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Novel Quantitative Assessment of Metamorphopsia in Maculopathy

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Novel Quantitative Assessment of Metamorphopsia in Maculopathy Low Vision Novel Quantitative Assessment of Metamorphopsia in Maculopathy Emily Wiecek,1–3 Kameran Lashkari,1,2 Steven C. Dakin,3–5 and Peter Bex1,2,6 1Schepens Eye Research Institute/Mass. Eye and Ear, Boston, Massachusetts, United States 2Harvard Medical School, Department of Ophthalmology, Boston, Massachusetts, United States 3Institute of Ophthalmology, University College London, London, United Kingdom 4National Institute for Health Research (NIHR) Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom 5Department of Optometry & Vision Science, University of Auckland, New Zealand 6Department of Psychology, Northeastern University, Boston, Massachusetts, United States Correspondence: Emily Wiecek, PURPOSE. Patients with macular disease often report experiencing metamorphopsia (visual 105-107 Forsyth Street, Boston, MA distortion). Although typically measured with Amsler charts, more quantitative assessments of 02115, USA; perceived distortion are desirable to effectively monitor the presence, progression, and [email protected]. remediation of visual impairment. Submitted: August 4, 2014 METHODS. Participants with binocular ( 33) and monocular ( 50) maculopathy across Accepted: October 27, 2014 n ¼ n ¼ seven disease groups, and control participants (n ¼ 10) with no identifiable retinal disease Citation: Wiecek E, Lashkari K, Dakin completed a modified Amsler grid assessment (presented on a computer screen with eye SC, Bex P. Novel quantitative assess- tracking to ensure fixation compliance) and two novel assessments to measure metamor- ment of metamorphopsia in maculop- phopsia in the central 58 of visual field. A total of 81% (67/83) of participants completed a athy. Invest Ophthalmol Vis Sci. 2015;56:494–504. DOI:10.1167/ hyperacuity task where they aligned eight dots in the shape of a square, and 64% (32/50) of iovs.14-15394 participants with monocular distortion completed a spatial alignment task using dichoptic stimuli. Ten controls completed all tasks. RESULTS. Horizontal and vertical distortion magnitudes were calculated for each of the three assessments. Distortion magnitudes were significantly higher in patients than controls in all assessments. There was no significant difference in magnitude of distortion across different macular diseases. There were no significant correlations between overall magnitude of distortion among any of the three measures and no significant correlations in localized measures of distortion. CONCLUSIONS. Three alternative quantifications of monocular spatial distortion in the central visual field generated uncorrelated estimates of visual distortion. It is therefore unlikely that metamorphopsia is caused solely by retinal displacement, but instead involves additional top- down information, knowledge about the scene, and perhaps, cortical reorganization. Keywords: metamorphopsia, maculopathy, low vision, visual distortion, macular degeneration ge-related macular degeneration, epiretinal membrane Since metamorphopsia may go undetected during normal A (ERM), macular edema, macular hole, and central serous activity,16 Amsler grids are widely used to monitor metamor- retinopathy (CSR) have significant impairments of central visual phopsia in the clinic but have limited value. Lack of fixation functioning, through reductions in acuity,1–3 the development monitoring and perceptual ‘‘filling in’’ (e.g., in areas of the grid 4,5 of visual scotomas, and the experience of distortions of visual missing due to visual field loss) make it extremely difficult to 6–10 space (metamorphopsia). It is thought that metamorphop- identify the location or extent of distortion.17,18 Other sia is a consequence of structural changes in the retina that techniques have been developed to quantify distortion, result in displacement of retinal layers, and in turn, spatial including M-CHARTS,7,19,20 preferential hyperacuity perime- distortion.6,11 Metamorphopsia may therefore serve as a ters,21–23 and shape discrimination hyperacuity.24 However, sensitive biomarker for detecting the presence, progression, none of these tests track eye movements and must assume that and remediation of macular disease. However, while acuity and scotomas are routinely used as quantitative outcome measures, participants retain fixation so that measurements are relative to metamorphopsia is only assessed qualitatively, if at all. We a constant retinal position, ideally the fovea. Although such recently reported a nonlinear interaction between letter assessments intend to monitor disease progression, it has identification and the size and shape of visual distortion, which proven difficult to localize distortion and quantify distortion suggests that it may be difficult to infer changes in distortion across participants. More information available on the location, from changes in acuity.12 Despite advances in vitrectomy, anti- size, and nature of a perceived distortion would allow it to be VEGF, and laser treatments, metamorphopsia continues to be a mapped to an anatomical correlate. Moreover, understanding common complaint of maculopathy patients.8,13–15 the retinal basis of metamorphopsia across different patholo- Copyright 2015 The Association for Research in Vision and Ophthalmology, Inc. www.iovs.org j ISSN: 1552-5783 494 Downloaded from jov.arvojournals.org on 10/01/2021 Quantitative Assessment of Metamorphopsia IOVS j January 2015 j Vol. 56 j No. 1 j 495 TABLE. Diagnosis and Age of Participants Computerized Amsler Grid Square Completion Task Dichoptic Pointing Task Participants, n Mean Age Participants, n Mean Age Participants, n Mean Age Wet AMD 24 78 13 74 2 62 Dry AMD 10 77 7 76 1 80 ERM 18 66 14 67 11 65 Macular edema 14 69 9 70 5 67 Macular hole 6 71 5 72 4 71 CSR 7 53 7 53 7 53 Retinal detachment 2 55 2 55 1 57 Macular scar 1 61 0 NA 1 61 Best disease 1 76 1 76 0 NA Control 10 62 10 62 10 62 gies promises to provide information about disease progression viewed a grid monocularly on a LG 23-inch LCD monitor with derived from noninvasive perceptual measurements. 1920 3 1080 resolution at viewing distance of 90 cm. Gaze was We examined three methods for quantifying metamorphop- monitored by a remote eye tracker operating at 500 Hz sia that focus on characterizing the location and spatial extent (EyeLink 1000; SR Research Ltd., Ontario, Canada). Eye of monocular visual distortion. First, we determine if these positions were initially calibrated using a 16-point calibration methods can quantify metamorphopsia by comparing mea- in the eye tracker software (SR Research Ltd.). To bring surements in participants with maculopathy and age-matched awareness to eye movements and gaze direction, a green ring controls. Second, we hypothesize if metamorphopsia arises pattern was presented on the screen at the participant’s point directly from disruptions of retinal layers, measurements of of regard. Participants were instructed to try to keep fixation distortion obtained with different methods should be correlat- centered on the fixation point in the center of the display, ed if those methods are indeed measuring pathological changes guided by the green ring. in the retina. Alternatively, if methods are uncorrelated, we can The Amsler grid was presented with two different line assume that other perceptual factors play a role in the final spacings, with lines spaced either 2 or 68 apart. The line percept of metamorphopsia and the symptom is not only thickness was adjusted from 0.04 to 0.188 (2–10 pixels) to dependent on photoreceptor displacement in the retina. This make the grid easily visible for each participant, and the mean would also imply the quantification of metamorphopsia is line thickness was 0.18 (60.038). Participants were required to entirely dependent on the measurement tool, which is maintain fixation on a central point, while their eye position important in light of the many tools currently used in research was displayed (updated in real time) as a 18, green circle and clinic. overlaid on the grid. Each participant was first asked to determine the location of any distorted areas (while maintain- ing central fixation). The participant was then was asked to METHODS report the extent and shape of the perceived distortion on the grid, and then to guide the experimenter (EW) as she used the Participants mouse to draw the described visual distortion as a series of Eighty-three participants were recruited from Advanced Eye overlaid white lines. Note that the white distorted line drawn Centers in Dartmouth, Massachusetts, based on the presence by the experimenter was only visible to the participant when of macular pathology based on clinical examination and testing the participant was not fixating centrally. This allowed the including slit-lamp biomicroscopy and SD-OCT retinal imaging, participant to move his/her eyes back and forth between the identified by an ophthalmologist (KL). Fifty had monocular fixation marker (when they could experience the distorted maculopathy, 33 had binocular maculopathy, and all partici- view of the unmodified grid without any overlaid drawing) and pants had intact foveal vision in the tested eye (no geographic the distorted region (when they could experience the overlaid atrophy at the fovea). The Table lists the age and number of drawing of the distortion). This facilitated comparison of the participants who completed each task, but the majority of participant’s perceived distortion with the experimenter’s on- diagnoses were AMD, epiretinal membrane, macular edema, screen rendition.
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