Data methods in optometry. Part 10: non-linear regression analysis

1. The techniques associated with regression, whether linear or non-linear, are some of the most useful statistical procedures that can be applied in clinical studies in optometry. 2. In some cases, there may be no scientific model of the relationship between X and Y that can be specified in advance and the objective may be to provide a ‘curve of best fit’ for predictive purposes. In such cases, the fitting of a general polynomial type curve may be the best approach. 3. An investigator may have a specific model in mind that relates Y to X and the data may provide a test of this hypothesis. Some of these curves can be reduced to a linear regression by transformation, e.g., the exponential and negative exponential decay curves. 4. In some circumstances, e.g., the asymptotic curve or logistic growth law, a more complex process of curve fitting involving non-linear estimation will be required.

The influence of age on the pattern and flash visual evoked field

We have investigated the effect of ageing on the visual system using the relatively new technique of magentoencephalography (MEG). This technique measures the magnetic signals produced by the visual system using a SQUID magnetometer. The magnetic visual evoked field (VEF) was measured over the occipital cortex to pattern and flash stimuli in 86 normal subjects aged 15 - 86 years. Factors that influenced subject defocussing or defixating the stimulus or selective attention were controlled as far as possible. The latency of the major positive component to the pattern reversal stimulus (P100M) increased with age particularly after the age of 55 years while the amplitude of the P100M decreased over the life span. The latency of the major flash component (P2M) increased much more slowly with age, while its amplitude decreased in only a proportion of elderly subjects. Changes in the P100M with age may reflect senile changes in the eye and optic nerve, e.g. senile miosis or degenerative changes in the retina. The P2M may be more susceptible to senile changes in the retina. The data suggest that the spatial frequency channels deteriorate more rapidly with age than the luminance channels and that MEG may be an effective method of studying ageing in the visual system.

Topography of visual evoked magnetic responses to pattern shift, pattern onset and flash stimuli

Different visual stimuli may activate separate channels in the visual system and produce magnetic responses from the human bran which originate from distinct regions of the visual cortex. To test this hypothesis, we have investigated the distribution of visual evoked magnetic responses to three distinct visual stimuli over the occipital region of the scalp with a DC-SQUID second-order gradiometer in an ubshielded environment. Patterned stimuli were presented full field and to the right half field, while a flash stimulus was presented full field only, in five normal subjects. Magnetic responses were recorded from 20 to 42 positions over the occipital scalp. Topographic maps were prepared of the major positive component within the first 150ms to the three stimuli, i.e., the P100m (pattern shift), C11m (pattern onset) and P2m (flash). For the pattern shift stimulus the data suggested the source of the P100m was close to the midline with the current directed towards the medial surface. The data for the pattern onset C11m suggested a source at a similar depth but with the current directed away from the midline towards the lateral surface. The flash P2m appeared to originate closer to the surface of the occipital pole than both the patterned stimuli. Hence the pattern shift (which may represent movement), and the pattern onset C11m (representing contrast and contour) appear to originate in similar areas of brain but to represent different asepcts of cortical processing. By contrast, the flash P2m (representing luminance change) appears to originate in a distinct area of visual cortex closer to the occipital pole.

Topography of the visual evoked magnetic response and hemispherical specialization

The visual evoked magnetic response CIIm component to a pattern onset stimulus presented half field produced a consistent scalp topography in 15 normal subjects. The major response was seen over the contralateral hemisphere, suggesting a dipole with current flowing away from the medial surface of the brain. Full field responses were more unpredictable. The reponses of five subjects were studied to the onset of a full, left half and right half checkerboard stimuli of 38 x 27 min arc checks appearing for 200 ms. In two subjects the full field CIIm topography was consistent with that of the mathematical summation of their relevant half field distribution. The remaining subjects had unpredictable full field topographies, showing little or no relationship to their half or summated half fields. In each of these subjects, a distribution matching that of the summated half field CIIm distribution appears at an earlier latency than that of the predominant full field waveform peak. By examining the topography of the full and half field responses at 5 ms intervals along the waveform for one such subject, the CIIm topography of the right hemisphere develops 10 ms before that of the left hemisphere, and is replaced by the following CIIIm component 20 ms earlier. Hence, the large peak seen in full field results from a combination of the CIIm component of the left hemisphere plus that of the CIIIm from the right. The earlier peak results from the CIIm generated in both hemispheres, at a latency where both show similar amplitudes. As the relative amplitudes of these two peaks alter with check and field size, topographic studies would be required for accurate CIIm identification. In addition. the CIIm-CIIIm complex lasts for 80 ms in the right hemisphere and 135 ms in the left, suggesting hemispherical apecialization in the visual processing of the pattern onset response.

The correlation between tests of visual function and perceived visual ability in central field loss patients

Purpose: To investigate the correlation between tests of visual function and perceived visual ability recorded with a 'quality-of-life' questionnaire for patients with central field loss. Method: 12 females and 7 males (mean age = 53.1 years; Range = 23 - 80 years) with subfoveal neovascular membranes underwent a comprehensive assessment of visual function. Tests included unaided distance vision, high and low contrast distance logMAR visual acuity (VA), Pelli-Robson contrast senstivity (at 1m), near logMAR word VA and text reading speed. All tests were done both monocularly and binocularly. The patients also completed a 28 point questionnaire separated into a 'core' section consisting of general questions about perceived visual function and a 'module' section with specific questions on reading function. Results: Step-wise multiple regression analysis was used to determine which visual function tests were correlated with the patients's perceived visual function and to rank them in order of importance. The visual function test that explains most of the variance in both 'core' score (66%0 and the 'module' score (68%) of the questionnaire is low contrast VA in the better eye (P<0.001 in both cases). Further, the module score also accounts for a significant proportion of the variance (P<0.01) of the distance logMAR VA in both the better and worse eye, and the near logMAR in both the better eye and binocularly. Conclusions: The best predictor of both perceived reading ability and of general perceived visual ability in this study is low contrast logMAR VA. The results highlight that distance VA is not the only relevant measure of visual fucntion in relation to a patients's perceived visual performance and should not be considered a determinant of surgical or management success.

Variant Creutzfeldt-Jakob disease and the eye

Variant Creutzfeldt-Jakob disease (vCJD) was first described in the UK in 1996 and is one of a group of diseases, the transmissible spongiform encephalopathies (TSEs) which affect both animals and humans. This review discusses vCJD in the context of other TSEs, considers the controversial 'prion' hypothesis as to the cause of the disease, the ocular features of vCJD, and the possible transmission of the disease via optoetric devices.

Alzheimer’s disease and the eye

Dementia, including Alzheimer’s disease (AD), is a major disorder causing visual problems in the elderly population. The pathology of AD includes the deposition in the brain of abnormal aggregates of ß-amyloid (Aß) in the form of senile plaques (SP) and abnormally phosphorylated tau in the form of neurofibrillary tangles (NFT). A variety of visual problems have been reported in patients with AD including loss of visual acuity (VA), colour vision and visual fields; changes in pupillary response to mydriatics, defects in fixation and in smooth and saccadic eye movements; changes in contrast sensitivity and in visual evoked potentials (VEP); and disturbances of complex visual functions such as reading, visuospatial function, and in the naming and identification of objects. Many of these changes are controversial with conflicting data in the literature and no ocular or visual feature can be regarded as particularly diagnostic of AD. In addition, some pathological changes have been observed to affect the eye, visual pathway, and visual cortex in AD. The optometrist has a role in helping a patient with AD, if it is believed that signs and symptoms of the disease are present, so as to optimize visual function and improve the quality of life. (J Optom 2009;2:103-111 ©2009 Spanish Council of Optometry)

Sample size estimation and statistical power analyses

The concept of sample size and statistical power estimation is now something that Optometrists that want to perform research, whether it be in practice or in an academic institution, cannot simply hide away from. Ethics committees, journal editors and grant awarding bodies are now increasingly requesting that all research be backed up with sample size and statistical power estimation in order to justify any study and its findings. This article presents a step-by-step guide of the process for determining sample sizeand statistical power. It builds on statistical concepts presented in earlier articles in Optometry Today by Richard Armstrong and Frank Eperjesi.

Visual signs and symptoms of Parkinson's disease

There are two aspects of PD of particular interest to optometrists. First, PD patients can develop a range of visual problems including those affecting eye movement, pupillary function, and in complex visual functions involving the ability to judge distance or make out the shape of an object. Second, the symptoms of PD can be treated successfully using a variety of drugs, some of which have significant ocular adverse reactions (OAR). This article describes the general features of PD, the dopamine neurotransmitter system and its relevance to eye symptoms, the visual symptoms reported in PD, and the OAR that have been reported.

Reproducibility and repeatability of the OcuSense TearLab™ osmometer

BACKGROUND: Some studies report that increased tear osmolarity is a reliable indicator of dry eye syndrome (DES). The OcuSense TearLab™ osmometer requires less than a 100-nl sample of tears and provides an instant quantitative result. Our aim was to clinically evaluate this instrument in terms of its reproducibility and repeatability. METHODS: Twenty-nine participants who ranged in age from 19 to 49 years (mean?±?SD: 23.3?±?5.5 years) were recruited. Osmolarity readings were collected by two operators, in two sessions separated by 1 or 2 weeks in order to assess test reproducibility and repeatability. RESULTS: The coefficient of reproducibility was 39 mOsms/l; the coefficient of repeatability was 33 mOsms/l. CONCLUSIONS: Our mean coefficient of variation over four readings for 29 subjects is 2.9%, which compares well with that reported by the manufacturer. Our results inform practitioners about the level of change over time that can be considered clinically relevant for healthy subjects. This value is 33mOsms/l; any change smaller than this could be attributed to measurement noise.

Visual signs and symptoms of progressive supranuclear palsy

Progressive supranuclear palsy is a rare, degenerative brain disorder and the second most common syndrome in which the patient exhibits 'parkinsonism', that is, a variety of symptoms involving problems with movement. General symptoms include difficulties with gait and balance; the patient walking clumsily and often falling backwards. The syndrome can be difficult to diagnose and visual signs and symptoms can help to separate it from closely related movement disorders such as Parkinson's disease, multiple system atrophy, dementia with Lewy bodies and corticobasal degeneration. A combination of the presence of vertical supranuclear gaze palsy, fixation instability, lid retraction, blepharospasm and apraxia of eyelid opening and closing may be useful visual signs in the identification of progressive supranuclear palsy. As primary eye-care practitioners, optometrists should be able to identify the visual problems of patients with this disorder and be expected to work with patients and their carers to manage their visual welfare.

Aspects of tonic accommodation and tonic vergence

Under conditions of reduced visual stimulation, the systems of accommodation and vergence tend towards physiological resting states that are intermediate within their functional range. The terms tonic accommodation (TA) and tonic vergence (TV) are used in the study to describe these stimulus-free, intermediate adjustments and to represent the systems as being in a state of innervational tonicity. The literature relating to TA and TV and the various experiments of this thesis are reviewed. Methodology has been developed enabling the determination of TA and TV under conditions of total darknessl laser optometry for TA and ~ernier-alignment for TV. The thesis describes a series of experiments designed to investigate various aspects of TA and TV, and their role in ametropia, binocular vision and their adaptation to sustained visual tasks. Measurements of TA were also utilised to investigate the effect of various autonomic effector drugs on the ciliary muscle. The effects of ethanol on binocular function are shown to be directly proportional to the .initial level of TVJ which is itself unaffected. These results support the concept of TV as the reference point for normal vergence responses. The results of the pharmacological investigations indicate the presence of a small but significant, beta-receptor mediated inhibitory sympathetic input to the ciliary muscle, and that the wide distribution in TA is a consequence of inter-observer variations in parasympathetic, rather than sympathetic tone. Following interaction with visual tasks of t5mins duration, the levels of TA and TV are found to be biased in the direction of, and proportional to, the task position: except during near-task viewing where the task-to-TA stimulus-distance exceeds 1.5D (for TA) and 3.5deg (for TV). Under these conditions the expected level of bias is attenuated, Adaptive models are discussed, proposing TA and TV as the reference points of the accommodative and vergence system.

Regional differences in oxygen saturation in retinal arterioles and venules

BACKGROUND: Retinal vessel oxygenation saturation measurements have been the focus of much attention in recent years as a potential diagnostic parameter in a number of ocular and systemic pathologies. This interest has been heightened by the ability to measure oxygen saturation in vivo using a photographic technique. METHODS: Retinal vessel oxygenation in venules and arterioles of 279 retinal vessels of 12 healthy Caucasian participants (mean age: 30 SD (+/- 6) years) were measured consecutively three times to evaluate short-term variation in oxygen saturation and regional variability of retinal vessel oxygen saturation using dual-wavelength technology (Oxymetry Modul, Imedos, Germany). All subjects underwent standard optometric assessment including non-contact intra-ocular pressure assessment as well as having their systemic blood pressure measured. RESULTS: Vessels were grouped as either near-macula or peripheral, depending on their location. Peripheral arterioles and venules exhibited significantly lower oxygen saturation compared to their near-macula counterparts (arterioles: 94.7% (SD 3.9) vs. 99.7% (SD 3.2); venules: 65.1% (SD 7.2) vs. 90.3% (SD 6.7)). Both arterioles and venules, main branches, and those feeding and draining the retina near the macula and periphery showed low short-term variability of oxygen saturation (arterioles: COV 1.2-1.8%; venules: COV 2.9-4.9%). CONCLUSIONS: Retinal arterioles and venules exhibit low short-term variation of oxygen saturation in healthy subjects. Regional differences in oxygen saturation could be a potential useful marker for risk stratification and diagnostic purposes of area-specific retinal pathology such as age-related macula degeneration and diabetic maculopathy.

Visual signs and symptoms of Multiple System Atrophy

Multiple system atrophy (MSA) is a rare movement disorder and a member of a group of neurodegenerative diseases, which include Parkinson’s disease (PD) and progressive supranuclear palsy (PSP), and referred to as the ‘parkinsonian syndromes’. Although primarily a neurological disorder, patients with MSA may also develop visual signs and symptoms that could be useful in differential diagnosis. In addition, the eye-care practitioner may contribute to the management of visual problems of MSA patients and therefore, help to improve quality of life. This second article in the series considers the visual signs and symptoms of MSA with special reference to those features most useful in differential diagnosis of the parkinsonian syndromes.

Abnormal retinal vascular function and lipid levels in a sample of healthy UK South Asians

Background/aims To investigate ethnic differences in retinal vascular function and their relationship to traditional risk indicators for cardiovascular disease (CVD). Methods A total of 90 normoglycaemic subjects (45 South Asian (SA) and 45 age- and gender-matched white Europeans (WEs)) were recruited for the present study. Retinal vessel reactivity to flickering light was assessed by means of the dynamic retinal vessel analyser according to a modified protocol. Fasting plasma glucose, triglycerides (TG), total, LDL and HDL cholesterol were also measured in all individuals. Results SA individuals showed higher fasting triglyceride (p=0.001) and lower HDL levels (p=0.007), leading to a higher TG:HDL-C ratio (p=0.001) than age-matched WE subjects. Additionally, in SAs, the retinal arterial reaction time in response to flicker stimulation was significantly longer in the last flicker cycle than in the WEs (p=0.039), and this change correlated positively with measured plasma TG levels (r=0.60; p=0.01). No such relationship was observed in the WEs (p>0.05). Conclusion Even in the absence of overt vascular disease, in otherwise healthy SAs there are potential signs of retinal vascular function impairment that correlates with established plasma markers for CVD risk.