The role of sensory ocular dominance on through-focus visual performance in monovision presbyopia corrections

Outcomes of Corneal Compound Myopic Astigmatism with Presbyopia by Zeiss PRESBYOND® Laser Blended Vision LASIK Using Default CRS-Master® Target Refractions for Reduced Anisometropia

Background/Objectives: Presbyopia, a common age-related refractive error, affects over a billion people globally and significantly impacts daily life. Methods: This retrospective study analyzed 288 eyes of 144 patients undergoing LBV PRESBYOND® treatment for myopic presbyopia with astigmatism, aiming to evaluate precision, efficacy, safety, and stability over six months. Results: Key findings include high efficacy, with 99% of distance-eyes achieving uncorrected distance visual acuity (UDVA) of 20/25 or better, and 85% of near-eyes achieving UDVA of 20/32 or better. The results show excellent refractive outcomes, with 99% of long-sighted eyes and 97% of near-sighted eyes having a postoperative spherical equivalent within ±1.00 D. Safety was demonstrated by no loss of two or more Snellen lines after treatment, with 94% of patients maintaining corrected distance visual acuity (CDVA) before and after surgery. Conclusions: Overall, LBV PRESBYOND® proved effective, safe, and well tolerated for myopic presbyopia correction, offering satisfactory visual outcomes and potential spectacle independence for various distances. This study underscores the importance of individualized treatment based on patient age, highlighting the positive impact of binocular summation on visual function. This study contributes to the growing body of evidence supporting LBV PRESBYOND® as a viable option for addressing presbyopic myopia, offering insights into its efficacy and safety profile. Further research could explore postoperative stereopsis and long-term outcomes to enhance understanding and refine treatment protocols.

BCLA CLEAR Presbyopia: Evaluation and diagnosis

It is important to be able to measure the range of clear focus in clinical practice to advise on presbyopia correction techniques and to optimise the correction power. Both subjective and objective techniques are necessary: subjective techniques (such as patient reported outcome questionnaires and defocus curves) assess the impact of presbyopia on a patient and how the combination of residual objective accommodation and their natural DoF work for them; objective techniques (such as autorefraction, corneal topography and lens imaging) allow the clinician to understand how well a technique is working optically and whether it is the right choice or how adjustments can be made to optimise performance. Techniques to assess visual performance and adverse effects must be carefully conducted to gain a reliable end-point, considering the target size, contrast and illumination. Objective techniques are generally more reliable, can help to explain unexpected subjective results and imaging can be a powerful communication tool with patients. A clear diagnosis, excluding factors such as binocular vision issues or digital eye strain that can also cause similar symptoms, is critical for the patient to understand and adapt to presbyopia. Some corrective options are more permanent, such as implanted inlays / intraocular lenses or laser refractive surgery, so the optics can be trialled with contact lenses in advance (including differences between the eyes) to better communicate with the patient how the optics will work for them so they can make an informed choice.

Exploring the Effect of Preoperative Stereopsis on Visual Outcomes in Hyperopic Presbyopes Treated with PresbyOND® Laser Blended Vision Micro-Monovision

We investigated the effects of Laser Blended Vision (LBV) on binocular summation and stereopsis in the treatment of presbyopia and hyperopia. Using a unidirectional, retrospective longitudinal design, data from 318 patients who underwent the Zeiss PresbyOND® LBV surgical procedure at Tecnolaser Clinic Vision Ophthalmology Center in Seville, Spain, were analyzed. The findings indicate that stereopsis quality significantly influenced short-term post-operative visual outcomes in measures like Uncorrected Distance and Near Visual Acuity (UDVA and UNVA). However, the impact of stereopsis on visual outcomes appeared to diminish over time, becoming statistically insignificant at the 12-month post-operative mark. The study suggests that while stereopsis is a crucial factor in the short term, its influence on visual outcomes tends to wane in the long-term postoperative period. Future studies are essential to elucidate the enduring clinical ramifications of these observations.

Binocular imbalance in patients after implantable collamer lens V4c implantation or femtosecond laser-assisted in situ keratomileusis for myopia with presbyopia

Aim

To investigate the long-term safety, efficacy, and binocular balance of monovision surgery using Implantable Collamer Lens (ICL) V4c implantation and Femtosecond Laser-Assisted in situ Keratomileusis (FS-LASIK) for the treatment of myopic patients with presbyopia.

Methods

This case series study involved 90 eyes of 45 patients (male/female = 19/26; average age:46.27 ± 5.54 years; average follow-up time:48.73 ± 14.65 months) who underwent the aforementioned surgery to treat myopic presbyopes. Data on manifest refraction, corrected distance visual acuity, dominant eye, presbyopic addition, intraocular pressure, and anterior segment biometric parameters were collected. The visual outcomes and binocular balance at 0.4 m, 0.8 m, and 5 m were documented.

Results

The safety index for the ICL V4c and FS-LASIK groups were 1.24 ± 0.27 and 1.04 ± 0.20 (p = 0.125), respectively. Binocular visual acuity (logmar) for 0.4 m, 0.8 m, and 5 m were -0.03 ± 0.05, -0.03 ± 0.02, and 0.10 ± 0.03 for the ICL V4c group, and -0.02 ± 0.09, -0.01 ± 0.02, and 0.06 ± 0.04 for the FS-LASIK group, respectively. The proportions of all patients with imbalanced vision at 0.4 m, 0.8 m, and 5 m distances were 68.89, 71.11, and 82.22%, respectively (all p > 0.05 between the two groups). There were significant differences in refraction between the balanced and imbalanced vision for patients at 0.4 m distance (for non-dominant eye spherical equivalent [SE]: -1.14 ± 0.17D and -1.47 ± 0.13D, p < 0.001), 0.8 m distance (for preoperative ADD:0.90 ± 0.17D and 1.05 ± 0.11D, p = 0.041), and 5 m distance (for non-dominant SE: -1.13 ± 0.33D and -1.42 ± 0.11D, p < 0.001).

Conclusion

ICL V4c implantation and FS-LASIK monovision treatment demonstrated good long-term safety and binocular visual acuity at various distances. After the procedure, the imbalanced patients' vision is primarily related to the age-related presbyopia and anisometropia progression caused by the monovision design.

Monovision Correction Preference and Eye Dominance Measurements

Purpose

To propose new methods for eye selection in presbyopic monovision corrections.

Methods

Twenty subjects with presbyopia performed two standard methods of binary eye dominance identification (sensory with +1.50 diopters [D ]and +0.50 D and sighting with "hole-in-the-card") and two psychophysical methods of perceived visual quality: (1) the Preferential test, 26 natural images were judged with the near addition in one eye or in the other in a 2-interval forced-choice task, and the Eye Dominance Strength (EDS) defined as the proportion of trials where one monovision is preferred over the other; (2) the Multifocal Acceptance Score (MAS-2EV) test, the perceived quality of a natural images set (for 2 luminance levels and distances) was scored and EDS defined as the score difference between monovision in one eye or the other. Left-eye and right-eye dominance are indicated with negative and positive values, respectively. Tests were performed using a Simultaneous Vision Simulator, which allows rapid changes between corrections.

Results

Standard sensory and sighting dominances matched in only 55% of subjects. The Preferential EDS (ranging from -0.7 to +0.9) and MAS-2EV EDS (ranging from -0.6 to +0.4) were highly correlated. Selecting the eye for far in monovision with the MAS-2EV, sensory, or sighting tests would have resulted in 79%, 64%, and 43% success considering the Preferential test as the gold standard.

Conclusions

Tests based on perceptual preference allow selection of the preferred monovision correction and measurement of dominance strength.

Translational Relevance

The binocular visual simulator allows efficient implementation of eye preference tests for monovision in clinical use.

The Perceptual Magic of Binocular Rivalry

Binocular rivalry (BR) refers to the spontaneous, unpredictable fluctuations in visual awareness provoked by dissimilar stimulation of the two eyes. Reports of the phenomenon date back several centuries, but interest in BR has exploded in recent years as researchers in diverse disciplines—psychology, neuroscience, medicine, philosophy—have found reasons to study it. New ideas about BR have emerged, sparking controversies about its neural bases, which may be resolved thanks to new methodological developments. This essay provides a synopsis of some key empirically determined aspects of BR as well as an overview of theoretical developments in this field. Work published during the past decade or so is emphasized (and explicitly referenced); earlier key findings are mentioned and referenced in the annotated bibliography included in the Supplemental Material.

Visual Performance and Optical Quality after Implantation of a New Generation Monofocal Intraocular Lens

Purpose

To evaluate the performance of two intraocular lenses (IOLs). The new monofocal IOL using a higher-order aspheric optic (Tecnis Eyhance ICB00) was compared to a standard monofocal IOL (Tecnis monofocal ZCB00) of the identical platform and material.

Methods

The medical records of the patients who had undergone cataract surgery with implantation of either the ZCB00 or the ICB00 in the dominant eye from March 2020 to August 2020 and with available data from the 3-month visit were reviewed. Subjects with ocular comorbidities or corneal astigmatism greater than 1.00 diopters were excluded. The uncorrected near, intermediate, distance visual acuity and corrected distance visual acuity were the main outcome measures. Optical quality parameters measured using an optical quality analysis system, clinical records including age, sex, laterality, ocular dominance, and information related to refractory errors was also collected. Parameters related to the refractory errors were all uniformly based on the Barrett Universal II formula.

Results

Of the 197 recruited patients, 111 and 86 were implanted with the ICB00 and ZCB00, respectively. No statistically significant differences in baseline parameters were observed between the two groups. While no statistically significant differences in distance visual acuity or optical quality were found between the two groups, compared to the ZCB00 group, the ICB00 group showed significantly higher intermediate visual acuity (p < 0.001) and near visual acuity (p < 0.05) 3 months postoperatively.

Conclusions

ICB00 provided superior intermediate vision and comparable distance performance and photic phenomena compared to a standard monofocal IOL.

Cataract surgery in Kinshasa-Is there a place for "Monovision"?

OBJECTIVES

Monovision is a method of correcting presbyopia where one eye is focused for far and the other for near vision. It is a simple, cost-effective approach to overcome the loss of accommodation with age and to become spectacles independent.

METHODOLOGY

About 50 patients, where bilateral cataract extraction was indicated, were included in this study performed at the St. Joseph's Eye Hospital in Kinshasa (DR Congo). Small incision cataract surgery technique (SICS) was applied with the implantation of 6 mm PMMA lenses in the capsular bag. IOL refractive power choice was made to achieve a post-operative refraction of -0.5 dpt for the eye selected for far vision. The second eye received an implant heading for a post-operative myopia of -1.5 dpt suitable for intermediated and near vision. According to the literature, monovision criteria have been regarded as fulfilled when (a) far vision was 0.5 (logMAR) or better and (b) near vision was P3 (0.40, Decimal 32 cm) or better. Spectacle dependence after bilateral cataract surgery heading for monovision was analysed using a dedicated questionnaire.

RESULTS

Out of all 50 patients 22 (44%) fulfilled the above defined criteria of monovision in terms of post-operative refraction and visual acuity. About 19 out of these 22 (86.3%) patients were happy without glasses. Two of them used bifocal spectacles, whereas the remaining patient refused spectacles. About 28 patients did not fulfill monovision criteria. Out of these 28 patients, however, 9 (32.1%) of them are happy without glasses.

CONCLUSION

In view of the described local circumstances aiming for monovision after bilateral cataract surgery is a suitable approach to optimise cataract surgical outcomes with no extra costs for surgery but considerable improvement of patient's visual performance in daily life.

Psychophysical Tests Do Not Identify Ocular Dominance Consistently

Classical sighting or sensory tests are used in clinical practice to identify the dominant eye. Several psychophysical tests were recently proposed to quantify the magnitude of dominance but whether their results agree was never investigated. We addressed this question for the two most common psychophysical tests: The perceived-phase test, which measures the cyclopean appearance of dichoptically presented sinusoids of different phase, and the coherence-threshold test, which measures interocular differences in motion perception when signal and noise stimuli are presented dichoptically. We also checked for agreement with three classical tests (Worth 4-dot, Randot suppression, and Bagolini lenses). Psychophysical tests were administered in their conventional form and also using more dependable psychophysical methods. The results showed weak correlations between psychophysical measures of strength of dominance with inconsistent identification of the dominant eye across tests: Agreement on left-eye dominance, right-eye dominance, or nondominance by both tests occurred only for 11 of 40 observers (27.5%); the remaining 29 observers were classified differently by each test, including 14 cases (35%) of opposite classification (left-eye dominance by one test and right-eye dominance by the other). Classical tests also yielded conflicting results that did not agree well with classification based on psychophysical tests. The results are discussed in the context of determination of ocular dominance for clinical decisions.

On Sensory Eye Dominance Revealed by Binocular Integrative and Binocular Competitive Stimuli

Purpose

Two core processes underlie 3-D binocular vision. The first, a binocular combination/summation process, integrates similar feature signals from the two eye channels to form a binocular representation. The second, a binocular inhibitory process, suppresses interocular conflicting signals or falsely matched binocular representations to establish single vision. Having an intrinsic interocular imbalance within one or both processes can cause sensory eye dominance (SED), related to imbalances of combination (SEDcombo) and/or inhibition (SEDinhibition). While much has recently been revealed about SEDcombo and SEDinhibition, the relationship between them is still unknown.

Methods

We measured observers' foveal SEDcombo and SEDinhibition, respectively, with a pair of dichoptic horizontal sine wave gratings with different phases and binocular rivalry stimulus with vertical and horizontal gratings. We then measured horizontal and vertical monocular contrast thresholds using sinusoidal grating stimuli, and stereo thresholds using random-dot stereograms.

Results

There exists a strong correlation between SEDcombo and SEDinhibition. An observer's interocular difference in contrast threshold was not always consistent with his/her SEDcombo and SEDinhihition, suggesting a partial binocular origin for the underlying imbalances. We also found stereo thresholds significantly increased with the magnitudes of SEDcombo, as well as with the magnitude of SEDinhibition.

Conclusions

Our findings suggest a common origin for interocular imbalance in the two different binocular processes and that both types of sensory eye dominance are significant factors in impeding stereopsis.

Does direction of walking impact binocular rivalry between competing patterns of optic flow?

When dissimilar monocular images are viewed simultaneously by the two eyes, stable binocular vision gives way to unstable vision characterized by alternations in dominance between the two images in a phenomenon called binocular rivalry. These alternations in perception reveal the existence of inhibitory interactions between neural representations associated with conflicting visual inputs. Binocular rivalry has been studied since the days of Wheatstone, but one recent strategy is to investigate its susceptibility to influences caused by one's own motor activity. This paper focused on the activity of walking, which produces an expected, characteristic direction of optic flow dependent upon the direction of one's walking. In a set of experiments, we employed virtual reality technology to present dichoptic stimuli to observers who walked forward, backward, or were sitting. Optic flow was presented to a given eye, and was sometimes congruent with the direction of walking, sometimes incongruent, and sometimes random, except when the participant was sitting. Our results indicate that, while walking had a reliable influence on rivalry dynamics, the predominance of congruent or incongruent motion did not.

Individual differences in sensory eye dominance reflected in the dynamics of binocular rivalry

Normal binocular vision emerges from the combination of neural signals arising within separate monocular pathways. It is natural to wonder whether both eyes contribute equally to the unified cyclopean impression we ordinarily experience. Binocular rivalry, which occurs when the inputs to the two eyes are markedly different, affords a useful means for quantifying the balance of influence exerted by the eyes (called sensory eye dominance, SED) and for relating that degree of balance to other aspects of binocular visual function. However, the precise ways in which binocular rivalry dynamics change when the eyes are unbalanced remain uncharted. Relying on widespread individual variability in the relative predominance of the two eyes as demonstrated in previous studies, we found that an observer's overall tendency to see one eye more than the other was driven both by differences in the relative duration and frequency of instances of that eye's perceptual dominance. Specifically, larger imbalances between the eyes were associated with longer and more frequent periods of exclusive dominance for the stronger eye. Increases in occurrences of dominant eye percepts were mediated in part by a tendency to experience "return transitions" to the predominant eye - that is, observers often experienced sequential exclusive percepts of the dominant eye's image with an intervening mixed percept. Together, these results indicate that the often-observed imbalances between the eyes during binocular rivalry reflect true differences in sensory processing, a finding that has implications for our understanding of the mechanisms underlying binocular vision in general.

Aspheric Micro-monovision LASIK in Correction of Presbyopia and Myopic Astigmatism: Early Clinical Outcomes in a Chinese Population

PURPOSE

To analyze early clinical outcomes of aspheric micro-monovision LASIK for correction of presbyopia and myopia with or without astigmatism.

METHODS

Prospective, non-comparative case series of 80 eyes of 40 patients with a mean age of 43.4 ± 4.9 years (range: 38 to 63 years) treated bilaterally using an aspheric micro-monovision protocol. The target refraction was plano for the distance eye and between -0.75 and -2.25 diopters (D) for the near eye. Visual acuity, ocular aberrations, contrast sensitivity, corneal topography, amplitude of accommodation, binocular sensorial function, and satisfaction score questionnaires were evaluated at 3 months after surgery.

RESULTS

Three months after surgery, the mean spherical equivalent (SE) refraction in the distance eye was -0.08 ± 0.27 D, whereas the attempted and achieved SE in the near eye were -1.41 ± 0.28 and -1.32 ± 0.35 D, respectively. Ninety-three percent of eyes were within ±0.50 D of target correction of SE. The uncorrected distance visual acuity (UDVA) after surgery was -0.10 ± 0.06 logMAR (20/15.5), 0.22 ± 0.12 logMAR (20/34), and -0.11 ± 0.06 logMAR (20/15), for distance eyes, near eyes, and binocularly, respectively. Ninety-five percent of patients achieved simultaneously uncorrected distance visual acuity 0.0 logMAR (20/20) or better and uncorrected near visual acuity J2 (20/25) or better. Stability was achieved from 1 week of follow-up. The overall satisfaction score for surgery was 92 ± 6.

CONCLUSIONS

The aspheric micro-monovision protocol provided a well-tolerated and effective means for treating myopic astigmatism and alleviating presbyopic symptoms simultaneously. [J Refract Surg. 2016;32(10):680-685.].

Binocular rivalry after right-hemisphere stroke: Effects of attention impairment on perceptual dominance patterns

Binocular rivalry is when perception fluctuates while the stimuli, consisting of different images presented to each eye, remain unchanged. The fluctuation rate and predominance ratio of these images are regarded as information source for understanding properties of consciousness and perception. We administered a binocular rivalry task to 26 right-hemisphere stroke patients and 26 healthy control participants, using stimuli such as simple Gabor anaglyphs. Each single Gabor image was of unequal spatial frequency compared to its counterpart, allowing assessment of the effect of relative spatial frequency on rivalry predominance. Results revealed that patients had significantly decreased alternation rate compared to healthy controls, with severity of patients' attention impairment predicting alternation rates. The patient group had higher predominance ratio for high compared to low relative spatial frequency stimuli consistent with the hypothesis that damage to the right hemisphere may disrupt processing of relatively low spatial frequencies. Degree of attention impairment also predicted the effect of relative spatial frequencies. Lastly, both groups showed increased predominance rates in the right eye compared to the left eye. This right eye dominance was more pronounced in patients than controls, suggesting that right hemisphere stroke may additionally affect eye predominance ratios.

Persistent Biases in Binocular Rivalry Dynamics within the Visual Field

Binocular rivalry is an important tool for measuring sensory eye dominance-the relative strength of sensory processing in an individual's left and right eye. By dichoptically presenting images that lack corresponding visual features, one can induce perceptual alternations and measure the relative visibility of each eye's image. Previous results indicate that observers demonstrate reliable preferences for several image features, and that these biases vary within the visual field. However, evidence about the persistence of these biases is mixed, with some suggesting they affect only the onset (i.e., first second) of rivalry, and others suggesting lasting effects during prolonged viewing. We directly investigated individuals' rivalry biases for eye and color within the visual field and interestingly found results that mirrored the somewhat contradictory pattern in the literature. Each observer demonstrated idiosyncratic patterns of biases for both color and eye within the visual field, but consistent, prolonged biases only for the eye of presentation (sensory eye dominance, SED). Furthermore, the strength of eye biases predicted one's performance on a stereoacuity task. This finding supports the idea that binocular rivalry and other binocular visual functions m ay rely on shared mechanisms, and emphasizes the importance of SED as a measure of binocular vision.

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.

Perceptual training profoundly alters binocular rivalry through both sensory and attentional enhancements

The effects of attention, as well as its functional utility, are particularly prominent when selecting among multiple stimuli that compete for processing resources. However, existing studies have found that binocular rivalry-a phenomenon characterized by perceptual competition between incompatible stimuli presented to the two eyes-is only modestly influenced by selective attention. Here, we demonstrate that the relative resistance of binocular rivalry to selective modulations gradually erodes over the course of extended perceptual training that uses a demanding, feature-based attentional task. The final result was a dramatic alteration in binocular rivalry dynamics, leading to profound predominance of the trained stimulus. In some cases, trained observers saw the trained rival image nearly exclusively throughout 4-min viewing periods. This large change in binocular rivalry predominance was driven by two factors: task-independent, eye-specific changes in visual processing, as well as an enhanced ability of attention to promote predominance of the task-relevant stimulus. Notably, this strengthening of task-driven attention also exhibited eye specificity above and beyond that from observed sensory processing changes. These empirical results, along with simulations from a recently developed model of interocular suppression, reveal that stimulus predominance during binocular rivalry can be realized both through an eye-specific boost in processing of sensory information and through facilitated deployment of attention to task-relevant features in the trained eye. Our findings highlight the interplay of attention and binocular rivalry at multiple visual processing stages and reveal that sustained training can substantially alter early visual mechanisms.

Soft multifocal simultaneous image contact lenses: a review

Soft multifocal simultaneous image contact lenses have boomed in recent years due to the growing number of presbyopic patients demanding visual solutions, allowing them to maintain their current standard of living. The concept of 'simultaneous image' is based on blur interpretation and/or blur tolerance of superimposed multiple images on the retina formed by various powers of a contact lens. This is the basis for a specific type of multifocal contact lens developed for the compensation of presbyopia. Manufacturers have released a great variety of soft simultaneous image lens designs to meet different patient needs but their fitting is still unsatisfactory in some cases. Some presbyopes discontinue wearing contact lenses due to some limitations in visual quality and comfort that can be overcome with an appropriate contact lens selection based on a comprehensive pre-fitting evaluation. This paper aims to review the different types of soft multifocal contact lenses that are currently available for presbyopic correction and to define the steps and factors crucial for their fitting, such as pupil, aberrations, accommodation and centring. A discussion about useful tools to achieve a customised fitting leading to a successful outcome, such as the defocus curve, power profile and questionnaires, is performed.

Monocular blur alters the tuning characteristics of stereopsis for spatial frequency and size

Our sense of depth perception is mediated by spatial filters at different scales in the visual brain; low spatial frequency channels provide the basis for coarse stereopsis, whereas high spatial frequency channels provide for fine stereopsis. It is well established that monocular blurring of vision results in decreased stereoacuity. However, previous studies have used tests that are broadband in their spatial frequency content. It is not yet entirely clear how the processing of stereopsis in different spatial frequency channels is altered in response to binocular input imbalance. Here, we applied a new stereoacuity test based on narrow-band Gabor stimuli. By manipulating the carrier spatial frequency, we were able to reveal the spatial frequency tuning of stereopsis, spanning from coarse to fine, under blurred conditions. Our findings show that increasing monocular blur elevates stereoacuity thresholds 'selectively' at high spatial frequencies, gradually shifting the optimum frequency to lower spatial frequencies. Surprisingly, stereopsis for low frequency targets was only mildly affected even with an acuity difference of eight lines on a standard letter chart. Furthermore, we examined the effect of monocular blur on the size tuning function of stereopsis. The clinical implications of these findings are discussed.