Change in visual acuity is highly correlated with change in six image quality metrics independent of wavefront error and/or pupil diameter

Allowable movement of wavefront-guided contact lens corrections in normal and keratoconic eyes

PURPOSE

The goal was to use SyntEyes modelling to estimate the allowable alignment error of wavefront-guided rigid contact lens corrections for a range of normal and keratoconic eye aberration structures to keep objectively measured visual image quality at or above average levels of well-corrected normal eyes. Secondary purposes included determining the required radial order of correction, whether increased radial order of the corrections further constrained the allowable alignment error and how alignment constraints vary with keratoconus severity.

METHODS

Building on previous work, 20 normal SyntEyes and 20 keratoconic SyntEyes were fitted with optimised wavefront-guided rigid contact lens corrections targeting between three and eight radial orders that drove visual image quality, as measured objectively by the visual Strehl ratio, to near 1 (best possible) over a 5-mm pupil for the aligned position. The resulting wavefront-guided contact lens was then allowed to translate up to ±1 mm in the x- and y-directions and rotate up ±15°.

RESULTS

Allowable alignment error changed as a function of the magnitude of aberration structure to be corrected, which depends on keratoconus severity. This alignment error varied only slightly with the radial order of correction above the fourth radial order. To return the keratoconic SyntEyes to average levels of visual image quality depended on maximum anterior corneal curvature (Kmax). Acceptable tolerances for misalignment that returned keratoconic visual image quality to average normal levels varied between 0.29 and 0.63 mm for translation and approximately ±6.5° for rotation, depending on the magnitude of the aberration structure being corrected.

CONCLUSIONS

Allowable alignment errors vary as a function of the aberration structure being corrected, the desired goal for visual image quality and as a function of keratoconus severity.

Defining metrics of visual acuity from theoretical models of observers

Many experimental studies show that metrics of visual image quality can predict changes in visual acuity due to optical aberrations. Here we use statistical decision theory and Fourier optics formalism to demonstrate that two metrics known in the field of vision sciences are approximations of two different theoretical models of linear observers. The theory defines metrics of visual acuity to potentially predict changes in visual acuity due to optical aberrations, without needing a posteriori scale or offset. We illustrate our approach with experiments, using combinations of defocus and spherical aberration, and pure coma.

Temporal fluctuations in defocus may reverse the acuity loss encountered with induced refractive errors

A recent template-matching model hypothesized that simulated visual acuity loss with uncorrected refractive errors may be recovered by adding temporal defocus fluctuations up to the magnitude of the refractive error. Acuity recovery saturates or gets attenuated beyond this magnitude. These predictions were confirmed for monocular high-contrast visual acuity of 10 young, cyclopleged adults with 0.5-2.0D of induced myopia combined with the same range of temporal defocus fluctuations at 4.0 Hz frequency. The outcomes reinforce that spatial resolution may be optimized by averaging time-varying defocus over the entire stimulus presentation epoch or around the point of least defocus within this epoch.

Utilising a visual image quality metric to optimise spectacle prescriptions for eyes with keratoconus

PURPOSE

To compare optical performance, visual performance, and patient-perceived quality of vision with: (1) spectacles determined using subjective refraction and (2) spectacles determined using an objective optimisation method based on wavefront aberration data for eyes with keratoconus.

METHODS

Thirty-seven eyes (20 subjects) with keratoconus underwent both subjective refraction and uncorrected wavefront aberration measurement. Wavefront aberration data were used to objectively identify a sphero-cylindrical refraction that optimised the visual image quality metric visual Strehl ratio (VSX). The two refractions were assembled in trial frames and worn by the subject in a random order. High-contrast visual acuity (VA), letter contrast sensitivity (CS), and the patient's short-term subjective preference were recorded for each prescription.

RESULTS

Median magnitude of the dioptric difference (a measure of similarity between the subjective and objective refractions) was 2.77 D (range = 0.21-20.44 D, first quartile = 1.02 D, third quartile = 4.36 D). Sixty-eight per cent of eyes had better VA with the objective refraction and 32% of eyes gained more than one line of VA. Monocularly, objective refraction was preferred 68% of the time when looking at a distant acuity chart and 76% of the time when viewing a real-world dynamic scene.

CONCLUSIONS

Objective refraction based on visual image quality derived from wavefront aberration data can be valuable in the determination of monocular spectacle refractions for individuals with keratoconus.

Absolute prediction of relative changes in contrast sensitivity with aberrations using a single metric of retinal image quality

Metrics of retinal image quality predict optimal refractive corrections and correlate with visual performance. To date, they do not predict absolutely the relative change in visual performance when aberrations change and therefore need to be a-posteriori rescaled to match relative measurements. Here we demonstrate that a recently proposed metric can be used to predict, in an absolute manner, changes in contrast sensitivity measurements with Sloan letters when aberrations change. Typical aberrations of young and healthy eyes (for a 6 mm pupil diameter) were numerically introduced, and we measured the resulting loss in contrast sensitivity of subjects looking through a 2 mm diameter pupil. Our results suggest that the metric can be used to corroborate measurements of visual performance in clinical practice, thereby potentially improving patient follow-ups.

Objective method for visual performance prediction

We propose, implement, and validate a new objective method for predicting the trends of visual acuity through-focus curves provided by specific optical elements. The proposed method utilized imaging of sinusoidal gratings provided by the optical elements and the definition of acuity. A custom-made monocular visual simulator equipped with active optics was used to implement the objective method and to validate it via subjective measurements. Visual acuity measurements were obtained monocularly from a set of six subjects with paralyzed accommodation for a naked eye and then that eye compensated by four multifocal optical elements. The objective methodology successfully predicts the trends of the visual acuity through-focus curve for all considered cases. The Pearson correlation coefficient was 0.878 for all tested optical elements, which agrees with results obtained by similar works. The proposed method constitutes an easy and direct alternative technique for the objective testing of optical elements for ophthalmic and optometric applications, which can be implemented before invasive, demanding, or costly procedures on real subjects.

Computational analysis of retinal image quality with different contact lens designs in keratoconus

PURPOSE

To determine 1) the relative differences in optical quality of keratoconic eyes fitted with four routinely used CL designs and 2) the Zernike coefficients in the residual wavefront aberration map that may be responsible for differences in the optical quality of keratoconic eyes fitted with these CLs.

METHODS

Wavefront aberrations over a 3-mm pupil diameter were measured without and with Kerasoft IC®, Rose K2®, conventional spherical Rigid Gas Permeable (RGP), and Scleral CLs in 15 mild to moderate keratoconic eyes (20 - 28 years) and under unaided viewing in 10 age-similar non-contact lens wearing controls. The resultant through-focus curves constructed for the logarithm of Neural Sharpness (logNS) Image Quality (IQ) metric were quantified in terms of peak value, best focus, and depth of focus. Sensitivity analyses determined the impact of the residual Zernike coefficients of keratoconic eyes fitted with CLs on the IQ of controls at emmetropic refraction.

RESULTS

The peak IQ and depth of focus were similar with Rose K2®, conventional RGP, and Scleral CLs (p > 0.05, for all) but significantly better than Kerasoft IC® CLs (p < 0.01 for all). Best focus was similar across all four CLs (p > 0.2 for all). However, the IQ parameters of all the lenses remained significantly poorer than the controls (p < 0.01, for all). The IQ of the controls dropped to keratoconic levels with induced residual lower-order Zernike terms and 3rd-order coma across all lenses in the sensitivity analysis (p < 0.001).

CONCLUSIONS

IQ of keratoconic eyes remain suboptimal with routinely dispensed CL designs, largely due to residual lower-order aberrations and coma, all relative to the controls. The performance drop appears greater for the Kerasoft IC® CL relative to the other CL designs. These results may provide the optical basis for psychophysical spatial visual performance reported earlier across these four CL designs for keratoconus.

Optical modelling of an accommodative light field display system and prediction of human eye responses

The spatio-angular resolution of a light field (LF) display is a crucial factor for delivering adequate spatial image quality and eliciting an accommodation response. Previous studies have modelled retinal image formation with an LF display and evaluated whether accommodation would be evoked correctly. The models were mostly based on ray-tracing and a schematic eye model, which pose computational complexity and inaccurately represent the human eye population's behaviour. We propose an efficient wave-optics-based framework to model the human eye and a general LF display. With the model, we simulated the retinal point spread function (PSF) of a point rendered by an LF display at various depths to characterise the retinal image quality. Additionally, accommodation responses to the rendered point were estimated by computing the visual Strehl ratio based on the optical transfer function (VSOTF) from the PSFs. We assumed an ideal LF display that had an infinite spatial resolution and was free from optical aberrations in the simulation. We tested points rendered at 0-4 dioptres of depths having angular resolutions of up to 4x4 viewpoints within a pupil. The simulation predicted small and constant accommodation errors, which contradict the findings of previous studies. An evaluation of the optical resolution on the retina suggested a trade-off between the maximum achievable resolution and the depth range of a rendered point where in-focus resolution is kept high. The proposed framework can be used to evaluate the upper bound of the optical performance of an LF display for realistically aberrated eyes, which may help to find an optimal spatio-angular resolution required to render a high quality 3D scene.

Predicting the effects of defocus blur on contrast sensitivity with a model-based metric of retinal image quality

We measure the effect of defocus blur on contrast sensitivity with Sloan letters in the 0.75-2.00 arc min range of letter gaps. We compare our results with the prediction of the Dalimier and Dainty model [J. Opt. Soc. Am. A25, 2078 (2008)JOAOD60740-323210.1364/JOSAA.25.002078] and propose a new metric of retinal image quality that we define as the model limit for very small letters. The contrast sensitivity is measured for computationally blurred Sloan letters (0, 0.25, and 0.50 diopters for a 3 mm pupil) of different sizes (20/40 to 20/15 visual acuity), and subjects look through a small (2 mm) diaphragm to limit the impact of their own aberration on measurements. Measurements and model predictions, which are normalized by the blur-free condition, weakly depend on letter size and are in good agreement with our metric of retinal image quality. Our metric relates two approaches of modeling visual performance: complete modeling of the optotype classification task and calculation of retinal image quality with a descriptive metric.

Clinical applications of personalising the neural components of visual image quality metrics for individual eyes

PURPOSE

Eyecare is evolving increasingly personalised corrections and increasingly personalised evaluations of corrections on-eye. This report describes individualising optical and neural components of the VSX (visual Strehl) metric and evaluates personalisation using two clinical applications. (1) Better understanding visual experience: While VSX tracks visual performance in typical eyes, non-individualised metrics underestimated visual performance in highly aberrated eyes - could this be understood by personalising metrics? (2) Metric-optimised objective spherocylindrical refractions in typical and atypical eyes have used neural weighting functions of typical eyes - will personalisation affect the outcome in clinical 0.25D steps?

METHODS

Orientation-specific neural contrast sensitivity was measured in four typical myopic and astigmatic eyes and six eyes with keratoconus. Wavefront error was measured in all eyes while uncorrected and when the keratoconic eyes wore wavefront-guided scleral lenses. Total experiment duration was 24-28 h per subject. Two versions of VSX were calculated for each application: one weighted ocular optics with measured neural contrast sensitivity data from that eye, another weighted optics with a representative neural function of typical eyes. Wavefront-guided corrections were evaluated using the two metric values. Spherocylindrical corrections that optimised each metric were identified.

RESULTS

Metric values for keratoconic eyes improved by a mean factor of 1.99 (~0.3 log units) when personalised. Applying this factor to a larger sample of eyes from a previous keratoconus study reconciled dissonances between the percentage of eyes reaching normative best-corrected metric levels and the percentages of eyes reaching normative levels of visual acuity and contrast sensitivity. Spherocylindrical corrections that optimised both versions of VSX were clinically equivalent (mean ± SD Euclidean dioptric difference 0.13 ± 0.18 D).

CONCLUSIONS

Personalising visual image quality metrics is beneficial when actual metric values are used (evaluating ophthalmic corrections on-eye against norms) and when fine increments in visual quality are imparted (wavefront-guided corrections). However, partially individualised metrics appear adequate when metrics relatively rank spherocylindrical corrections in 0.25 D steps.

Correlation between Contrast Sensitivity and Modulation Transfer Functions

SIGNIFICANCE

Previous studies found no correlation between visual acuity and optical quality in a population of young subjects with good vision. Using sinusoidal gratings, we systematically investigate the correlation between contrast sensitivity and optical quality as a function of spatial frequency.

PURPOSE

This study describes the correlation between the contrast sensitivity function (CSF) and the modulation transfer function (MTF) in a sample of young and informed subjects. Our results are compared with prior studies on the correlation between visual acuity and metrics of image quality. We also compare our results with previous studies that compare the CSF, the MTF, and the neural contrast sensitivity function (NCSF).

METHODS

The CSF of 28 informed subjects is measured in photopic conditions. The polychromatic MTF is computed from the measurements of monochromatic aberrations. The (CSF, MTF) correlation is estimated as the Pearson correlation coefficient, at each spatial frequency. The NCSF of each subject is estimated as the ratio of CSF to MTF.

RESULTS

We obtain high correlation coefficients (0.8) in the range of spatial frequencies of 3 to 6 cycles per degree, which also corresponds to high NCSF. Correlation decreases with increasing spatial frequency in the range of 6 to 18 cycles per degree (down to 0.0 at 18 cycles per degree). In that range, optical and neural contrast sensitivities are both approximately reduced by factor 4.

CONCLUSIONS

In our sample of young subjects with good vision, the CSF with sinusoidal gratings better differentiates eyes of good optical quality at intermediate spatial frequencies (3 to 6 cycles per degree) than at higher spatial frequencies (12 to 18 cycles per degree). At the highest tested spatial frequency of sinusoidal gratings (18 cycles per degree), there is no significant correlation between optical quality and contrast sensitivity.

Visual image quality after small-incision lenticule extraction compared with that of spectacles and contact lenses

PURPOSE

To assess the influence of small-incision lenticule extraction (SMILE) for high myopia on the visual image quality assessed by the logarithm of the visual Strehl ratio (logVSX) and put this into a clinical context by pairwise comparing the logVSX of postoperative eyes with those of myopic controls wearing spectacles and/or contact lenses.

SETTING

University hospital.

DESIGN

Prospective and cross-sectional clinical study.

METHODS

Patients with a myopic spherical equivalent of at least 6.00 diopters treated with SMILE aimed at emmetropia and correspondingly myopic controls corrected with spectacles and/or contact lenses were included. The logVSX calculation was divided into habitual logVSX based on the wavefront aberration measurement directly and optimal logVSX calculated in a theoretical through-focus experiment to obtain the best-achievable logVSX.

RESULTS

A total of 117 eyes of 61 patients and 64 eyes of 34 myopic controls were included. SMILE did not affect the habitual logVSX but worsened the optimal logVSX (P < .001). The postoperative habitual logVSX was statistically significantly worse compared with contact lenses (P = .002). The postoperative optimal logVSX was significantly worse compared with both spectacles (P < .01) and contact lenses (P = .003). There was no statistically significant difference in habitual or optimal logVSX between spectacles and contact lenses.

CONCLUSIONS

SMILE for high myopia does not affect the habitual logVSX but decreases the optimal logVSX slightly. The postoperative habitual logVSX is worse than for contact lenses but not spectacles, and the postoperative optimal logVSX is worse than for both contact lenses and spectacles. There is no statistically significant difference in either habitual or optimal logVSX between spectacles and contact lenses.

Influence of Lenslet Configuration on Short-Term Visual Performance in Myopia Control Spectacle Lenses

Purpose: This study aimed to evaluate short-term visual performance and optical quality of three different lenslet configurations on myopia control spectacle lenses.

Materials and Methods: This study utilized a cross-over design. Distance visual acuity (VA) was measured in 50 myopic children; contrast sensitivity (CS) was measured in 36 myopic children. For each test, four spectacle lenses were evaluated in a random order: single-vision lens (SVL), lens with concentric rings of highly aspherical lenslets (HAL), lens with concentric rings of slightly aspherical lenslets (SAL), and lens with honeycomb configuration of spherical lenslets (HC). The modulation transfer function (MTF) and MTF area (MTFa) were used to determine optical quality. All tests were performed monocularly on the right eye with full correction.

Results: HAL and SAL had larger MTFa than HC. VA in lenses with lenslets was significantly reduced compared to SVL (all p < 0.01). The reduction in VA was worse with HC than with SAL (p = 0.02) and HAL (p = 0.03); no effect of lenslet asphericity was found (p > 0.05). VA changes induced by lenslets showed no correlation with spherical equivalent refraction (all p > 0.05) and were weakly positively associated with age for SAL (r = 0.36, p = 0.01) and HC (r = 0.31, p = 0.03), but not for HAL (p = 0.30). The area under the log contrast sensitivity function (AULCSF) decreased with HAL and HC (all p < 0.001) in all illumination levels, and AULCSF with HAL was higher than that with HC in a photopic condition (1.17 ± 0.10 vs. 1.10 ± 0.13, p = 0.0004). The presence of lenslets did not affect CS at 3 cycles per degree (cpd) (p = 0.80). At 6 to 18 cpd, CS was significantly reduced by HAL and HC (all p < 0.05), but not SAL (p > 0.05) compared to SVL. At high spatial frequencies (>12 cpd) both SAL and HAL reduced CS significantly less than HC (all p < 0.01).

Conclusion: Short-term visual performance was minimally impaired by looking through the lenslet structure of myopia control spectacle lenses. Concentric rings with aspherical lenslets had a significantly lower impact on both VA and CS than honeycomb configuration with spherical lenslets.

Joint effect of defocus blur and spatial attention

Defocus blur and spatial attention both act on our ability to see clearly over time. However, it is currently unknown how these two factors interact because studies on spatial resolution only focused on the separate effects of attention and defocus blurs. In this study, eleven participants performed a resolution acuity task along the diagonal 135˚/315˚ with horizontal, at 8˚ eccentricity for clear and blurred Landolt C images under various manipulations of covert endogenous attention. All the conditions were interleaved and viewed binocularly on a visual display. We observed that attention not just improves the resolution of clear stimuli, but also modulates the resolution of defocused stimuli for compensating the loss of resolution caused by retinal blur. Our results show, however, that as the degree of attention decreases, the differences between clear and blurred images largely diminish, thus limiting the benefit of an image quality enhancement. It also appeared that attention tends to enhance the resolution of clear targets more than blurred targets, suggesting potential variations in the gain of vision correction with the level of attention. This demonstrates that the interaction between spatial attention and defocus blur can play a role in the way we see things. In view of these findings, the development of adaptive interventions, which adjust the eye's defocus to attention, may hold promise.

Orientation-specific long-term neural adaptation of the visual system in keratoconus

Eyes with the corneal ectasia keratoconus have performed better than expected (e.g. visual acuity) given their elevated levels of higher-order aberrations that cause rotationally asymmetric retinal blur. Adapted neural processing has been suggested as an explanation but has not been measured across multiple meridional orientations. Using a custom Maxwellian-view laser interferometer to bypass ocular optics, sinusoidal grating neural contrast sensitivity was measured in six eyes (three subjects) with keratoconus and four typical eyes (two subjects) at six spatial frequencies and eight orientations using a two-interval forced-choice paradigm. Total measurement duration was 24 to 28 hours per subject. Neural contrast sensitivity functions of typical eyes agreed with literature and generally showed the oblique effect on a linear-scale and rotational symmetry on a log-scale (rotational symmetry was quantified as the ratio of the minor and major radii of an ellipse fit to all orientations within each spatial frequency; typical eye mean 0.93, median 0.93; where a circle = 1). Mean sensitivities of eyes with keratoconus were 20% to 60% lower (at lower and higher spatial frequencies respectively) than typical eyes. Orientation-specific neural contrast sensitivity functions in keratoconus showed substantial rotational asymmetry (ellipse radii ratio: mean 0.84; median 0.86) and large meridional reductions. The visual image quality metric VSX was used with a permutation test to combine the asymmetric optical aberrations of the eyes with keratoconus and their measured asymmetric neural functions, which illustrated how the neural sensitivities generally mitigated the detrimental effects of the optics.

Combining optical and neural components in physiological visual image quality metrics as functions of luminance and age

Visual image quality metrics combine comprehensive descriptions of ocular optics (from wavefront error) with a measure of the neural processing of the visual system (neural contrast sensitivity). To improve the ability of these metrics to track real-world changes in visual performance and to investigate the roles and interactions of those optical and neural components in foveal visual image quality as functions of age and target luminance, models of neural contrast sensitivity were constructed from the literature as functions of (1) retinal illuminance (Trolands, td), and (2) retinal illuminance and age. These models were then incorporated into calculation of the visual Strehl ratio (VSX). Best-corrected VSX values were determined at physiological pupil sizes over target luminances of 104 to 10-3 cd/m2 for 146 eyes spanning six decades of age. Optical and neural components of the metrics interact and contribute to visual image quality in three ways. At target luminances resulting in >900 td at physiological pupil size, neural processing is constant, and only aberrations (that change as pupil size changes with luminance) affect the metric. At low mesopic luminances below where pupil size asymptotes to maximum, optics are constant (maximum pupil), and only the neural component changes with luminance. Between these two levels, both optical and neural components of the metrics are affected by changes in target luminance. The model that accounted for both retinal illuminance and age allowed VSX, termed VSX(td,a), to best track visual acuity trends (measured at 160 and 200 cd/m2) as a function of age (20s through 70s) from the literature. Best-corrected VSX(td,a) decreased by 2.24 log units between maximum and minimum target luminances in the youngest eyes and by 2.58 log units in the oldest. The decrease due to age was more gradual at high target luminances (0.70 log units) and more pronounced as target luminance decreased (1.04 log units).

Investigation of the impact of blur under mobile attentional orientation using a vision simulator

It is well-known that correction of blur can improve visual perception. However, it is unclear how the beneficial effect of correction is affected by the regions of correction and the spatial uncertainty introduced by the retinal stimulation. The purpose of this study was two-fold: first, to compare the impacts of blur correction between isoeccentric locations of the visual field; and second, to evaluate the effect of spatial cueing in each corrected location on performing a simple task. Five subjects were asked to complete a simple detection task of a small dark spot stimulus presented randomly at four cardinal retinal locations (eccentricity: 5°) under manipulation of attention via an exogenous cue. Both clear and blurred targets were randomly displayed across the visual field and viewed monocularly through a vision simulator, used to minimize peripheral ocular aberrations. Results confirmed the advantage of clear vs/ blurred images under spatial uncertainty. It was also found that the visual benefit from blur correction is unequal at isoeccentric locations, even for a simple detection task. While manipulation of attention in the presence of spatial uncertainty significantly modulated response time (RT) performance, no differential effect was observed for clear and blurred stimuli, suggesting that attention has only a small effect on the optical benefit for a simple detection task when the display is depleted (no distractor). Those observations highlight the importance of field performance asymmetries in optical interventions and may offer useful implications for the design of extrafoveal refractive correction. Further studies are needed to elucidate how the focus of attention interacts with the perceived gain of vision correction.

Understanding the Impact of Individual Perceived Image Quality Features on Visual Performance

Purpose

This study aimed to quantify the impact of blur, contrast, and ghosting on perceived overall image quality (IQ) as well as resultant predicted visual acuity, utilizing simulated acuity charts from objective refraction among eyes of individuals with Down syndrome (DS).

Methods

Acuity charts were produced, simulating the retinal image when applying 16 different metric-derived sphero-cylindrical refractions for each eye of 30 adult patients with DS. Fourteen dilated adult observers (normal vision) viewed subsets of logMAR acuity charts displayed on an LCD monitor monocularly through a unit magnification 3-mm aperture telescope. Observers rated features blur, ghosting, and contrast on 10-point scales (10 = poorest) and overall IQ on a 0- to 100-point scale (100 = best) and read each chart until five total letters were missed (logMAR technique). Mixed modeling was used to estimate feature influence on overall perceived IQ and relative acuity (compared with an unaberrated chart), separately.

Results

Perceived IQ spanned the entire scale (mean = 59 ± 22) and average reduction in relative acuity was two lines (0.2 ± 0.14 logMAR). Perceived blur, ghosting, and contrast were individually correlated with overall IQ and relative acuity. Blur, contrast, and ghosting exert unique effects on overall perceived IQ (P < 0.05). Blur (b = -.009, P < 0.001) and ghosting (b = -.003, P < 0.001) influence relative acuity over and beyond their effects on overall IQ (b = .001, P < 0.0001) and contrast.

Conclusions

Objectively identified refractions would ideally provide high contrast, low blur, and low ghosting. These data suggest that blur and ghosting may be given priority over contrast when improving acuity is the goal.

Translational Relevance

Findings may guide objective refraction in clinical care.

Comparison of Wavefront-guided and Best Conventional Scleral Lenses after Habituation in Eyes with Corneal Ectasia

SIGNIFICANCE

Visual performance with wavefront-guided (WFG) contact lenses has only been reported immediately after manufacture without time for habituation, and comparison has only been made with clinically unrefined predicate conventional lenses. We present comparisons of habitual corrections, best conventional scleral lenses, and WFG scleral lenses after habituation to all corrections.

PURPOSE

The purpose of this study was to compare, in a crossover design, optical and visual performance of eyes with corneal ectasias wearing dispensed best conventional scleral lens corrections and dispensed individualized WFG scleral lens corrections.

METHODS

Ten subjects (20 eyes) participated in a randomized crossover study where best conventional scleral lenses and WFG scleral lenses (customized through the fifth radial order) were worn for 8 weeks each. These corrections, as well as each subject's habitual correction and normative data for normal eyes, were compared using (1) residual higher-order aberrations (HORMS), (2) visual acuity (VA), (3) letter contrast sensitivity (CS), and (4) visual image quality (logarithm of the visual Strehl ratio, or logVSX). Correlations were performed between Pentacam biometric measures and gains provided by WFG lenses.

RESULTS

Mean HORMS was reduced by 48% from habitual to conventional and 43% from conventional to WFG. Mean logMAR VA improved from habitual (+0.12) to conventional (-0.03) and further with WFG (-0.09); six eyes gained greater than one line with WFG over conventional. Area under the CS curve improved by 26% from habitual to conventional and 14% from conventional to WFG. The percentage of the eyes achieving normal levels were as follows: HORMS, 40% for conventional and 85% for WFG; VA, 50% for conventional and 85% for WFG; and CS, 60% for conventional and 90% for WFG. logVSX improved by 16% from habitual to conventional and 25% further with WFG. Reduction in aberrations with WFG lenses best correlated with posterior cornea radius of curvature.

CONCLUSIONS

Visual performance was superior to that reported with nonhabituated WFG lens wear. With WFG lenses, HORMS and logVSX significantly improved, allowing more eyes to reach normal levels of optical and visual performance compared with conventional lenses.

Validation of an automated-ETDRS near and intermediate visual acuity measurement

BACKGROUND

The aim of this study was to determine the repeatability of an automated-ETDRS (Early Treatment Diabetic Retinopathy Study) near and intermediate visual acuity measurement in subjects with normal visual acuity and subjects with reduced visual acuity. The agreement of automated-ETDRS with gold standard chart-based visual acuity measurement was also studied.

METHODS

Fifty-one subjects were tested (aged 23 to 91 years; 33 subjects with normal visual acuity: 6/7.5 or better; 18 subjects with reduced visual acuity: 6/9 to 6/30). Near and intermediate visual acuity of one eye from each subject was measured with an automated tablet-computer system (M&S Technologies, Inc.) and Precision Vision paper chart in a random sequence. Subjects were retested one week later. Repeatability was evaluated using the 95 per cent limits of agreement (LoA) between the two visits.

RESULTS

Average difference between automated-ETDRS near visual acuity and near visual acuity by paper chart was 0.02 ± 0.10 logMAR (p > 0.05). Agreement of near visual acuity between automated-ETDRS and paper chart was good, with 95 per cent LoA of ±0.19 logMAR. Furthermore, automated-ETDRS near visual acuity showed good repeatability (95 per cent LoA of ±0.20). Mean difference between automated-ETDRS intermediate visual acuity and intermediate visual acuity by paper chart was 0.02 ± 0.10 logMAR (p > 0.05). Agreement of intermediate visual acuity between automated-ETDRS and paper chart was good, with 95 per cent LoA of ±0.20 logMAR. In addition, automated-ETDRS intermediate visual acuity had good repeatability (95 per cent LoA of ±0.16).

CONCLUSION

Automated-ETDRS near and intermediate visual acuity measurement showed good repeatability and agreement with the gold standard chart-based visual acuity measurement. The findings of this study indicate the automated visual acuity measurement system may have potential for use in both patient care and clinical trials.

Comparison of endpoint of subjective cycloplegic refraction with artificial aperture and post-mydriatic test among adults with refractive error

PURPOSE

There is a need to understand the requirement for the post-mydriatic test (PMT) among adults for the final prescription of spectacles as this test increases the cost of eye care and causes inconvenience to the patient because of the additional visit to an eye care practitioner. We aim to compare the cycloplegic subjective refraction using apertures of various sizes and PMT in an adult population.

METHODS

This prospective crossover study was conducted under standard settings in an eye clinic. Adult individuals between 18 and 35 years of with emmetropia and various degrees of ametropia participated in this study. Individuals with known ocular pathology were excluded. Non-cycloplegic objective refraction was performed followed by subjective refraction. Cycloplegic objective refraction was performed followed by subjective refraction with custom designed artificial apertures. After a washout period of cycloplegic, PMT was performed. The distribution of data was tested using the Kolmogorov-Smirnov test. Depending on the distribution of the data, either parametric or nonparametric test was done.

RESULTS

Fifty-nine eyes of thirty individuals with a mean (±SD) age of 23(±4) years with a male: female ratio of 1:4 participated in this study. A comparison of measures of PMT and subjective refraction with 2, 3, 4, 5, and 6 mm aperture under cycloplegic effect using the Friedman test rendered a Chi square value (df = 5) of 1.92 which was not statistically different (P = 0.86).

CONCLUSION

Performing subjective refraction with an appropriate spherical and cylindrical endpoint under cycloplegic effect with appropriate aperture overcomes the necessity of PMT.

Binocular cross-correlation analyses of the effects of high-order aberrations on the stereoacuity of eyes with keratoconus

Stereoacuity losses are induced by increased magnitudes and interocular differences in high-order aberrations (HOAs). This study used keratoconus as a model to investigate the impact of HOAs on disparity processing and stereoacuity. HOAs and stereoacuity were quantified in subjects with keratoconus (n = 21) with HOAs uncorrected (wearing spectacles) or minimized (wearing rigid gas-permeable contact lenses) and in control subjects without keratoconus (n = 5) for 6-mm pupil diameters. Disparity signal quality was estimated using metrics derived from binocular cross-correlation functions of stereo pairs convolved with point-spread functions from these HOAs. Metrics computed for all subjects were compared with stereoacuities. The effects of contrast losses and phase shifts on disparity signal quality were studied independently by manipulating the amplitude and phase components of optical transfer functions. The magnitudes, orientations, interocular relationships in magnitude, and shape of the point-spread function affected the cross-correlation metrics that determine disparity signal quality. Stereoacuity covaries strongly with cross-correlation metrics and moderately with image-quality metrics. Both phase distortions and contrast losses due to HOAs significantly influence computations of binocular disparity. HOA-induced stereoacuity reductions are attributable to disparity blur and noise from image properties that reduce the height and kurtosis of the peak stimulus disparity match of the cross-correlation. Phase distortions and contrast losses due to HOAs are both partly responsible for the greater stereoacuity losses seen with spectacles compared to rigid gas-permeable contact lenses in keratoconus.

Image Quality Metric Derived Refractions Predicted to Improve Visual Acuity Beyond Habitual Refraction for Patients With Down Syndrome

Purpose

To determine which optimized image quality metric (IQM) refractions provide the best predicted visual acuity (VA).

Methods

Autorefraction (AR), habitual refraction (spectacles, n = 23; unaided, n = 7), and dilated wavefront error (WFE) were obtained from 30 subjects with Down syndrome (DS; mean age, 30 years; range, 18–50). For each eye, the resultant metric value for 16 IQMs was calculated after >25000 sphero-cylindrical combinations of refraction were added to the measured WFE to generate residual WFE. The single refraction corresponding to each of the 16 optimized IQMs per eye was selected and used to generate acuity charts. Charts also were created for AR, habitual refraction, and a theoretical zeroing of all lower-order aberrations, and grouped into 10 sets with a clear chart in each set. Dilated controls (five observers per set) read each chart until five letters were missed on a high contrast monitor through a unit magnification telescope with a 3 mm pupil aperture. Average letters lost for the five observers for each chart was used to rank the IQMs for each DS eye.

Results

Average acuity for the best performing refraction for all DS eyes was within five letters (0.11 ± 0.05 logMAR) of the clear chart acuity. Optimized IQM refractions had ∼3.5 lines mean improvement from the habitual refraction (0.37 ± 0.22 logMAR, P < 0.001). Three metrics (Visual Strehl Ratio [VSX], VSX computed in frequency domain [VSMTF], and standard deviation of intensity values [STD]) identified refractions that were ranked first, or within 0.09 logMAR of first, in >98% of the eyes.

Conclusions

Optimized IQM refraction is predicted to improve VA in DS eyes based on control observers reading simulated charts.

Translational Relevance

Refractions identified through optimization of IQM may bypass some of the challenges of current refraction techniques for patients with DS. The optimized refractions are predicted to provide better VA compared to their habitual correction.

Normative best-corrected values of the visual image quality metric VSX as a function of age and pupil size

The visual image quality metric the visual Strehl ratio (VSX) combines a comprehensive description of the optics of an eye (wavefront error) with an estimate of the photopic neural processing of the visual system, and has been shown to be predictive of subjective best focus and well correlated with change in visual performance. Best-corrected visual image quality was determined for 146 eyes, and the quantitative relation of VSX, age, and pupil size is presented, including 95% confidence interval norms for age groups between 20 and 80 years and pupil diameters from 3 to 7 mm. These norms were validated using an independently collected population of wavefront error measurements. The best visual image quality was found in young eyes at smaller pupil sizes. Increasing pupil size caused a more rapid decrease in VSX than increasing age. These objectively determined benchmarks represent the best theoretical levels of visual image quality achievable with a sphere, cylinder, and axis correction in normal eyes and can be used to evaluate both traditional and wavefront-guided optical corrections provided by refractive surgery, contact lenses, and spectacles.

Blur Unblurred-A Mini Tutorial

Optical blur from defocus is quite frequently considered as equivalent to low-pass filtering. Yet that belief, although not entirely wrong, is inaccurate. Here, we wish to disentangle the concepts of dioptric blur, caused by myopia or mis-accommodation, from blur due to low-pass filtering when convolving with a Gaussian kernel. Perhaps surprisingly-if well known in optometry-the representation of a blur kernel (or point-spread function) for dioptric blur is, to a good approximation and disregarding diffraction, simply a cylinder. Its projection onto the retina is classically referred to as a blur circle, the diameter of which can easily be deduced from a light-ray model. We further give the derivation of the relationship between the blur-disk's diameter and the extent of blur in diopters, as well as the diameter's relation to the near or far point, and finally its relationship to visual acuity.

Repeatability of Monocular Acuity Testing in Adults with and without Down Syndrome

PURPOSE

Individuals with Down syndrome may experience greater difficulty reliably performing visual acuity (VA) tests because of intellectual disability and limitations in visual quality. This study evaluated the repeatability of acuity (Bailey-Lovie [BL] and HOTV) in subjects with and without Down syndrome.

METHODS

High-contrast VA was measured in both eyes of 30 subjects with Down syndrome (mean, 30 years; range, 18 to 50 years) and 24 control subjects without Down syndrome (mean, 29 years; range, 18 to 50 years). In the Down syndrome group, 23 subjects performed BL, and 7 subjects performed HOTV. All control subjects performed both BL and HOTV, but for HOTV analysis, only seven age-matched control subjects were included. For each eye, subjects performed VA three times on different charts (computer controlled, single-line display) until five total letters were missed on each chart. A repeated-measure ANOVA was used to compare the acuity measures between groups.

RESULTS

The average logMAR VA for subjects with Down syndrome was approximately six lines worse than the control subjects (BL: Down syndrome = right eye: 0.51 ± 0.16, left eye: 0.53 ± 0.18; control = right eye: -0.06 ± 0.06, left eye: -0.06 ± 0.08, P < .0001; HOTV: Down syndrome = right eye: 0.47 ± 0.19, left eye: 0.46 ± 0.16; control: right eye = -0.11 ± 0.09, left eye: -0.07 ± 0.07, P < .001). Bailey-Lovie VA repeatability (1.96 * Sw * √2) was 0.13 logMAR (6.5 letters) for Down syndrome and 0.09 logMAR (4.5 letters) for control subjects. HOTV VA repeatability was 0.16 logMAR (eight letters) for both Down syndrome and control subjects.

CONCLUSIONS

Despite poorer acuity in individuals with Down syndrome, repeatability of VA measurements was comparable to control subjects for both BL and HOTV techniques.

Interaction of aberrations, diffraction, and quantal fluctuations determine the impact of pupil size on visual quality

Our purpose is to develop a computational approach that jointly assesses the impact of stimulus luminance and pupil size on visual quality. We compared traditional optical measures of image quality and those that incorporate the impact of retinal illuminance dependent neural contrast sensitivity. Visually weighted image quality was calculated for a presbyopic model eye with representative levels of chromatic and monochromatic aberrations as pupil diameter was varied from 7 to 1 mm, stimulus luminance varied from 2000 to 0.1  cd/m², and defocus varied from 0 to -2 diopters. The model included the effects of quantal fluctuations on neural contrast sensitivity. We tested the model's predictions for five cycles per degree gratings by measuring contrast sensitivity at 5  cyc/deg. Unlike the traditional Strehl ratio and the visually weighted area under the modulation transfer function, the visual Strehl ratio derived from the optical transfer function was able to capture the combined impact of optics and quantal noise on visual quality. In a well-focused eye, provided retinal illuminance is held constant as pupil size varies, visual image quality scales approximately as the square root of illuminance because of quantum fluctuations, but optimum pupil size is essentially independent of retinal illuminance and quantum fluctuations. Conversely, when stimulus luminance is held constant (and therefore illuminance varies with pupil size), optimum pupil size increases as luminance decreases, thereby compensating partially for increased quantum fluctuations. However, in the presence of -1 and -2 diopters of defocus and at high photopic levels where Weber's law operates, optical aberrations and diffraction dominate image quality and pupil optimization. Similar behavior was observed in human observers viewing sinusoidal gratings. Optimum pupil size increases as stimulus luminance drops for the well-focused eye, and the benefits of small pupils for improving defocused image quality remain throughout the photopic and mesopic ranges. However, restricting pupils to <2  mm will cause significant reductions in the best focus vision at low photopic and mesopic luminances.

Is an objective refraction optimised using the visual Strehl ratio better than a subjective refraction?

PURPOSE

To prospectively examine whether using the visual image quality metric, visual Strehl (VSX), to optimise objective refraction from wavefront error measurements can provide equivalent or better visual performance than subjective refraction and which refraction is preferred in free viewing.

METHODS

Subjective refractions and wavefront aberrations were measured on 40 visually-normal eyes of 20 subjects, through natural and dilated pupils. For each eye a sphere, cylinder, and axis prescription was also objectively determined that optimised visual image quality (VSX) for the measured wavefront error. High contrast (HC) and low contrast (LC) logMAR visual acuity (VA) and short-term monocular distance vision preference were recorded and compared between the VSX-objective and subjective prescriptions both undilated and dilated.

RESULTS

For 36 myopic eyes, clinically equivalent (and not statistically different) HC VA was provided with both the objective and subjective refractions (undilated mean ± S.D. was -0.06 ± 0.04 with both refractions; dilated was -0.05 ± 0.04 with the objective, and -0.05 ± 0.05 with the subjective refraction). LC logMAR VA provided by the objective refraction was also clinically equivalent and not statistically different to that provided by the subjective refraction through both natural and dilated pupils for myopic eyes. In free viewing the objective prescription was preferred over the subjective by 72% of myopic eyes when not dilated. For four habitually undercorrected high hyperopic eyes, the VSX-objective refraction was more positive in spherical power and VA poorer than with the subjective refraction.

CONCLUSIONS

A method of simultaneously optimising sphere, cylinder, and axis from wavefront error measurements, using the visual image quality metric VSX, is described. In myopic subjects, visual performance, as measured by HC and LC VA, with this VSX-objective refraction was found equivalent to that provided by subjective refraction, and was typically preferred over subjective refraction. Subjective refraction was preferred by habitually undercorrected hyperopic eyes.

Vision science and adaptive optics, the state of the field

Adaptive optics is a relatively new field, yet it is spreading rapidly and allows new questions to be asked about how the visual system is organized. The editors of this feature issue have posed a series of question to scientists involved in using adaptive optics in vision science. The questions are focused on three main areas. In the first we investigate the use of adaptive optics for psychophysical measurements of visual system function and for improving the optics of the eye. In the second, we look at the applications and impact of adaptive optics on retinal imaging and its promise for basic and applied research. In the third, we explore how adaptive optics is being used to improve our understanding of the neurophysiology of the visual system.

A Comparison of Three Methods to Increase Scleral Contact Lens On-Eye Stability

PURPOSE

To quantify on-eye rotational and translational stability of three scleral contact lens stabilization methods and to model the variation in visual acuity when these movements occur in a wavefront-guided correction for highly aberrated eyes.

METHODS

Three lens stabilization methods were integrated into the posterior periphery of a scleral contact lens designed at the Visual Optics Institute. For comparison, a lens with no stabilization method (rotationally symmetric posterior periphery) was designed. The lenses were manufactured and lens movements were quantified on 8 eyes as the average SD of the observed translations and rotations over 60 min of wear. In addition, the predicted changes in acuity for five eyes with keratoconus wearing a simulated wavefront-guided correction (full correction through the fifth order) were modeled using the measured movements.

RESULTS

For each lens design, no significant differences in the translation and rotation were found between left and right eyes, and lenses behaved similarly on all subjects. All three designs with peripheral stability modifications exhibited no statistically significant differences in translation and rotation distributions of lens movement and were statistically more stable than the spherical lens in rotation. When the measured movements were used to simulate variation in visual performance, the 3 lenses with integrated stability methods showed a predicted average loss in acuity from the perfectly aligned condition of approximately 0.06 logMAR (3 letters), compared with the loss of over 0.14 logMAR (7 letters) for the lens with the spherical periphery.

CONCLUSION

All three stabilization methods provided superior stability, as compared with the spherical lens design. Simulations of the optical and visual performance suggest that all three stabilization designs can provide desirable results when used in the delivery of a wavefront-guided correction for a highly aberrated eye.

Preclinical metrics to predict through-focus visual acuity for pseudophakic patients

This study compares the clinical through-focus visual acuity (VA) in patients implanted with different intraocular lens (IOL) to optical bench testing of the same IOLs to evaluate the suitability of optical metrics of predicting clinical VA. Modulation transfer function and phase transfer function for different spatial frequencies and US Air Force pictures were measured using an optical bench for two monofocal IOLs, three multifocal IOLs and an extended range of vision IOL. Four preclinical metrics were calculated and compared to the clinical through-focus VA collected in three different clinical studies (243 patients in total). All metrics were well correlated (R(2)≥0.89) with clinical data and may be suitable for predicting through-focus VA in pseudophakic eyes.

Determinants and standardization of mesopic visual acuity

PURPOSE

It is well established that visual acuity (VA) decreases with luminance but the specific factors that are responsible remain unclear. The purpose of this study was to quantify the contributions of accommodative error, pupil size, and higher-order aberrations to the decrease in VA when transitioning from photopic to mesopic light levels. Additionally, repeatability of VA at photopic and mesopic levels was measured to derive a luminance recommendation for mesopic VA testing, which can provide the standardization needed for future translational clinical studies and the widespread adoption of mesopic VA testing.

METHODS

Monocular VAs were assessed at one photopic and three mesopic light levels: 94, 3, 0.75, and 0.38 cd/m, with an E-ETDRS testing system in 43 normal subjects. Accommodative error, pupil size, and higher-order aberrations were obtained. Twenty subjects were retested at another visit to assess VA repeatability.

RESULTS

The mean (±SD) logMAR (logarithm of the minimum angle of resolution) VA was -0.08 (±0.06) at 94 cd/m, 0.05 (±0.07) at 3 cd/m, 0.16 (±0.06) at 0.75 cd/m, and 0.27 (±0.09) at 0.38 cd/m. Light level and accommodative error were significantly associated with VA, and light level explained 75% of the variance. The mean differences in VAs between two visits were not significantly different from zero (p > 0.05). The coefficients of repeatability for 94, 3, 0.75, and 0.38 cd/m were 0.08, 0.11, 0.14, and 0.14 logMAR, respectively.

CONCLUSIONS

Light level, among all other factors studied, contributes the most to the reduction in VA tested under mesopic conditions. Testing mesopic VA at 0.75 cd/m, or about 2.0 log units less than photopic testing, provides a significant and repeatable decrease in VA similar to standardized low-contrast VA testing, and therefore this level is recommended.

Wavefront-guided scleral lens correction in keratoconus

PURPOSE

To examine the performance of state-of-the-art wavefront-guided scleral contact lenses (wfgSCLs) on a sample of keratoconic eyes, with emphasis on performance quantified with visual quality metrics, and to provide a detailed discussion of the process used to design, manufacture, and evaluate wfgSCLs.

METHODS

Fourteen eyes of seven subjects with keratoconus were enrolled and a wfgSCL was designed for each eye. High-contrast visual acuity and visual quality metrics were used to assess the on-eye performance of the lenses.

RESULTS

The wfgSCL provided statistically lower levels of both lower-order root mean square (RMS) (p < 0.001) and higher-order RMS (HORMS) (p < 0.02) than an intermediate spherical equivalent scleral contact lens. The wfgSCL provided lower levels of lower-order RMS than a normal group of well-corrected observers (p << 0.001). However, the wfgSCL does not provide less HORMS than the normal group (p = 0.41). Of the 14 eyes studied, 10 successfully reached the exit criteria, achieving residual HORMS wavefront error less than or within 1 SD of the levels experienced by normal, age-matched subjects. In addition, measures of visual image quality (logVSX, logNS, and logLIB) for the 10 eyes were well distributed within the range of values seen in normal eyes. However, visual performance as measured by high-contrast acuity did not reach normal, age-matched levels, which is in agreement with prior results associated with the acute application of wavefront correction to keratoconic eyes.

CONCLUSIONS

Wavefront-guided scleral contact lenses are capable of optically compensating for the deleterious effects of higher-order aberration concomitant with the disease and can provide visual image quality equivalent to that seen in normal eyes. Longer-duration studies are needed to assess whether the visual system of the highly aberrated eye wearing a wfgSCL is capable of producing visual performance levels typical of the normal population.

Retinal image quality during accommodation

PURPOSE

We asked if retinal image quality is maximum during accommodation, or sub-optimal due to accommodative error, when subjects perform an acuity task.

METHODS

Subjects viewed a monochromatic (552 nm), high-contrast letter target placed at various viewing distances. Wavefront aberrations of the accommodating eye were measured near the endpoint of an acuity staircase paradigm. Refractive state, defined as the optimum target vergence for maximising retinal image quality, was computed by through-focus wavefront analysis to find the power of the virtual correcting lens that maximizes visual Strehl ratio.

RESULTS

Despite changes in ocular aberrations and pupil size during binocular viewing, retinal image quality and visual acuity typically remain high for all target vergences. When accommodative errors lead to sub-optimal retinal image quality, acuity and measured image quality both decline. However, the effect of accommodation errors of on visual acuity are mitigated by pupillary constriction associated with accommodation and binocular convergence and also to binocular summation of dissimilar retinal image blur. Under monocular viewing conditions some subjects displayed significant accommodative lag that reduced visual performance, an effect that was exacerbated by pharmacological dilation of the pupil.

CONCLUSIONS

Spurious measurement of accommodative error can be avoided when the image quality metric used to determine refractive state is compatible with the focusing criteria used by the visual system to control accommodation. Real focusing errors of the accommodating eye do not necessarily produce a reliably measurable loss of image quality or clinically significant loss of visual performance, probably because of increased depth-of-focus due to pupil constriction. When retinal image quality is close to maximum achievable (given the eye's higher-order aberrations), acuity is also near maximum. A combination of accommodative lag, reduced image quality, and reduced visual function may be a useful sign for diagnosing functionally-significant accommodative errors indicating the need for therapeutic intervention.

Registration tolerance of a custom correction to maintain visual acuity

PURPOSE

To present a predictive model of the registration tolerance for wavefront-guided correction to maintain acuity within fixed limits and demonstrate the potential utility using two typical keratoconic eyes.

METHODS

Change in log visual Strehl was plotted as a function of translation error for a series of rotations of a wavefront-guided correction. Contour lines were added at Δlog visual Strehl levels predicted to induce one- and two-line losses of logMAR visual acuity. The model was validated by regressing measured acuity loss from subjects viewing acuity charts that were degraded by the residual wavefront error resulting from the movement of wavefront-guided correction against the model's predicted acuity.

RESULTS

The model's predicted change in acuity can be substituted for measured change in acuity (R² = 0.91) within measurement error (±0.1 logMAR). Translation and/or rotation of a wavefront-guided correction induced asymmetric optical tolerance to movement. Induced errors depended on the wavefront error being corrected, the wavefront-guided correction design, and the amount of registration error.

CONCLUSIONS

Change in log visual Strehl can be used to determine the registration tolerance necessary to keep the variation in acuity within user-defined limits. This tolerance is unique for each wavefront error and wavefront-guided correction design.

Change in visual acuity is well correlated with change in image-quality metrics for both normal and keratoconic wavefront errors

We determined the degree to which change in visual acuity (VA) correlates with change in optical quality using image-quality (IQ) metrics for both normal and keratoconic wavefront errors (WFEs). VA was recorded for five normal subjects reading simulated, logMAR acuity charts generated from the scaled WFEs of 15 normal and seven keratoconic eyes. We examined the correlations over a large range of acuity loss (up to 11 lines) and a smaller, more clinically relevant range (up to four lines). Nine IQ metrics were well correlated for both ranges. Over the smaller range of primary interest, eight were also accurate and precise in estimating the variations in logMAR acuity in both normal and keratoconic WFEs. The accuracy for these eight best metrics in estimating the mean change in logMAR acuity ranged between ±0.0065 to ±0.017 logMAR (all less than one letter), and the precision ranged between ±0.10 to ±0.14 logMAR (all less than seven letters).

Accounting for the phase, spatial frequency and orientation demands of the task improves metrics based on the visual Strehl ratio

Advances in ophthalmic instrumentation have allowed high order aberrations to be measured in vivo. These measurements describe the distortions to a plane wavefront entering the eye, but not the effect they have on visual performance. One metric for predicting visual performance from a wavefront measurement uses the visual Strehl ratio, calculated in the optical transfer function (OTF) domain (VSOTF) (Thibos et al., 2004). We considered how well such a metric captures empirical measurements of the effects of defocus, coma and secondary astigmatism on letter identification and on reading. We show that predictions using the visual Strehl ratio can be significantly improved by weighting the OTF by the spatial frequency band that mediates letter identification and further improved by considering the orientation of phase and contrast changes imposed by the aberration. We additionally showed that these altered metrics compare well to a cross-correlation-based metric. We suggest a version of the visual Strehl ratio, VScombined, that incorporates primarily those phase disruptions and contrast changes that have been shown independently to affect object recognition processes. This metric compared well to VSOTF for letter identification and was the best predictor of reading performance, having a higher correlation with the data than either the VSOTF or cross-correlation-based metric.

Predicting through-focus visual acuity with the eye's natural aberrations

PURPOSE

To develop a predictive optical modeling process that utilizes individual computer eye models along with a novel through-focus image quality metric.

METHODS

Individual eye models were implemented in optical design software (Zemax, Bellevue, WA) based on evaluation of ocular aberrations, pupil diameter, visual acuity, and accommodative response of 90 subjects (180 eyes; 24-63 years of age). Monocular high-contrast minimum angle of resolution (logMAR) acuity was assessed at 6 m, 2 m, 1 m, 67 cm, 50 cm, 40 cm, 33 cm, 28 cm, and 25 cm. While the subject fixated on the lowest readable line of acuity, total ocular aberrations and pupil diameter were measured three times each using the Complete Ophthalmic Analysis System (COAS HD VR) at each distance. A subset of 64 mature presbyopic eyes was used to predict the clinical logMAR acuity performance of five novel multifocal contact lens designs. To validate predictability of the design process, designs were manufactured and tested clinically on a population of 24 mature presbyopes (having at least +1.50 D spectacle add at 40 cm). Seven object distances were used in the validation study (6 m, 2 m, 1 m, 67 cm, 50 cm, 40 cm, and 25 cm) to measure monocular high-contrast logMAR acuity.

RESULTS

Baseline clinical through-focus logMAR was shown to correlate highly (R² = 0.85) with predicted logMAR from individual eye models. At all object distances, each of the five multifocal lenses showed less than one line difference, on average, between predicted and clinical normalized logMAR acuity. Correlation showed R² between 0.90 and 0.97 for all multifocal designs.

CONCLUSIONS

Computer-based models that account for patient's aberrations, pupil diameter changes, and accommodative amplitude can be used to predict the performance of contact lens designs. With this high correlation (R² ≥ 0.90) and high level of predictability, more design options can be explored in the computer to optimize performance before a lens is manufactured and tested clinically.

Optimizing wavefront-guided corrections for highly aberrated eyes in the presence of registration uncertainty

Dynamic registration uncertainty of a wavefront-guided correction with respect to underlying wavefront error (WFE) inevitably decreases retinal image quality. A partial correction may improve average retinal image quality and visual acuity in the presence of registration uncertainties. The purpose of this paper is to (a) develop an algorithm to optimize wavefront-guided correction that improves visual acuity given registration uncertainty and (b) test the hypothesis that these corrections provide improved visual performance in the presence of these uncertainties as compared to a full-magnitude correction or a correction by Guirao, Cox, and Williams (2002). A stochastic parallel gradient descent (SPGD) algorithm was used to optimize the partial-magnitude correction for three keratoconic eyes based on measured scleral contact lens movement. Given its high correlation with logMAR acuity, the retinal image quality metric log visual Strehl was used as a predictor of visual acuity. Predicted values of visual acuity with the optimized corrections were validated by regressing measured acuity loss against predicted loss. Measured loss was obtained from normal subjects viewing acuity charts that were degraded by the residual aberrations generated by the movement of the full-magnitude correction, the correction by Guirao, and optimized SPGD correction. Partial-magnitude corrections optimized with an SPGD algorithm provide at least one line improvement of average visual acuity over the full magnitude and the correction by Guirao given the registration uncertainty. This study demonstrates that it is possible to improve the average visual acuity by optimizing wavefront-guided correction in the presence of registration uncertainty.