Properties of the Manchester radial deformation acuity charts

By Nayha Patel Supervised by Dr Paul H Artes

Contents
Title 1. 2. 3. 4. Abstract Introduction 2.1 Aims and Objectives Visual Acuity & Hyperacuities Radial deformation acuity 4.1 4.2 4.3 Radial deformation acuity RDA Stimuli The Manchester RDA charts 4.3.1 4.3.2 4.3.3 4.3.4 5. 6. 7. The Manchester RDA charts Manchester RDA chart layout Recording results Scoring Page 4 5 7 9 13 13 13 15 15 16 17 19 21 24 26 26 26 26 26 26 26 28 28 28 28 28 28 29 29 29 30

Psychometric Functions Perceptual Learning Methods 7.1 7.2 Subjects 7.1.1 Inclusion Criteria Procedure 7.2.1 7.2.2 7.2.3 7.2.4 7.2.5 7.2.6 7.3 7.3.1 Sessions Monocular versus binocular testing Randomised presentation Environment Lighting Guessing answers RDA Distribution 7.3.1.1 Psychometric functions 7.3.1.2 Binocular versus monocular observation 7.3.2 7.3.3 7.3.4 Comparing scoring techniques RDA associations Learning

Data analysis

8.

Results 8.1 Distribution 8.1.1 8.1.2 8.1.3 8.2 8.2.1 8.2.2 8.2.3 8.3 8.4 8.5 Psychometric Functions Binocular versus monocular viewing Fitted threshold versus simple scoring technique Variability of results Manchester RDA chart scoring errors Predicted error on a Manchester RDA chart

31 31 31 33 34 35 35 37 39 40 41 42 43 43 43 44 45 45 46 46 46 46 47 48 49 50 RDA Distribution Scoring techniques Scoring Errors RDA associations Learning with the Manchester RDA charts Larger testing groups Binocular versus monocular investigations Manchester Royal Infirmary studies

Scoring Errors

RDA and Contrast Sensitivity RDA and logMAR VA Learning Limitations and potential improvements to the Manchester 9.1.1 9.1.2 9.1.3 9.1.4 9.1.5

9.

Discussions 9.1

9.2

Future Experiments 9.2.1 9.2.2 9.2.3

10. 11. 12.

Conclusions Acknowledgements References

1.

Abstract

PURPOSE. To investigate the properties of the Manchester radial deformation acuity (RDA) charts in young healthy observers. METHODS. Ten visually-normal young volunteers (mean age: 19.6 years, age range: 18 to 22 years) were examined on six Manchester RDA charts in four sessions over four weeks. Five volunteers observed the chart binocularly and five monocularly. RESULTS. Results were obtained from a simple scoring algorithm as well as by fitting psychometric functions to the data. In this group of observers radial deformation acuity (RDA) ranged from 2.73 log RDA to 3.32 log RDA (mean: 2.948 log RDA, SD: 0.21). The width of the psychometric function (difference between radial deformation at 10% and 90% performance) ranged from 0.54 to 1.10 (mean: 0.75, SD: 0.23). The simple scoring technique appeared to be more precise in estimating threshold RDA compared to the RDA obtained from fitting the psychometric function. Compared to the simple scoring algorithm, the psychometric function scoring technique overestimated RDA at higher RDA levels. No associations of RDA with Pelli-Robson CS or logMAR VA measurements were seen (Pearson correlation co-efficient: r=0.105, p=0.77 for CS, r=-0.398, p=0.25 for logMAR VA). Of the ten observers, seven showed evidence for a learning effect. The magnitude of this effect, however, was small compared to the overall variation. CONCLUSIONS. The results indicate that the current version (V2) of the Manchester RDA charts do not provide a sufficiently low radial deformation level (ceiling effect). The simple scoring technique compared well to psychometric function fitting.

2.

Introduction

The Manchester radial deformation acuity (RDA) charts are a novel shape-discrimination test. They are designed to screen for diseases which cause retinal distortion, such as agerelated macular degeneration (AMD). This study will look at the properties of the Manchester RDA charts in ten young, healthy observers. Five volunteers will be asked to observe the charts monocularly and five volunteers will asked to observe the charts binocularly to investigate any possible differences. Firstly, this study will evaluate two different scoring techniques that can be used to measure RDA. These are a simple scoring technique and fitting a psychometric function to the data to score threshold RDA. The variability and error of the two scoring systems will be quantified according to the number of charts presented. Secondly, RDA scores will be compared with logMAR visual acuity (VA) and contrast sensitivity to investigate any associations. Finally, this study will look at the learning effects associated with the Manchester RDA charts by looking for a correlation between the threshold RDA measured and the number of charts presented. Studying the properties of the Manchester RDA chart properties will allow us to investigate differences between two scoring techniques and determine the most precise scoring technique for the charts, highlight any limitations of the chart and observe learning effects. The importance of these properties is outlined below. The chart is designed to screen for retinal distortion caused by diseases such as AMD. For clinical use, a threshold RDA criterion will have to be produced. For example, what RDA threshold measured merits referral in an optometric practice or, merits surgery in a hospital? There are two ways in which the Manchester RDA chart can be scored. It is important that the most precise scoring technique is used to determine the threshold RDA and when exploring remaining properties of the chart. The scoring errors can also be quantified so that they can be accounted for when the Manchester RDA charts are used clinical practice. This will estimate a more precise threshold RDA.

The Manchester RDA chart is a novel vision test so it is important to investigate if logMAR VA and contrast sensitivity have any correlation with RDA. If a correlation is found, this would suggest RDA is influenced by these measurements and limits its usefulness. Ideally we would want no correlation so that the Manchester RDA chart can be used as a universal screening test suitable for all patients, unaffected by logMAR VA and contrast sensitivity. It is seen in practice that patients will learn to perform visual tasks. Examples include reading a Snellen chart and performing the TNO stereopsis test. Attention and fatigue have also been associated with visual tasks and the validity of their results (Fahle 1996). Learning has been investigated and quantified with many visual tasks including visual field testing (Wild et al., 2006) and stereopsis (Westheimer 1994). However, no one has yet quantified the amount of learning achieved with the Manchester RDA charts. If learning can be quantified for the number of charts presented it can be taken into consideration by the practitioner to give a more accurate RDA threshold for the patient. Ten, young, visually-healthy volunteers will be recruited to take part in the study. Each volunteer will have their logMAR VA and contrast sensitivity measured. To participate in this study these measurements must be within the pre-defined inclusion criteria set. Following this, the volunteer will be tested on each of the six Manchester RDA charts in four separate sessions. At each session the scores generated on each chart will be recorded on a specialised computer programme (Datalogger). Possible conclusions that may be indicated from the results are discussed below. There are two different scoring techniques that can be used to measure RDA. Therefore, each volunteer will have two RDA scores from each chart observed. These will be a simple threshold RDA and a fitted threshold RDA (interpolated from a psychometric function). On analysis of these RDA scores it may be found that one scoring technique is more precise in measuring threshold RDA. The pattern of distribution of the RDA thresholds may highlight limitations of the Manchester RDA charts. For example, all volunteers may score the highest RDA presented on the charts. threshold RDA. This would be a limitation of the charts not presenting a low enough radial deformation level to measure

Learning effects will also be highlighted from RDA thresholds measured. For example, all the volunteers RDA thresholds may improve within and over a number of sessions. This will be evidence to suggest that the volunteer has learnt how to perform the visual task (learning effect). This is because it is unlikely that a true change in the underlying sensory process has taken place. If this learning effect can be quantified according to the number of charts presented, it can be taken into consideration when the final threshold RDA is measured. This will give a more accurate estimate of threshold RDA. Finally, associations between logMAR VA and contrast sensitivity with threshold RDA measurements will highlight limitations of measuring RDA on the Manchester RDA charts. For example, we may find a positive relationship between logMAR VA and RDA. This would limit the use of the Manchester RDA chart since threshold RDA could potentially be predicted from logMAR VA. RDA may be a useful quantitative vision measurement for early degenerative eye diseases. Shape discrimination ability has already been shown to be decreased in patients with agerelated macular degeneration, AMD (Wang 2002). Because the Manchester RDA chart is a new vision test, many important properties of the test are still unknown. It is valuable to investigate the properties of the chart itself (e.g. learning effects) and any factors that may affect RDA measurements (e.g. logMAR VA). The results may advocate improving the design of the chart or how the chart is used, for example monocular or binocular viewing. This study will look at RDA scoring techniques, RDA distribution in monocular and binocular viewers, RDA associations with logMAR VA and contrast sensitivity and learning effects as factors which may affect threshold RDA.

2.1

Aims and Objectives

The aim of this study is to investigate the properties of the Manchester RDA charts in young, healthy observers. Scoring techniques, observation methods (monocular versus binocular), logMAR VA and contrast sensitivity associations with threshold RDA measured and learning effects will be investigated. Where applicable the factors will be quantified.

The objectives of this study will be to examine RDA in ten visually-healthy, young volunteers. Five will be tested binocularly and five monocularly. Each volunteer will be tested weekly for four weeks on the six charts. This data will be analysed by fitting a psychometric function to it. Psychometric functions are thought to be the most accurate way of extracting information on stimulusresponse relationships. These will generate what we will call the fitted threshold RDA. An alternative way of scoring RDA is by using a simple scoring technique. Volunteers will be asked to stop reading the Manchester RDA chart according to the termination rule (three consecutive incorrect responses). The threshold RDA is calculated by taking the smallest RDA level reached (before the termination rule applies) and subtracting 0.10 for each error made (for a more detailed explanation see section scoring 4.3.4. figure 7). The variation between these two scoring techniques will be calculated and analysed to generate a predicted error for a specific number of charts presented. The distribution of RDA in binocular and monocular observers will be plotted to investigate binocular summation effects on RDA. Threshold RDA scores will be compared to logMAR VA and contrast sensitivity to highlight any associations. To investigate any possible learning effects associated with the Manchester RDA charts, threshold RDA from each session will be plotted for each volunteer. An improvement in threshold RDA can be called a learning effect since it is unlikely that a true change in the underlying sensory process has taken place. The purpose of the investigation is to identify and quantify, where possible, the nonvisual factors that will affect threshold RDA measured and perhaps significantly change its clinical value as a measure of hyperacuity over time.

3.

Visual Acuity & Hyperacuities

Clinically, ordinary visual acuity (VA) tends to be the most commonly performed test of vision. VA is a threshold measurement (i.e. smallest level of visual stimulation that a person can detect) taken by varying the spatial dimension of a target. Within this definition there are three main sub-divisions described by Westheimer (2003). Firstly, there is the minimum visible measurement. This is performed by varying the object size, which is a single feature of the target. An example would be to detect if a target was present or not. Secondly, there is the ordinary VA or minimum resolvable acuity (MAR). This is the ability to discriminate and recognise one target from another. This involves the subject making a subjective decision based on spatial judgement, for example, is that an O or a C? Ordinary VA or MAR can be expressed in seconds of arc or as the log of the MAR (logMAR). Typical values range from 30 seconds of arc to 1 minute of arc for ordinary VA (Westheimer 2003) or -0.14 logMAR to -0.02 logMAR (Elliott, Yang et al., 1995, figure 1). The targets for visual acuities have to be high contrast. The British Standards Institute (BSI) states the contrast sensitivity of VA targets should not be less than 90% (BSI 2003). The final subdivision of VA, and more relevant to this study, is spatial minimum discriminable or hyperacuity. This is the ability to determine the relative location of the same two targets with respect to one another.

Figure 1: An illustrated Snellen Letter explaining the principle behind measuring VA. You vary the size of the critical detail and express the angle where it is distinguished approximately 50% of the time (Extracted from Kolb. H. Fernandez. E. & Nelson website) Hyperacuities are fascinating to study since they are a visual task whose threshold value exceeds any expectations based upon retinal receptor spacing (Levi, 1982; Shapley, 1986; Whitaker, 1992). In visual tasks the human visual system uses hyperacuities to evaluate spatial resolutions with the precision of a fraction of a photoreceptors diameter (Poggio, 1992). This suggests that higher order functions are responsible for this acuity. Typically, hyperacuities thresholds range from 2 to 8 seconds of arc. There are several different types of hyperacuities. Vernier acuity is the ability to detect the smallest perceptible misalignment between two lines (Levi, 1982). Hyperacuities and vernier acuities are often used synonymously but vernier acuity is simply one type of hyperacuity (figure 2). Stereoscopic acuity testing is another type of hyperacuity. In clinical practice, it is used to assess depth perception and binocularity. The visual processing for stereopsis is thought to be different to that used to detect radial deformation (Westheimer, 2003). The Manchester RDA charts are based upon a global shape discrimination hyperacuity task. This involves detection by retinal photoreceptors, followed by processing of polar arranged, orientation selective cells in V1 in the extrastriate cortex (Hess, 1999).

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Figure 2: Hyperacuity target examples. (a) and (b) are examples of radial deformation acuity visual stimuli and (c) and (d) are examples of vernier acuity visual stimuli. (Extracted from Wang 2001) Hyperacuities can be used to assess the health and function of the retinal photoreceptors. Reductions in hyperacuities can be indicative of pathological diseases not only affecting the retinal photoreceptors, but lateral geniculate nuclei (LGN) cells (Moss, 1986) and striate cortex cells (Parker, 1985; Swindale, 1986). The hyperacuity stimulus used in the Manchester RDA charts was initially designed to determine whether a deficit for global shape detection was seen in strabismic amblyopes (Hess, 1999). The stimulus was then later used in normals to determine whether the judgement of circularity was done in a localised space of similar size to the stimulus or whether they were computed as a global shape (Hess, 1999; Wang et al., 1999). More recently, the RDA stimulus has been used to show how it is not affected by normal ageing (Wang, 2001) and how AMD affects shape-discrimination (Wang, 2002). While different areas of the visual pathway have been found to contribute to vernier hyperacuity abilities, the neural basis of hyperacuities is still not well understood (Spear, 1993). Hyperacuities measured for this study are a global task. This means that the visual system must integrate visual information over several areas, including a vast array of retinal photoreceptors and several different visual pathways. This ability to integrate information over several areas was researched in primates. Primates were found to have receptor field diameters of 2.0 arc and in comparison 25 x larger threshold value for

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vernier acuity (DeMonasterio, 1975). With this evidence and Westheimers hyperacuity definition, it was most likely that higher order processes must be involved in the summation of these responses (Westheimer, 2003; DeMonasterio, 1975). Later work done by Shapley and Victor (1986) in cat ganglion cells found hyperacuities were a result of high gain (lots of visual information) and low noise (low interference, for example from eye movements, selective attention) of the receptive field centre mechanism. All of the above findings suggest that in order to detect radial deformations the photoreceptors have to compare the signals received from retinal cells with both small and large receptive fields. A higher order of visual processing must be involved to perform this hyperacuity task (Hess, 1999). Although research of the mechanism of hyperacuities is still being explored it is fair to say that the neural processing involved is likely to be complex. However, since hyperacuities are relatively unaffected by degenerative changes that affect the optical media, they are useful for assessing retinal diseases. These include blur, reduced contrast and image diffusion due to light scatter (Spear, 1993).

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4.
4.1

Radial deformation acuity

Radial deformation acuity
It is a

Radial deformation acuity (RDA) is the ability to detect different levels of radial deformations in a circular D4 (4th derivative of Gaussian contour) pattern. hyperacuity task that is largely unaffected by contrast (Wilkinson, 1998; Hess, 1999; Wang et al., 1999). Radial deformations in a circular target are processed with the same precision as deformations in straight lines. RDA is a relatively new type of hyperacuity (Watt, 1982). RDA is currently not used in clinical practice for vision assessment but recent studies have outlined its usefulness. RDA can be applied to detect spatial vision abnormalities in infants (Birch, 2000). Wang (2001) suggested that RDA may be sensitive enough to quantify early visual loss in age-related eye diseases, for example age-related macular degeneration (AMD). In 2002, Wang et al., concluded that shape discrimination may be useful in assessing the integrity of photoreceptors and therefore as a clinical test for monitoring AMD. Currently, the clinical value of RDA in retinal diseases is still being investigated. Some of the advantages of RDA over the more traditional letter acuity tasks are discussed below. Some hyperacuities are less affected by exposure duration and contrast compared to VA (Westheimer, 1982). VA can decrease due to media opacities (e.g. cataract) as they reduce the contrast of the visual stimulus. It has been shown that RDA stimuli are unaffected by contrast and largely unaffected by degenerative changes of ageing (Wang, 2001). With RDA we want to screen for diseases which result in retinal distortion, for example AMD. Having a test that is robust to media changes such as low level cataracts will mean that our measurement is less influenced by the optical condition of the eye (cornea, lens). This will make the Manchester RDA charts suitable for patients who have early cataract or other media opacities. Since no letters have to be read, the chart can also be used on illiterate patients.

4.2

RDA Stimuli

The RDA stimuli are sinusoidal perturbations of contours constructed from 4th derivatives of a Gaussian contour. Firstly, they are a low spatial frequency visual target. 13

To decrease variables, one spatial frequency in the RDA stimulus would be ideal. Since this is not possible to produce, the stimulus is a narrow-band of low spatial frequencies. Low spatial frequencies were used because of what the RDA stimulus was initially designed for. The circular (D4) contour was the visual target of choice in a study done by Hess et al., in 1999 to investigate vision in amblyopes. The RDA stimulus targeted cells in V1 with specific spatial, temporal, orientation and contrast filtering properties. They found amblyopes had poor sensitivity to sinusoidal deformations due to the downstream processing from V1 rather than a sampling deficiency (Hess, 1999). A low spatial frequency stimulus is an advantageous since it makes the target relatively immune to moderate dioptre blur (Elliott, 1997). Secondly, the RDA stimuli are suprathreshold high contrast. This makes the stimulus less sensitive to small changes in contrast which would occur with, for example, low level cataracts. Thirdly the amplitude of circular distortion is well controlled in circular D4 contours and is calculated as below, allowing a large variety of stimuli to be presented (figure 3). The initial circle is created using the equations below: CD4 = Lm [1 + c (1 - 4r2 + 4/3r4-e-r2)] r = (x2 + y2) R = 2 p Where is the space constant of D4, p is the D4 peak spatial frequency, R is the radius of the circular D4 contour and the formula below calculates the deformation of the circle: R = Rm [1 + Asin [fr arctan (y/x) + ]] Where Rm is the mean radius, fr is the radial frequency, A is the amplitude of the radial deformation and is the phase modulation where 0< <2.

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Figure 3: (a) An unmodulated circular D4 contour (b) A modulated circular D4 contour with radial frequency of 8 cyc/360 and radius modulation of 4% (Hess 1999) On the Manchester RDA charts the levels of distortion are stated as log RDA. This is calculated by taking the radial deformation (as calculated above) as a percentage distortion threshold value. RDA is then stated on the charts as a log of the reciprocal of this threshold value.

4.3

The Manchester RDA charts

4.3.1 The Manchester RDA charts

The Manchester RDA chart uses a simple, uncomplicated odd-one out paradigm. At each RDA level there are five circles. One circle is deformed and the volunteer must guess which out of the five circles is deformed. There are six charts, with twenty increasing RDA levels where the amplitude of deformation decreases. Six charts allow more variation in presentation which may reduce learning effects that could be seen on performing the visual task. The Manchester RDA chart is a hand-held vision test. This has advantages over distance tasks since is more convenient. For example the charts are portable and both chart illumination and working distances can be controlled.

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4.3.2 Manchester RDA chart layout

Three Manchester RDA charts are illustrated in Figure 4. On each row there are five D4 circles, one of which is distorted. The choice of five circles increases the repeatability of the charts since it decreases the chances of correctly guessing the distorted circle. The amount by which each circle is distorted on each row will decrease by an arbitrary amount making it increasingly difficult for the observer to guess the distorted circle. The stimuli will be presented on a board printed in high resolution (600 dpi) as opposed to computer generated which has previously been used (Hess, 1999; Hess, 1999; Wang et al., 1999; Wang 2001; Wang 2002). Unlike computer generated RDA stimuli, printed RDA stimuli are not limited to a particular number of pixels. Printed stimuli therefore present a crisper, sharper image of the stimulus. The D4 circles are printed on a 0.5% reflectance background and therefore reflect 50% of the light incident on it.

Figure 4: The Manchester RDA charts. Three out of six charts are shown here. The charts measure radial deformation acuity. This is the smallest level of radial deformation detected by an observer.

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4.3.3 Recording results

As the charts are being read the responses will be inputted into Datalogger. This is a programme specifically designed to record RDA responses from each of the Manchester RDA charts. The screenshot below illustrates the layout of this programme (figure 5). Before each session, the name, chart and whether the volunteer is carrying out the test monocularly or binocularly are entered on the right hand side. As the volunteer responds the responses are entered into the programme. Figure 5 illustrates what Datalogger programme records after a chart is completed.

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Figure 5: Screenshot of the Datalogger programme. The top screenshot illustrates what the Datalogger looks like when the programme is opened up. The bottom screenshot illustrates a completed chart, with details on the right-hand side of the screen of the chart number, volunteers name and the eye that was tested. The green indicates a correct response and the red indicated an incorrect response. This data is automatically written to a spreadsheet file.

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4.3.4 Scoring
Volunteers are asked to stop guessing according to the termination rule. This is when three consecutive incorrect responses are given. Volunteers will be offered a second guess at those RDA levels they incorrectly guessed. If an improvement has been made on the three consecutive incorrect responses, the volunteer will be allowed to continue further on the chart until the termination rule applies again. The spreadsheet generated from Datalogger (figure 6) can be used to mark volunteers responses on a scoring sheet. A simple scoring system is used to calculate the threshold RDA score, illustrated in figure 7. An alternative way to score threshold RDA is to plot a psychometric function.

Figure 6: Screenshot of the spreadsheet generated automatically from the Datalogger programme. From right to left the columns represent: Name, eye tested, date of chart presentation, time, Manchester RDA chart number, response number, RDA level line number, RDA level, volunteers guessed answer, actual answer and, time taken to make next guess according to previous guess in milliseconds.

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Figure 7: Illustration of the scoring sheet used to calculate the final, simple RDA score, for chart 1. In this example the observer reached the end of the scoring sheet with scores for 3.10, 3.20 and 3.30 being the three consecutive incorrect responses given as criteria to stop testing. The observers score after the first round of testing was 2.80 since the lowest correct score was 3.00 but two incorrect responses reduces this score to 2.80 (3.00 - 0.20).

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5.

Psychometric Functions

Psychometric functions will relate an observers performance to the intensity of a psychophysical stimulus (Wichmann and Hill, 2001). One of the ways the sensory response can be recorded is as a response probability. Another way to record the sensory response is in terms of effect size. For responses recorded as a probability, a continuous function is usually seen with a sigmoid profile (figure 8).

Figure 8: A psychometric function relating response probability to stimulus intensity. The stimulus intensity increases from left to right on an arbitrary scale. The upper and lower asymptotes are the limits of sensory performance. The threshold response criterion is a specified response probability corresponding to a particular threshold stimulus value. The slope of the function is the gradient of the function at the threshold point. (Reproduced with permission from Gilchrist, Gilchrist et al 2005) There are four operating parameters described by Gilchrist et al., (2005) that can be used to describe a psychometric function. These are the horizontal asymptotes (upper and lower asymptotes), the location of the function on the abscissa and the local gradient or slope at some specific location. Each parameter will now be discussed.

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The horizontal asymptotes are the limits of sensory performance and are further divided into the upper and lower asymptotes (Gilchrist et al., 2005). The upper asymptote is the limit of accuracy of perceptual processes. The lower asymptote is where the observer begins to guess, for example guesses a stimulus is presented even if it is absent (Wichmann and Hill, 2001). The location parameter, which is parameter of the function on the abscissa, will have the same units as the stimulus (Gilchrist et al., 2005). For example, in this study the location parameter will be measured in log RDA. It is more generally interpreted as the sensory threshold. Therefore, this parameter is also known as the threshold parameter (Gilchrist et al., 2005). The location of this parameter is a specified response probability which will correspond to a particular stimulus value. For this study, to measure threshold RDA, the location of this parameter will be at the level midway between chance performance and the upper asymptote of the response probability. The final parameter of the psychometric function is the slope parameter. This is the gradient of the tangent at the threshold location parameter. It determines the rate at which the response probability changes per unit change in the stimulus level (Gilchrist et al., 2005). Treutwein (1995) reported that threshold estimation dominated experimental psychophysics and the other parameters described above were ignored. However, it has more recently been found that the slope parameter is an important measure of perceptual performance. The clinical significance is now appreciated for the slope parameter (Chauhan et al., 1993; Patterson et al., 1980; Strasburger, 2001). Subsequent to these findings, the mathematical models on which psychometric functions estimated slope and threshold parameters have been developed (Kaernbach, 2001; Kontsevich et al., 1999; Snoeren et al., 1997). All of the parameters discussed above will vary according to the mathematical model used to plot the psychometric function. Such models include cumulative Gaussian, logistic, Weibull, or Gumbel functions (Wichmann and Hill, 2001). The estimated range of variation in parameter values is likely to be very small for the threshold parameter and upper and lower asymptote parameters. It is possible to define threshold in terms of some associated response probability, and the upper and lower asymptotes are response probabilities. Therefore the variation in the values for these parameters is not a King-Smith et al., 1997;

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significant problem (Gilchrist et al., 2005). The slope parameter variability in comparison is larger. This is because the slope does not have any fixed unit or range of values for its interpretation. Variation in parameter values is seen as more of a problem when it comes to comparing psychometric function slope parameter data with other data fitted to the same experimental data. For example, in this study, further investigations using psychometric functions would have to use the same mathematical model to compare their results to ones found in this study. Psychometric functions are useful since they consider the observers performance when generating a fitted threshold RDA (Wichmann and Hill, 2001). This may measure a more accurate RDA threshold compared to the simple scoring technique (described in section 4.25). This is because all of the subjects responses are being used to derive threshold, rather than just a small part as in the simple scoring method. However, Hazel and Elliott (2002) found no advantage of fitting a psychometric function to the data generated for observers reading a logMAR chart (logMAR VA versus percentage of letters called correctly). They found psychometric functions to over-estimate visual acuity measurements by approximately two letters (0.02 logMAR). For this study psychometric functions will be used to estimate a fitted threshold RDA for each volunteer. Furthermore, we have expressed the slope according to the parameterisation originally suggested by Alcal-Quintana et al., in 2004. We expressed the slope as the width of the psychometric function is the distance between the RDA levels associated with performance levels of 0.28 and 0.92 (corrected for the 0.20 probability that the observer will guess correctly). The width of the psychometric The widths of the function will illustrate how quickly each volunteer went from being able to detect the radial deformation to guessing which circle was deformed. psychometric functions will be compared. This will illustrate whether the step sizes at which radial deformation decreases is precise enough to measure RDA on the Manchester RDA charts. For example, a steeper slope will suggest the observer quickly regresses from being able to detect radial deformation to not being able to detect radial deformation on the Manchester RDA charts. Finally, this project will look at the learning effects associated with the Manchester RDA charts.

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6.

Perceptual Learning

Perceptual learning can be described as the ability to extract information from the environment as a result of learning in that environment (Sireteanu, 1995). For the purpose of this study perceptual learning is the change in RDA score over time. There are four main mechanisms of perceptual learning that have been reviewed by Goldstone in 1998. These are attention weighting, stimulus imprinting, differentiation and unitization. The attention weighting mechanism shows increasing attention allows for perceptual adaptation i.e. learning (Goldstone, 1998). Depending on the stimuli the information is processed within different pathways, and different visual tasks show different visual adaptation and therefore learning patterns. Secondly, stimulus imprinting can allow perception to adapt. This involves the retinal receptors and higher visual pathways which are known to respond to certain visual stimuli specifically. Thirdly, the differentiation mechanism separates stimuli psychophysically and into categories including complex and simple and differential dimensions. Finally, the fourth mechanism is unitization, which works in the opposite direction to differentiation. It constructs what differentiation separated from the stimuli (Goldstone, 1998). Perceptual learning is important to consider as it is sensitive to training, and is seen to occur for visual detection and discrimination threshold testing. Perceptual learning can be disrupted if the patient is asked to perform a different hyperacuity task with different stimuli (Seitz, 2005). In this study however, the volunteer will only be exposed to one type of hyperacuity task and therefore perceptual learning can be assumed to be continuous. Perceptual learning can be influenced by cognitive aspects such as global pattern structure, attention and motivation which must be considered in every learning task (Fahle, 1996). Obviously, the more driven a person is to learn the more attention they will pay and therefore, this will not only affect how well they perform at the visual task but the score they achieve at the end. processing task (Poggio, 1992; Fahle, 1996) Perceptual learning will occur without feedback so patients do not need to know whether they have correctly completed the visual task (Fahle 1995). This discovery by Fahle et al., 24 Perceptual learning is an early stage visual

led to the hypothesis that current models for perceptual learning are not biologically plausible. Although it was found that learning was slower without feedback this was highly dependent on the target stimulus that was used in the experiment. Fahle et al., concluded that the HyperBF-like model for learning would take place in two distinct ways. Firstly the unsupervised learning which create or tune centres do not require feedback. Secondly, supervised learning which determines synaptic weights for the coefficients does require feedback. Perceptual learning and hyperacuities are linked and it has been suggested that the ability of humans to perform hyperacuities to some extent depends on a fast learning process fast perceptual learning (Poggio, 1992). The proposed model is that the cortex sets up task-specific modules that receive input from retinal photoreceptor cells and after a short training period the cells are able to solve the task. In agreement with Hess et al., (1999) the learning stage is provided by the circular centre-surround and orientation cells in V1. Perceptual learning is important to consider in all visual tasks since it occurs all the time and could be a good indicator of how repeatable and accurate a visual test can be at diagnosing ocular diseases.

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7.
7.1

Methods
Subjects

Ten young, visually healthy volunteers were informed about the study and their level of involvement. Written consent was then obtained from each volunteer. Volunteers could participate in the study if they fell into the inclusion criteria set for this study.

7.1.1 Inclusion Criteria

All volunteers had to be over the age of eighteen years old for legal reasons. There was no upper age boundary set as there is no significant evidence at present to suggest that RDA is affected by age in healthy volunteers. Volunteers were included in the study if they had a VA of equal to or better than 0.20 logMAR on the ETDRS chart. Stereopsis had to measure at least 120 seconds of arc on the TNO test i.e. each volunteer must have good binocular vision. Finally, volunteers needed to score at least 1.50 log units monocularly on the Pelli-Robson contrast sensitivity chart.

7.2

Procedure

There were six Manchester radial deformation acuity (RDA) charts to be completed at each session. Sessions were scheduled at times that were convenient for the volunteer.

7.2.1 Sessions
All the volunteers were tested on all six charts weekly for a period of four weeks. The session duration varied between 20 to 30 minutes. Due to time constraints, having to input responses into Datalogger and inter-subject response and intra-subject response variability, no breaks were given between each of the six charts used at each session.

7.2.2 Monocular versus binocular testing

Half the volunteers completed the RDA chart binocularly and half monocularly. For monocular testing, the volunteer and eye tested were chosen at random. The eye was occluded with an elasticated, leather eye patch.

7.2.3 Randomised presentation

At each session a specific chart order was used and kept standard inter-participants. This was chosen at random and changed at each test session. 26

Eye Name CEs DM JR MP MM MH TC AK CaE FT DOB 06.03.86 04.09.87 10.10.88 05.01.87 06.06.84 28.03.86 06.05.88 25.07.85 20.06.88 09.10.85 Tested Binocular Binocular Binocular Binocular Binocular RE LE RE RE RE RE Refraction -1.00/-1.00x5 -1.50/-0.25x10 -3.25DS +0.25/-0.50x105 0.00/+0.25x40 +0.50/-1.25x15 +3.00/-0.50x125 +1.50DS -6.50/-0.75x25 -0.25DS LE Refraction -0.75/-1.25x170 -1.25/-1.00x160 -3.25DS +1.00/-0.75x48 -.25/+0.25x160 +0.50/-0.25x175 +2.25/-0.25x115 +1.50DS -7.50/-0.25x155 -0.50DS

RE LogMAR -0.22 -0.06 -0.06 -0.10 -0.16 -0.02 -0.06 -0.26 -0.22 -0.12

LE LogMAR -0.16 -0.06 -0.04 -0.02 -0.20 -0.04 -0.08 -0.26 -0.20 0.02

RE Contrast Sensitivity (log) 2.00 1.90 1.75 1.65 1.75 1.60 1.75 1.90 1.85 1.55

LE Contrast Sensitivity (log) 1.80 1.95 1.80 1.70 1.60 1.60 1.80 1.80 1.80 1.60

Stereoacuity
(seconds of arc)

60" 30" 60" 120" 60" 60" 60" 30" 30" 30"

Table 1: Clinical data of the ten volunteers who participated in this study

27

7.2.4 Environment A 40cm (10cm) working distance was employed each time the chart was read. Volunteers were given time to adopt a comfortable position as discomfort can affect attention. A measuring tape was used to set the chart reading distance each time a chart was being read.

7.2.5 Lighting
Lighting was kept constant during each chart that was read. The chart was directly illuminated with a 100 watt light bulb fixed to the ceiling of the room and fluorescent light stand. The fluorescent lighting stand position was adjusted until lumination incident on the chart measured between 500-600 lux. A digital lightmeter was used (Center 337 Mini-lightmeter by Onsite Tools) to measure this and lighting was checked at every session.

7.2.6 Guessing answers

Volunteers were verbally forced to guess the answers on each RDA level (forced choice). They were stopped after three consecutive incorrect responses were given on each chart (termination rule). Volunteers were given another final opportunity at levels where they guessed incorrectly.

7.3

Data analysis

7.3.1 RDA Distribution

7.3.1.1 Psychometric functions Psychometric functions according to the Gumbel-model were fitted using Bayesian estimation in the open-source statistical software R by my project supervisor (Kuss et al., 2005a; Kuss et al., 2005b). This function will allow us to estimate a fitted threshold RDA for each chart. This threshold RDA will be compared to the threshold RDA derived from the simple score technique. The simple scoring technique will be the hypothesised model from which the psychometric function is generated. Therefore a simple comparison of the two results will show the goodness of the fit of the psychometric function. The slope parameter of the psychometric function will illustrate the transition from when volunteers can detect the radial deformation to when this becomes too difficult. A steep 28

slope would suggest the transition is very fast in contrast to a flatter slope indicating a very slow transition. 7.3.1.2 Binocular versus monocular observation The fitted RDA thresholds plotted against the slope of the psychometric function will illustrate differences in the distributions of RDA in volunteers tested binocularly and monocularly.

7.3.2 Comparing scoring techniques

A simple RDA scoring technique and a fitted threshold RDA interpolated from a psychometric function technique were used to measure each volunteers threshold RDA on each chart. Each volunteer completed six charts at every one of the four sessions. An average RDA from each session and from all sessions was calculated for each scoring system for each volunteer. These results were plotted on a scatterplot to illustrate the distribution. 5% and 95% confidence intervals will show the precision of each scoring system. A narrow confidence interval will indicate high precision of the scoring techniques and a broad confidence interval will indicate a poor precision of the scoring techniques. To assess the variability between the two scoring techniques, standard deviations of the average RDA scores were calculated and plotted. To quantify the error generated, the RDA generated from most accurate scoring technique was used. For each volunteer the standard deviation of their RDA scores was divided by the square root of the number of charts that had been presented. This was done for each chart and for each session. The spread of these two bar charts (individual chart and sessional error) allowed construction of a predicted scoring error according to the number of Manchester RDA charts presented.

7.3.3 RDA associations

By comparing the scoring techniques as described above, the most precise threshold RDA was plotted against each volunteers logMAR VA and contrast sensitivity to highlight any associations.

29

7.3.4 Learning
To assess whether there is a learning effect associated with the Manchester RDA charts, the volunteers most precise threshold RDA was plotted for each of the four sessions and the rank correlation coefficient was calculated.

30

8.
8.1

Results
Distribution

8.1.1 Psychometric Functions

The psychometric functions in this group of ten volunteers are shown in figure 9. The psychometric functions shown on the left hand side are from volunteers who observed the chart monocularly (AK, TC, CaE, FT, MH). Those shown on the right hand side are from binocular observers (CEs, DM, JR, MP, MM). The numbers shown beneath each function are the threshold and slope parameters (slope is expressed as the width of the psychometric function). The threshold parameter will be called the fitted threshold RDA (log radial deformation). The highest fitted threshold RDA is seen in CEs (3.32 log RDA). The highest RDA level presented at the bottom of the Manchester RDA chart is 3.30 log RDA. Therefore, CEss psychometric function illustrates a ceiling effect where her fitted threshold RDA is greater than the radial deformation presented on the chart. This is also seen for MMs psychometric function (3.31 log RDA). Both CEs and MM were tested binocularly. The lowest fitted threshold RDA were seen in TC (2.73 log RDA) and FT (2.73 log RDA) both of whom were tested monocularly. The slope parameter (expressed as the width of the psychometric function) illustrates the transition from when volunteers see the radial deformation and when they dont see. For some volunteers the transition is very steep and for others it is very shallow. There seems to be no specific pattern as to how the slope parameter varies between each volunteer. The steepest slopes were seen with AK (0.54) and FT (0.54), both monocularly tested. The flattest slope is seen in MM (1.2) who was tested binocularly. However, CEs and MMs psychometric function illustrates a ceiling effect. This will affect the slope and threshold parameters interpolated so this result may not be true.

31

Response Probability

Figure 9: Psychometric functions for each volunteer for all four testing sessions. Those volunteers in the first column were tested monocularly and those in the second column were tested binocularly. The legend numbers are the fitted RDA threshold for the 24 charts (left) and the slope parameter expressed as the width of the psychometric function (right).

Stimulus Intensity (log radial deformation) 32

8.1.2 Binocular versus monocular viewing

Five volunteers were chosen at random to complete the chart monocularly and five completed the charts binocularly. AK, TC, CaE, FT and MH were monocular observers. CEs, DM, JR, MP and MM were binocular observers. The distribution of fitted threshold RDAs estimated within these two groups is illustrated in figure 10. The slope parameter value and fitted threshold RDA scores were interpolated from the psychometric functions illustrated in figure 9. In this group of volunteers no significant relationship is seen between the slope and fitted threshold RDA (R-square=0.16, p=0.25). No significant difference is seen in fitted threshold RDA values between volunteers tested monocularly and volunteers tested binocularly (p=0.31, Mann-Whitney U test).

Figure 10: Relationship between the slope and fitted threshold parameters of the psychometric functions (R-square 0.16, p=0.25). Interestingly, CEs and MM scored highest fitted threshold and were tested binocularly. monocularly. Red initials are those volunteers tested binocularly, black initials are those tested

33

8.1.3 Fitted threshold versus simple scoring technique

Volunteers were tested on six charts at four sessions. Two scoring techniques were used to score each chart. The average RDA (24 charts) for each scoring technique was calculated for each volunteer. Figure 11 illustrates this distribution. The simple scoring technique underestimates RDA at higher RDA levels. A greater difference is seen between the two scoring techniques at higher RDA levels compared to lower RDA levels. In this group of subjects the RDA scores are seen to range from 2.75-3.25 log RDA using the fitted threshold scoring technique and from 2.80-3.20 log RDA using the simple scoring technique. There is a linear positive association between the simple scoring technique (RDA score) and fitting a psychometric function to the data (fitted threshold) (R-square=0.98). The slope of this graph (0.67) indicates that in this group of volunteers, the scoring error is dependent on the RDA measured. It is seen that the simple scoring RDA technique may be a slightly more precise scoring technique. The narrow confidence intervals show both scoring techniques have high precision.

Figure 11: Relationship between log RDA score and log fitted threshold RDA interpolated from psychometric function plots (R-square=0.98, slope=0.67). RDA scores are seen to range from 2.753.25 using the fitted threshold scoring technique and from 2.80-3.20 using the simple scoring technique. Red lines are 5% and 95% confidence intervals for linear regression. 34

8.2

Scoring Errors

8.2.1 Variability of results

The variability for each type of scoring technique was calculated for each volunteer. This was done by computing the standard deviation (SD) of all 24 measurements. The SD of both the RDAs measured by the two different scoring techniques was determined. Figure 12 shows a comparison of the variability. There appears to be a greater variation with the fitted threshold RDA scores compared to the simple scoring technique RDA scores. There is more variation in the two scoring techniques seen in volunteers who scored lower on the Manchester RDA charts. For instance, TC and FT both scored 2.73 log RDA on the fitted threshold scoring technique and 2.80 log RDA by the simple scoring technique respectively. There is a 0.10 log RDA difference in the two different scoring techniques seen for TC and FT. CEs and MM both scored the highest RDA with both scoring techniques. However, they both seem to have very different amounts of variation between both the scoring techniques compared to each other. CEs has less variation with both scoring techniques compared to MM. Figure 12: Variability of two different scoring techniques used to score RDA (simple and fitted threshold RDA) across the 6 charts and 4 sessions.

35

Some individual charts fitted threshold RDA scores were estimated from a psychometric function which was step-like. This gave the slope of the psychometric function an inaccurate value of zero. Figure 13 illustrates the distribution of variability omitting these step-like psychometric function fitted RDA thresholds with zero slopes. The distribution of variability is very similar to figure 12. This means omitting the steplike psychometric function data does not make much difference to the distribution of variability. Figure 13: Variability of two different scoring techniques used to score RDA (simple and fitted threshold RDA) across the 6 charts and 4 sessions, omitting individual chart psychometric functions with step-like slopes.

36

8.2.2 Manchester RDA chart scoring errors

The simple scoring technique is a more precise way of scoring RDA on the Manchester RDA charts (figure 11). Figure 14 shows the error generated by the simple scoring technique against the number of charts presented. The error was calculated by taking the SD (variation) of the simple RDA threshold of n number of charts and dividing the SD by the square root of n. An error in the range of +/- 0.4 log RDA for each individual chart (figure 14). This seems to be skewed towards +0.4 log RDA illustrating an overestimation of RDA with the simple scoring technique.

Figure 14: The error for each individual Manchester RDA chart and the number of charts which were seen with this error. Error=(SD simple RDA threshold of n number of charts) / n number of charts.

37

Figure 15 illustrates the sessional chart error. This was calculated from the threshold RDA averaged from four sessions. This shows less error of -0.2 to +0.1 compared to figure 14. Therefore, RDA is slightly underestimated when an average is taken.

Figure 15: The RDA averaged error over four sessions and how many charts were seen with this error. Error=(SD averaged RDA over four sessions) / n number of charts.

38

8.2.3 Predicted error on a Manchester RDA chart

From calculating the errors produced on each individual chart and within each session a predicted error according to the number of charts tested can be calculated (figure 16). This was done by using the standard error of mean (SEM) equation (SEM=SD of single measurement - number of measurements). The predicted score error decreases by almost 0.70 log RDA by the time 5 charts are used to measure RDA. When ten charts are used to measure RDA the predicted scoring error is close to 0.05 log RDA error. The spread of the error generated from single measurements and over the four sessions (figures 14 and 15) are in good agreement with this predicted theory.

Figure 16: Manchester RDA chart spread of predicted error. Calculated curves of predicted measurement error with 1 to 20 averaged measurements. The black line shows the relationship between the predicted error (standard error of the mean) if single measurement had an SD of 0.15. If ten such measurements were combined, the error of the combined measurements would be close to 0.05. Red lines show predicted curves for SDs of 0.20 (top curve) and 0.10 (bottom curve). The empirical data (red dots) of single measurements and 4 combined measurements show good agreement with theory.

39

8.3

RDA and Contrast Sensitivity

In this group of subjects there is no significant association between RDA and contrast sensitivity (Pearson correlation coefficient r=0.10478, p=0.77, figure 17). These results show that RDA can not replace or predict contrast sensitivity, or vice versa. It can be said that in this group of subjects, RDA is not influenced by contrast sensitivity. Interestingly, CEs scored the highest threshold RDA (3.30 log RDA) and has the highest contrast sensitivity in this group (CEs=1.90 log CS). However, DM had a similar contrast sensitivity score to CEs (DM=1.925 log CS) but showed a lower threshold RDA (2.80 log RDA). FT scored the lowest RDA (2.70 log RDA) and had the lowest contrast sensitivity (FT=1.55 log CS).

Figure 17: Relationship between contrast sensitivity and log RDA score. Those initials in red are volunteers who were tested binocularly and those in black were tested monocularly. (Pearson correlation coefficient r =0.10478).

40

8.4

RDA and logMAR VA

This group of volunteers show no significant association between RDA and logMAR VA. (Pearson correlation coefficient r=-0.3982, p=0.25, figure 18). In this group of volunteers RDA is unaffected by logMAR VA. From this observation it can be said that RDA cannot replace or predict logMAR VA, or vice versa. Worthy of note is perhaps the fact that both MM and CEs who both scored the highest RDA scores (CEs=3.20 log RDA, MM=3.20 log RDA) have almost the same logMAR acuity (CEs=-0.19 logMAR VA, MM=-0.18 logMAR VA).

Figure 18: Relationship between log RDA score and logMAR VA. Those initials in red are volunteers tested binocularly and those in black were tested monocularly. (Pearson correlation coefficient r=-0.3982).

41

8.5

Learning

Figure 19 shows the variation in RDA over the four sessions. The rank correlation coefficient is listed under each volunteers name. A value of greater than 0 shows positive correlation between the number of sessions and log RDA. A value of less than 1 is negative correlation. A rank correlation of 0 shows no association. Seven volunteers scored positive rank correlations and improved their RDA score over the four sessions (FT, MM, TC, AK, DM, MD, JR). MH was the only volunteer to show no improvement in RDA over the four sessions. Two volunteers showed a decrease in threshold RDA over the four sessions (CaE, CEs). However, CEs showed a ceiling effect on the charts (figure 9). Therefore, threshold RDAs for CEs and MM used for this graph may not be precise.

Figure 19: Threshold RDA for each session for each volunteer (simple scoring technique). The charts are ordered from the volunteer who has the highest Spearman-rank correlation coefficient (the most consistent with learning effect with each RDA result being higher than the result previously). Negative values indicate that the order of the results was opposite that expected from a learning effect. 42

9.
9.1

Discussions
Potential improvements to the Manchester RDA charts

9.1.1 RDA Distribution

The distribution of fitted threshold RDA in this group of volunteers showed a ceiling effect (figure 9). The lowest threshold RDA stimulus presented at the bottom of the Manchester RDA chart is -3.30 log radial deformation. This study has shown two volunteers (CEs and MM) could still correctly identify 19 out of 20 RDA stimuli presented on the charts. To avoid this ceiling effect the Manchester RDA charts need to present a lower threshold RDA stimulus. Ideally, the Manchester RDA charts lowest threshold RDA level should be 3.50 log RDA so that a clear cut off point is seen without a ceiling effect. This would be when no observer would be able to detect the radial deformation. It is important not to include too many difficult levels because it can upset patients when they cannot see more than half the chart. To more precisely decide on the lowest threshold RDA stimulus presented, the experimental protocol described for this study should be repeated with the improved charts on visually healthy volunteers before it is tested on non- visually healthy volunteers. The slope parameter of the psychometric functions (expressed as the width of the psychometric function) illustrated the transition of seeing to not seeing a radial deformation. Specifically this implied what the step sizes for radial deformation should be used on the Manchester RDA charts. opposed to a sigmoid function. For some psychometric functions fitted (particularly those fitted to single chart data) a step-like function (slope=0) was seen as This revealed that for some volunteers, the steps between each RDA level increased too quickly. That is to say the amount by which radial deformation decreased was too quick, and an observer went from seeing a radial deformation to not seeing one in the space of one line. Ideally, a smooth transition should be seen. This sharp transition was seen more frequently at levels 2.60, 2.70, 2.80, 2.90 and 3.00 log RDA. As a solution the Manchester RDA charts could present RDA levels where the amount of radial deformation decreases in 0.05 steps rather than 0.10 steps. This may

43

also improve the precision by which RDA is measured. An alternative would be to have a coarse and fine Manchester RDA chart. In this group of volunteers, no association was seen between the slope (expressed as the width of the psychometric function) and fitted threshold interpolated from the psychometric functions (p=0.25, figure 10). It was seen that the volunteers who had lower RDA thresholds had a slower transition (smaller slope) between seeing and not seeing the radial deformation. Those volunteers who had higher thresholds had slightly higher slope values. This result also implies the step sizes by which radial deformation decreases are too coarse. From this distribution it is suggested the optimum step size should be between 0.25-0.33 (p=0.25, R-Square, p=0.31, Mann-Whitney U test, figure 10). However, the step sizes already decrease radial deformation by 0.10, so this distribution of fitted threshold RDA and slope values may change when lower threshold radial deformation levels are presented on the chart. There was no significant difference seen in the distribution of fitted threshold RDA scores in the two groups of binocular and monocular observers (figure 10). However, this may be because only ten volunteers participated in this study. To ascertain with more confidence if a binocular summation effect is seen with viewing the Manchester RDA charts, fifty-five binocular and fifty-five monocular volunteers would need to be tested (DSS researcher's toolkit online).

9.1.2 Scoring techniques

From the data collected from this volunteer group, the more accurate scoring technique cannot be determined but it can be seen that the simple scoring technique is more precise (figure 11). However, the results clearly demonstrate that the error generated with each scoring technique is dependent on the threshold RDA measured (R-square=0.98, slope=0.67). The psychometric functions over-estimates threshold RDA when higher RDA levels were measured compared to the simple scoring technique (figure 11). Ideally, we would want a scoring technique where error is independent of RDA measured (slope=1.0). It is evident that the lowest threshold RDA level presented on the Manchester RDA chart is not low enough (3.30 log RDA). This may explain the RDA distribution described above since the upper scoring boundary is different for each scoring technique. For a fitted threshold RDA interpolated from a psychometric function, there is no upper

44

limit for the RDA interpolated. For the simple scoring system the highest RDA that can be scored is limited to 3.30 log RDA. The result described above correlates with those Hazel and Elliott (2002) found when they fitted psychometric functions to data generated from observers reading a logMAR chart (logMAR VA versus percentage of letters called correctly). (0.02 logMAR). We can say the fitted RDA thresholds were more variable over time than the RDA thresholds measured by the simple scoring technique (figures 12 and 13). Since omission of step-like functions made little difference to this variability it is unlikely that the fit of the psychometric function is the reason for the greater variation. This result was surprising since psychometric functions are thought to be the most accurate way of extracting information on stimulus-response relationships (Wichmann and Hill, 2001). They also found psychometric functions to over-estimate VA measurements by approximately two letters

9.1.3 Scoring Errors

The range of error generated from the simple scoring technique decreases as the number of charts tested increases (figures 14 and 15). For a <0.05 error in the threshold RDA score measured our results predict a range of fifteen to twenty charts should be tested (figure 16). For this study each volunteer completed six Manchester RDA charts. For six Manchester RDA charts our results predict a 0.09 log RDA scoring error. Ideally, we would want to testing times to be short and scoring errors to be small for the Manchester RDA chart. This error generated may be less if the steps by which radial deformation decreases is changed. This may reduce the number of step-like psychometric functions fitted and perhaps change the distribution of scoring error. This would in turn affect the predicted error and the number of charts presented to have an error of <0.05 (currently our data suggest 15-20 charts for a <0.05 error).

9.1.4 RDA associations

Contrast sensitivity and logMAR VA showed no association with RDA in this group of subjects. However, it was an interesting result that both CEs and MM had the highest contrast sensitivity and RDA. In order to see a stronger association between contrast sensitivity and threshold RDA a bigger testing group will be required. This would be similar to that needed to see a binocular summation effect (one hundred and ten volunteers). In addition to a larger testing group, our study methodology would also

45

have to change so each observer has their RDA measured monocularly and binocularly, to account for the effect of inter-subject variability on the threshold RDAs measured.

9.1.5 Learning with the Manchester RDA charts

Seven of the volunteers who completed the Manchester RDA charts showed some evidence of a learning effect (figure 19). These were FT, MM, TC, AK, DM, MP and JR. FTs threshold RDA improved at each testing session and she showed a definite learning effect (Rank correlation coefficient r=1). This can be called a learning effect since it is unlikely that a true change in the underlying sensory process has taken place. Evidence seen against a learning effect (Rank correlation coefficient r 0) may be the result of fatigue (MH, CaE, CEs). This study did not look at the fatigue effects. Fatigue effects may have explained the step-like slopes seen from individual chart data fitted to a psychometric function. To quantify fatigue effects more charts would have to be observed in one session. From this small group of volunteers we cannot say whether there is a significant learning effect associated with the Manchester RDA charts.

9.2

Future Experiments

9.2.1 Larger testing groups

Larger testing groups would be beneficial for the study of associations. Associations were difficult to find in such a small testing group. There may be an association between contrast sensitivity and RDA. Having more than ten data points will allow a visual association to be seen more clearly. One hundred and ten data points will allow us to determine whether binocular summation affects RDA with more certainty (number of volunteers required to investigate binocular summation). It was difficult to conclude whether binocular summation affected RDA in such a small testing group so larger testing groups could confirm whether performing the Manchester RDA charts is difference monocularly versus binocularly. These associations may reveal the need for further investigations, for example quantifying the effect of the association.

9.2.2 Binocular versus monocular investigations

Once the association has been identified from a larger testing group it will be important to investigate and quantity these effects so that they can be considered when scoring RDA.

46

If threshold RDA measurements are found to be positively associated with logMAR VA or contrast sensitivity, one may expect binocular RDA to be better than monocular RDA. Quantifying how much RDA should improve by binocularly will also be of clinical importance should this value vary in visually normal and non-visually normal observers.

9.2.3 Manchester Royal Infirmary studies

After all the properties of the Manchester RDA chart have been identified on visual normals the chart should be tested on patients who may have retinal eye diseases, for example macular degeneration, diabetic maculopathy and central serous retinopathy. It will be interesting to look at how the associations researched in this study change in these patients and whether the Manchester RDA chart would be a useful diagnostic tool in clinical practice.

47

10. Conclusions
Firstly, this study has highlighted limitations of the Manchester RDA charts themselves. The lowest threshold RDA stimulus presented on the Manchester RDA chart is not low enough to measure RDA in young, healthy observers. The lowest threshold RDA stimulus should be at least 3.50 log RDA.

Secondly, this study has shown psychometric function fitted RDA thresholds yield higher RDA thresholds at higher RDA testing levels. This relationship is reversed for lower RDA testing levels. Scoring errors for RDA decreased as the number of Manchester RDA charts presented increased. Presenting between fifteen to twenty Manchester RDA charts will generate a less than 0.05 log RDA error compared to presenting 6 Manchester RDA charts which generates a 0.09 log RDA error (almost one step of RDA level on the chart). Thirdly, in this group of visually normal, healthy, young volunteers no statistical association is seen between RDA and logMAR VA measurements or RDA and contrast sensitivity measurements.

Furthermore, in seven out of ten volunteers some evidence of a learning effect is seen but it was not very large compared to the variation between subjects. To ascertain if binocular summation affects threshold RDA a total of one hundred and ten volunteers would need to be tested, fifty-five monocularly and fifty-five binocularly.

This study has indicated future research on the Manchester RDA charts. Initially, it will be necessary to measure RDA on a larger group of visually-normal, healthy, young volunteers. This may determine the most accurate technique to score RDA. Once associations and factors affecting RDA have been quantified, RDA should be measured on volunteers who have retinal eye diseases, for example age-related macular degeneration, diabetic maculopathy and central serous retinopathy. The analysis of these results should conclude the clinical advantages for testing RDA.

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11. Acknowledgements
I would first and foremost like to acknowledge and thank all my volunteers (AK, CEs, CaE, DM, FT, JR, MH, MP, MM and TC) for donating their free time to participate in this study. Their dedication and commitment is very much appreciated. I would especially like to thank CEs and AH for also donating their time for the pilot study. I would like to acknowledge and thank my project supervisor, Paul Artes. His guidance throughout the project was always available. He was very positive about the results collected and I am grateful to him for plotting the psychometric functions for this study. I would like to thank my family and friends for their encouragement and feedback into this project.

49

12.

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