Evaluation of Agreement Between Sweep Visual Evoked Potential Testing and Subjective Visual Acuity.

Objectives: The primary objective of this study was to evaluate the agreement of visual acuity (VA) obtained with the sweep visual evoked potential (sVEP) method with the VA obtained with the Snellen chart. The secondary objective was to examine the effect of age and gender on agreement. Materials and Methods: Best corrected VAs of subjects were recorded with the Snellen chart, and sVEP testing was performed according to the recommendations of the International Society for Clinical Electrophysiology of Vision (ISCEV). Snellen VAs and sVEP measurements were analyzed using logMAR conversion for statistical analysis. Agreement was evaluated with Bland-Altman analysis. Results: The study included 49 subjects with a mean age of 53.5±17.3 years (range: 19-75 years) and mean Snellen VA of 0.31±0.32 logMAR (range: 1.3-0.0 logMAR). In the Bland-Altman analysis, the mean differences between the VA and sVEP measurements (VA-sVEP) were significantly different and outside the limits of agreement (p=0.035). A significant proportional bias (p=0.0007) was found in the regression analysis performed between VA-sVEP and the mean VA. According to the Bland-Altman analysis of sex subgroups, there was a significant difference between VA and sVEP measurements in female subjects (p=0.006). The difference between VA and sVEP measurement increased significantly with older age (R2: 0.306, p<0.001, ß: 0.05 [0.03, 0.08]). Conclusion: In conclusion, sVEP measurements and VAs did not show statistical agreement. Cranial anatomy and endocrine differences of the subjects may affect their sVEP measurements. The difference between the methods varies according to VA level. Directly using sVEP results instead of VA would not be appropriate.

Comparison of CRT and LCD monitors for objective estimation of visual acuity using the sweep VEP.

PURPOSE: To investigate the applicability of liquid crystal displays (LCD) as suitable replacement for cathode ray tube monitors (CRT) as stimulator for the sweep VEP for estimating visual acuity. METHODS: In a first experiment, sweep VEPs were recorded in 13 healthy volunteers with best-corrected visual acuity with an LCD and a CRT monitor, respectively. Time-to-peak after stimulus and peak-to-trough amplitudes as well as the visual acuity, estimated using a second-order polynomial and the modified Ricker model, were compared between both monitor types. In a second experiment, sweep VEPs were recorded in six healthy volunteers with two levels of stimulus contrast using artificially reduced visual acuities as well as best-corrected with the same monitors as in the first experiment and additionally, a modern LCD gaming monitor with a response time of 1 ms. Time-to-peak after stimulus and peak-to-trough amplitudes were compared between the different combinations of monitors and contrasts. Finally, visual acuities estimated using the modified Ricker model were compared to subjective visual acuities determined using the Freiburg Visual Acuity and Contrast Test (FrACT). RESULTS: In the first experiment, the time-to-peak after stimulus presentation was statistically significantly delayed for LCD displays (mean difference [confidence interval]: 60.0 [54.0, 65.9] ms; t(516) = 19.7096, p < 0.0001). Likewise, peak-to-trough amplitudes were statistically significantly smaller for the LCD stimulator, however, not clinically relevant (mean difference [confidence interval]: - 0.89 [- 1.59, - 0.20] µV; t(516) = - 2.5351, p = 0.0115). No statistically significant effect of the monitor type on the estimated visual acuity was found for neither method, second-order polynomial, nor the modified Ricker model. In the second experiment, statistically significant delays of the time-to-peak after stimulus onset were found for all combinations of monitor and contrast compared to the CRT monitor. A statistically significant, but not clinically relevant, difference of the peak-to-trough amplitudes was only found between the CRT monitor and the LCD gaming monitor (mean difference [confidence interval]: 2.6 [1.2, 4.0] µV; t(814) = 4.66, p < 0.0001). Visual acuities estimated from LCD stimulation significantly underestimated the subjective visual acuity up to 0.2 logMAR using the conversion formula of the first experiment. No statistically significant difference was found when using conversion formulas adjusted for each combination of monitor and contrast. CONCLUSIONS: Based on the results of this study, LCD monitors may substitute CRT monitors for presenting the stimuli for the sweep VEP to objectively estimate visual acuity. Nevertheless, it is advisable to perform a calibration and to collect normative data of healthy volunteers using best-corrected and artificially reduced visual acuity for establishing a conversion formula between sweep VEP outcome and the subjective visual acuity before replacing a CRT with an LCD stimulator.

Contribution of objectively measured grating acuity by sweep visually evoked potentials to the diagnosis of unexplained visual loss.

PURPOSE: To investigate the diagnostic contribution of grating visual acuity (GVA) measured by sweep pattern-reversal visually evoked potentials (SPRVEP) in unexplained visual loss (UVL). METHODS: This case-control study included adult patients under suspicion of UVL referred to SPRVEP and transient pattern-reversal visually evoked potentials (TPRVEP) testing. Optotype visual acuity (OVA) was measured by ETDRS 4-meter chart and GVA by SPRVEP. UVL patients were assigned into three distinctive categories, according to the presence of ocular disease, motivation, and electrophysiological evaluation, as follows: exaggerators, malingerers, and psychogenic. Healthy controls and patients with organic visual loss were also tested. Receiver operating characteristic (ROC) curve was constructed to evaluate the diagnostic performance of GVA and TPRVEP parameters. RESULTS: A total of 76 patients with UVL were analyzed: 60 (79.0%) exaggerators, 11 (14.4%) malingerers, and 5 (6.6%) psychogenic. Controls were 49 subjects evaluated for TPRVEP and 28 subjects for SPRVEP. There were 13 patients with organic visual loss enrolled. Mean difference between OVA and GVA was 1.19±0.67 (median=0.84; 95% CI: 1.04 to 1.34) in UVL and 0.14 ±0.09 (median= 0.14; 95% CI: 0.08 to 0.20) in organic visual loss. The area under the ROC curve (AUC) of GVA to distinguish UVL from healthy controls was 0.998 with a cutoff of 0.09 logMAR showing specificity of 100% and sensitivity of 96.0%. CONCLUSIONS: GVA measured by SPRVEP had good diagnostic validity to discriminate patients with unexplained visual loss from healthy controls and patients with organic visual loss, demonstrating its contribution to the diagnosis of this condition.

VEP estimation of visual acuity: a systematic review.

PURPOSE: Visual evoked potentials (VEPs) can be used to measure visual resolution via a spatial frequency (SF) limit as an objective estimate of visual acuity. The aim of this systematic review is to collate descriptions of the VEP SF limit in humans, healthy and disordered, and to assess how accurately and precisely VEP SF limits reflect visual acuity. METHODS: The protocol methodology followed the PRISMA statement. Multiple databases were searched using "VEP" and "acuity" and associated terms, plus hand search: titles, abstracts or full text were reviewed for eligibility. Data extracted included VEP SF limits, stimulus protocols, VEP recording and analysis techniques and correspondence with behavioural acuity for normally sighted healthy adults, typically developing infants and children, healthy adults with artificially degraded vision and patients with ophthalmic or neurological conditions. RESULTS: A total of 155 studies are included. Commonly used stimulus, recording and analysis techniques are summarised. Average healthy adult VEP SF limits vary from 15 to 40 cpd, depend on stimulus, recording and analysis techniques and are often, but not always, poorer than behavioural acuity measured either psychophysically with an identical stimulus or with a clinical acuity test. The difference between VEP SF limit and behavioural acuity is variable and strongly dependent on the VEP stimulus and choice of acuity test. VEP SF limits mature rapidly, from 1.5 to 9 cpd by the end of the first month of life to 12-20 cpd by 8-12 months, with slower improvement to 20-40 cpd by 3-5 years. VEP SF limits are much better than behavioural thresholds in the youngest, typically developing infants. This difference lessens with age and reaches equivalence between 1 and 2 years; from around 3-5 years, behavioural acuity is better than the VEP SF limit, as for adults. Healthy, artificially blurred adults had slightly better behavioural acuity than VEP SF limits across a wide range of acuities, while adults with heterogeneous ophthalmic or neurological pathologies causing reduced acuity showed a much wider and less consistent relationship. For refractive error, ocular media opacity or pathology primarily affecting the retina, VEP SF limits and behavioural acuity had a fairly consistent relationship across a wide range of acuity. This relationship was much less consistent or close for primarily macular, optic nerve or neurological conditions such as amblyopia. VEP SF limits were almost always normal in patients with non-organic visual acuity loss. CONCLUSIONS: The VEP SF limit has great utility as an objective acuity estimator, especially in pre-verbal children or patients of any age with motor or learning impairments which prevent reliable measurement of behavioural acuity. Its diagnostic power depends heavily on adequate, age-stratified, reference data, age-stratified empirical calibration with behavioural acuity, and interpretation in the light of other electrophysiological and clinical findings. Future developments could encompass faster, more objective and robust techniques such as real-time, adaptive control. REGISTRATION: International prospective register of systematic reviews PROSPERO ( https://www.crd.york.ac.uk/PROSPERO/ ), registration number CRD42018085666.

ISCEV extended protocol for VEP methods of estimation of visual acuity.

The International Society for Clinical Electrophysiology of Vision (ISCEV) standard for visual evoked potentials (VEPs) describes a minimum procedure for clinical VEP testing and encourages more extensive testing. This ISCEV extended protocol is an extension to the VEP standard. It describes procedures for recording multiple VEPs to a range of sizes of pattern stimuli to establish the VEP spatial frequency limit (threshold) and for relating this limit to visual acuity.

Objective assessment of visual acuity: a refined model for analyzing the sweep VEP.

PURPOSE: The aim of this study was to develop a simple and reliable method for the objective assessment of visual acuity by optimizing the stimulus used in commercially available systems and by improving the methods of evaluation using a nonlinear function, the modified Ricker model. METHODS: Subjective visual acuity in the normal subjects was measured with Snellen targets, best-corrected, and in some cases also uncorrected and with plus lenses (+ 1 D, + 2 D, + 3 D). In patients, subjective visual acuity was measured best-corrected using the Freiburg Visual Acuity Test. Sweep VEP recordings to 11 spatial frequencies, with check sizes in logarithmically equidistant steps (0.6, 0.9, 1.4, 2.1, 3.3, 4.9, 7.3, 10.4, 18.2, 24.4, and 36.5 cpd), were obtained from 56 healthy subjects aged between 17 and 69 years (mean 42.5 ± 15.3 SD years) and 20 patients with diseases of the lens (n = 6), retina (n = 8) or optic nerve (n = 6). The results were fit by a multiple linear regression (2nd-order polynomial) or a nonlinear regression (modified Ricker model) and parameters compared (limiting spatial frequency (sflimiting) and the spatial frequency of the vertex (sfvertex) of the parabola for the 2nd-order polynomial fitting, and the maximal spatial frequency (sfmax), and the spatial frequency where the amplitude is 2 dB higher than the level of noise (sfthreshold) for the modified Ricker model. RESULTS: Recording with 11 spatial frequencies allows a more accurate determination of acuities above 1.0 logMAR. Tuning curves fitted to the results show that compared to the normal 2nd-order polynomial analysis, the modified Ricker model is able to describe closely the amplitudes of the sweep VEP in relation to the spatial frequencies of the presented checkerboards. In patients with a visual acuity better than about 0.5 (decimal), the predicted acuities based on the different parameters show a good match of the predicted visual acuities based on the models established in healthy volunteers to the subjective visual acuities. However, for lower visual acuities, both models tend to overestimate the visual acuity (up to ~ 0.4 logMAR), especially in patients suffering from AMD. CONCLUSIONS: Both models, the 2nd-order polynomial and the modified Ricker model performed equally well in the prediction of the visual acuity based on the amplitudes recorded using the sweep VEP. However, the modified Ricker model does not require the exclusion of data points from the fit, as necessary when fitting the 2nd-order polynomial model making it more reliable and robust against outliers, and, in addition, provides a measure for the noise of the recorded results.

Tuning functions for automatic detection of brief changes of facial expression in the human brain.

Efficient decoding of even brief and slight intensity facial expression changes is important for social interactions. However, robust evidence for the human brain ability to automatically detect brief and subtle changes of facial expression remains limited. Here we built on a recently developed paradigm in human electrophysiology with full-blown expressions (Dzhelyova et al., 2017), to isolate and quantify a neural marker for the detection of brief and subtle changes of facial expression. Scalp electroencephalogram (EEG) was recorded from 18 participants during stimulation of a neutral face changing randomly in size at a rapid rate of 6 Hz. Brief changes of expression appeared every five stimulation cycle (i.e., at 1.2 Hz) and expression intensity increased parametrically every 20 s in 20% steps during sweep sequences of 100 s. A significant 1.2 Hz response emerged in the EEG spectrum already at 40% of facial expression-change intensity for most of the 5 emotions tested (anger, disgust, fear, happiness, or sadness in different sequences), and increased with intensity steps, predominantly over right occipito-temporal regions. Given the high signal-to-noise ratio of the approach, thresholds for automatic detection of brief changes of facial expression could be determined for every single individual brain. A time-domain analysis revealed three components, the two first increasing linearly with increasing intensity as early as 100 ms after a change of expression, suggesting gradual low-level image-change detection prior to visual coding of facial movements. In contrast, the third component showed abrupt sensitivity to increasing expression intensity beyond 300 ms post expression-change, suggesting categorical emotion perception. Overall, this characterization of the detection of subtle changes of facial expression and its temporal dynamics open promising tracks for precise assessment of social perception ability during development and in clinical populations.

Maturation of Binocular, Monocular Grating Acuity and of the Visual Interocular Difference in the First 2 Years of Life.

The sweep visual evoked potential method (sVEP) is a powerful tool for measurement of visual acuity in infants. Despite the applicability and reliability of the technique in measuring visual functions the understanding of sVEP acuity maturation and how interocular difference of acuity develops in early infancy, as well as the availability of normality ranges, are rare in the literature. We measured binocular and monocular sVEPS acuities in 481 healthy infants aged from birth to 24 months without ophthalmological diseases. Binocular sVEP acuity was significantly higher than monocular visual acuities for almost all ages. Maturation of monocular sVEP acuity showed 2 longer critical periods while binocular acuity showed three maturation periods in the same age range. We found a systematic variation of the mean interocular acuity difference (IAD) range according to age from 1.45 cpd at birth to 0.31 cpd at 24 months. An additional contribution was the determination of sVEP acuity norms for the entire age range. We conclude that binocular and monocular sVEP acuities have distinct growth curves reflecting different maturation profiles for each function. Differences in IAD range shorten according to age and they should be considered in using the sVEP acuity measurements for clinical diagnosis as amblyopia.

VEP-based acuity assessment in low vision.

PURPOSE: Objective assessment of visual acuity (VA) is possible with VEP methodology, but established with sufficient precision only for vision better than about 1.0 logMAR. We here explore whether this can be extended down to 2.0 logMAR, highly desirable for low-vision evaluations. METHODS: Based on the stepwise sweep algorithm (Bach et al. in Br J Ophthalmol 92:396-403, 2008) VEPs to monocular steady-state brief onset pattern stimulation (7.5-Hz checkerboards, 40% contrast, 40 ms on, 93 ms off) were recorded for eight different check sizes, from 0.5° to 9.0°, for two runs with three occipital electrodes in a Laplace-approximating montage. We examined 22 visually normal participants where acuity was reduced to ≈ 2.0 logMAR with frosted transparencies. With the established heuristic algorithm the "VEP acuity" was extracted and compared to psychophysical VA, both obtained at 57 cm distance. RESULTS: In 20 of the 22 participants with artificially reduced acuity the automatic analysis indicated a valid result (1.80 logMAR on average) in at least one of the two runs. 95% test-retest limits of agreement on average were ± 0.09 logMAR for psychophysical, and ± 0.21 logMAR for VEP-derived acuity. For 15 participants we obtained results in both runs and averaged them. In 12 of these 15 the low-acuity results stayed within the 95% confidence interval (± 0.3 logMAR) as established by Bach et al. (2008). CONCLUSIONS: The fully automated analysis yielded good agreement of psychophysical and electrophysiological VAs in 12 of 15 cases (80%) in the low-vision range down to 2.0 logMAR. This encourages us to further pursue this methodology and assess its value in patients.

The effect of contrast polarity reversal on face detection: evidence of perceptual asymmetry from sweep VEP.

Contrast polarity inversion (i.e., turning dark regions light and vice versa) impairs face perception. We investigated the perceptual asymmetry between positive and negative polarity faces (matched for overall luminance) using a sweep VEP approach in the context of face detection (Journal of Vision 12 (2012) 1-18). Phase-scrambled face stimuli alternated at a rate of 3 Hz (6 images/s). The phase coherence of every other stimulus was parametrically increased so that a face gradually emerged over a 20-s stimulation sequence, leading to a 3 Hz response reflecting face detection. Contrary to the 6 Hz response, reflecting low-level visual processing, this 3 Hz response was larger and emerged earlier over right occipito-temporal channels for positive than negative polarity faces. Moreover, the 3 Hz response emerged abruptly to positive polarity faces, whereas it increased linearly for negative polarity faces. In another condition, alternating between a positive and a negative polarity face also elicited a strong 3 Hz response, indicating an asymmetrical representation of positive and negative polarity faces even at supra-threshold levels (i.e., when both stimuli were perceived as faces). Overall, these findings demonstrate distinct perceptual representations of positive and negative polarity faces, independently of low-level cues, and suggest qualitatively different detection processes (template-based matching for positive polarity faces vs. linear accumulation of evidence for negative polarity faces).

Effect of contrast and gaps between Vernier stimulus elements on sweep visual evoked potential measurements of human cortical Vernier responses

The present paper focuses on a classic hyperacuity, Vernier acuity-the ability to discriminate breaks in the collinearity of lines or edges on the order of only arcseconds of visual angle. We measured steady-state sweep visual evoked potentials (sVEPs) in response to 6 Hz periodic breaks in collinearity (Vernier offsets) in horizontal squarewave gratings. Vernier thresholds, estimated by extrapolating the amplitude of the first harmonic (1F) to 0 µV, were measured for gratings with 4%, 8%, 16%, 32%, 64%, and 80% contrast, with gaps of 0, 2, or 5 arcmin introduced between neighboring bar elements that formed the Vernier offsets. Thresholds for the 2F response component provided an estimate of motion thresholds. The data confirmed and extended evidence that the odd- and even-harmonic components reflect cortical activity of different neurons (i.e., neurons that respond asymmetrically to the periodic breaks in alignment and neurons that respond symmetrically to the local relative motion cue of the stimulus). Suprathreshold data (peak amplitude, response slope, and response phase at the peak amplitude) provided additional independent evidence of this notion. Vernier thresholds decreased linearly as contrast increased, with a slope of approximately -0.5 on log-log axes, similar to prior psychophysical results. The form of contrast dependence showed more similarity to measures of magnocellular ganglion cell spatial precision than measures from parvocellular ganglion cells. Our data thus support the hypothesis that magnocellular ganglion cell output from the retina has the requisite properties to support cortical calculation of Vernier offsets at a hyperacuity level...

Effect of contrast and gaps between Vernier stimulus elements on sweep visual evoked potential measurements of human cortical Vernier responses

The present paper focuses on a classic hyperacuity, Vernier acuity-the ability to discriminate breaks in the collinearity of lines or edges on the order of only arcseconds of visual angle. We measured steady-state sweep visual evoked potentials (sVEPs) in response to 6 Hz periodic breaks in collinearity (Vernier offsets) in horizontal squarewave gratings. Vernier thresholds, estimated by extrapolating the amplitude of the first harmonic (1F) to 0 µV, were measured for gratings with 4%, 8%, 16%, 32%, 64%, and 80% contrast, with gaps of 0, 2, or 5 arcmin introduced between neighboring bar elements that formed the Vernier offsets. Thresholds for the 2F response component provided an estimate of motion thresholds. The data confirmed and extended evidence that the odd- and even-harmonic components reflect cortical activity of different neurons (i.e., neurons that respond asymmetrically to the periodic breaks in alignment and neurons that respond symmetrically to the local relative motion cue of the stimulus). Suprathreshold data (peak amplitude, response slope, and response phase at the peak amplitude) provided additional independent evidence of this notion. Vernier thresholds decreased linearly as contrast increased, with a slope of approximately -0.5 on log-log axes, similar to prior psychophysical results. The form of contrast dependence showed more similarity to measures of magnocellular ganglion cell spatial precision than measures from parvocellular ganglion cells. Our data thus support the hypothesis that magnocellular ganglion cell output from the retina has the requisite properties to support cortical calculation of Vernier offsets at a hyperacuity level.(AU)

Neuromotor development and visual acuity in premature infants submitted to early visuo-motor stimulation

To investigate the effects of early visual stimulation on the development of tonus and posture control and of grating visual acuity of preterm infants, eight infants received visual stimulation that induced head motion during the first 6 months of life in weekly sessions. Their performance was compared with that of unstimulated preterm infants of same age (n = 6). Both groups were evaluated in the developmental scale of Gesell and had their grating visual acuity measured by swept visually evoked potentials (sweep-VEP). Visuomotor performance and adoption and maintenance of postures were significantly better for the stimulated group (p < .05) compared to the unstimulated group. There was no statistical difference between the two groups for the development of visual acuity. Visuo-motor and postural development improved with the early visuo-motor stimulation program. The lack of influence of this program in the development of visual acuity may be attributed to differences in the pathways involved in the processing of visual acuity of patterns and in the responses elicited by visuo-motor stimulation.