Reference Clinical Database for Fixation Stability Metrics in Normal Subjects Measured with the MAIA Microperimeter

Characterizing the Preferred Retinal Locus and Fixation Stability in Diabetic Macular Ischemia: A One-Year Study

Eyes with maculopathy usually have poor fixation stability (FS) and develop a new preferred retinal locus (PRL). The exact FS and PRL have never been studied in diabetic macular ischemia (DMI). In this one-year observational study, we recruited 79 patients (145 eyes) with evidence of DMI on optical coherence tomography angiography (OCTA). Microperimetry (MP) was performed at baseline and 52 weeks. Overall, DMI eyes demonstrated relatively stable FS without evolving into eccentric fixation over one year. When comparing the better-seeing eye (BSE) with the worse-seeing eye (WSE) in eyes with bilateral DMI, the latter presented with a larger bivariate contour ellipse area (BCEA) initially but gradually aligned with the one in the BSE at the end of the study. Conversely, the foveolar retinal sensitivity (RS) worsened significantly alongside the extension of disorganization of the retinal inner layers (DRIL) in the WSE at one year despite the best-corrected visual acuity (BCVA) being maintained. This suggests that foveolar RS might reflect the start of DMI deterioration more sensitively than BCVA.

Quantifying the Progression of Stargardt Disease in Double-Null ABCA4 Carriers Using Fundus Autofluorescence Imaging

Purpose

To score real-world fundus autofluorescence (FAF) images of pediatric patients with ABCA4-related Stargardt disease (STGD1), in a way that is automatable, scales with the disease progression, and is applicable to a wide time interval in the natural history of the disease.

Methods

We developed the score based on a series of Optos wide-field FAF images of pediatric STGD1 patients (73 images; 14 individuals) and controls (27 images; 8 individuals). The patients' images were obtained over up to 6 years, and the controls over up to 5 years. In each image, we manually selected an artifact-free region, within which we evaluated an average of the pixel-level intensity score, constructed so that the average increases with progression of the disease.

Results

The score we propose provides a statistically robust measure of disease progression (91% Spearman correlation with the absolute age, 97% with the estimated time from onset, when averaged over both eyes), comparable across timepoints and patients.

Conclusions

FAF is a reliable tool in STGD1 diagnostics, but its quantitative description must be modified to be applicable to tracking the disease progression. Analyzing images obtained in the course of clinical care of pediatric patients poses special challenges that make complete automation difficult.

Translational Relevance

Our methodology provides a quantitative tool for investigating the natural progression of the Stargardt disease, and, potentially, the effects of genotype, environment, and therapeutic intervention on its course.

Assessment of CRB1-Associated Retinopathies Using the S-MAIA Fast Protocol and Spectral-Domain Optical Coherence Tomography

Background: A cross-sectional study was conducted at Moorfields Eye Hospital, UK, involving patients with CRB1-associated retinopathies: macular dystrophy (MD), cone-rod dystrophy (CORD), and early-onset severe retinal dystrophy/Leber congenital amaurosis (EOSRD/LCA). The study aimed to evaluate CRB1-associated retinopathies using microperimetry (macular integrity assessment (S-MAIA) fast protocol) and spectral domain optical coherence tomography (SD-OCT). Methods: Data quality and participant attrition were assessed in 18 patients (10 MD, 5 EOSRD/LCA, 3 CORD), aged 10-52 years, with a median best corrected visual acuity (BCVA) of 0.41 logMAR. Results: Microperimetry and SD-OCT data were obtained from 14 and 18 patients, respectively, but eccentric fixation hindered structure-function analysis. All participants showed overall abnormal sensitivity on the S-MAIA fast protocol. Parafoveal volume was significantly increased, while foveal thickness and volume were reduced compared to normative data (p < 0.01). Conclusions: This study highlights the challenges of participant attrition and the need for alternative functional metrics to complement traditional evaluations. It also reinforces previous findings of abnormal retinal architecture in CRB1-associated retinopathies, providing further insights into S-MAIA and SD-OCT assessments for this patient population.

Relationship between the full-field stimulus test and self-reported visual function in patients with retinitis pigmentosa: REPEAT Study report No. 3

PURPOSE

To determine the relationship between the full-field stimulus test (FST) and self-reported visual function using the Michigan Retinal Degeneration Questionnaire (MRDQ) in patients with retinitis pigmentosa (RP).

METHODS

In this cross-sectional study, patients with clinically diagnosed RP (n = 31) performed FST to determine retinal sensitivity thresholds for blue, red and white stimuli. The difference between the blue and red thresholds was used to identify photoreceptor mediation type. Patients completed the MRDQ from which disability (Θ) scores were derived across seven visual function domains. Correlations between the FST thresholds and MRDQ domain Θ-scores were analysed using Spearman's rank correlation.

RESULTS

The median age was 38.0 years, and photoreceptor mediation was rod-based in 11 patients (35.5%), cone-based in seven patients (22.6%) and mixed in 13 patients (41.9%). The highest disability scores were reported in the domains of 'mesopic peripheral function' and 'scotopic function'. Significant correlations were found between all chromatic stimuli thresholds and the MRDQ domains of 'scotopic function', 'mesopic peripheral function' and 'photopic peripheral function'. The strongest correlations of these domains were observed with the blue FST (p < 0.001). The threshold on blue stimulus FST and age were significant predictors of the domain scores on 'scotopic function' (p < 0.001), 'mesopic peripheral function' (p < 0.001) and 'photopic peripheral function' (p < 0.001).

CONCLUSIONS

Strong correlations between MRDQ domains related to rod function and FST were found in patients with RP. These findings confirm that FST can be used as an informative and clinically relevant endpoint in RP trials when evaluating therapeutic interventions.

A telerehabilitation program to improve visual perception in children and adolescents with hemianopia consecutive to a brain tumor: a single-arm feasibility and proof-of-concept trial

Background

Brain tumor in children can induce hemianopia, a loss of conscious vision, profoundly impacting their development and quality of life, yet no effective intervention exists for this pediatric population. This study aimed to explore the feasibility, safety, and potential effectiveness of a home-based audiovisual stimulation in immersive virtual-reality (3D-MOT-IVR) to improve visual function and functional vision.

Methods

In a phase 2a, open-labeled, nonrandomized, single-arm study, conducted from July 2022 to October 2023 (NCT05065268), 10 children and adolescents with stable hemianopia were enrolled to perform 20-min sessions of 3D-MOT-IVR every other day for six weeks from home. We assessed feasibility by monitoring adoption, adherence and completion rates, remote data transfer and qualitative feedback. Safety was evaluated using validated cybersickness questionnaires. Comprehensive vision assessments following standardized low-vision evaluation procedures were conducted pre- and post-intervention, with follow-ups at 1- and 6 months.

Findings

The home-based 3D-MOT-IVR intervention proved both feasible and safe, with no reported adverse events. All participants completed the prescribed stimulations and the pre- and post-intervention assessment points, 90% completed the follow-ups. Nine out of ten participants showed clinically meaningful enhancement in visual function and/or functional vision, namely binocular visual field restoration and increased reading speed, but two showed concomitant deterioration in monocular visual field. These positive effects were sustained at the 6-month follow-up. Exploratory outcomes revealed a significant positive correlation between the performance at the 3D-MOT-IVR intervention and the visual perception at the binocular visual field test.

Interpretation

Our findings underscore the feasibility and safety of home-based audiovisual stimulation in immersive virtual-reality as a potential intervention for improving visual perception in children/adolescents with hemianopia consecutive to a pediatric brain tumor. These promising results lay a strong foundation for a larger randomized controlled trial, offering hope for a meaningful breakthrough in visual rehabilitation for this vulnerable population.

Funding

Meagan Bebenek Foundation and University Health Network Foundation.

Test-retest variability of mesopic microperimetry-associated parameters in patients with retinitis pigmentosa: REPEAT Study Report No. 2

PURPOSE

Understanding test-retest variability (TRV) of mesopic microperimetry is critical for defining meaningful treatment effects in retinitis pigmentosa (RP) trials. This study uniquely evaluates intra- and intervisit TRV and coefficients of repeatability (CoRs) for microperimetry parameters in RP patients with varying best-corrected visual acuity (BCVA) levels.

METHODS

In this single-centre prospective cohort study, RP patients were assessed on two visits, 14.0 days apart. Patients were grouped by BCVA: low (≤20/50 Snellen; ≥0.4 logMAR) or moderate (>20/50 Snellen; <0.4 logMAR). Using Bland-Altman analyses, the CoRs for intra- and intervisit variability were determined for pointwise (dB), mean (dB), and volume sensitivity (dB*deg2) on mesopic microperimetry.

RESULTS

Intravisit CoRs for mean, volume, and pointwise sensitivity were 1.7 dB, 353.2 dB*deg2, and 8.6 dB, respectively, in the low-BCVA group (n = 32), and 0.9 dB, 254.5 dB*deg2, and 7.3 dB in the moderate-BCVA group (n = 15). Intervisit CoRs for mean, volume, and pointwise sensitivity were 2.4 dB, 355.2 dB*deg2, and 10.2 dB in the low-BCVA group (n = 31). The moderate-BCVA group (n = 16) showed smaller CoRs of 1.6 dB, 386.8 dB*deg2, and 7.7 dB for mean, volume, and pointwise sensitivity. BCVA and mean sensitivity, but not fixation stability, are predictors of TRV for volume sensitivity.

CONCLUSIONS

Due to significant TRV, pointwise sensitivity is an unreliable endpoint for RP patients, irrespective of BCVA. Mean sensitivity is suitable as an endpoint when BCVA is relatively preserved. Volume sensitivity provides additional spatial information, and shows promise as a clinical endpoint for assessing macular sensitivity changes on mesopic microperimetry in patients with RP.

Exploring Scotopic Microperimetry as an Outcome Measure in Choroideremia

Purpose

Choroideremia is an X-linked outer retinal degeneration. Early symptoms include nyctalopia and progressive visual field loss, but visual acuity is preserved until late disease stages. Dark-adapted two-color fundus-controlled perimetry (also known as scotopic microperimetry) has been developed to enable spatial assessment of rod and cone photoreceptor function. This study explores the use of scotopic microperimetry in patients with choroideremia.

Methods

Twenty patients with choroideremia and 21 age-matched healthy controls completed visual acuity and scotopic microperimetry testing, which used the Scotopic Macular Integrity Assessment (S-MAIA) microperimeter. A subset of participants completed repeat scotopic testing to enable Bland-Altman repeatability analyses. Test reliability was assessed using fixation stability, fixation losses, and assessment of the rod-free zones. Pointwise sensitivity, mean sensitivity, and volume sensitivity indices were analyzed.

Results

False positive responses were the main source of poor test reliability, indicated by stimuli responses in the physiological blind spot and lack of rod-free mapping. Scotopic cyan and red sensitivities were significantly reduced in choroideremia participants (n = 17) compared to healthy controls (n = 16) (P < 0.01, Mann-Whitney U test). Scotopic cyan sensitivity was statistically lower than scotopic red sensitivity in both healthy controls and choroideremia (P < 0.01, Wilcoxon signed rank test). Interpretation of scotopic cyan-red differences should be used with caution due to high test-retest variability.

Conclusions

Scotopic microperimetry could be a useful outcome measure in patients with early choroideremia. Careful selection of test grid design and sensitivity indices is required.

Translational Relevance

Scotopic microperimetry may be a useful outcome measure in clinical trials for patients with early stage choroideremia.

Foveolar Drusen Decrease Fixation Stability in Pre-Symptomatic AMD

Purpose

This study aims at linking subtle changes of fixational eye movements (FEM) in controls and in patients with foveal drusen using adaptive optics retinal imaging in order to find anatomo-functional markers for pre-symptomatic age-related macular degeneration (AMD).

Methods

We recruited 7 young controls, 4 older controls, and 16 patients with presymptomatic AMD with foveal drusen from the Silversight Cohort. A high-speed research-grade adaptive optics flood illumination ophthalmoscope (AO-FIO) was used for monocular retinal tracking of fixational eye movements. The system allows for sub-arcminute resolution, and high-speed and distortion-free imaging of the foveal area. Foveal drusen position and size were documented using gaze-dependent imaging on a clinical-grade AO-FIO.

Results

FEM were measured with high precision (RMS-S2S = 0.0015 degrees on human eyes) and small foveal drusen (median diameter = 60 µm) were detected with high contrast imaging. Microsaccade amplitude, drift diffusion coefficient, and ISOline area (ISOA) were significantly larger for patients with foveal drusen compared with controls. Among the drusen participants, microsaccade amplitude was correlated to drusen eccentricity from the center of the fovea.

Conclusions

A novel high-speed high-precision retinal tracking technique allowed for the characterization of FEM at the microscopic level. Foveal drusen altered fixation stability, resulting in compensatory FEM changes. Particularly, drusen at the foveolar level seemed to have a stronger impact on microsaccade amplitudes and ISOA. The unexpected anatomo-functional link between small foveal drusen and fixation stability opens up a new perspective of detecting oculomotor signatures of eye diseases at the presymptomatic stage.

The effect of duration between sessions on microperimetric biofeedback training in patients with maculopathies

Aim of this study was to explore the optimal training interval and times of microperimetric biofeedback training (MBFT) in maculopathies. Twenty-nine patients with maculopathies were divided into two groups: daily training (Group A) or alternate daily training (Group B). Both groups underwent 15 MBFT sessions. We compared the BCVA, reading speed, and fixation stability at baseline, after 5, 10, 15 sessions. After 15 sessions of MBFT, all visual parameters in both groups improved. There was a significant increase in BCVA after 5 sessions in both groups (P=0.016, and P<0.001 respectively), but Group A showed further improvement after 10 sessions (P<0.001). Regarding reading speed, Group A showed significant improvement from baseline after 15 sessions(P=0.020), Group B improved significantly after 5 sessions (P=0.047) and continued to improve after 10 sessions (P=0.030). Additionally, P1 and LgBCEA of Group A significantly improved after 10 sessions (P=0.001, and P=0.001 respectively), while Group B significantly improved after 5 sessions (P=0.002, and P<0.001 respectively). There was no significant difference in visual outcomes between the two groups (P>0.05) except LgBCEA (P=0.046) after 15 sessions. We concluded that the both MBFT frequencies are effective at improving vision and quality of life in patients with maculopathies. The alternate daily training group showed less time-dependent of improvement in all parameters and a greater benefit in fixation stability. Ten sessions are the optimal number of treatment sessions for alternate daily training.

Photoreceptor Integrity in MEWDS: Longitudinal Structure-Function Correlations

Purpose

The purpose of this study was to investigate structure-function correlations in multiple evanescent white dot syndrome (MEWDS) using microperimetry (MP) and spectral-domain optical coherence tomography (SD-OCT).

Methods

Single-center prospective observational study including 14 eyes from 13 patients with MEWDS monitored over a median of 49.5 days (interquartile range = 29-92 days). Investigations focused on best-corrected visual acuity (BCVA), foveal granularity, and the Photoreceptor Reflectivity Ratio (PRR) as a measure of photoreceptor integrity. MP assessed average retinal threshold sensitivity (RTS) and bivariate contour ellipse area (BCEA) for fixation stability. A linear mixed model was used to test associations and interactions among RTS, time, and clinical variables. A hierarchical linear mixed model was used to analyze structure-function relationships, addressing both individual and location-specific variations.

Results

Overall, 2340 MP locations were tested. PRR revealed a transient decrease within 30 days post-presentation, indicative of early photoreceptor disruption, followed by a progressive increase, signaling recovery. Significantly lower foveal sensitivity (RTS = 14.8 ± 7.4 vs. 22.5 ± 4.4 decibel [dB], P = 0.04) and increased fixation spread (63% BCEA = 1.26 ± 0.97 vs. 0.48 ± 0.35 deg2, P = 0.06) were noted in eyes with foveal granularity compared to those without. A significant increase in RTS was demonstrated over time (0.066 dB/day, P < 0.001), with a central-to-peripheral gradient of improvement. The interaction between follow-up time and baseline BCVA (P < 0.001) indicated more rapid improvement in eyes with worse initial vision. There was a robust, nonlinear association between PRR and RTS across all tested locations (P < 0.001), becoming asymptotic for sensitivity losses exceeding 20 dB.

Conclusions

Photoreceptor reflectivity accurately aligned with visual function in MEWDS on longitudinal examinations. The central-to-peripheral gradient of improvement may suggest specific vulnerabilities underlying the area around the disc.

Microperimetry assessment in foveal hypoplasia: functional results in a series of pediatric patients

OBJECTIVE

To study the relationships of functional and morphologic retinal parameters in a series of pediatric patients with varying degrees of foveal hypoplasia (FH).

DESIGN

Monocentric observational retrospective study.

PARTICIPANTS

Among 21 pediatric patients, 16 met inclusion criteria, having FH confirmed with spectral-domain optical coherence tomography (SD-OCT) scan METHODS: Data were analyzed retrospectively. Patients able to undergo macular microperimetry (MP) and SD-OCT examinations were included in the analysis. MP and SD-OCT outcomes were compared with FH grading and best-corrected visual acuity (BCVA) using Pearson's correlation.

RESULTS

Thirty-one eyes from 16 patients (mean age 12.4 years) with different degrees of FH were analyzed. Two patients had grade 1, 7 had grade 2, 5 had grade 3, and 2 had grade 4 FH. Clinical nystagmus was present in 8 patients. The correlation between BCVA and SD-OCT data (-0.31) was lower than that found between BCVA and nystagmus (0.64), that for fixation index P1 (-0.60), as well as that for macular sensitivity (-0.63).

CONCLUSIONS

Although limited by the small sample, our study confirms the feasibility of automated MP evaluation in pediatric patients with FH. The added value of this work is the provision of data on relationships between anatomic and functional macular measurements acquired with SD-OCT, MP, and BCVA in eyes with various degrees of FH. Larger prospective studies are necessary to confirm these results.

Fixation Location and Stability in Best Vitelliform Macular Dystrophy

Purpose

To analyze fixation location and stability in best vitelliform macular dystrophy (BVMD) and test their association with best-corrected visual acuity (BCVA).

Design

Observational, cross-sectional study.

Participants

Thirty patients (55 eyes) affected by genetically confirmed BVMD were followed up at the Retinal Heredodystrophies Unit of IRCCS San Raffaele Scientific Institute, Milan.

Methods

Patients underwent testing with macular integrity assessment (MAIA) microperimeter. Fixation location was measured as distance in degrees (°) between preferred retinal locus (PRL) and estimated fovea location (EFL); fixation was defined as eccentric when the distance between PRL and EFL exceeded 2°. Fixation stability was graded as stable, relatively unstable, or unstable and expressed as bivariate contour ellipse area (BCEA, °²).

Main Outcome Measures

Fixation location and stability.

Results

The median distance of the PRL from the anatomic fovea was 0.7°, and fixation location was eccentric in 27% of eyes. Fixation was graded as stable in 64% of eyes, relatively unstable in 13%, and unstable in 24%, with a median 95% BCEA of 6.2°². The atrophic/fibrotic stage was associated with worse fixation parameters (all P < 0.01). Both PRL eccentricity and fixation stability were linearly associated with BCVA: every 1° increase in PRL eccentricity was associated with a 0.07 logarithm of the minimum angle of resolution (logMAR) worse BCVA (P < 0.0001) while every 1°² increase in 95% BCEA was associated with a 0.01 logMAR worse BCVA (P < 0.001). No significant intereye correlation was found for PRL eccentricity and fixation stability, as well as no association between the patient's age and fixation parameters.

Conclusions

We demonstrated that most eyes affected by BVMD retain a central stable fixation and provided evidence that both fixation eccentricity and stability are strongly associated with visual acuity in BVMD. These parameters may serve as secondary end points for future clinical trials.

Financial Disclosures

Proprietary or commercial disclosure may be found after the references.

Comparison of Novel Volumetric Microperimetry Metrics in Intermediate Age-Related Macular Degeneration: PINNACLE Study Report 3

Purpose

To investigate and compare novel volumetric microperimetry (MP)-derived metrics in intermediate age-related macular degeneration (iAMD), as current MP metrics show high variability and low sensitivity.

Methods

This is a cross-sectional analysis of microperimetry baseline data from the multicenter, prospective PINNACLE study (ClinicalTrials.gov NCT04269304). The Visual Field Modeling and Analysis (VFMA) software and an open-source implementation (OSI) were applied to calculate MP-derived hill-of-vison (HOV) surface plots and the total volume (VTOT) beneath the plots. Bland-Altman plots were used for methodologic comparison, and the association of retinal sensitivity metrics with explanatory variables was tested with mixed-effects models.

Results

In total, 247 eyes of 189 participants (75 ± 7.3 years) were included in the analysis. The VTOT output of VFMA and OSI exhibited a significant difference (P < 0.0001). VFMA yielded slightly higher coefficients of determination than OSI and mean sensitivity (MS) in univariable and multivariable modeling, for example, in association with low-luminance visual acuity (LLVA) (marginal R2/conditional R2: VFMA 0.171/0.771, OSI 0.162/0.765, MS 0.133/0.755). In the multivariable analysis, LLVA was the only demonstrable predictor of VFMA VTOT (t-value, P-value: -7.5, <0.001) and MS (-6.5, <0.001).

Conclusions

The HOV-derived metric of VTOT exhibits favorable characteristics compared to MS in evaluating retinal sensitivity. The output of VFMA and OSI is not exactly interchangeable in this cross-sectional analysis. Longitudinal analysis is necessary to assess their performance in ability-to-detect change.

Translational Relevance

This study explores new volumetric MP endpoints for future application in therapeutic trials in iAMD and reports specific characteristics of the available HOV software applications.

The Relationship between Fixation Stability and Retinal Structural Parameters in Children with Anisometropic, Strabismic and Mixed Amblyopia

(1) Background: Amblyopia is an ocular condition leading to structural and functional changes. The relationship between these changes is complex and remains poorly understood. (2) Methods: Participants included 31 children aged 5 to 9 years with strabismic (n = 9), anisometropic (n = 16) and mixed (n = 6) unilateral amblyopia, and 14 age-matched non-amblyopic children. The 95% and 63% Bivariate Contour Ellipse Area (BCEA), axial length, Foveal Avascular Zone (FAZ) area, center macular thickness and volume were assessed. The relationship between these parameters was explored. (3) Results: Statistically significant differences were found among the four groups in best corrected distance visual acuity (BCVA) (p < 0.001), BCEA 95% (p = 0.002) and BCEA 63% (p = 0.002), but not in the FAZ area, central macular thickness, central macular volume and axial length. Eyes with amblyopia had poorer BCVA and larger fixation instability than controls. Inter-ocular differences were more significant in patients with strabismic amblyopia, particularly in BCVA (p = 0.003), central macular thickness (p < 0.001) and central macular volume (p = 0.002). In amblyopic eyes, BCEA 95% and 63% were correlated with BCVA, but not with the FAZ area. (4) Conclusion: Amblyopia is associated with a reduction in fixation stability and BCVA, although there is a general lack of correlation with structural changes, suggesting a complex interaction between anatomy and function in amblyopia.

Fotopic and scotopic retinal sensitivity and foveal fixation normal values using microperimetry in healthy population

PURPOSE

To determine normal values of fotopic and scotopic retinal sensitivity and foveal fixation obtained by microperimetry, using MP3-S microperimeter (Nidek, Gamagori, Japan), in a healthy population.

METHODS

Observational, crossectional, single centre study. Fotopic and scotopic microperimetry was performed using with a customized 13-point fovea-centered pattern in healthy volunteers without ocular pathology. A intraclass correlation coefficient (ICC) was performed to evaluate fotopic and scotopic microperimetry reliability.

RESULTS

We analyzed 102 eyes of 54 patients with a mean age of 49.8 +/- 15 years old. The fotopic and scotopic mean retinal sensitivity (MRS) was 28.55±3.3dB (95% CI=[27.87-29.23]) and 15.72±1.9dB (95% CI=[15.35-16.09]) respectively, showing a significant statistical difference (p<0.05). No differences were found when comparing SRM by gender group. However, when analyzing the SRM by age groups, statistically significant differences were found in both modalities of the test; SRM being higher in the group of subjects under 35 years of age with 30.3±1.7dB in the photopic and 16.3±1.3dB in the scotopic; and lower in the group of older than 65 years with 26.7±2.2dB in the photopic and 13.8±1.8dB in the scotopic with p=0.0001. The reliability analysis of both tests, revealed an excellent reliability of the fotopic microperimetry with a Crombach alpha of 0.958 and a good reliability of 0.841 in scotopic microperimetry.

CONCLUSIONS

Microperimetry is a test with good reliability both under photopic and scotopic conditions. SRM and fixation stability under photopic and scotopic conditions do not differ according to sex, but it does decrease with age. There is a positive correlation between photopic and scotopic SRM.

Gaze tracker parameters have little association with visual field metrics of intrasession frontloaded SITA-Faster 24-2 visual field results

PURPOSE

To determine the usefulness of Humphrey Field Analyser (HFA) SITA-Faster 24-2 gaze tracker outputs on interpreting intra-visit visual field (VF) result pairs.

METHODS

Analysis of 1380 right-left eye pairs and 1432 pairs of test 1-test 2 intrasession VF results of patients seen within a university-based glaucoma service was undertaken to understand gaze deviation distributions. Output gaze tracker results were aggregated into total ticks, sum of amplitudes and average amplitudes. Correlations between visual field indices (mean deviation [MD], "events" and overall hill of vision) and independent variables (age and test order) were performed using one eye from each subject.

RESULTS

There was no association of test order (right-left, test 1-test 2) with eye movements. There was a significant, but weak correlation between eye movements and age (r = 0.16). Correlations of eye movements with MD were driven by more severe MD values. There were no significant correlations between intrasession difference in eye movements and the change in MD, number of "events" and hill of vision, or in the root mean square of sensitivity and total deviation values. There was also no significant correlation between gaze tracker outputs and another commonly used "reliability" metric, false positive rate.

CONCLUSIONS

Eye movement parameters as currently reported by the HFA do not appear to be correlated with key sensitivity parameters when considering the repeatability of intrasession SITA-Faster 24-2 VF results. Thus, current gaze tracker outputs do not appear to provide clinically meaningful information for interpretation of intra-visit visual field results that cannot already be garnered using other strategies.

Alterations in Fixation Indices in Primary Open-Angle Glaucoma by Microperimetry

The aim of this study was to determine whether primary open-angle glaucoma (POAG) is associated with changes in fixation stability parameters assessed by microperimetry (MP) and whether the severity of glaucoma is related to a deterioration in these indicators. This study analyzed fixation stability using MP macular analyzer integrity assessment (MAIA) in patients with mild and moderate/severe POAG and healthy controls. The resulting fixation indices were correlated with parameters used to assess retinal function with MP and standard automated perimetry (SAP) and retinal structure with optical coherence tomography (OCT) and OCT angiography (OCTA). We enrolled 54 eyes in the POAG groups (32 eyes with mild POAG and 22 eyes with moderate/severe POAG) and 24 eyes in the healthy group. It was shown that fixation stability in POAG eyes deteriorated with increasing disease severity, and significant differences in bivariate contour ellipse area (BCEA) including 95% of fixation points were observed among groups (p = 0.042). Quantitative analysis of structural and functional retinal parameters also showed significant deterioration with the progression of glaucoma (p < 0.001). Correlations among fixation parameters and abnormalities in the retinal structure and function were confirmed. We concluded that POAG is associated with disturbances in the fixation pattern, which worsen as the disease progresses and can be effectively assessed by performing a MP test.

Short-Term Clinical Results of Preferred Retinal Locus Training

Objectives

This study evaluated acoustic biofeedback training using microperimetry in patients with foveal scars and an eligible retinal locus for better fixation.

Materials and Methods

A total of 29 eligible patients were enrolled in the study. The acoustic biofeedback training module in the MAIA (Macular Integrity Assessment, CenterVue®, Italy) microperimeter was used for training. To determine the treatment efficacy, the following variables were compared before and after testing: best corrected visual acuity (BCVA); MAIA microperimeter full threshold 4-2 test parameters of average threshold value, fixation parameters P1 and P2, and bivariate contour ellipse area (BCEA) for 63% and 95% of fixation points; contrast sensitivity (CSV 1000E Contrast Sensitivity Test); reading speed using the Minnesota Low-Vision Reading Test (MNREAD reading chart); and quality of life (NEI-VFQ-25). In addition, fixation stability parameters were recorded during each session.

Results

The study group consisted of 29 patients with a mean age of 68.72±8.34 years. Median BCVA was initially 0.8 (0.2-1.6) logMAR and was 0.8 (0.1-1.6) logMAR after 8 weeks of preferred retinal locus training (p=0.003). The fixation stability parameter P1 improved from a mean of 21.28±3.08% to 32.69±3.69% (p=0.001) while mean P2 improved from 52.79±4.53% to 68.31±3.89% (p=0.001). Mean BCEA 63% decreased from 16.11±2.27^°2 to 13.34±2.26^°2 (p=0.127) and mean BCEA 95% decreased from 45.87±6.72^°2 to 40.01±6.78^°2 (p=0.247) after training. Binocular reading speed was 38.28±6.25 words per minute (wpm) before training and 45.34±7.35 wpm after training (p<0.001). Statistically significant improvement was observed in contrast sensitivity and quality of life questionnaire scores after training.

Conclusion

Beginning with the fifth session, biofeedback training for a new trained retinal locus improved average sensitivity, fixation stability, reading speed, contrast sensitivity, and quality of life in patients with macular scarring.

Evaluation of Fixational Behavior throughout Life

Background: To quantify development of gaze stability throughout life during short and long fixational tasks using eye tracking technology. Methods: Two hundred and fifty-nine participants aged between 5 months and 77 years were recruited along the study. All participants underwent a complete ophthalmological assessment. Fixational behavior during long and short fixational tasks was analyzed using a DIVE (Device for an Integral Visual Examination), a digital test assisted with eye tracking technology. The participants were divided into ten groups according to their age. Group 1, 0–2 years; group 2, 2–5 years; group 3, 5–10 years; group 4, 10–20 years; group 5, 20–30 years; group 6, 30–40 years; group 7, 40–50 years; group 8, 50–60 years; group 9, 60–70 years; and group 10, over 70 years. Results: Gaze stability, assessed by logBCEA (log-transformed bivariate contour ellipse area), improved with age from 5 months to 30 years (1.27 vs. 0.57 deg² for long fixational task, 0.73 vs. −0.04 deg² for short fixational task), while fixations tend to be longer (1.95 vs. 2.80 msec for long fixational tasks and 0.80 vs. 1.71 msec for short fixational tasks). All fixational outcomes worsened progressively from the fifth decade of life. Log-transformed bivariate contour ellipse area (0.79, 0.83, 0.91, 1.42 deg² for long fixational task and 0.01, 0.18, 0.28, 0.44 deg² for short fixational task, for group 7, 8, 9, and 10 respectively). Stimuli features may influence oculomotor performance, with smaller stimuli providing prolonged fixations. Conclusions: Fixational behavior can be accurately assessed from 5 months of age using a DIVE. We report normative data of gaze stability and duration of fixations for every age group. Currently available technology may increase the accuracy of our visual assessments at any age.

Clinical applications of microperimetry in RPGR-related retinitis pigmentosa: a review

Microperimetry, or fundus-tracked perimetry, is a precise static-automated perimetric technique to assess central retinal function. As visual acuity only deteriorates at a late disease stage in RPGR-related retinitis pigmentosa (RP), alternative markers for disease progression are of great utility. Microperimetry assessment has been of critical value as an outcome measure in a recently reported phase I/II gene therapy trial for RPGR-related RP, both in terms of detecting safety and efficacy signals. Here, we performed a review of the literature. We describe the principles of microperimetry before outlining specific parameters that may be useful as outcome measures in clinical trial settings. The current state of structure-function correlations between short-wavelength autofluorescence, optical coherence tomography and adaptive optics in RPGR-related retinitis pigmentosa are also summarized.

Retinal Sensitivity Correlates With the Superficial Vessel Density and Inner Layer Thickness in Diabetic Retinopathy

Purpose

The purpose of this paper was to present our study on the relationship between the parafoveal sensitivity measured using microperimetry and the vessel density (VD) assessed by optical coherence tomography-angiography (OCT-A) in eyes with diabetic retinopathy (DR).

Methods

The observational case series was conducted in a tertiary ophthalmology center. Eyes with DR and without macular edema were consecutively included. All eyes underwent microperimetry and OCT-A. The correlation between the regional retinal sensitivity and the corresponding local capillary changes and structural alterations seen on OCT-A was assessed in each retinal quadrant.

Results

Thirty-seven eyes of 21 patients were included. The mean retinal sensitivity was 28.7 ± 2 decibel (dB). The mean parafoveal VD was 43.2 ± 4.2% in the superficial capillary plexus (SCP) and 48.1 ± 3.3% in the deep capillary complex (DCC). In the multivariate linear regression model, the mean retinal sensitivity was positively correlated with the VD in the SCP in the parafoveal ring (P = 0.01) and with the inner nuclear layer (INL) thickness (P = 0.01). The qualitative analysis of each quadrant showed the presence of areas of capillary dropout with a normal sensitivity. Conversely, all areas of decreased sensitivity (<25 dB) were associated with a decreased VD in the SCP and the DCC.

Conclusions

The parafoveal sensitivity positively correlated with the VD in the SCP in DR eyes. Areas with a low retinal sensitivity were always co-located with a loss of capillaries in the SCP and the DCC despite preserved outer retinal layers.

An Overview of Preferred Retinal Locus and Its Application in Biofeedback Training for Low-Vision Rehabilitation

Central vision loss (CVL) caused by macular damage generally disables common daily tasks, which cannot be reversed by present treatments. Fortunately, it has been found that biofeedback training by inducing or reinforcing preferred retinal locus (PRL) as an eccentric fixation reference contributes to the improvement of visual performance in patients with CVL. However, the clinical application is still under controversy due to poor knowledge of its fundamental and inconsistent practical standards. This article aims to summarize the possible rationale for the development, location, re-location and evaluating indicators of PRL, and the general apparatus, protocol, and outcome of biofeedback PRL training.

Evaluating fMRI-Based Estimation of Eye Gaze During Naturalistic Viewing

The collection of eye gaze information during functional magnetic resonance imaging (fMRI) is important for monitoring variations in attention and task compliance, particularly for naturalistic viewing paradigms (e.g., movies). However, the complexity and setup requirements of current in-scanner eye tracking solutions can preclude many researchers from accessing such information. Predictive eye estimation regression (PEER) is a previously developed support vector regression-based method for retrospectively estimating eye gaze from the fMRI signal in the eye's orbit using a 1.5-min calibration scan. Here, we provide confirmatory validation of the PEER method's ability to infer eye gaze on a TR-by-TR basis during movie viewing, using simultaneously acquired eye tracking data in five individuals (median angular deviation < 2°). Then, we examine variations in the predictive validity of PEER models across individuals in a subset of data (n = 448) from the Child Mind Institute Healthy Brain Network Biobank, identifying head motion as a primary determinant. Finally, we accurately classify which of the two movies is being watched based on the predicted eye gaze patterns (area under the curve = 0.90 ± 0.02) and map the neural correlates of eye movements derived from PEER. PEER is a freely available and easy-to-use tool for determining eye fixations during naturalistic viewing.

Microperimetry differences in macular sensitivity threshold between first and second tested eyes

PURPOSE

To comparatively assess the macular sensitivity threshold of microperimetry and the fixation stability between the first (right) and second (left) tested eye of normal participants.

METHODS

Thirty healthy patients were randomly assigned to two groups. The participants underwent microperimetry in the fast mode and expert mode in groups I and II, respectively. Each participant underwent a single test and the right eye was tested first.

RESULTS

The mean macular sensitivity threshold (± standard deviation [SD]) was 24.5 ± 2.3 dB and 25.7 ± 1.1 dB in the first (right) and second (left) eyes of group I, respectively (p=0.0415) and 26.7 ± 4.5 dB and 27.3 ± 4.0 dB in the first (right) and second (left) eyes of group II, respectively (p=0.58). There was no statistically significant difference between eyes in either group (p=0.1512). Regarding fixation stability (evaluated in the microperimetry expert mode group), the mean ± SD percentage of fixation points within the 1-degree central macula (P1) was 87.9 ± 11.5% in the right eye and 93.8 ± 6.6% in the left eye. The paired t-test did not show a statistically significant difference between eyes (p=0.140). Mean ± SD P2 value was 95.5 ± 4.9% in the right eye and 98.5 ± 2.1% in the left eye. The analysis demonstrated an increase in the percentage of fixation points in the second tested eye compared with the first one (paired t-test= 2.364; p=0.034). There was a negative correlation between the macular sensitivity threshold of the right eye and the duration of the examination for both groups (microperimetry expert mode: r=-0.717; p=0.0026; microperimetry in the fast mode: r=-0.843; p<0.0001).

CONCLUSION

Mean macular sensitivity threshold was higher in the second tested eye in the microperimetry in the fast mode group and was similar in both eyes in the expert mode. Our data suggest that comprehension of the examination by the individual may impact the results of the microperimetry test.

Fundus-controlled perimetry (microperimetry): Application as outcome measure in clinical trials

Fundus-controlled perimetry (FCP, also called 'microperimetry') allows for spatially-resolved mapping of visual sensitivity and measurement of fixation stability, both in clinical practice as well as research. The accurate spatial characterization of visual function enabled by FCP can provide insightful information about disease severity and progression not reflected by best-corrected visual acuity in a large range of disorders. This is especially important for monitoring of retinal diseases that initially spare the central retina in earlier disease stages. Improved intra- and inter-session retest-variability through fundus-tracking and precise point-wise follow-up examinations even in patients with unstable fixation represent key advantages of these technique. The design of disease-specific test patterns and protocols reduces the burden of extensive and time-consuming FCP testing, permitting a more meaningful and focused application. Recent developments also allow for photoreceptor-specific testing through implementation of dark-adapted chromatic and photopic testing. A detailed understanding of the variety of available devices and test settings is a key prerequisite for the design and optimization of FCP protocols in future natural history studies and clinical trials. Accordingly, this review describes the theoretical and technical background of FCP, its prior application in clinical and research settings, data that qualify the application of FCP as an outcome measure in clinical trials as well as ongoing and future developments.

Relationship Between Choriocapillaris Flow and Scotopic Microperimetry in Early and Intermediate Age-related Macular Degeneration

PURPOSE

To evaluate the correlation between choriocapillaris (CC) flow alterations and scotopic macular sensitivity (sMS) in patients with early and intermediate age-related macular degeneration (AMD).

DESIGN

Prospective cross-sectional study.

METHODS

We acquired 2 3 × 3 mm and 2 6 × 6 mm swept-source optical coherence tomography angiography (OCTA) images of 1 eye of consecutive early or intermediate AMD patients at the Doheny UCLA Eye Centers. After 30 minutes of dark adaptation, the same eye underwent scotopic microperimetry with an 18-degree-wide grid (52 stimuli) centered on the fovea. The 2 en face CC angiograms obtained from each scan pattern were compensated for signal loss and averaged. The main outcome measures were correlation between percentages of flow deficits (FD_3mm and FD_6mm) and sMS in the central 10° (MS₁₀) and the overall pattern (MS₁₈).

RESULTS

Thirty eyes of 30 patients were enrolled, with 14 (46.7%) having subretinal drusenoid deposits (SDD). In the averaged OCTA scans, the FD_3mm was 12.56% ± 2.41% while the FD_6mm was 9.33% ± 1.84%. The mean MS₁₀ and MS₁₈ were 13.84 ± 5.89 dB and 14.64 ± 5.21 dB, respectively. For the MS_10, the multivariate regression analysis showed a significant association only with FD_3mm (β: -0.628, P < .001) while the MS₁₈ was significantly correlated with both SDD (β: -0.32, P = .047) and FD_6mm (β: -0.473, P = .005).

CONCLUSIONS

Our study reports a significant correlation between the CC flow impairment and the sMS in eyes with early or intermediate AMD. If replicated in future longitudinal studies, the choriocapillaris FD may prove to be a useful parameter for evaluating the functional status and prognosis of these eyes.

Fixation stability as a biomarker for differentiating mild traumatic brain injury from age matched controls in pediatrics

OBJECTIVES

Traumatic brain injury (TBI) is an increasingly significant health concern worldwide, compounded by the difficultly in detection and diagnosis. Fortunately, a growing body of research has identified oculomotor behavior, specifically fixations, saccades and smooth pursuit eye movements as a promising endophenotype for neurotrauma. To date, limited research exists using fixation stability in a comparative study to indicate the presence of a mild TBI (mTBI), especially in the pediatric population.

METHODS

The present study examined data from 91 individuals clinically diagnosed with mTBI and a further 140 age- and gender-matched controls. They all completed the RightEye fixation stability test using a remote eye tracker. Participants were compared on five fixation metrics: Bivariate Contour Ellipse Area (BCEA), Convergence Point, Depth, Disassociated Phoria, and Targeting Displacement.

RESULTS

Results were analyzed using one-way univariate ANOVAs, ROC analysis, and stepwise logistic regression. BCEA results revealed significant differences between groups with the mTBI group showing a larger gaze spread, indicative of less ability to keep the eyes close to the target without deviating.

CONCLUSIONS

Fixation stability is detrimentally impacted by mTBI in pediatric patients, and the oculomotor test can be used to differentiate between those with and without an mTBI.

One-Year Functional and Anatomical Outcomes After Selective Retina Therapy With Real-Time Feedback-Controlled Dosimetry in Patients With Intermediate Age-Related Macular Degeneration: A Pilot Study

BACKGROUND AND OBJECTIVES

This pilot study sought to evaluate changes in macular function and drusen volume (DV) after selective retina therapy (SRT) in patients with intermediate age-related macular degeneration (iAMD).

STUDY DESIGN/MATERIALS AND METHODS

Twenty participants with bilateral iAMD were included in this prospective interventional case series study. After titrating pulse energy by real-time feedback-controlled dosimetry, SRT with a wavelength of 527 nm was applied around the macula of one eye of each patient. Changes in best-corrected visual acuity (BCVA), DV within the central 5-mm ring (C5), and retinal sensitivity (RS) of the SRT-treated eyes (treated eyes) and untreated fellow eyes (untreated eyes) were evaluated at baseline and then at 3, 6, 9, and 12 months after treatment using linear mixed models.

RESULTS

The mean BCVA did not change significantly between baseline and 12 months in both treated and untreated eyes (P = 0.06, P = 0.24, respectively), whereas the BCVA increase rate was faster for treated than for untreated eyes at the 12-month visit (-0.072 logMAR; 95% confidence interval [CI], -0.085 to -0.059 logMAR; P = 0.006). The mean cube root transformation of DV (cube root DV) within C5 in the untreated eyes increased significantly from 0.278 ± 0.115 at baseline to 0.295 ± 0.132 mm (P = 0.027) at 12 months, whereas the cube root DV change in treated eyes was not significant (P = 0.553). The rate of increase in the cube root DV was lower in treated than in untreated eyes at the 12-month visit (-0.016 mm; 95% CI, -0.018 to -0.011 mm; P = 0.015). The mean RS was increased from 22.49 ± 2.40 dB to 24.09 ± 2.19 dB (P < 0.001) in the treated eyes, whereas the change of mean RS in the untreated eyes was not significant at the 12-month visit (P = 0.18). The treated eyes had a higher rate of increase in RS than untreated eyes at the 12-month visit (1.012 dB; 95% CI, 0.776-1.251 dB; P = 0.037). The RS change was significantly associated with the interaction between SRT treatment and time (P = 0.028), whereas it was not associated with cube root DV change (P = 0.106). No SRT-related adverse effects were observed in all participants during the 1-year follow-up.

CONCLUSION

Since SRT improved the mean RS and reduced the rate of change in drusen load in the treated eyes, as compared to the untreated eyes, SRT might slow the progression of iAMD. However, further large randomized clinical trials are necessary to confirm the efficacy of SRT for iAMD. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

The efficacy of biofeedback visual rehabilitation therapy in patients with infantile nystagmus syndrome: A retrospective study

OBJECTIVE

To report fixation stability changes in patients with different forms of infantile nystagmus syndrome (INS), who have undergone a visual rehabilitation through biofeedback fixation training (BFT) with microperimetry (MP).

DESIGN

Retrospective study.

METHODS

Patients 6 to 12 years-old with INS who performed BFT with MP. Initially 10 once-weekly followed by eight twice-weekly sessions of BFT during a minimum of 6 months period were performed. Visual acuity (VA) and MP fixation stability indices were analyzed, including displacement from fixation point (P1, P2) and percentage of retinal loci used during fixation attempt (BCEA 63% and 95%). Statistical analysis was conducted at baseline (BL), 10 weeks (W10) and 6 months (M6).

RESULTS

Twelve patients (mean age 8.9 years.) with INS completed the whole training session. All patients showed significant improvement in the mean BCEA fixation area (deg²): For BCEA@95% BL was 78.0, 46.1 at W10, and 27.4 at M6 (p-value = 0.004). For BCEA@63% BL was 27.3, 15.4 in W10, and 9.17 at M6 (p = 0.01). The ANOVA test for the FS indices of P1 and P2, as well as for BCVA showed no significant difference when compared at the same intervals.

CONCLUSION

Fixation stability (FS) indices of BCEAs (63% and 95%) improved at W10 and M6, while P1 and P2 showed significant improvement at W10 but not at M6, probably because BCEA involves a much larger area than P1 and P2. VA did not show significant improvement at any time point.

Biofeedback fixation training method for improving eccentric vision in patients with loss of foveal function secondary to different maculopathies

Purpose

Fixation stability (FS) of the preferred retinal locus (PRL) may be improved by biofeedback fixation training (BFT) with microperimetry. Such training can be done on the patient’s PRL or in different retinal loci with better functional characteristics. We studied both options and compared the outcomes.

Methods

Sixty-seven consecutive patients with bilateral central vision loss, poor FS and visual acuity (VA) lower than 0.3 LogMAR were recruited for BFT with microperimeter. Patients were assigned into 2 groups. In group A, BFT was performed on the patient’s spontaneous PRL. In group B, PRL was located between 2 adjacent loci with the highest light sensitivity and the lowest distance from the fovea. Two sets of 12 weekly BFT sessions were performed. Primary outcomes were: FS, VA and reading speed.

Results

Outcomes were statistically significantly better in group B. Mean percentage of FS at therapy end improved from 32 to 35% for group A and from 40 to 55% in group B. Mean VA improved from 1 to 0.86 in group A and from 1 to 0.84 in group B. Reading speed (wpm) improved from 56 to 58 in group A and from 63 to 89 in group B.

Conclusions

This study describes a reliable methodology of improving eccentric fixation stability using BFT in microperimetry, when the fixation training locus is individualized as the retinal area with best functional characteristics. Further studies are needed to validate its value in a larger scale of patients, at different stages of the disease, and its persistence over time.

Microperimetry for geographic atrophy secondary to age-related macular degeneration

Geographic atrophy (GA) is a progressive, advanced form of age-related macular degeneration leading to visual function impairment and irreversible vision loss. Standard clinical tests to evaluate visual function in patients with GA provide poor anatomic-functional correlation, whereas fundus imaging does not assess the visual function deficit. Microperimetry is a psychophysical visual function test that spatially maps retinal sensitivity and allows for identification of correlation of anatomic features with visual function. In this review, we present an overview of mesopic microperimetry for GA, including commercially available microperimetry devices, strategies to capture a mesopic microperimetry test, and strategies to assess and interpret microperimetry data in patients with GA. We demonstrate the importance of microperimetry data for assessing GA progression and for evaluating visual function loss through anatomic-functional correlations. Although valuable, current microperimetry tests require an extensive time commitment from the patient and examiner, and the development of faster, more reproducible and accessible methods is important to enable broader use of microperimetry in both clinical and research settings.

Usefulness of Eye Fixation Assessment for Identifying Type 2 Diabetic Subjects at Risk of Dementia

Type 2 diabetic (T2D) subjects have a significantly higher risk of developing mild cognitive impairment (MCI) and dementia than age-matched non-diabetic individuals. However, the accurate evaluation of cognitive status is based on complex neuropsychological tests, which makes their incorporation into the current standard of care for the T2D population infeasible. Given that the ability to maintain visual gaze on a single location (fixation) is hampered in Alzheimer’s disease (AD), the aim of the present study was: (1) To assess whether the evaluation of gaze fixation during fundus-driven microperimetry correlated with cognitive status in T2D subjects; (2) to examine whether the addition of fixational parameters to the assessment of retinal sensitivity increased the predictive value of retinal microperimetry in identifying T2D subjects with MCI. For this purpose, fixation parameters and retinal sensitivity were compared in three age-matched groups of T2D subjects: normocognitive (n = 34), MCI (n = 33), and AD (n = 33). Our results showed that fixation is significantly more unstable in MCI subjects than normocognitive subjects, and even more altered in those affected by AD (ANOVA; p < 0.01). Moreover, adding fixation parameters to retinal sensitivity significantly increases the predictive value in identifying those subjects with MCI: ROC (Receiver Operating Characteristic) Area 0.68 with retinal sensitivity alone vs. ROC Area 0.86 when parameters of fixation are added to retinal sensitivity (p < 0.01). In conclusion, our results suggest that fixational eye movement parameters assessed by fundus-microperimetry represent a new tool for identifying T2D subjects at risk of dementia.

Ocular effects of virtual reality headset wear in young adults

Virtual Reality (VR) headsets create immersion by displaying images on screens placed very close to the eyes, which are viewed through high powered lenses. Here we investigate whether this viewing arrangement alters the binocular status of the eyes, and whether it is likely to provide a stimulus for myopia development. We compared binocular status after 40-minute trials in indoor and outdoor environments, in both real and virtual worlds. We also measured the change in thickness of the ocular choroid, to assess the likely presence of signals for ocular growth and myopia development. We found that changes in binocular posture at distance and near, gaze stability, amplitude of accommodation and stereopsis were not different after exposure to each of the 4 environments. Thus, we found no evidence that the VR optical arrangement had an adverse effect on the binocular status of the eyes in the short term. Choroidal thickness did not change after either real world trial, but there was a significant thickening (≈10 microns) after each VR trial (p < 0.001). The choroidal thickening which we observed suggest that a VR headset may not be a myopiagenic stimulus, despite the very close viewing distances involved.