Crowding can impact both low and high contrast visual acuity measurements.

The adverse impact of adjacent contours on letter visual acuity is known as crowding but there is conflicting evidence that foveal crowding may be reduced or disappears under low contrast conditions. Potential differences in foveal crowding with contrast on clinical measurements of visual acuity, including test-retest repeatability, were assessed. Visual acuity was measured at the fovea on adult participants with normal vision under three different contrast levels (- 90, - 10 and - 5%). Three rows of 5 letters, each row differing in size by 0.05 logarithm of the minimum angle of resolution (logMAR) from largest to smallest were displayed at the center of a monitor. Crowding was varied by varying the separation between horizontally adjacent letters from 100% optotype size to 50%, 20% and 10% optotype size. Inter-row spacing was proportional to optotype size. Observers read the letters on the middle row only. Measurements continued by reducing the size of the letters until 3 or more errors were made and were repeated on two separate days. Visual acuity worsened as both letter contrast decreased and inter-optotype separation reduced (expressed as a percentage of letter width). When expressed in minutes of arc of separation the impact of crowding was the same across all contrasts. Crowding occurs for both high and low contrast charts and should be considered when assessing low contrast visual acuity. Test-retest repeatability showed little or no dependence on either contrast or inter-optotype separation.

Differences in stereoacuity between crossed and uncrossed disparities reduce with practice.

INTRODUCTION: Stereoacuity, like many forms of hyperacuity, improves with practice. We investigated the effects of repeated measurements over multiple visits on stereoacuity using two commonly utilised clinical stereotests, for both crossed and uncrossed disparity stimuli. METHODS: Participants were adults with normal binocular vision (n = 17) aged between 18 and 50 years. Stereoacuity was measured using the Randot and TNO stereotests on five separate occasions over a six week period. We utilised both crossed and uncrossed stimuli to separately evaluate stereoacuity in both disparity directions. A subset of the subject group also completed a further five visits over an additional six week period. Threshold stereoacuity was determined by the lowest disparity level at which the subjects could correctly identify both the position and disparity direction (crossed or uncrossed) of the stimulus. Data were analysed by repeated measures analysis of variance. RESULTS: Stereoacuity for crossed and uncrossed stimuli improved significantly across the first five visits (F1,21  = 4.24, p = 0.05). The main effect of disparity direction on stereoacuity was not significant (F1  = 0.02, p = 0.91). However, a significant interaction between disparity direction and stereotest was identified (F1  = 7.92, p = 0.01). CONCLUSIONS: Stereoacuity measured with both the TNO and Randot stereotests improved significantly over the course of five repetitions. Although differences between crossed and uncrossed stereoacuity were evident, they depended on the stereotest used and reduced or disappeared after repeated measurements. A single measure of stereoacuity is inadequate for properly evaluating adult stereopsis clinically.

Number of flankers influences foveal crowding and contour interaction differently.

Nearby flanking objects degrade visual resolution. If the flankers are similar to the acuity target, this influence is called crowding (CW), whereas if the flanking stimuli are simple bars then the phenomenon is known as contour interaction (CI). The aim of this study was to compare the influence of the number and position of flankers on foveal CW and CI to investigate possible differences in mechanism of these two effects. Five normal observers viewed single, foveally presented Sloan letters surrounded by 1, 2 or 4 flankers (either a Sloan letter or one-stroke-width bars), presented at several edge-to-edge separations. Single flankers were presented in the right, left, top or bottom position, 2 flankers were placed equally to the right and left or top and bottom of the central target, and 4 flankers were equally spaced in all four directions. Percent correct letter identification was determined for each type, number, position and separation of flankers and confusion matrices were constructed for separations equal to 20% and 100% letter width. Increasing the number of flankers caused an increase in the magnitude of both phenomena. CW showed a greater magnitude than CI for higher numbers of flankers. Analysis of confusion matrices suggests that in addition to the edge-to-edge interaction that appears to mediate CI, letter substitution and feature pooling contribute significantly to CW when higher numbers of flankers are presented. Foveal CW is more strongly influenced by an increase in the number of flankers than CI, which can be explained by the presence of additional interaction effects.

Detection of anomalies in the red reflex test requires adequate training.

CLINICAL RELEVANCE: Midwives should receive appropriate training to enable them to reliably detect an abnormality in the red reflex, so as to detect potentially sight- (and possibly life-) threatening visual anomalies in newborns. BACKGROUND: Midwives who had completed the relevant Newborn and Infant Physical Examination (NIPE) training in the UK, were tested to determine whether they could reliably detect an abnormality in the red reflex of a model eye. Their results were compared to a group of undergraduate optometry students in their final year, who had considerably more experience with ophthalmoscopy. METHODS: Two groups of adult participants, 27 post-graduate midwives and 10 undergraduate optometry students with different levels of experience in ophthalmoscopy were recruited. Participants were required to perform the red reflex test repeatedly on a set of 10 model eyes with interchangeable simulated retinas, that produced both normal and abnormal 'red' reflexes, under controlled conditions. RESULTS: A total of 1,810 observations were recorded across both groups of participants. Both the sensitivity and the specificity for distinguishing between normal and abnormal reflexes were higher for the optometry students (sensitivity 77.5 per cent and specificity 96.7 per cent) than the midwives (sensitivity 53.9 per cent and specificity 75.4 per cent). The positive predictive values were 21.7 per cent and 67.4 per cent for the midwives and optometry students, respectively. The negative predictive values were 92.8 per cent for the midwives and 98.0 per cent for the optometry students. CONCLUSION: Despite completion of required training on the red reflex test, optometry students outperformed midwives in the detection of anomalous red reflex test simulations from a model eye. This result is likely due to differences in training in ophthalmoscopy between the two groups of participants. Additional training in the conduct of the red reflex test for midwives is therefore recommended.

Technical Report: The Mechanism of Contour Interaction Differs in the Fovea and Periphery.

SIGNIFICANCE: Both foveal and peripheral contour interactions are based on, as yet, unexplained neural mechanisms. Our results show that, unlike foveal contour interaction, peripheral contour interaction cannot be explained on the basis of the antagonistic structure of neural receptive fields. PURPOSE: Foveal contour interaction is markedly reduced for mesopic compared with photopic targets. This finding is consistent with an explanation based on the antagonistic structure of neural receptive fields. However, no reduction was found for low-luminance targets in the periphery, possibly because the luminances used previously remained substantially above peripheral scotopic detection thresholds. In this study, we compared foveal and peripheral contour interactions for long-wavelength photopic and mesopic targets, which would be expected to significantly elevate the peripheral retinal detection threshold. METHODS: Five normal observers viewed a randomly selected Sloan letter surrounded by four flanking bars at several edge-to-edge separations (min arc). Photopic and mesopic stimuli were viewed foveally and at 6° peripherally through a selective red filter that ensured that mesopic targets were within 1 log unit of detection threshold at both retinal locations. RESULTS: Whereas the magnitude of foveal contour interaction was substantially less at mesopic compared with photopic luminance (20 vs. 46% reduction of percent correct, on average), no significant difference was observed in peripheral contour interaction, which had average mesopic and photopic magnitudes of 38 and 40%. Moreover, confusion matrices representing photopic and mesopic contour interaction differed in the fovea but not in the periphery. The extent of contour interaction did not change with luminance at either retinal location. CONCLUSIONS: Our results indicate that, although the characteristics of foveal contour interaction can be accounted for by the antagonistic structure of neural receptive fields, the same mechanism is not compatible with the characteristics of peripheral contour interaction.

Upturn of the contour-interaction function at small flanking bar-to-target separations.

Nearby flanking bars degrade letter identification and resolution, a phenomenon known as contour interaction. However, many previous studies found that the relationship between foveal letter identification and flanker separation is non-monotonic, with an upturn in performance at very small target-to-flanker separations. Here, we replicate this observation and show that a similar upturn occurs also for targets presented at 5 deg in the inferior field, if the target-to-flanker separation is sufficiently small. The presence and magnitude of the observed performance upturn depends on the flanking-bar width, being more evident for narrower compared to wider flanking bars. We interpret our results to indicate that neural interactions between nearby contours reduce performance when the target and flanking bars form discrete neural images. At sufficiently small separations, the images of the target and flanking bars can not be distinguished and performance is governed by the contrast of the target in the blended neural image.

Contrast Energy and Contour Interaction.

SIGNIFICANCE: Contour interaction describes an impairment of visual acuity produced by nearby flanking features, which exerts a significant impact in many clinical tests of visual acuity. Our results indicate that the magnitude of interaction depends either on the flanker contrast energy (i.e., the product of flanker contrast and width) or the flanker contrast alone, depending on the contrast energy of the flankers. PURPOSE: The discrimination of acuity targets is impaired by the presence of nearby flanking contours, a phenomenon known as contour interaction. METHODS: In this study, we measured percent correct identification for threshold size, high-contrast Sloan letters at the fovea and at 5° in the inferior visual field for different combinations of flanking-bar width, and Weber contrast corresponding to specific fixed values of contrast energy (width × contrast, in %-min arc). RESULTS: For flanking bars with low-contrast energy, contour interaction exhibited no systematic dependence on the flanking-bar width. However, when the flanking bars had higher contrast energy, narrower high-contrast bars produced significantly greater contour interaction than wider bars of lower contrast. CONCLUSIONS: The results are consistent with the interpretation that contour interaction depends primarily on the contrast energy of flanking contours when their contrast energy is low. As the contrast energy of the flanking contours increases, the magnitude of contour interaction depends on the flanker contrast. For high-contrast flanking contours, the magnitude of contour interaction saturates when the width of the flanking contours is approximately 20% of letter size.

Assessment of Visual Acuity in Children Using Crowded Lea Symbol Charts.

SIGNIFICANCE: Vision charts comprising single Lea symbols surrounded by either flanking bars or flanking Lea symbols are available for measurement of visual acuity in children. However, the results obtained with such charts may not be interchangeable owing to potential differences in the crowding effect. PURPOSE: The purpose of this study was to compare habitual visual acuity in a sample of young children using two versions of the single Lea symbols charts with different crowding features. METHODS: Monocular habitual visual acuity was measured in a sample of 77 young children aged between 4 and 6 years using crowded Lea symbols charts with either flanking bars separated from the central symbol by 0.5 optotype width or flanking Lea optotypes separated from the central symbol by 1.0 optotype width. RESULTS: Mean visual acuity was higher (i.e., lower logarithm of the minimum angle of resolution) with the Lea symbols crowded using flanking optotypes, equivalent to about 1.5 optotype difference. Visual acuity measured with the two charts was significantly correlated; however, the 95% limits of agreement were larger than expected from repeatability studies using Lea symbols. CONCLUSIONS: Lea symbols with flanking optotypes resulted in higher visual acuity than the Lea symbols with flanking bars, probably as a result of differences in the crowding effect. The two charts showed insufficient agreement, and we do not recommend their use interchangeably. We recommend using the Lea symbols with flanking bars because of the closer flanker-target separation.

Contour interaction under photopic and scotopic conditions.

In the present study, we asked whether contour interaction undergoes significant changes for different luminance levels in the central and peripheral visual field. This study included nine normal observers at two laboratories (five at Palacky University Olomouc, Czech Republic and four at the University of Houston, USA). Observers viewed a randomly selected Sloan letter surrounded by four equally spaced bars for several separations measured edge-to-edge in min arc. Stimuli were viewed foveally under photopic and mesopic luminances and between 5° and 12° peripherally for four different background luminances of the display monitors, corresponding to photopic, mesopic, scotopic, and dim scotopic levels. The extent of the contour interaction in the fovea is approximately 20 times smaller than in the periphery. Whereas the magnitude of foveal contour interaction markedly decreases with decreasing luminance, no consistent luminance-induced change occurs in peripheral contour interaction. The extent of contour interaction does not scale with the size of the target letter, either in the fovea or peripherally. The results support a neural origin of contour interaction consistent with the properties of center-surround antagonism.

Mesopic visual acuity is less crowded.

PURPOSE: The decrease in visual acuity under low luminance conditions is well known. Recent laboratory evidence showed that crowding under low luminance (mesopic) light levels is less robust than under photopic conditions. The present study examines whether such differences in crowding influence clinical measurements of mesopic visual acuity, including test-retest repeatability. METHODS: Twenty adult subjects with normal or corrected to normal visual acuity were recruited for the study. Monocular visual acuity was measured under photopic (228 cd/m2) and mesopic (0.164 cd/m2) luminance conditions using a letter chart, similar in principle to the ETDRS logMAR chart, presented on a computer monitor. Three rows of five letters, each row differing in size by 0.05 logMAR from largest to smallest were displayed at the center of the monitor. The level of crowding was varied by varying the separation between horizontally adjacent letters from 100% optotype size to 50, 20, and 10% optotype size. Inter-row spacing was proportional to optotype size. Observers read the letters on the middle row only. Measurements continued by reducing the size of the letters, until three or more errors on the middle row were made. Each correctly identified letter contributed 0.01 to the recorded logMAR score. All measurements were repeated for each subject on two separate days. RESULTS: Visual acuity (logMAR) was significantly better under photopic than mesopic luminance conditions with a mean difference of 0.48 logMAR. Visual acuity also decreased with decreasing letter separation (i.e. increase in crowding). However, the decrease in visual acuity for the smallest letter separation was less under the mesopic luminance condition, even after accounting for the increased size of threshold acuity letters. Test-retest repeatability for mesopic and photopic conditions was not significantly different. CONCLUSIONS: Crowding under mesopic luminance conditions has less impact on visual acuity than under photopic luminance.

A standardized logarithm of the minimum angle of resolution visual acuity chart in Hindi.

Purpose: The purpose of this study to develop and calibrate a new Hindi logarithm of the minimum angle of resolution (logMAR) visual acuity chart. Methods: A new Hindi visual acuity chart was designed to logMAR specifications using Hindi optotypes experimentally selected to have similar relative legibility under equivalent spherical and cylindrical defocus. The chart calibration study was carried out in a large clinical setup in India. Participants who were literate in English and Hindi participated in the study. Visual acuity was measured with the new Hindi logMAR chart and a modified ETDRS (m-ETDRS) logMAR chart. The method of presentation was randomized between the charts. Repeat visual acuity was measured on a subsequent day with a second version of the Hindi logMAR chart. Results: The Hindi logMAR chart correlated highly with the m-ETDRS logMAR chart (r2 = 0.92); however, the mean visual acuity difference (Hindi logMAR-m-ETDRS logMAR) was nearly one and half lines (0.13 logMAR, 95% confidence interval [CI] = ±0.15 logMAR). The Hindi logMAR chart also proved to be highly repeatable (r2 = 0.99; mean difference 0.005, 95% CI = ±0.04 logMAR). Conclusion: This study reports the first standardized visual acuity chart developed in Hindi incorporating equal letter legibility and logMAR chart design features. The Hindi logMAR visual acuity chart provides a valid and repeatable tool for the measurement of visual acuity in native Hindi language speakers. Future use of the new Hindi chart should incorporate an increase in optotype size of 0.13 logMAR.

Effect of stimulus configuration on crowding in strabismic amblyopia.

Foveal vision in strabismic amblyopia can show increased levels of crowding, akin to typical peripheral vision. Target-flanker similarity and visual-acuity test configuration may cause the magnitude of crowding to vary in strabismic amblyopia. We used custom-designed visual acuity tests to investigate crowding in observers with strabismic amblyopia. LogMAR was measured monocularly in both eyes of 11 adults with strabismic or mixed strabismic/anisometropic amblyopia using custom-designed letter tests. The tests used single-letter and linear formats with either bar or letter flankers to introduce crowding. Tests were presented monocularly on a high-resolution display at a test distance of 4 m, using standardized instructions. For each condition, five letters of each size were shown; testing continued until three letters of a given size were named incorrectly. Uncrowded logMAR was subtracted from logMAR in each of the crowded tests to highlight the crowding effect. Repeated-measures ANOVA showed that letter flankers and linear presentation individually resulted in poorer performance in the amblyopic eyes (respectively, mean normalized logMAR = 0.29, SE = 0.07, mean normalized logMAR = 0.27, SE = 0.07; p < 0.05) and together had an additive effect (mean = 0.42, SE = 0.09, p < 0.001). There was no difference across the tests in the fellow eyes (p > 0.05). Both linear presentation and letter rather than bar flankers increase crowding in the amblyopic eyes of people with strabismic amblyopia. These results suggest the influence of more than one mechanism contributing to crowding in linear visual-acuity charts with letter flankers.

Monocular microsaccades are visual-task related.

During visual fixation, we constantly move our eyes. These microscopic eye movements are composed of tremor, drift, and microsaccades. Early studies concluded that microsaccades, like larger saccades, are binocular and conjugate, as expected from Hering's law of equal innervation. Here, we document the existence of monocular microsaccades during both fixation and a discrimination task, reporting the location of the gap in a foveal, low-contrast letter C. Monocular microsaccades differ in frequency, amplitude, and peak velocity from binocular microsaccades. Our analyses show that these differences are robust to different velocity and duration criteria that have been used previously to identify microsaccades. Also, the frequency of monocular microsaccades differs systematically according to the task: monocular microsaccades occur more frequently during fixation than discrimination, the opposite of their binocular equivalents. However, during discrimination, monocular microsaccades occur more often around the discrimination threshold, particularly for each subject's dominant eye and in case of successful discrimination. We suggest that monocular microsaccades play a functional role in the production of fine corrections of eye position and vergence during demanding visual tasks.

Evidence for an eye-movement contribution to normal foveal crowding.

PURPOSE: Along with contour interaction, inaccurate and imprecise eye movements and attention have been suggested to contribute to poorer acuity for "crowded" versus uncrowded targets. To investigate the role of eye movements in foveal crowding, we compared percent correct letter identification for short and long lines of near-threshold letters with different separations. METHODS: Five normal observers read short (4 to 6 letters) and long (10 to 12 letters) lines of near-threshold, Sloan letters with edge-to-edge letter separations of 0.5, 1, and 2 letter spaces. Percent correct letter identification for the 2 to 4 interior letters in short strings and the 8 to 10 interior letters in long strings was compared with a no-crowding condition. RESULTS: Letter identification was significantly worse than the no-crowding condition for long letter strings with a separation of 1 letter space and for both long and short letter strings with a separation of 0.5 letter spaces. Observers more often reported the incorrect number of letters in long than in short letter strings, even for a separation of 2 letter spaces. Similar results were obtained during straight-ahead gaze and while viewing in 30 to 40 degrees left gaze, where two of the five observers exhibited an increase in horizontal fixational instability. CONCLUSIONS: We argue that lower percent correct letter identification and more frequent errors in reporting the number of letters in long compared with short letter strings reflect an eye-movement contribution to foveal crowding.

Foveal crowding differs in children and adults.

We used custom-designed acuity tests to compare the magnitude and extent of crowded letter recognition in children and adults. Visual acuity (logMAR) was measured monocularly in children and adults using five custom-designed letter tests with varying degrees of crowding: single letter, single letter surrounded by four flanking bars, single letter surrounded by four flanking letters, line of five letters surrounded by flanking bars, and line of five letters surrounded by flanking letters. The tests were constructed using Sloan letters and presented on an iPad (Apple Incorporated, Cupertino, CA) at 4 m using a standardized endpoint and instructions. Crowded logMAR was normalized to unflanked logMAR and results were analyzed in three groups: younger children aged 4-6 (n = 32), older children, aged 7-9 (n = 30), and adults (n = 27). Both groups of children showed a greater extent of crowding than the adults. The adult participants showed no difference in performance between single or linear presentation and letter or bar flankers. Letter flankers and linear presentation individually resulted in poorer performance in the younger children p < 0.001 and p = 0.003, respectively (mean normalized logMAR 0.17 in each case) and together had an additive effect (mean 0.24), p < 0.001. Crowding in the older children was adult-like except in the linear presentation with letter flankers, p < 0.001. These results indicate that both target-flanker similarity and linear presentation contribute more to foveal crowding in young children than in adults.

A new Gujarati language logMAR visual acuity chart: development and validation.

AIMS: Gujarati is the main spoken language of a large proportion of the population of India. The aim of this study was to develop and validate a new Minimum Angle of Resolution (logMAR) visual acuity chart in the Gujarati language. MATERIALS AND METHODS: A new Gujarati visual acuity chart was designed to logMAR specifications using Gujarati optotypes experimentally selected to have similar relative letter legibility under spherical and cylindrical defocus. The chart validation study was carried out using 153 adult subjects in a large clinical setting in India. Subjects who were literate in English and Gujarati participated in the study. Visual acuity was measured with the new Gujarati logMAR chart and a modified Early Treatment of Diabetic Retinopathy Study-(m-ETDRS) logMAR chart. The method of presentation was randomized between the charts. Repeat visual acuity was measured on a subsequent day with a second version of the Gujarati logMAR chart. RESULTS: The Gujarati chart correlated highly with the m-ETDRS logMAR chart (r² = 0.974). The mean visual acuity difference (Gujarati - m-ETDRS logMAR) was equal to three letters (-0.06 logMAR). The Gujarati logMAR chart also proved to be highly repeatable (r² = 0.994, test-retest) with 95% CI of ± 0.04 logMAR. CONCLUSIONS: The new Gujarati logMAR visual acuity chart provides a valid and repeatable tool for the measurement of visual acuity in native Gujarati language speakers.

Contour interaction for foveal acuity targets at different luminances.

Single-letter visual acuity is impaired by nearby flanking stimuli, a phenomenon known as contour interaction. We showed previously that when foveal acuity is degraded by a reduction of letter contrast, both the magnitude and angular spatial extent of foveal contour interaction remain unchanged. In this study, we asked whether contour interaction also remains unchanged when foveal visual acuity is degraded by a reduction of the target's background luminance. Percent correct letter identification was measured for isolated, near-threshold black Sloan letters and for letters surrounded by 4 flanking bars in 10 normal observers, 5 at Anglia Ruskin University, UK (ARU) and 5 at Palacky University, Czech Republic (PU). A stepwise reduction in the background luminance over 3 log units resulted in an approximately threefold increase in the near-threshold letter size. At each background luminance, black flanking bars with a width equal to 1 letter stroke were presented at separations between approximately 0.45 and 4.5 min arc (ARU) or 0.32 and 3.2 min arc (PU). The results indicate that the angular extent of contour interaction remains unchanged at approximately 4 min arc at all background luminances. On the other hand, the magnitude of contour interaction decreases systematically as luminance is reduced, from approximately a 50% reduction to a 30% reduction in percent correct. The constant angular extent and decreasing magnitude of contour interaction with a reduction of background luminance suggest foveal contour interaction is mediated by luminance-dependent lateral inhibition within a fixed angular region.

Foveal contour interaction for low contrast acuity targets.

Previous investigators reported the impairment of foveal visual acuity by nearby flanking targets (contour interaction) is reduced or eliminated when acuity is measured using low contrast targets. Unlike earlier studies, we compared contour interaction for high and low contrast acuity targets using flankers at fixed angular separations, rather than at specific multiples of the acuity target's stroke width. Percent correct letter identification was determined in 4 adult observers for computer generated, high and low contrast dark Sloan letters surrounded by 4 equal contrast flanking bars. Two low contrast targets were selected to reduce each observer's visual acuity by 0.2 and 0.4 logMAR. The contour interaction functions measured for high and low contrast letters are very similar when percent correct letter identification is plotted against the flanker separation in min arc. These results indicate that contour interaction of foveal acuity targets occurs within a fixed angular zone of a few min arc, regardless of the size or contrast of the acuity target.