Tropicamide (1%): an effective cycloplegic agent for myopic children.

PURPOSE: To evaluate the cycloplegic effect of 1% tropicamide in myopic children and to determine whether its efficacy is associated with age, gender, iris color, ethnicity, magnitude of the refractive error, or latent error. METHODS: Four hundred sixty-nine children enrolled in the Correction of Myopia Evaluation Trial (COMET; a multicenter, randomized, double-masked clinical trial evaluating the rate of progression of juvenile-onset myopia in children wearing progressive-addition versus single-vision lenses) were given 1 drop of proparacaine in each eye followed 1 minute later by 1 drop of 1% tropicamide and then a second drop of 1% tropicamide 4 to 6 minutes later. Five accommodative responses to 20/100 letters located at 4 m and 33 cm were obtained in each eye with an autorefractor, 20 minutes after the second drop. Residual accommodation was calculated as the difference between the mean spherical equivalent responses obtained at the two distances. An examiner graded iris color, and ethnicity was reported by the children's parents or guardians. RESULTS: The mean residual accommodation was small: 0.38 +/- 0.41 diopters (D) in the right eye and 0.30 +/- 0.41 D in the left eye. Small but statistically significant differences in residual accommodation were associated with ethnicity, but not with any of the other factors. CONCLUSIONS: Tropicamide (1%) is an effective cycloplegic agent in myopic children.

Electrophysiological correlates of vernier and relative motion mechanisms in human visual cortex.

Vernier onset/offset thresholds were measured both psychophysically and with the steady-state VEP by introducing a series of horizontal breaks in a vertical square-wave luminance grating. Several diagnostic tests indicated that the first harmonic component of the evoked response generated by periodic modulation of offset gratings taps mechanisms that encode the relative position of spatial features. In the first test, a first harmonic component was only found with targets that contained transitions between collinear and noncollinear states. VEP vernier onset/offset thresholds obtained with foveal viewing were in the range of 15-22 arc sec. Control experiments with transitions between symmetrical, noncollinear patterns (relative motion) did not produce first harmonic components, nor did full-field motion of a collinear grating. A second series of experiments showed that VEP thresholds based on the first harmonic component of the vernier onset/offset response had an eccentricity dependence that was very similar to that found in a psychophysical discrimination task that required a left/right position judgment (vernier acuity). Other recordings showed that the first harmonic of the vernier onset/offset VEP was degraded by the introduction of a gap between stimulus elements, as is the displacement threshold. The vernier onset/offset target also produced a second harmonic component that was virtually identical to the one produced by a relative motion stimulus. Displacement thresholds based on these second harmonic components showed a more gradual decline with retinal eccentricity than did the first harmonic component elicited by vernier offsets. The second harmonic of the vernier onset/offset VEP was relatively unaffected by the introduction of gaps between the stimulus elements. The first and second harmonic components of the vernier onset/offset VEP thus tap different mechanisms, both of which support displacement thresholds that are finer than the resolution limits set by the spacing of the photoreceptors (hyperacuity).

Short-term repeatability of hand-held keratometry measurements.

PURPOSE: The Collaborative Longitudinal Evaluation of Ethnicity and Refractive Error (CLEERE) Study is a multi-center, observational investigation of ocular component and refractive error development in schoolchildren. Anterior corneal curvature is one of several ocular components which influence refractive status of the eye, and the CLEERE Study uses the Alcon Auto-Keratometer to measure corneal curvature. This report assesses the repeatability of this hand-held instrument. Previous studies have demonstrated the validity of the Alcon Auto-Keratometer; however, none have assessed its repeatability. METHODS: Sixty children were recruited from clinics affiliated with the Southern California College of Optometry and the University of Houston College of Optometry. Two sets of five hand-held keratometry measurements were obtained on the right eye of each child by one investigator at each site using the Alcon Auto-Keratometer. The two sets of measurements were performed at least 10 minutes apart. RESULTS: The mean differences between the two occasions were not significantly different from zero for either the flat or steep corneal curvature measurements regardless of the number of readings taken. The largest improvement in repeatability, primarily for the steep meridian, occurred when the first two readings were averaged. The addition of readings 3, 4, and 5 to the average did not substantially improve repeatability for either meridian. The 95% limits of agreement between the average of two readings on two occasions for the flat and steep meridians were +/-0.28 and +/-0.39 D, respectively. The 95% limits of agreement after two readings were +/-0.28, +/-0.20, and +/-0.24 D for the M, J0, and J45 vectors, respectively. CONCLUSION: The Alcon hand-held keratometer provides a repeatable measure of corneal curvature as demonstrated by short-term repeat agreement within +/-0.50 D. This level of repeatability can be achieved only by manually averaging two consecutive measurements.

Cycloplegia in African-American children.

PURPOSE: The selection of a cycloplegic agent depends on the desired outcome, the characteristics of the patient receiving the drug, and the associated risks. The Orinda Longitudinal Study of Myopia (OLSM) has used 1% tropicamide to assess the ocular components and cycloplegic refractions in a large cohort of predominantly Caucasian children. Although tropicamide has provided adequate cycloplegia and mydriasis for the OLSM cohort, conventional clinical wisdom and scientific investigations have suggested that tropicamide might not produce adequate cycloplegia and mydriasis for subjects with darker iris pigmentation. In this study one drop of 1% tropicamide followed by one drop of 1% cyclopentolate was used to determine their effectiveness in producing adequate cycloplegia and mydriasis for cycloplegic refraction and ocular component measurements in a group of African-American children. METHODS: Nineteen children [age range 5.5 to 15.6 years, mean 8.4 years +/- (SD) 2.5 years] were tested at Family HealthCare of Alabama, Eutaw, AL. Their accommodative responses were measured using a Canon R-1 autorefractor prior to and at 30, 45, and 60 min after instillation of one drop of 0.5% proparacaine, 1% tropicamide (Mydriacyl), and 1% cyclopentolate (Cyclogyl) in both eyes. A target of 20/155 letters in a 4x4 grid positioned behind a +6.50 diopter (D) Badal lens provided accommodative stimuli of 1.00 D, 2.00 D, and 4.00 D. RESULTS: All results are presented as mean +/-1 SD. Pupils, measured from video frames, dilated rapidly and maximally at 30 min after instillation of eye drops (7.3+/-0.5 mm) Predilation, the mean accommodative responses were 0.17+/-0.29 D for the 1.00 D stimulus, 1.01+/-0.40 D for the 2.00 D stimulus, and 2.77+/-0.74 for the 4.00 D stimulus. At 30 min after drop instillation, the responses were 0.07+/-0.14 D for the 1.00 D stimulus, 0.36+/-0.35 D for the 2.00 D stimulus, and 0.77+/-0.61 for the 4.00 D stimulus. Results were very similar at 45 and 60 min after drop instillation. CONCLUSIONS: Combining 1% tropicamide and 1% cyclopentolate was very effective in providing both cycloplegia and mydriasis adequate for ocular biometry and cycloplegic refractions 30 min after drop instillation in African-American children.

Screening for anisometropia in preschool children.

PURPOSE: A preschool vision screening program was reviewed to evaluate eccentric photoscreening (EP), visual acuity, and stereopsis in identifying anisometropia. METHODS: Patients referred by the screening were examined to assess efficacy of the three screening techniques in a population of preschool children. Testability and comparison of screening results to the classification of anisometropia (> or = 1 D) by retinoscopy obtained during a complete examination were evaluated. RESULTS: Although EP identified 94.5% of the anisometropic children as abnormal, only 27.8% were classified as anisometropic by EP. Of the anisometropic children, 36.1% failed acuity, but only 19.4% failed based on a 2 line or greater interocular acuity difference. Stereopsis correctly identified only 7.3% of anisometropes as abnormal. CONCLUSIONS: The sensitivity of EP in identifying anisometropic children as abnormal was superior to acuity and stereopsis, yet its ability to identify anisometropia specifically was poor. Anisometropia of low magnitude or that masked by the dead zone of the EP system was frequently classified as isometropic. Altering the EP referral criterion and/or taking photographs through adequate power plus lenses may improve the sensitivity for specifically identifying anisometropia. However, caution must be exercised when using EP to examine the prevalence of anisometropia in a population or if used to screen for only amblyogenic refractive errors (i.e., anisometropia), because many anisometropes will be missed, resulting in inaccurate prevalence data and significant underreferrals.

Development of Vernier acuity in childhood.

PURPOSE: To measure Vernier acuity and resolution development after 3 years of age. METHODS: Observers were 39 children with normal vision (aged 3 to 12 years), 10 adult observers with normal vision (aged 19 to 24 years), and 7 adults with amblyopia. Vernier acuity and resolution were measured using uncrowded static stimuli and a 3AFC psychophysical paradigm. Curve fitting was used to estimate A2, the age at which thresholds are twice asymptotic levels. RESULTS: Vernier acuity was hyperacute (i.e., finger than predicted from foveal cone size or spacing) in 3- to 4-year-old observers, but developed later (A2 = 5.6 +/- 1.5 years) than resolution acuity (A2 = 2.2 +/- 0.9 years). CONCLUSIONS: Children's Vernier thresholds are poorer than would be predicted solely from their decreased foveal photon capture. Therefore cortical immaturity may play a role in children's relative position acuity deficit. R/V ratios (resolution/Vernier thresholds) for the youngest age group are similar to those for adult nonstrabismic amblyopes, but better than for strabismic amblyopes.

Development of temporal contrast sensitivity in human infants.

The time course for the development of the temporal contrast sensitivity function in humans is uncertain. Some studies indicate that temporal contrast sensitivity is immature in infants. However, earlier work suggests that critical flicker fusion is adult-like by 2 months. We traced the development of temporal contrast sensitivity to uniform field flicker in 2-, 3- and 4-month-old infants using a modified preferential-looking technique that employed a rating scale. Two-month-old infants exhibited highest sensitivities at 1 and 2 Hz. Three- and 4-month infants exhibited peak sensitivity at 4 and 8 Hz, respectively. Overall temporal contrast sensitivity increased with age and the peak frequency shifted toward higher temporal frequencies. Using this paradigm, no infant subjects showed responses to 32 Hz, the highest temporal frequencies tested.

The development of accommodation.

We investigated the roles that blur, proximity and vergence cues play in the development of accommodation. Accommodative responses to targets incorporating one or more of these cues were measured for four adults and eight infants at 1.5 and 3 months of age using eccentric photorefraction. Adults showed accurate accommodation to blur cues, and variable accommodation with proximity cues alone. Some infants at both ages showed fixed accommodative responses to all stimulus conditions. Others responded consistently in the correct direction for pattern targets at different distances, but made poorer responses when blur was presented in conflict with distance. Binocular viewing improved the accommodative responses in only some infants.

Visibility of motion in infant vernier displays, using adult subjects.

Motion is frequently incorporated in stimuli used for psychophysical testing of vernier acuity in infants and young children. In such stimuli, detection of the vernier offset is necessary in order to perceive the motion. Research described in this report tested whether the perception of a vernier offset is sufficient to signal the stimulus motion in adults. We measured how motion detectability changed as a function of vernier offset for two adult subjects, using a stimulus similar to that employed by other authors to measure vernier acuity in infants and children. Motion visibility varied with offset size, achieving a detectability of motion (d') of 0.95 (comparable to two-alternative forced-choice thresholds) at stimulus offsets of 16-19 s arc. In comparison to the motion, the stimulus offset itself was much easier to see, being detectable on 95-100% of trials with the smallest offset, 6.6 s arc. This distinction, between the visibility of motion and the visibility of the vernier offset itself, should be considered when interpreting vernier results using such displays, especially in infants and children for whom motion may be the attractive cue.

[Measuring vernier acuity and motion perception with the parameter sweep VEP]. / Messung der Noniussehschärfe und der Bewegungswahrnehmung mit dem Parameter-Sweep-VEP.

BACKGROUND: The visual abilities of infants and small children, who are unable to communicate verbally, can be determined with "objective" visual acuity tests as, e.g., preferential looking (PL) or visual evoked potentials (VEP). Both methods provide an estimate of grating visual acuity, but are unable to determine optotype visual acuity. Grating acuity, however, is not an optimum indicator for visual performance, as it is less affected than optotype acuity by pathological changes. The diagnostic relevance of objective methods may be improved by testing visual functions that are more strongly degraded by a malfunction of the fovea than is grating acuity. Visual functions such as vernier acuity and relative motion sensitivity are potential candidates. METHODS: Characteristic properties of vernier- and motion-VEP have been determined on adult subjects with a rapid-sweep-technique at various eccentricities. RESULTS: Both vernier and motion stimuli elicited VEP-responses at the 2nd harmonic (F2) of the stimulus frequency. A VEP-response at the fundamental frequency (F1) could be recorded with the vernier stimulus only. Foveal VEP-thresholds were very similar to psychophysical thresholds lying in the range from 11 to 25 arcsecs. The eccentricity dependence of the VEP-threshold recorded with vernier- and motion stimuli shows different cortical magnifications and supports the notion that the F1 response is related to the detection of the vernier offset, whereas the F2 response is generated by motion components of the stimuli. CONCLUSIONS: Vernier and relative motion-related VEP thresholds can be recorded with the steady-state VEP. They may provide more sensitive tests of foveal vision loss than grating visual acuity tests.

Resistance to occlusion: sensitivity to induced blur in 6- to 12-month-old infants.

BACKGROUND: Resistance to occlusion and fix and follow are often used to make inferences about the acuity of young children. In this study, the acuity of 6- to 12-month-old infants was degraded monocularly to elicit resistance to occlusion or loss of fixation. METHODS: Occlusion foils and optical blur were used to simulate monocular acuity reduction. Two different targets, a mechanical rabbit and a "flickering" light were used for fixation. RESULTS: More infants resisted occlusion when viewing the rabbit than the light. Resistance to occlusion was observed in the majority of infants when acuity was degraded to the level expected for 6 to 12-month-old infants (20/80-20/300). CONCLUSIONS: The sensitivity of resistance to occlusion is influenced by the test target and if an interesting target is used, resistance to occlusion may be a useful tool for detecting interocular acuity differences in 6- to 12-month-old infants.

1% Cyclopentolate hydrochloride: another look at the time course of cycloplegia using an objective measure of the accommodative response.

The time course of cycloplegia was measured by monitoring residual accommodation after the application of 1 drop (29.3 microliters) of 1% cyclopentolate hydrochloride. Three different measures of residual accommodation were made, one objective assessment with an optometer, and two subjective assessments similar to those used by previous investigators. Pupil diameter was also measured in a subgroup of individuals to compare the time course of the induced mydriasis to that of the cycloplegia. When residual accommodation is measured objectively, maximum cycloplegia occurs 10 min after the application of 1% cyclopentolate hydrochloride in individuals with light irides. This result suggests that the standard clinical protocol of delaying refraction 30 to 60 min after the application of cyclopentolate hydrochloride may be too conservative for individuals with light irides. For individuals with dark irides, 30 to 40 min is required for maximum cycloplegia, and the magnitude of residual accommodation in these individuals is similar to that found in light iris individuals at 10 min. When subjective measures are used to estimate residual accommodation, more accommodation is present and the time at which maximum cycloplegia occurs is delayed for individuals with light irides. These results are in agreement with previous studies using subjective techniques. Regardless of iris color or measurement method, the time course for pupil dilation is not the same as the time course for cycloplegia.

Orientation selectivity of 3-month-old infants.

A modification of the visual evoked potential (VEP) technique, first employed by Braddick, Wattam-Bell and Atkinson [(1986) Nature, London, 320, 617-619] was used to estimate the orientation selectivity of 3-month-old infants. The orientation-selective VEP was recorded in response to various changes in the orientation of a square-wave grating. The magnitude (the square root of the power of the FFT) at the frequency of orientation change was assumed to represent the response to the change in grating orientation. Orientation sensitivity was then estimated by plotting the magnitude of the FFT at the frequency of orientation change as a function of the log of the orientation change in degrees. For each individual, the data were fit by nonlinear regression and threshold was defined as the largest orientation angle for which the magnitude of the FFT was zero. The results suggest that the orientation selectivity of 3-month-old infants (1.33 deg) is similar to that of adults (1.13 deg) tested with the same stimulus parameters (1 c/deg, 9 Hz). However, when adults are tested with stimulus parameters selected to optimize their VEP response (4 c/deg, 18 Hz) instead of those which optimize the infant's response, the orientation discrimination of adults improves by a factor of 2 (0.53 deg). The results obtained from adults under optimum stimulus conditions (4 c/deg, 18 Hz) approach the estimates reported in the literature for static stimuli.

Effects of interocular suppression on spectral sensitivity.

A stable form of interocular suppression, referred to as "permanent suppression," can be produced by presenting a contoured field to one eye and a spatially homogenous field to the fellow eye, a viewing condition analogous to the classic "hole-in-the-hand" illusion. We examined the relation between permanent suppression and binocular rivalry suppression by comparing the changes in the increment-threshold spectral sensitivity function produced by these two forms of suppression. Permanent suppression produced a reduction in spectral sensitivity; however, in contrast to binocular rivalry suppression, the sensitivity alterations associated with permanent suppression were independent of the test-probe wavelength. The different patterns of sensitivity loss observed during binocular rivalry and permanent suppression indicate that different neural mechanisms mediate these two forms of interocular suppression.

Testing stereopsis in the preschool child: is it clinically useful?

The evaluation of stereoacuity should provide an unambiguous assessment of binocular function in infants and young children. Unfortunately, clinical measures of stereopsis in these young patients often result in stereotheresholds poorer than the criteria suggested to differentiate normal from anomalous binocular vision. Thus, two experiments were conducted to determine whether the large stereothresholds frequently demonstrated on tests designed for young children are diagnostic of normal binocular function in preschool children. The first experiment investigated the salience of the monocular cues in the Lang and Frisby stereotests in normal preschool children (2 to 5 years old). None of the children who passed either the Frisby or the Lang stereotest under binocular conditions were able to pass either test monocularly, even after passing the test binocularly. In the second experiment, preschool children with abnormal binocular vision were tested with the Lang and Frisby stereotests to determine if large disparities (730 to 800 seconds of arc [arcsec]) could be passed without normal binocular vision. None of the children with strabismus passed either stereotest. However, two children with anisometropia passed the Frisby test and one of these children also passed the Lang test. These results suggest that in the absence of other clinical findings to the contrary, the demonstration of gross stereopsis with either the Frisby (730 arcsec) or Lang (733 or 800 arcsec) test in the preschool child implies normal binocular function. Thus, clinical tests of stereopsis for infants and preschool children, like those used routinely for adults, can provide evidence of binocular function without approaching stereothreshold.

Motion coherence in infants.

Two perpendicular square-wave gratings (i.e. plaids) were used to investigate motion coherence in 1-, 2- and 3-month-old infants. The direction of motion of the stimulus was judged by an adult observer, on the basis of the induced optokinetic nystagmus (OKN) in an eight-alternative eye movement voting paradigm. Infants as young as 1 month of age demonstrated OKN in the direction consistent with motion coherence. There was no significant difference among the performances of 1-, 2- or 3-month-old infants. However, the percentage of trials on which infants demonstrated OKN in the coherence direction was less than that obtained from adults tested with the same paradigm. Movshon, Adelson, Gizzi and Newsome (1985) have suggested that the cohered motion of a complex pattern may be processed after the orientation of the components of the pattern, perhaps in the middle temporal area of the visual cortex (MT). The present results suggest that either young infants and adults process the motion of complex patterns similarly or that the OKN consistent with the direction of motion coherence observed in infants involves subcortical nonoriented visual centers rather than the higher level process which is presumed to occur in adults.

The visually evoked potential in response to vernier offsets in infants.

The visually evoked potential (VEP) was recorded from infants (1 month 25 days to 13 months 3 days) in response to vernier offsets, motion displacements, and a stationary stimulus which served as a noise control. The records were analyzed by five masked adult observers familiar with VEP recordings using a signal detection method. The results suggest that a VEP can be recorded from infants in response to a vernier offset and the response resembles that obtained from adults tested with the same procedure. However, unlike adults, infants also showed a response to a motion displacement of the same magnitude suggesting that infants may not show the same specificity for the break in colinearity characteristic of the adult VEP.

Contour interaction function in the preschool child.

Contour interaction was investigated in 12 preschool children 3 to 4 years of age, and compared to the results obtained from 5 normal adults tested under an identical paradigm. Observers viewed the display from a distance at which they could identify the location of a gap (up or down) in an isolated C correctly on 90 to 95% of the trials. The isolated C and C's with bars tangentially located at various positions above and below the test optotype were intermixed randomly. Percent correct was plotted as a function of the angular subtense of the gap width of the test optotype. A significant decrease in performance was found when the bars were positioned at 0.71 to 1.42 times the angular subtense of the gap for both the preschool children and the adults. The results suggest that preschool children demonstrate contour interaction that is quantitatively similar to adults. Because the spacing of letters on standard acuity charts is typically larger than the range over which contour interaction occurs, the poorer acuity often measured with charts compared to isolated letter presentation in preschool children suggests that factors other than contour interaction (perhaps attentional factors) are involved.

Contour interaction in the preschool child.

Preschool children show poorer visual acuity when tested with multiple optotypes than when tested with isolated optotypes. This difference in performance could be the result of contour interaction or the greater distractions imposed by a multiple optotype display, which may be beyond a young child's ability. To differentiate between these alternatives, isolated and surrounded visual acuity were measured in children aged 2 to 7 years by pairing a Landolt C with an O. The surrounded optotypes were identical to the isolated optotypes with the exception of the flanking bars located at 2.5 times the minimum angle of resolution (MAR) of the optotype. A two-alternative forced choice interleaved paradigm was used to measure surrounded and isolated visual acuity defined as 75% correct. When the test demands were equated by measuring isolated and surrounded acuity using a single optotype, poorer visual acuity was obtained with surrounded optotypes. This suggests that preschool children, like adults, show contour interaction.