An Italian Translation and Validation of the near Activity Visual Questionnaire (NAVQ)

Cortical dynamics in visual areas induced by the first use of multifocal contact lenses in presbyopes

A common non-spectacle strategy to correct presbyopia is to provide simultaneous images with multifocal optical designs. Understanding the neuroadaptation mechanisms behind multifocal devices usage would have important clinical implications, such as predicting whether patients will be able to tolerate multifocal optics. The aim of this study was to evaluate the brain correlates during the initial wear of multifocal contact lenses (CLs) using high-density visual evoked potential (VEP) measures. Fifteen presbyopes (mean age 51.8 ± 2.6 years) who had previously not used multifocal CLs were enrolled. VEP measures were achieved while participants looked at arrays of 0.5 logMAR Sloan letters in three different optical conditions arranged with CLs: monofocal condition with the optical power appropriate for the distance viewing; multifocal correction with medium addition; and multifocal correction with low addition. An ANOVA for repeated measures showed that the amplitude of the C1 and N1 components significantly dropped with both multifocal low and medium addition CL conditions compared to monofocal CLs. The P1 and P2 components showed opposite behavior with an increase in amplitudes for multifocal compared to monofocal conditions. VEP data indicated that multifocal presbyopia corrections produce a loss of feedforward activity in the primary visual cortex that is compensated by extra feedback activity in extrastriate areas only, in both early and late visual processing.

2022 Glenn A. Fry Award lecture: Enhancing clinical assessment for improved ophthalmic management

ABSTRACT

Detailed clinical assessment is critical to allow sensitive evaluation of the eye and its management. As technology advances, these assessment techniques can be adapted and refined to improve the detection of pathological changes of ocular tissue and their impact on visual function. Enhancements in optical medical devices including spectacle, contact, and intraocular lenses have allowed for a better understanding of the mechanism and amelioration of presbyopia and myopia control. Advancements in imaging technology have enabled improved quantification of the tear film and ocular surface, informing diagnosis and treatment strategies. Miniaturized electronics, large processing power, and in-built sensors in smartphones and tablets capacitate more portable assessment tools for clinicians, facilitate self-monitoring and treatment compliance, and aid communication with patients. This article gives an overview of how technology has been used in many areas of eye care to improve assessments and treatment and provides a snapshot of some of my studies validating and using technology to inform better evidence-based patient management.

Translation and validation of convergence insufficiency symptom survey to Italian: Psychometric results

PURPOSE

This study aimed to translate the Convergence Insufficiency Symptom Survey (CISS) into the Italian language and assess psychometric properties of the translated questionnaire (CISS_I).

METHODS

The CISS_I was arranged according to guidelines for a comprehensive multistep methodologic process for translating, adapting, and validating psychometric instruments in health care research. The CISS_I questionnaire was administered to 103 volunteers (21.8 ± 2.2 years), students in higher education, at two different times. A complete optometric evaluation was performed including subjective refraction, best corrected visual acuity, near point of convergence, prism fusional ranges to blur, diplopia and recovery, TNO stereo test and prism cover test for measurement of heterophoria.

RESULTS

The performance of the CISS_I in terms of validity showed some points of weakness. Sensitivity was 42%, specificity was 74%, positive predictive value was 27% and negative predictive value was 85%. The area under the ROC curve was 0.672. On the contrary, the results showed good internal consistency of the CISS_I (Cronbach's alpha - α=0.89) and good test-retest reliability (ICC = 0.92). Rasch analysis showed good model fit (all items, except one, with infit and outfit mean square between 0.7 and 1.3), good measurement precision (person separation = 2.66) and good targeting -0,81 logits but also some evidence of multidimensionality.

CONCLUSIONS

The CISS_I showed some point of weakness in terms of validity but also good psychometric properties and has been shown to be applicable to an Italian speaking population to quantify the visual discomfort associated with near vision in higher education students. The results show that high CISS_I score is not necessarily linked to convergence insufficiency, while low scores can exclude the presence of this anomaly. The CISS_I can help in interpreting and monitoring convergence insufficiency symptoms in already identified subjects, but it is not suitable for screening a general population of young adults.

Italian translation, validation, and repeatability of Standard Patient Evaluation of Eye Dryness (SPEED) Questionnaire

PURPOSE

The assessment of symptoms of dry eye disease using a questionnaire is an effective and simple method of quantifying symptoms. The aim of this study was to translate the SPEED questionnaire and adapt it for the Italian language and verify the main psychometric performance of the translated version, including repeatability and agreement.

METHODS

The SPEED questionnaire was translated into Italian following a standard methodology. The resulting questionnaire was administered to 206 adult participants in order to perform a validation analysis. A subgroup of 82 participants was retested after one week to give a repeatability and agreement assessment.

RESULTS

Internal consistency showed an alpha of 0.852 (95% CI 0.818-0.881) and no unnecessary items. The factor analysis showed a saturation for three main factors related to (i) Dryness and Soreness, (ii) Fatigue, and (iii) Burning. Repeatability was high, with a CCC of 0.896 (95% CI 0.844-0.931). Agreement analysis showed no significant bias between sessions and an interval of agreement of 5 points for SPEED score.

CONCLUSION

The translation and adaptation of the SPEED questionnaire for the Italian language have demonstrated good psychometric properties for the translated questionnaire, confirming and expanding the original psychometric characteristics. Consequently, the SPEED questionnaire could be used to measure the presence of symptoms of dry eye quantitatively.

Viewing distance of smartphones in presbyopic and non-presbyopic age

PURPOSE

The aim of this cross-sectional observational study was to measure habitual viewing distance with smartphones in individuals of different ages, and to identify factors influencing viewing distance.

MATERIAL

Gender, reading position, forearm length, ametropia, correction modality, and near vision quality were investigated as factors affecting viewing distance. Participants were asked to read a typical text message on their own smartphone, while sitting and standing. A total of 233 subjects (129 females and 104 males), aged from 16 to 90 years old, were included and divided in two groups: 131 non-presbyopes (median 21.1, range 16 - 39), and 102 presbyopes (median 54.5, range 42 - 90).

RESULTS

Mean viewing distance was 36.1 ± 7.2 cm while sitting, and 37.4 ± 6.8 cm while standing (P < 0.05), and 36.8 +/- 6.6 cm overall. The average viewing distance was 35.0 ± 6.4 cm in non-presbyopes, and 39.0 ± 6.1 cm in presbyopes (P < 0.05). The average viewing distance was 34.7 ± 6.2 cm in females, and 38.2 ± 6.3 cm in males (P <  0.001).

CONCLUSIONS

Significant differences between males and females were observed, due to the different average body size between the two gender groups. Average viewing distance with smartphones in presbyopes matched approximately to the typical near reading distance of 40 cm. In the non-presbyopic group, the accommodative demand when reading a smartphone was slightly higher than in the presbyopic group. High variability was observed in both age groups, without a statistically significant correlation with other assessed factors as reading position, ametropia, correction modality, and near vision quality.

Accuracy, inter-observer and intra-observer reliability in topography assessment of multifocal contact lens centration

PURPOSE

To evaluate the accuracy and reliability (inter and intra-observer) of a method to assess multifocal contact lenses (MCLs) centration using a corneal topography unit.

METHOD

Daily-disposable MCLs (Fusion 1 day Presbyo) were fitted on both eyes of the subjects. For each lens fit a slit lamp digital picture and videokeratograph image were taken in a rapid but randomised sequence. Photo-editing software was used to assess the position of the MCL centre with respect to pupil centre as taken from the slit lamp photograph. The position of the MCL centre was automatically detected as the point of maximum curvature from the videokeratography. Three further manual and qualitative procedures to detect MCL centre, comparing a template of CLs optic zones to the videokeratographic image were performed by 4 practitioners using 3 different algorithms to represent the topographic map. Each manual reading was repeated 3 times.

RESULTS

Twenty-two subjects (11 males) aged 22.8 ± 1.9 years (range 20.8-27.0 years) were recruited. The accuracy of the 4 topographic assessments in determining the centre coordinates of the MCL with respect to SL assessment was good: no differences were found in the left eyes and although in the right eyes a more temporal and superior position of MCLs was determined (paired t-test, p < 0.05) the difference was clinically negligible (0.16 ± 0.36 mm horizontally, 0.23 ± 0.48 vertically). Amongst the 4 practitioners one-way Anova for repeated measures showed no differences for any of the 3 manual assessments. Intra-class correlation coefficient was calculated among the 3 readings for each manual procedure and was very good (between 0.75 and 0.98) in 3 practitioners and moderate (between 0.49 and 0.92) in the fourth.

CONCLUSIONS

The assessment of MCL centration by performing corneal topography over the MCL is an accurate method. Furthermore, inter and intra-practitioner reliability showed by manual procedures appeared very good.

Pattern of reading eye movements during monovision contact lens wear in presbyopes

Monovision can be used as a method to correct presbyopia with contact lenses (CL) but its effect on reading behavior is still poorly understood. In this study eye movements (EM) were recorded in fifteen presbyopic participants, naïve to monovision, whilst they read arrays of words, non-words, and text passages to assess whether monovision affected their reading. Three conditions were compared, using daily disposable CLs: baseline (near correction in both eyes), conventional monovision (distance correction in the dominant eye, near correction in the non-dominant eye), and crossed monovision (the reversal of conventional monovision). Behavioral measures (reading speed and accuracy) and EM parameters (single fixation duration, number of fixations, dwell time per item, percentage of regressions, and percentage of skipped items) were analyzed. When reading passages, no differences in behavioral and EM measures were seen in any comparison of the three conditions. The number of fixations and dwell time significantly increased for both monovision and crossed monovision with respect to baseline only with word and non-word arrays. It appears that monovision did not appreciably alter visual processing when reading meaningful texts but some limited stress of the EM pattern was observed only with arrays of unrelated or meaningless items under monovision, which require the reader to have more in-depth controlled visual processing.

Immediate cortical adaptation in visual and non-visual areas functions induced by monovision

KEY POINTS

Monovision is an optical correction for presbyopes that consists of correcting one eye for far distance and the other for near distance, creating a superimposition of an in-focus with a blurred image. Brain adaptation to monovision was studied in unexperienced observers by measuring visual evoked potentials from 64-channels. The first clear effect of monovision on visual evoked potentials was the C1 amplitude reduction, indicating that the unilateral blurring induced by monovision reduces feed-forward activity in primary visual area. Monovision led also to an increased amplitude of the P1 and pP1 components, with the latter originating in prefrontal regions. This effect probably works as an attentional compensatory activity used to compensate for the degraded V1 signal.

ABSTRACT

A common and often successful option to correct presbyopia with contact lenses is monovision. This is an unbalanced correction across the two eyes where one eye is corrected for far vision and the other eye is corrected for near vision. Monovision is therefore a form of acquired anisometropia that causes a superimposition of an in-focus image with a blurred image. In spite of this visual anisometropia, monovision has been successfully used for many decadesl however the brain mechanism supporting monovision is not well understood. The present study aimed to measure the visual evoked potentials with a high-density electrode array (64-channel) in a group of presbyopes and to provide a detailed spatiotemporal analysis of the cortical activity after a short period of adaptation to monovision with contact lenses. When compared with a balanced eye near correction, monovision produced both a clear reduction of the earliest visual evoked potential components, the C1 and the N1, and an amplitude increase of the P1 and pP1. These results indicate that the unilateral blurring induced by wearing monovision contact lenses reduces feed-forward activity in the primary visual area and feedback activity in extrastriate areas (C1 and N1 reduction). Interestingly, other brain activities in both extrastriate visual areas (the P1 component) and in the anterior insula (the pP1 component) appear to compensate for this dysfunction, increasing their activity during monovision. These changes confirm the presence of fluid brain adaptation in visual and non-visual areas during monocular interferences.