A technique to train new oculomotor behavior in patients with central macular scotomas during reading related tasks using scanning laser ophthalmoscopy: immediate functional benefits and gains retention

BACKGROUND: Reading with a central scotoma involves the use of preferred retinal loci (PRLs) that enable both letter resolution and global viewing of word. Spontaneously developed PRLs however often privilege spatial resolution and, as a result, visual span is commonly limited by the position of the scotoma. In this study we designed and performed the pilot trial of a training procedure aimed at modifying oculomotor behavior in subjects with central field loss. We use an additional fixation point which, when combined with the initial PRL, allows the fulfillment of both letter resolution and global viewing of words. METHODS: The training procedure comprises ten training sessions conducted with the scanning laser ophthalmoscope (SLO). Subjects have to read single letters and isolated words varying in length, by combining the use of their initial PRL with the one of an examiner's selected trained retinal locus (TRL). We enrolled five subjects to test for the feasibility of the training technique. They showed stable maculopathy and persisting major reading difficulties despite previous orthoptic rehabilitation. We evaluated ETDRS visual acuity, threshold character size for single letters and isolated words, accuracy for paragraphed text reading and reading strategies before, immediately after SLO training, and three months later. RESULTS: Training the use of multiple PRLs in patients with central field loss is feasible and contributes to adapt oculomotor strategies during reading related tasks. Immediately after SLO training subjects used in combination with their initial PRL the examiner's selected TRL and other newly self-selected PRLs. Training gains were also reflected in ETDRS acuity, threshold character size for words of different lengths and in paragraphed text reading. Interestingly, subjects benefited variously from the training procedure and gains were retained differently as a function of word length. CONCLUSION: We designed a new procedure for training patients with central field loss using scanning laser ophthalmoscopy. Our initial results on the acquisition of newly self-selected PRLs and the development of new oculomotor behaviors suggest that the procedure aiming primarily at developing an examiner's selected TRL might have initiated a more global functional adaptation process

The Effect of Fractal Contact Lenses on Peripheral Refraction in Myopic Model Eyes

Purpose: To test multizone contact lenses in model eyes: Fractal Contact Lenses (FCLs), designed to induce myopic peripheral refractive error (PRE). Methods: Zemax ray-tracing software was employed to simulate myopic and accommodation-dependent model eyes fitted with FCLs. PRE, defined in terms of mean sphere M and 90–180 astigmatism J180, was computed at different peripheral positions, ranging from 0 to 35 in steps of 5, and for different pupil diameters (PDs). Simulated visual performance and changes in the PRE were also analyzed for contact lens decentration and model eye accommodation. For comparison purposes, the same simulations were performed with another commercially available contact lens designed for the same intended use: the Dual Focus (DF). Results: PRE was greater with FCL than with DF when both designs were tested for a 3.5 mm PD, and with and without decentration of the lenses. However, PRE depended on PD with both multizone lenses, with a remarkable reduction of the myopic relative effect for a PD of 5.5 mm. The myopic PRE with contact lenses decreased as the myopic refractive error increased, but this could be compensated by increasing the power of treatment zones. A peripheral myopic shift was also induced by the FCLs in the accommodated model eye. In regard to visual performance, a myopia under-correction with reference to the circle of least confusion was obtained in all cases for a 5.5 mm PD. The ghost images, generated by treatment zones of FCL, were dimmer than the ones produced with DF lens of the same power. Conclusions: FCLs produce a peripheral myopic defocus without compromising central vision in photopic conditions. FCLs have several design parameters that can be varied to obtain optimum results: lens diameter, number of zones, addition and asphericity; resulting in a very promising customized lens for the treatment of myopia progression.This research was supported by the Ministerio de Economia y Competitividad (grant FIS2011-23175), the Generalitat Valenciana (grant PROMETEO2009-077) and the Universitat Politecnica de Valencia (grant INNOVA SP20120569), Spain.Rodríguez Vallejo, M.; Benlloch Fornés, JI.; Pons Martí, A.; Monsoriu Serra, JA.; Furlan, WD. (2014). The Effect of Fractal Contact Lenses on Peripheral Refraction in Myopic Model Eyes. Current Eye Research. 39(12):1-10. https://doi.org/10.3109/02713683.2014.903498S110391

Visual consciousness in health and disease

Conscious experience is an essential part of normal human life and interaction with the environment. Yet the nature of consciousness and conscious perception remains a mystery. Because of its subjective nature, consciousness has been difficult to investigate scientifically, but clues have been gained through studies involving patients with cortical lesions. During the past decade, the development of event-related fMRI has provided insights into aspects of conscious perception in control subjects and patients with cortical lesions by correlating awareness and performance with neural activity during visual tasks. This article reviews how recent research has advanced understanding of conscious perception, its relationship to neural activity and visual performance, and how this relationship can be altered by visual dysfunction. It also presents recent research about how conscious awareness of vision might be represented at a neural level in the central nervous system

The usefulness of multimodal imaging for differentiating pseudopapilloedema and true swelling of the optic nerve head: A review and case series

Ophthalmic practitioners have to make a critical differential diagnosis in cases of an elevated optic nerve head. They have to discriminate between pseudopapilloedema (benign elevation of the optic nerve head) and true swelling of the optic nerve head. This decision has significant implications for appropriate patient management. Assessment of the optic disc prior to the advanced imaging techniques that are available today (particularly spectral domain optical coherence tomography and fundus autofluorescence), has mainly used diagnostic tools, such as funduscopy and retinal photography. As these traditional methods rely on the subjective assessment by the clinician, evaluation of the elevated optic nerve head to differentiate pseudopapilloedema from true swelling of the optic nerve head can be a challenge in clinical practice with patients typically referred for further neuroimaging investigation when the diagnosis is uncertain. The use of multimodal ocular imaging tools such as spectral domain optical coherence tomography, short wavelength fundus autofluorescence and ultrasonography, can potentially aid in the differentiation of pseudopapilloedema from true swelling of the optic nerve head, in conjunction with other clinical findings. By doing so, unnecessary patient costs and anxiety in the case of pseudopapilloedema can be reduced, and appropriate urgent referral and management in the case of true swelling of the optic nerve head can be initiated

Reconciling visual field defects and retinal nerve fibre layer asymmetric patterns in retrograde degeneration: an extended case series

Background: Accurate diagnosis in patients presenting with lesions at various locations within the visual pathway is challenging. This study investigated functional and structural changes secondary to such lesions to identify patterns useful to guide early and effective management. Methods: Over 10,000 records from patients referred for optic nerve head assessment were reviewed and 31 patients with a final diagnosis of likely neuropathic lesions posterior to the eye were included in the current study. Fundus photographs, optic coherence tomography images and visual field tests were evaluated for changes with respect to retinal nerve fibre layer topography and prediction of structure-function paradigms. Emerging clinical patterns were examined for their consistency with the likely anatomical origin of the underlying insult in the presence of varying diagnoses. Results: Data from patients with lesions along the visual system allowed identification of retinal nerve fibre layer asymmetry correlated with visual field defects and ganglion cell analysis. Bilateral discordance in retinal nerve fibre loss easily discernible from an altered pattern of the temporal-superior-nasal-inferior-temporal curve was characteristic for post-chiasmal lesions. These sometimes-subtle changes supported diagnosis in cases with multiple aetiologies or with ambiguous visual field analysis and/or ganglion cell loss. Conclusion: Intricate knowledge of the retinal architecture and projections allows coherent predictions of functional and structural deficits following various lesions affecting the visual pathway. The integration of adjunct imaging and retinal nerve fibre layer thinning will assist clinicians to guide clinical investigations toward a likely diagnosis in the light of significant individual variations. The case series presented in this study aids in differential diagnosis of retrograde optic neuropathies by using retinal nerve fibre layer asymmetric patterns as an important clinical marker

Can fixation instability improve text perception during eccentric fixation in patients with central scotomas?

Background: Oculomotor behaviour was investigated in 14 patients with central scotomas from age related macular degeneration (AMD) or Stargardt’s disease. A scanning laser ophthalmoscope (SLO) was used to project letters and words onto the retina and to assess fixation behaviour. Five patients reported while deciphering letters that they needed to “move their eye” to prevent the image from vanishing. The observation of the SLO fundus images revealed that the gradual disappearance of the stimulus did not result from a transient projection of the word in the lesion. This prompted the authors to investigate, in an experimental setting, whether purposeful changes in fixation position could improve the perception of an eccentrically fixated text stimulus. Methods: Twenty normal subjects were asked to alternate fixation, every three to four seconds, between two vertically aligned dots, spaced 10° apart, and to report any changes in the perception of a laterally located letter, 1.5° in height, 7° apart and equidistant between the two fixation spots. Results: Nineteen subjects reported a transient refreshment of the letter image immediately after the realisation of a saccade. Improved perception lasted approximately a second. With persistent fixation, they noted a rapid fading effect that reduced letter recognition. Conclusion: These observations suggest that ocular instability during eccentric viewing can have a functional advantage, probably related to counteracting Troxler’s phenomenon. In addition to alternating between PRLs, it appears that saccades related to fixation instability might be valuable and improve text perception in individuals with a central scotoma and eccentric fixation. This possibility should be taken into consideration when conducting visual rehabilitation procedures

Spectacle lens compensation in the pigmented guinea pig

When a young growing eye wears a negative or positive spectacle lens, the eye compensates for the imposed defocus by accelerating or slowing its elongation rate so that the eye becomes emmetropic with the lens in place. Such spectacle lens compensation has been shown in chicks, tree-shrews, marmosets and rhesus monkeys. We have developed a model of emmetropisation using the guinea pig in order to establish a rapid and easy mammalian model. Guinea pigs were raised with a +4D, +2D, 0D (plano), −2D or −4D lens worn in front of one eye for 10 days or a +4D on one eye and a 0D on the fellow eye for 5 days or no lens on either eye (littermate controls). Refractive error and ocular distances were measured at the end of these periods. The difference in refractive error between the eyes was linearly related to the lens-power worn. A significant compensatory response to a +4D lens occurred after only 5 days and near full compensation occurred after 10 days when the effective imposed refractive error was between 0D and 8D of hyperopia. Eyes wearing plano lenses were slightly more myopic than their fellow eyes (−1.7D) but showed no difference in ocular length. Relative to the plano group, plus and minus lenses induced relative hyperopic or myopic differences between the two eyes, inhibited or accelerated their ocular growth, and expanded or decreased the relative thickness of the choroid, respectively. In individual animals, the difference between the eyes in vitreous chamber depth and choroid thickness reached ±100 and ±40 μm, respectively, and was significantly correlated with the induced refractive differences. Although eyes responded differentially to plus and minus lenses, the plus lenses generally corrected the hyperopia present in these young animals. The effective refractive error induced by the lenses ranged between −2D of myopic defocus to +10D of hyperopic defocus with the lens in place, and compensation was highly linear between 0D and 8D of effective hyperopic defocus, beyond which the compensation was reduced. We conclude that in the guinea pig, ocular growth and refractive error are visually regulated in a bidirectional manner to plus and minus lenses, but that the eye responds in a graded manner to imposed effective hyperopic defocus

Retinoic acid signals the direction of ocular elongation in the guinea pig eye

A growing eye becomes myopic after form deprivation (FD) or compensates for the power and sign of imposed spectacle lenses. A possible mediator of the underlying growth changes is all-trans retinoic acid (RA). Eye elongation and refractive error (RE) was manipulated by raising guinea pigs with FD, or a spectacle lens worn on one eye. We found retinal-RA increased in myopic eyes with accelerated elongation and was lower in eyes with inhibited elongation. RA levels in the choroid/sclera combined mirrored these directional changes. Feeding RA (25 mg/kg) repeatedly to guinea pigs, also resulted in rapid eye elongation (up to 5 times normal), and yet the RE was not effected. In conclusion, RA may act as a signal for the direction of ocular growth