) percentile (Q) to establish their relationship for accurately determining RGC sizes. Good correlation (r = 0.9718) was found between D_(a) and apparent D_(v). Both flatmount and flow cytometric analyses of RGCs showed that 40 mM NMDA significantly reduced the numbers of small and medium RGCs but not large RGCs. Additionally, flow cytometry showed that the geometric means of FG and thy-1 intensities in three types of RGCs decreased to 90.96±2.24% (P<0.05) and 91.78±1.89% (P>0.05) for small, 69.62±2.11% (P<0.01) and 69.07±2.98% (P<0.01) for medium, and 69.68±6.48% (P<0.05) and 69.91±6.23% (P<0.05) for large as compared with the normal RGCs.

Conclusion

The established flow cytometric method provides high-content analysis for differential evaluation of RGC number and status and should be useful for the evaluation of various models of optic nerve injury and the effects of potential neuroprotective agents.

Determining mechanisms of visual loss in glaucoma using Rarebit perimetry

PURPOSE

Evidence for ganglion cell visual dysfunction in human glaucoma is often indirect, being either measured at the cellular level in animal models or being inferred from the pooled responses of a large number of ganglion cells in human observers. Rarebit perimetry (RBP) uses repeated, intense (150 cd/m2) stimuli-whose size is close to the spatial scale of a ganglion cell-to search for small retinal areas with zero sensitivity. Decreasing the stimulus luminance to 64 cd/m2 in normal observers does not alter the percentage of RBP stimuli detected [the mean hit rate (MHR)], and so we hypothesized that a similar response robustness should occur in glaucoma if the elements detecting the RBP target show no signs of visual dysfunction.

METHODS

Nineteen glaucoma subjects and 19 age-matched controls were tested with a customized RBP test at 13 stimulus luminances (10 to 150 cd/m2, 0.14 log unit intervals). A four-parameter (threshold, spread, false positive proportion, and miss rate) cumulative Gaussian psychometric function was fitted to the response rate data from a glaucoma-affected region (glaucoma subjects; MHR >50% and <80%) and from the corresponding region in an age-matched normal control. Our hypothesis would predict that only the miss rates should differ between groups.

RESULTS

Glaucoma subjects showed significantly higher miss rates (0.18 vs. 0.04, p < 0.001), lower false positive proportions (0.009 vs. 0.025, p = 0.004), greater spreads (0.30 vs. 0.19, p = 0.002), and elevated thresholds [1.57 log(cd/m2) vs. 1.13 log(cd/m2), p < 0.001].

CONCLUSIONS

Responses to RBP stimuli are not robust to decreasing luminances in glaucoma. Our results more directly imply the presence of ganglion cell visual dysfunction in human glaucoma than studies using larger targets where contrast sensitivity losses could result through ganglion cell death alone. Such dysfunction may not be detected by Rarebit's MHR given that dysfunctional elements may still respond to the very intense RBP stimulus.

Indicators of "healthy aging" in older women (65-69 years of age). A data-mining approach based on prediction of long-term survival

Background

Prediction of long-term survival in healthy adults requires recognition of features that serve as early indicators of successful aging. The aims of this study were to identify predictors of long-term survival in older women and to develop a multivariable model based upon longitudinal data from the Study of Osteoporotic Fractures (SOF).

Methods

We considered only the youngest subjects (n = 4,097) enrolled in the SOF cohort (65 to 69 years of age) and excluded older SOF subjects more likely to exhibit a "frail" phenotype. A total of 377 phenotypic measures were screened to determine which were of most value for prediction of long-term (19-year) survival. Prognostic capacity of individual predictors, and combinations of predictors, was evaluated using a cross-validation criterion with prediction accuracy assessed according to time-specific AUC statistics.

Results

Visual contrast sensitivity score was among the top 5 individual predictors relative to all 377 variables evaluated (mean AUC = 0.570). A 13-variable model with strong predictive performance was generated using a forward search strategy (mean AUC = 0.673). Variables within this model included a measure of physical function, smoking and diabetes status, self-reported health, contrast sensitivity, and functional status indices reflecting cumulative number of daily living impairments (HR ≥ 0.879 or RH ≤ 1.131; P < 0.001). We evaluated this model and show that it predicts long-term survival among subjects assigned differing causes of death (e.g., cancer, cardiovascular disease; P < 0.01). For an average follow-up time of 20 years, output from the model was associated with multiple outcomes among survivors, such as tests of cognitive function, geriatric depression, number of daily living impairments and grip strength (P < 0.03).

Conclusions

The multivariate model we developed characterizes a "healthy aging" phenotype based upon an integration of measures that together reflect multiple dimensions of an aging adult (65-69 years of age). Age-sensitive components of this model may be of value as biomarkers in human studies that evaluate anti-aging interventions. Our methodology could be applied to data from other longitudinal cohorts to generalize these findings, identify additional predictors of long-term survival, and to further develop the "healthy aging" concept.

Images perceived after chromatic or achromatic contrast sensitivity losses

PURPOSE

We simulate how subjects with losses in chromatic and achromatic contrast sensitivity perceive colored images by using the spatiochromatic corresponding pair algorithm.

METHODS

This is a generalized version of the algorithm by Capilla et al. (J Opt Soc Am (A) 2004;21:176-186) for simulating color perception of color deviant subjects, which incorporates a simple spatial vision model, consisting of a linear filtering stage, with a band-pass achromatic filter and two low-pass chromatic ones, for the red-green and blue-yellow mechanisms. These filters, except for the global scaling, are the subject's contrast sensitivity functions measured along the cardinal directions of the color space. In its present form, the algorithm would serve to simulate alterations both in the spectral sensitivities and in the contrast sensitivities of the visual mechanisms.

RESULTS

After a preliminary theoretical study on the effect of frequency selective and overall reductions in the contrast sensitivity function of a single mechanism, we present cases of real subjects with glaucoma and diabetes, suffering alterations of different magnitude in the three mechanisms.

CONCLUSIONS

The simulations allow us to learn about the different types of distortions that can be experienced by a subject with impaired contrast sensitivities (blur, haloes, color shifts, local or global contrast, brightness and colorfulness reductions, etc.) and highlight the difficulties arising when trying to predict the quality of the final image from the losses in the individual mechanisms.

Linking structure and function in glaucoma

The glaucomas are a group of relatively common optic neuropathies, in which the pathological loss of retinal ganglion cells causes a progressive loss of sight and associated alterations in the retinal nerve fiber layer and optic nerve head. The diagnosis and management of glaucoma are often dependent on methods of clinical testing that either, 1) identify and quantify patterns of functional visual abnormality, or 2) quantify structural abnormality in the retinal nerve fiber layer, both of which are caused by loss of retinal ganglion cells. Although it is evident that the abnormalities in structure and function should be correlated, propositions to link losses in structure and function in glaucoma have been formulated only recently. The present report describes an attempt to build a model of these linking propositions using data from investigations of the relationships between losses of visual sensitivity and thinning of retinal nerve fiber layer over progressive stages of glaucoma severity. A foundation for the model was laid through the pointwise relationships between visual sensitivities (behavioral perimetry in monkeys with experimental glaucoma) and histological analyses of retinal ganglion cell densities in corresponding retinal locations. The subsequent blocks of the model were constructed from clinical studies of aging in normal human subjects and of clinical glaucoma in patients to provide a direct comparison of the results from standard clinical perimetry and optical coherence tomography. The final formulation is a nonlinear structure-function model that was evaluated by the accuracy and precision of translating visual sensitivities in a region of the visual field to produce a predicted thickness of the retinal nerve fiber layer in the peripapillary sector that corresponded to the region of reduced visual sensitivity. The model was tested on two independent patient populations, with results that confirmed the predictive relationship between the retinal nerve fiber layer thickness and visual sensitivities from clinical perimetry. Thus, the proposed model for linking structure and function in glaucoma has provided information that is important in understanding the results of standard clinical testing and the neuronal losses caused by glaucoma, which may have clinical application for inter-test comparisons of the stage of disease.

Effect of higher order aberrations on contrast sensitivity function in myopic eyes

PURPOSE

To evaluate the relation between higher order aberrations (HOAs) and contrast sensitivity function (CSF) in a population with myopia.

METHODS

In this case series, HOAs were measured in 70 myopic eyes over a 6-mm pupil. Contrast sensitivity was also measured. From the contrast sensitivity data, the area under the log contrast sensitivity function (AULCSF) was calculated. Pupil diameter was measured under photopic conditions.

RESULTS

Seventy right eyes of 70 myopic subjects with a mean age of 26.6 +/- 5.7 years were studied. The mean spherical equivalent and refractive astigmatism were -4.97 +/- 1.6 D and 0.93 +/- 0.5 D, respectively. AULCSF was significantly but negatively correlated with the cycloplegic spherical equivalent (r (2) = 0.57, P = 0.02), the root mean square (RMS) of total HOAs (r (2) = 0.065, P = 0.03), the RMS of fourth-order aberrations (r (2) = 0.089, P = 0.015), and the RMS of the spherical aberration (r (2) = 0.037, P = 0.004). AULCSF did not have any significant association with age, photopic pupil diameter, refractive astigmatism, or the RMS of the coma aberration.

CONCLUSION

Spherical and fourth-order aberrations significantly affect CSF in myopic eyes. However, the effect of myopia on CSF cannot be attributed only to HOAs. Other factors such as neural elements in the visual pathway should be taken into account.

Early diagnosis in glaucoma

This chapter reviews the evidence for the clinical application of vision function tests and imaging devices to identify early glaucoma, and sets out a scheme for the appropriate use and interpretation of test results in screening/case-finding and clinic settings. In early glaucoma, signs may be equivocal and the diagnosis is often uncertain. Either structural damage or vision function loss may be the first sign of glaucoma; neither one is consistently apparent before the other. Quantitative tests of visual function and measurements of optic-nerve head and retinal nerve fiber layer anatomy are useful to either raise or lower the probability that glaucoma is present. The posttest probability for glaucoma may be calculated from the pretest probability and the likelihood ratio of the diagnostic criterion, and the output of several diagnostic devices may be combined to achieve a final probability. However, clinicians need to understand how these diagnostic devices make their measurements, so that the validity of each test result can be adequately assessed. Only then should the result be used, together with the patient history and clinical examination, to derive a diagnosis.

Computer-based primary visual cortex training for treatment of low myopia and early presbyopia

PURPOSE

The NeuroVision technology is a noninvasive, patient-specific, perceptual learning program based on visual stimulation and facilitation of neural connections at the cortical level, involving a computerized visual training regimen using Gabor patches, to improve contrast sensitivity and visual acuity. The efficacy of NeuroVision in enhancing uncorrected visual acuity (UCVA) and unaided contrast sensitivity function (CSF) in patients with low myopia or early presbyopia was evaluated.

METHODS

Seventeen patients with low myopia (up to -1.75 D) and 21 patients with early presbyopia (up to +2.50 D add) were recruited in 2 clinical sites. Eleven myopic and 18 presbyopic patients underwent the NeuroVision program (treatment group), and 9 patients performed visual examinations only, serving as a control group.

RESULTS

The low myopia treatment group achieved a mean improvement of 2.2 logMAR lines in unaided VA, from 0.42 to 0.20 logMAR. Unaided CSF improved at all spatial frequencies (1.5, 3, 6, 12, 18 cpd). The early presbyopia treatment group achieved a mean improvement of 2.2 logMAR lines in near UCVA, from 0.47 to 0.25 logMAR. Near unaided CSF also improved at all spatial frequencies. The control patients in both arms of the study have not shown any significant change in vision. Additionally, the mean refractive error in all groups remained unchanged after treatment.

CONCLUSIONS

Results to date suggest that the NeuroVision technology is effective in improving UCVA and unaided CSF in low myopia and early presbyopia.

Motion perception in the ageing visual system: minimum motion, motion coherence, and speed discrimination thresholds

We aimed to address two issues: first, to describe how the perception of motion differs in elderly observers as compared to younger ones; and, second, to see if these changes in motion perception could be accounted for by the known changes in the ability of elderly observers to detect patterns (as indexed via contrast sensitivity). The lower threshold of motion, motion coherence, and speed discrimination were measured, alongside contrast sensitivity, in a group of thirty-two older (mean age 61.5 years) and thirty-two younger (mean age 23.2 years) subjects. The older observers showed losses in their ability to detect slow motions as indexed via the lower threshold of motion for random-dot patterns and for gratings of a range of spatial frequencies. They also were impaired on a test of motion coherence, but only for stimuli of a slow to medium speed, whereas faster speeds showed no decline with age. Finally, at all speeds tested the older observers required greater differences in speed in order to discriminate between patterns moving at different speeds. The pattern of losses on motion perception tasks was not predicted by the deficits of the older groups, such as loss of detection thresholds for high spatial and/or temporal frequencies. It is concluded that these hypotheses do not provide an adequate account of the data, and therefore that the losses occurring with age are complex and probably are a result of the loss of several types of cell.

Generic and customized digital image enhancement filters for the visually impaired

This study compares the effectiveness of various image enhancement filters for improving the perceived visibility of coloured digital natural images for people with visual impairment. Generic filters were compared with Peli's adaptive enhancement and adaptive thresholding and custom-devised filters based on each subject's contrast sensitivity loss. Subjects with low vision made within filter rankings followed by between filter ratings. In general, subjects preferred filters with lower gains. Unsharp masking resulted in a significant increase in perceived visibility for some image types (p < or = 0.05) while Peli's adaptive enhancement, edge enhancement and histogram equalization resulted in borderline improvements. Adaptive thresholding and the custom devised filter did not result in overall improvements in perceived visibility.

Relationship between visual field loss and contrast threshold elevation in glaucoma

BACKGROUND

There is a considerable body of literature which indicates that contrast thresholds for the detection of sinusoidal grating patterns are abnormally high in glaucoma, though just how these elevations are related to the location of visual field loss remains unknown. Our aim, therefore, has been to determine the relationship between contrast threshold elevation and visual field loss in corresponding regions of the peripheral visual field in glaucoma patients.

METHODS

Contrast thresholds were measured in arcuate regions of the superior, inferior, nasal and temporal visual field in response to laser interference fringes presented in the Maxwellian view. The display consisted of vertical green stationary laser interference fringes of spatial frequency 1.0 c deg(-1) which appeared in a rotatable viewing area in the form of a truncated quadrant extending from 10 to 20 degrees from fixation which was marked with a central fixation light. Results were obtained from 36 normal control subjects in order to provide a normal reference for 21 glaucoma patients and 5 OHT (ocular hypertensive) patients for whom full clinical data, including Friedmann visual fields, had been obtained.

RESULTS

Abnormally high contrast thresholds were identified in 20 out of 21 glaucoma patients and in 2 out of 5 OHT patients when compared with the 95% upper prediction limit for normal values from one eye of the 36 normal age-matched control subjects. Additionally, inter-ocular differences in contrast threshold were also abnormally high in 18 out of 20 glaucoma patients who had vision in both eyes compared with the 95% upper prediction limit. Correspondence between abnormally high contrast thresholds and visual field loss in the truncated quadrants was significant in 5 patients, borderline in 4 patients and absent in 9 patients.

CONCLUSION

While the glaucoma patients tested in our study invariably had abnormally high contrast thresholds in one or more of the truncated quadrants in at least one eye, reasonable correspondence with the location of the visual field loss only occurred in half the patients studied. Hence, while contrast threshold elevations are indicative of glaucomatous damage to vision, they are providing a different assessment of visual function from conventional visual field tests.

The psychophysics of glaucoma: improving the structure/function relationship

Perimetry of some kind remains an important tool in the detection, diagnosis and monitoring of glaucomatous damage to the visual pathway. However, recent studies have served to reinforce the suspicion that conventional perimetry does not possess the sensitivity to detect the earliest signs of functional loss resulting from glaucoma. The relationship between differential light threshold and ganglion cell loss is extremely weak and, in the early stages of glaucoma, non-existent. Alternative, more novel perimetric techniques seem to offer promise of better detectability for early loss by claiming to tap in to one or other of the separate parallel pathways of the visual system. While some of these tests show potential for better detection and monitoring of glaucoma, the reasons why this might be so are not always clearly formulated or represented. This leads to misunderstanding of what the test actually measures and of the glaucomatous disease process itself. This paper seeks to revisit and review the theory underlying psychophysical testing of visual function related to glaucoma and stresses the importance of developing tests that are based on a firm theoretical understanding of visual function and processing in order to both detect glaucoma at an earlier stage and better understand the mechanisms of loss from the disease process.

Psychophysical investigation of ganglion cell loss in early glaucoma

PURPOSE

To evaluate ganglion cell loss in early glaucoma using a variety of psychophysical tests and to identify optimal perimetric technique(s) for detection of early glaucomatous visual function loss.

METHODS

Five perimetric tests, short wavelength automated perimetry (SWAP), temporal modulation perimetry (TMP), frequency doubling technology perimetry (FDT), detection acuity perimetry (DAP), and resolution acuity perimetry (RAP) were compared in their ability to discriminate between normal individuals and patients with early glaucoma or glaucoma suspects. Comparisons were also made by their ability to produce repeatable defects. The tests examined different visual functions that are likely to be mediated by different retinal ganglion cell subpopulations, thereby permitting examination of hypotheses of ganglion cell death in early glaucoma.

RESULTS

All visual field tests demonstrated high performance in separating glaucoma patients from normal individuals. SWAP, TMP, FDT, and DAP provided the greatest discrimination between normal individuals and high- and low-risk glaucoma suspects. However, SWAP, TMP, and FDT obtained better consistency across the various analysis approaches (global indices and pointwise) than DAP and RAP. Of all the test types, FDT exhibited the highest proportion of repeatable abnormal test locations, with poor confirmation rates achieved by DAP and RAP.

CONCLUSION

The performance of SWAP, FDT, and TMP suggests that these test types may all be suitable for detection of early loss of visual function in glaucoma. Ganglion cell subpopulations with lower levels of redundancy and/or those with larger cell sizes offer the most parsimonious explanation for earliest ganglion cell losses occurring in glaucoma.