How effective is low vision service provision? A systematic review

Visual impairment is a large and growing socioeconomic problem. Good evidence on rehabilitation outcomes is required to guide service development and improve the lives of people with sight loss. Of the 478 potentially relevant articles identified, only 58 studies met our liberal inclusion criteria, and of these only 7 were randomized controlled trials. Although the literature is sufficient to confirm that rehabilitation services result in improved clinical and functional ability outcomes, the effects on mood, vision-related quality of life (QoL) and health-related QoL are less clear. There are some good data on the performance of particular types of intervention, but almost no useful data about outcomes in children, those of working age, and other groups. There were no reports on cost effectiveness. Overall, the number of well-designed and adequately reported studies is pitifully small; visual rehabilitation research needs higher quality research. We highlight study design and reporting considerations and suggest a future research agenda.

Effect of uncorrected astigmatism on vision

PURPOSE: To examine the effect of uncorrected astigmatism in older adults. SETTING: University Vision Clinic METHOD: Twenty-one healthy presbyopes, aged 58.9±2.8 years, had astigmatism of 0.0 to -4.0 x 90?DC and -3.0DC of cylinder at 90?, 180? and 45? induced with spectacle lenses, with the mean spherical equivalent compensated to plano, in random order. Visual acuity was assessed binocularly using a computerised test chart at 95%, 50% and 10% contrast. Near acuity and reading speed were measured using standardised reading texts. Light scatter was quantified with the cQuant and driving reaction times with a computer simulator. Finally visual clarity of a mobile phone and computer screen was subjectively rated. RESULTS: Distance visual acuity decreased with increasing uncorrected astigmatic power (F=174.50, p<0.001) and was reduced at lower contrasts (F=170.77, p<0.001). Near visual acuity and reading speed also decreased with increasing uncorrected astigmatism power (p<0.001). Light scatter was not significantly affected by uncorrected astigmatism (p>0.05), but the reliability and variability of measurements decreased with increasing uncorrected astigmatic power (p<0.05). Driving simulator performance was also unaffected by uncorrected astigmatism (p>0.05), but subjective rating of clarity decreased with increasing uncorrected astigmatic power (p<0.001). Uncorrected astigmatism at 45? or 180? orientation resulted in a worse distance and near visual acuity, and subjective rated clarity than 90? orientation (p<0.05). CONCLUSION: Uncorrected astigmatism, even as low as 1.0DC, causes a significant burden on a patient’s vision. If left uncorrected, this could impact significantly on their independence, quality of life and wellbeing.

The role of oscillatory brain activity in object processing and figure-ground segmentation in human vision

The perception of an object as a single entity within a visual scene requires that its features are bound together and segregated from the background and/or other objects. Here, we used magnetoencephalography (MEG) to assess the hypothesis that coherent percepts may arise from the synchronized high frequency (gamma) activity between neurons that code features of the same object. We also assessed the role of low frequency (alpha, beta) activity in object processing. The target stimulus (i.e. object) was a small patch of a concentric grating of 3c/°, viewed eccentrically. The background stimulus was either a blank field or a concentric grating of 3c/° periodicity, viewed centrally. With patterned backgrounds, the target stimulus emerged--through rotation about its own centre--as a circular subsection of the background. Data were acquired using a 275-channel whole-head MEG system and analyzed using Synthetic Aperture Magnetometry (SAM), which allows one to generate images of task-related cortical oscillatory power changes within specific frequency bands. Significant oscillatory activity across a broad range of frequencies was evident at the V1/V2 border, and subsequent analyses were based on a virtual electrode at this location. When the target was presented in isolation, we observed that: (i) contralateral stimulation yielded a sustained power increase in gamma activity; and (ii) both contra- and ipsilateral stimulation yielded near identical transient power changes in alpha (and beta) activity. When the target was presented against a patterned background, we observed that: (i) contralateral stimulation yielded an increase in high-gamma (>55 Hz) power together with a decrease in low-gamma (40-55 Hz) power; and (ii) both contra- and ipsilateral stimulation yielded a transient decrease in alpha (and beta) activity, though the reduction tended to be greatest for contralateral stimulation. The opposing power changes across different regions of the gamma spectrum with 'figure/ground' stimulation suggest a possible dual role for gamma rhythms in visual object coding, and provide general support of the binding-by-synchronization hypothesis. As the power changes in alpha and beta activity were largely independent of the spatial location of the target, however, we conclude that their role in object processing may relate principally to changes in visual attention.

Binocular contrast vision at and above threshold

A fundamental problem for any visual system with binocular overlap is the combination of information from the two eyes. Electrophysiology shows that binocular integration of luminance contrast occurs early in visual cortex, but a specific systems architecture has not been established for human vision. Here, we address this by performing binocular summation and monocular, binocular, and dichoptic masking experiments for horizontal 1 cycle per degree test and masking gratings. These data reject three previously published proposals, each of which predict too little binocular summation and insufficient dichoptic facilitation. However, a simple development of one of the rejected models (the twin summation model) and a completely new model (the two-stage model) provide very good fits to the data. Two features common to both models are gently accelerating (almost linear) contrast transduction prior to binocular summation and suppressive ocular interactions that contribute to contrast gain control. With all model parameters fixed, both models correctly predict (1) systematic variation in psychometric slopes, (2) dichoptic contrast matching, and (3) high levels of binocular summation for various levels of binocular pedestal contrast. A review of evidence from elsewhere leads us to favor the two-stage model. © 2006 ARVO.

Psychophysical evidence for two routes to suppression before binocular summation of signals in human vision

Visual mechanisms in primary visual cortex are suppressed by the superposition of gratings perpendicular to their preferred orientations. A clear picture of this process is needed to (i) inform functional architecture of image-processing models, (ii) identify the pathways available to support binocular rivalry, and (iii) generally advance our understanding of early vision. Here we use monoptic sine-wave gratings and cross-orientation masking (XOM) to reveal two cross-oriented suppressive pathways in humans, both of which occur before full binocular summation of signals. One is a within-eye (ipsiocular) pathway that is spatially broadband, immune to contrast adaptation and has a suppressive weight that tends to decrease with stimulus duration. The other pathway operates between the eyes (interocular), is spatially tuned, desensitizes with contrast adaptation and has a suppressive weight that increases with stimulus duration. When cross-oriented masks are presented to both eyes, masking is enhanced or diminished for conditions in which either ipsiocular or interocular pathways dominate masking, respectively. We propose that ipsiocular suppression precedes the influence of interocular suppression and tentatively associate the two effects with the lateral geniculate nucleus (or retina) and the visual cortex respectively. The interocular route is a good candidate for the initial pathway involved in binocular rivalry and predicts that interocular cross-orientation suppression should be found in cortical cells with predominantly ipsiocular drive. © 2007 IBRO.

Interocular suppression and contrast gain control in human vision

The human visual system combines contrast information from the two eyes to produce a single cyclopean representation of the external world. This task requires both summation of congruent images and inhibition of incongruent images across the eyes. These processes were explored psychophysically using narrowband sinusoidal grating stimuli. Initial experiments focussed on binocular interactions within a single detecting mechanism, using contrast discrimination and contrast matching tasks. Consistent with previous findings, dichoptic presentation produced greater masking than monocular or binocular presentation. Four computational models were compared, two of which performed well on all data sets. Suppression between mechanisms was then investigated, using orthogonal and oblique stimuli. Two distinct suppressive pathways were identified, corresponding to monocular and dichoptic presentation. Both pathways impact prior to binocular summation of signals, and differ in their strengths, tuning, and response to adaptation, consistent with recent single-cell findings in cat. Strikingly, the magnitude of dichoptic masking was found to be spatiotemporally scale invariant, whereas monocular masking was dependent on stimulus speed. Interocular suppression was further explored using a novel manipulation, whereby stimuli were presented in dichoptic antiphase. Consistent with the predictions of a computational model, this produced weaker masking than in-phase presentation. This allowed the bandwidths of suppression to be measured without the complicating factor of additive combination of mask and test. Finally, contrast vision in strabismic amblyopia was investigated. Although amblyopes are generally believed to have impaired binocular vision, binocular summation was shown to be intact when stimuli were normalized for interocular sensitivity differences. An alternative account of amblyopia was developed, in which signals in the affected eye are subject to attenuation and additive noise prior to binocular combination.

Creutzfeldt-Jakob disease and vision

This review describes a group of diseases known as the transmissible spongiform encephalopathies (TSEs), which affect animals and humans. Examination of affected brain tissue suggests that these diseases are caused by the acquisition and deposition of prion protein (PrP). Creutzfeldt-Jakob disease (CJD) is the most important form of TSE in humans with at least four different varieties of the disease. Variant CJD (vCJD), a new form of the disease found in the UK, has several features that differ from the classical forms including early age of onset, longer duration of disease, psychiatric presentation (for example, depression) and extensive florid plaque development in the brain. About 10 per cent of patients with CJD exhibit visual symptoms at disease presentation and approximately 50 per cent during the course of the disease. The most commonly reported visual symptoms include diplopia, supranuclear palsies, complex visual disturbances, homonymous visual field defects, hallucinations and cortical blindness. Saccadic and smooth pursuit movements appear to be more rarely affected. The agent causing vCJD accumulates in lymphoid tissue such as the spleen and tonsils. The cornea has lymphoid tissue in the form of corneal dendritic cells that are important in the regulation of the immune response in the anterior segment of the eye. The presence of these cells in the cornea has raised the possibility of transmission between patients via optical devices that contact the eye. Although such transmission is theoretically possible it remains highly improbable.

Vitamin and mineral deficiencies in the developed world and their effect on the eye and vision

Vitamin and mineral deficiencies are common in developing countries, but also occur in developed countries. We review micronutrient deficiencies for the major vitamins A, cobalamin (B-12), biotin (vitamin H), vitamins C and E, as well as the minerals iron, and zinc, in the developed world, in terms of their relationship to systemic health and any resulting ocular disease and/or visual dysfunction. A knowledge of these effects is important as individuals with consequent poor ocular health and reduced visual function may present for ophthalmic care.

Proposing a systems vision of knowledge management in emergency care

This paper makes a case for taking a systems view of knowledge management within health-care provision, concentrating on the emergency care process in the UK National Health Service. It draws upon research in two casestudy organizations (a hospital and an ambulance service). The case-study organizations appear to be approaching knowledge (and information) management in a somewhat fragmented way. They are trying to think more holistically, but (perhaps) because of the ways their organizations and their work are structured, they cannot ‘see’ the whole of the care process. The paper explores the complexity of knowledge management in emergency health care and draws the distinction for knowledge management between managing local and operational knowledge, and global and clinical knowledge.

The relative contributions of colour and luminance signals towards the visuomotor localisation of targets in human peripheral vision

We sought to determine the extent to which colour (and luminance) signals contribute towards the visuomotor localization of targets. To do so we exploited the movement-related illusory displacement a small stationary window undergoes when it has a continuously moving carrier grating behind it. We used drifting (1.0-4.2 Hz) red/green-modulated isoluminant gratings or yellow/black luminance-modulated gratings as carriers, each curtailed in space by a stationary, two-dimensional window. After each trial, the perceived location of the window was recorded with reference to an on-screen ruler (perceptual task) or the on-screen touch of a ballistic pointing movement made without visual feedback (visuomotor task). Our results showed that the perceptual displacement measures were similar for each stimulus type and weakly dependent on stimulus drift rate. However, while the visuomotor displacement measures were similar for each stimulus type at low drift rates (<4 Hz), they were significantly larger for luminance than colour stimuli at high drift rates (>4 Hz). We show that the latter cannot be attributed to differences in perceived speed between stimulus types. We assume, therefore, that our visuomotor localization judgements were more susceptible to the (carrier) motion of luminance patterns than colour patterns. We suggest that, far from being detrimental, this susceptibility may indicate the operation of mechanisms designed to counter the temporal asynchrony between perceptual experiences and the physical changes in the environment that give rise to them. We propose that perceptual localisation is equally supported by both colour and luminance signals but that visuomotor localisation is predominantly supported by luminance signals. We discuss the neural pathways that may be involved with visuomotor localization. © 2007 Springer-Verlag.

Effect of light filters on reading speed in normal and low vision due to age-related macular degeneration

Purpose: To investigate the effects of light filters on reading speed in normal and low vision due to age-related macular degeneration (AMD). Methods: Reading speed was determined for 12 subjects with normal vision and 12 subjects with non-exudative AMD using stationary lowercase nonsensical print in Times Roman font and four light filters; a yellow Corning Photochromic Filter (CPF) 450, a grey neural density (ND) filter, an individual filter obtained using the Intuitive Colorimeter® and a clear filter. Results: There was no statistically significant light filter effect on reading speed for the normal subjects. The AMD group demonstrated a statistically significant 5% average improvement in reading speed with the CPF450 compared with the other filters although some AMD subjects had improvements of 10-15%. Conclusions: Light filters obtained using the Intuitive Colorimeter® performed poorly when compared with the CPF450, ND and clear filters for both the study groups. For the AMD group, average reading speed was statistically greater with the CPF450 than the other filters, however it is questionable whether the improvement (5%) would be clinically significant. As some of the subjects with AMD had greater improvements with the CPF450 we advocate clinical assessment of light filters using existing protocols on an individual basis. © 2004 The College of Optometrists.

Do tinted lenses or filters improve visual performance in low vision? A review of the literature

This is a review of studies that have investigated the proposed rehabilitative benefit of tinted lenses and filters for people with low vision. Currently, eye care practitioners have to rely on marketing literature and anecdotal reports from users when making recommendations for tinted lens or filter use in low vision. Our main aim was to locate a prescribing protocol that was scientifically based and could assist low vision specialists with tinted lens prescribing decisions. We also wanted to determine if previous work had found any tinted lens/task or tinted lens/ocular condition relationships, i.e. were certain tints or filters of use for specific tasks or for specific eye conditions. Another aim was to provide a review of previous research in order to stimulate new work using modern experimental designs. Past studies of tinted lenses and low vision have assessed effects on visual acuity (VA), grating acuity, contrast sensitivity (CS), visual field, adaptation time, glare, photophobia and TV viewing. Objective and subjective outcome measures have been used. However, very little objective evidence has been provided to support anecdotal reports of improvements in visual performance. Many studies are flawed in that they lack controls for investigator bias, and placebo, learning and fatigue effects. Therefore, the use of tinted lenses in low vision remains controversial and eye care practitioners will have to continue to rely on anecdotal evidence to assist them in their prescribing decisions. Suggestions for future research, avoiding some of these experimental shortcomings, are made. © 2002 The College of Optometrists.

Suppression and summation in contrast gain control for human vision

Over the last ten years our understanding of early spatial vision has improved enormously. The long-standing model of probability summation amongst multiple independent mechanisms with static output nonlinearities responsible for masking is obsolete. It has been replaced by a much more complex network of additive, suppressive, and facilitatory interactions and nonlinearities across eyes, area, spatial frequency, and orientation that extend well beyond the classical recep-tive field (CRF). A review of a substantial body of psychophysical work performed by ourselves (20 papers), and others, leads us to the following tentative account of the processing path for signal contrast. The first suppression stage is monocular, isotropic, non-adaptable, accelerates with RMS contrast, most potent for low spatial and high temporal frequencies, and extends slightly beyond the CRF. Second and third stages of suppression are difficult to disentangle but are possibly pre- and post-binocular summation, and involve components that are scale invariant, isotropic, anisotropic, chromatic, achromatic, adaptable, interocular, substantially larger than the CRF, and saturated by contrast. The monocular excitatory pathways begin with half-wave rectification, followed by a preliminary stage of half-binocular summation, a square-law transducer, full binocular summation, pooling over phase, cross-mechanism facilitatory interactions, additive noise, linear summation over area, and a slightly uncertain decision-maker. The purpose of each of these interactions is far from clear, but the system benefits from area and binocular summation of weak contrast signals as well as area and ocularity invariances above threshold (a herd of zebras doesn't change its contrast when it increases in number or when you close one eye). One of many remaining challenges is to determine the stage or stages of spatial tuning in the excitatory pathway.

Depth propagation and surface construction in 3-D vision

In stereo vision, regions with ambiguous or unspecified disparity can acquire perceived depth from unambiguous regions. This has been called stereo capture, depth interpolation or surface completion. We studied some striking induced depth effects suggesting that depth interpolation and surface completion are distinct stages of visual processing. An inducing texture (2-D Gaussian noise) had sinusoidal modulation of disparity, creating a smooth horizontal corrugation. The central region of this surface was replaced by various test patterns whose perceived corrugation was measured. When the test image was horizontal 1-D noise, shown to one eye or to both eyes without disparity, it appeared corrugated in much the same way as the disparity-modulated (DM) flanking regions. But when the test image was 2-D noise, or vertical 1-D noise, little or no depth was induced. This suggests that horizontal orientation was a key factor. For a horizontal sine-wave luminance grating, strong depth was induced, but for a square-wave grating, depth was induced only when its edges were aligned with the peaks and troughs of the DM flanking surface. These and related results suggest that disparity (or local depth) propagates along horizontal 1-D features, and then a 3-D surface is constructed from the depth samples acquired. The shape of the constructed surface can be different from the inducer, and so surface construction appears to operate on the results of a more local depth propagation process.