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Clinical and Experimental Optometry 88.

5 September 2005
313
Visual function Battista, Kalloniatis and Metha
OPTOMETRY
C L I N I C A L A N D E X P E R I M E N T A L
Clin Exp Optom 2005; 88: 5: 313321
Is peripheral visual function simply a
scaled down version of central vision? The
answer is no. The apparently poorer per-
formance of the peripheral retina, despite
the possibility of increased letter size or
contrast, is problematic for patients who
have lost their central vision and must rely
on their peripheral vision for activities of
daily living. Approximately 50 per cent of
patients presenting to low vision clinics
have lost their central vision.
1
Visual im-
pairment is more common with increas-
ing age. Among elderly people, macular
alteration is common and reading difficul-
ties result as a consequence of loss of reso-
lution. Although other definitions exist,
low vision can be defined functionally as
the inability to read newspaper print at a
normal reading distance of 40 cm, with the
best refractive correction.
2
Low vision can
result from defects in the eyes optics, the
retina or other parts of the visual system
and therefore encompasses a great vari-
ety of pathologies. According to statistics
from the Royal National Institute for the
Blind, in 1996, there were approximately
1.1 million blind or partially sighted
people in the United Kingdom. Of these,
82 per cent were aged 65 years or older.
The major causes of visual impairment in-
cluded age-related macular degeneration
(AMD) and cataract.
3-5
Statistics from the
Blue Mountain Eye Study
6
and the
Melbourne Visual Impairment Project
7,8
indicate that in 2004, approximately
480,300 Australians had low vision (visual
acuity less than 6/12), including 50,600
with blindness (visual acuity less than 6/60).
Almost half of all cases of blindness were
caused by AMD.
6-8
It is predicted that the
number of Australians with low vision and
blindness will double by 2024.
9
AMD is a degenerative disorder that
progressively affects the macular region of
the retina, often resulting in an irrevers-
ible central scotoma. In this common reti-
nal problem of the aging eye, the macular
area and fovea become compromised due
to pigment epithelial degeneration,
drusen formation and leakage of fluid
behind the fovea. A photograph of a
INVITED REVIEW
Visual function: the problem with eccentricity
Josephine Battista* BSc (Hons)
Michael Kalloniatis

PhD MScOptom
Andrew Metha* PhD BScOptom BSc
* Department of Optometry and Vision
Sciences, The University of Melbourne,
Parkville, Australia


Department of Optometry and Vision
Science, University of Auckland, Auck-
land, New Zealand
Submitted: 5 August 2005
Revised: 8 September 2005
Accepted for publication: 11 September
2005
Key words: eccentricity, periphery, reading
Age-related macular degeneration (AMD) is the leading cause of blindness in devel-
oped countries. With an ageing population, the prevalence of such a condition has
resulted in a large proportion of the population relying on peripheral vision to under-
take activities of daily living. Peripheral vision is not a scaled-down version of the fovea,
simply requiring larger print or increased contrast for detection of objects or reading
text. Even when print size is scaled and eye movements are minimised, the peripheral
retina cannot perform at the level of the foveal region. Understanding how and why
reading performance is limited as a function of eccentricity has important implications
for how we approach rehabilitation of patients with central visual loss. This brief review
of the extensive literature on reading with peripheral vision and the research aimed at
better reading rehabilitation for low vision patients focuses on why many of the problems
associated with the reduced reading capability of peripheral vision cannot be completely
solved with magnification, reducing eye movements or modifying print.
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Visual function Battista, Kalloniatis and Metha
normal retina as observed during
ophthalmoscopy is presented on the left
of Figure 1. The macula is a highly spe-
cialised area of the retina that provides
fine discrimination. It has a high cone
density and is located approximately four
millimetres temporal to the optic disc. At
the centre of the macula is the fovea, the
area of the retina that provides the best
visual resolution.
10
An ocular fundus with AMD is shown on
the right of Figure 1, where drusen can
be observed. Central visual loss eventually
results from the degeneration of the foveal
cones.
11
Peripheral vision is required for
patients with such a disorder to perform
everyday tasks, such as reading. However,
reading is particularly difficult for patients
with AMD because peripheral reading
performance is reduced in comparison to
that of the fovea.
2
Visual field abnormali-
ties such as relative or absolute scotomata
also present reading difficulties because
an abnormal field of effective vision re-
quires an adapted eye movement strat-
egy.
12
Surveys show that retaining the abil-
ity to read is regarded as the most
important concern for patients seeking
visual rehabilitation.
13-15
As central visual
loss is currently irreversible, research on
how to better rehabilitate patients with
AMD is aimed at determining why periph-
eral visual acuity and reading performance
are reduced in comparison to the fovea
and how to make the best use of the
remaining usable field.
Visual acuity provides an estimate of the
smallest characters that can be read; how-
ever maximum reading speed usually oc-
curs for characters much larger than the
acuity limit.
16
While widely used in the
clinic, visual acuity measurements do not
provide a predictive measure of reading
performance.
12,17,18
Therefore, while visual
acuity is important, it is critical to under-
stand the process of reading and its
specific limitations.
READING
The normal reading process can be de-
scribed as a language code picked up
through the visual or tactile system and
then processed further; a procedure
involving a number of different human
activities.
12
To understand the complex
process of reading, Legein and Bouma
12
attempted to discern the separate
subprocesses involved and these activities
were distinguished as involving the optics
of the eye and visual sensory input, the
control of eye movements, word recogni-
tion in a single eye pause (or eye fixation)
and the integration of text information
over consecutive eye pauses. Following
these subprocesses, many other language
processes occur that involve higher cog-
nitive aspects of comprehension and
memory. For fluent reading, all these
processes are very important.
12
When reading a horizontal line of text,
there are three regions of the retinal im-
age that need to be considered: the fovea,
parafovea and the periphery. The fovea
extends two degrees across the point of
fixation. Around the fixation point, the
parafovea extends 10 degrees and the re-
maining region is the periphery.
19
Like
visual acuity, which is highest in the fovea
and decreases towards the periphery, word
recognition decreases dramatically when
presented outside the fovea and at increas-
ing distances from central fixation.
20
Visual rehabilitation for patients with
AMD often involves the prescription of
either optical or electronic magnification.
While magnification compensates for loss
of visual acuity, reading speed is still im-
paired with a reading rate of less than 50
words per minute for low vision patients
with a central scotoma (within five de-
grees).
2
This is significantly lower than the
80 words per minute reading rate consid-
ered to be minimally fluent
21
and far
slower than the median normal reading
rate using central vision (150 words per
minute).
2
A wide variation in peak reading rates
exists among low-vision observers. Most of
the variance can be accounted for by two
major distinctions. These include intact
central fields versus central-field loss, and
cloudy versus clear ocular media. Observ-
ers with central-field loss have very low
peak reading rates (median 25 words per
minute), while peak reading rates for ob-
servers with intact central fields are at least
90 words per minute (median 130 words
per minute).
2
To read, most low vision
patients require magnification (which is
usually prescribed on the basis of their
acuity) and read best with enlarged print.
On average, four times the acuity limit is
the optimum letter size.
2
More magnifica-
tion is required for patients with a central
scotoma or advanced macular degenera-
tion, compared to those whose central
fields are intact and the required magnifi-
cation is usually a greater multiple of their
acuity.
2
A possible explanation for the reduced
reading speed of patients with central
visual loss may be associated with problems
of oculomotor control.
14,22,23
Studies exam-
Figure 1. Left: The posterior pole of the ocular fundus of a normal eye. Right: Ocular fundus
of a patient with early AMD showing drusen and retinal pigment epithelial disturbance.
Photographs kindly provided by Associate Professor Algis Vingrys.
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Visual function Battista, Kalloniatis and Metha
ining eye movements when reading text
with a simulated macular scotoma show
multiple fixations and small saccades
within words, resulting in a disorganised
eye movement pattern, even when the text
is magnified.
24-26
Eye movements have im-
portant implications for reading speed, as
is demonstrated in studies aimed at sim-
plifying the task of reading for low vision
patients, by employing the rapid serial
visual presentation (RSVP) paradigm. For
this mode of presentation, words are pre-
sented one at a time in a fixed location. If
the words fit within the visual span
27
(the
number of letters that can be recognised
in a single fixationdescribed in more
detail below), then eye movements are not
required to read the text. Normally-
sighted observers can read approximately
four times faster with RSVP in compari-
son to reading static text.
1,28
Low vision
patients with intact central visual fields can
double their reading speed using RSVP,
however, low vision patients with a macu-
lar scotoma show the least improvement,
reading on average 40 per cent faster with
RSVP. This result indicates that peripheral
reading is still reduced despite minimis-
ing eye movements.
1
This small improve-
ment in reading speed for patients who
use their peripheral vision for reading,
despite reducing oculomotor control,
demonstrates that eye movements alone
cannot account for reduced reading speed
in peripheral vision.
It is not yet fully understood why periph-
eral reading performance is reduced in
comparison to the fovea or how to over-
come this impasse for patients who are
forced to use their peripheral vision for
this task. The following sections review
studies examining the many possible ex-
planations for the differences in perform-
ance of visual functions in central and
peripheral vision.
DIMENSIONS OF THE RETINAL
MOSAIC
It is difficult to estimate the distribution
of rod and cone photoreceptors across the
human retina due to the large variability
between eyes. In the fovea, there may be
as much as a three-fold range in maximum
cone density of young adult human eyes.
29
Various studies have estimated that ap-
proximately four to six million cones
29-31
and approximately 120 million rods
29,30
tile
the average human retina. Rods and cones
differ not only in their shapes and num-
bers but also in their geographical distri-
bution over the retina. The peak density
of cones is at the fovea, with an approxi-
mate density of between 120,000 and
200,000/mm
2
.
29,30,32-35
This density de-
creases to approximately 5,000/mm
2
at
eccentricities greater than 10 degrees.
29,30
Cones are found all the way to the periph-
ery even though their density is reduced
away from the fovea, however, rods are
absent in the central foveola, with no rods
found at eccentricities smaller than 0.5
degrees.
29,30
The number of rods increases
rapidly beyond this distance and they are
most densely packed at approximately 20
degrees from the fovea, reaching a peak
density of approximately 170,000 rods/
mm
2
.
29,30
The density of rods then de-
creases regularly and always remains much
higher than the density of cones.
It has been suggested that photo-
receptors are lost in AMD, with rods
dying in older eyes without evidence of
overt retinal pigment epithelial disease.
36
For those susceptible to AMD, the retinal
pigment epithelium becomes dysfunc-
tional. Secondarily, rod loss continues and
cones begin to degenerate. Eventually,
only degenerate cones remain and all
photoreceptors may ultimately disappear.
36
These findings are consistent with func-
tional and clinical studies. Psychophysical
examinations of rod vulnerability in AMD
have demonstrated the greatest severity at
two to four degrees from the fovea, with
this deficit decreasing with increasing ec-
centricity.
37
It is well known that the human eyes
resolving power is greatest in the fovea and
falls off rapidly with increasing angular
distance from fixation. A possible expla-
nation for this reduced visual acuity with
eccentricity may be the reduced density
of cones and the changes in synaptic or-
ganisation with increasing eccentricity
from the fovea. Various studies, including
those by Polyak
31
and Jones and Higgins,
38
examined the role of cone density in lim-
iting visual acuity. While the results of
these early studies were potentially limited
by the eyes optical performance, it was
demonstrated that for Landolt C targets
presented at various distances from the
fovea, maximum acuity occurred at the
centre of the retina with a notable
reduction in visual acuity at a distance of
only two degrees from the fovea, reduc-
ing rapidly until approximately 10 to 12
degrees. As cone density declines in a simi-
lar manner, cone density and therefore the
retinal mosaic have been suggested as play-
ing a major role in limiting visual acuity.
More sophisticated studies have by-
passed the optics of the eye to determine
exclusively neural limits and showed that
at eccentricities of less than two degrees,
resolution closely correlates with
sterbergs
30
theoretical limits for a mo-
saic of receptors. At eccentricities greater
than two degrees, visual acuity is worse
than that predicted by cone spacing. This
indicates that post-receptoral retinal ele-
ments limit visual acuity and that the lim-
its of visual acuity cannot be determined
simply by only the fineness of the retinal
photoreceptor mosaic.
39
To further investigate whether reduced
reading speed with peripheral vision is
related to the differences between rod-
and cone-mediated vision, Chaparro and
Young
40
investigated cone- and rod-
mediated reading by comparing reading
speeds obtained when using targets
equated for detectability by rods and
cones. The speed of rod-mediated read-
ing was reduced in comparison to cone-
mediated reading. As the targets were
equally detectable by either photorecep-
tor, this finding suggests that the differ-
ences in visual sensitivity of the cone and
rod visual systems cannot account for the
differences in reading speed between cen-
tral and peripheral vision. In other words,
it is unlikely that the intrinsic differences
between rods and cones alone can explain
why reading speed is reduced with periph-
eral vision.
CORTICAL MAGNIFICATION
In a classic study by Weymouth
41
examin-
ing how visual performance for various
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Visual function Battista, Kalloniatis and Metha
visual functions varies with eccentricity,
many visual functions were found to de-
grade approximately linearly with eccen-
tricity and different visual functions de-
clined at different rates with increasing
distance from the fovea. This rate of fall-
off can be characterised for many visual
functions by the parameter E
2
, which rep-
resents the eccentricity at which the foveal
threshold has doubled.
42,43
Westheimer
44
and Levi, Klein and
Aitsebaomo
43
examined the results ob-
tained by Weymouth
41
in the light of the
cortical magnification or scaling factor.
Cortical magnification refers to the distor-
tion of the brains topographic map in the
primary visual cortex, as the amount of
cortical tissue devoted to the fovea far ex-
ceeds the amount devoted to the periph-
ery. The cortical magnification or scaling
factor refers to the linear extent of brain
tissue (mm) representing one degree of
visual angle in the primary visual cortex.
45
When the stimulus size is scaled in pro-
portion to the inverse of the linear cone
density at each eccentricity, the retinal
periphery performs as well as central vi-
sion for a variety of resolution tasks. The
inverse of the cortical magnification fac-
tor M
-1
, which is the number of degrees of
visual space per millimetre of cortex, rises
approximately linearly with eccentricity.
43
It has been suggested that the degradation
of some visual functions (vernier thresh-
olds, word acuity thresholds) is limited by
the cortical magnification factor, while
others (grating acuity, single letter acuity)
are limited by the change in retinal ele-
ments (ganglion cell density) as a function
of eccentricity.
43,46-48
These differences in
the rate of degradation with eccentricity
are presented schematically in Figure 2,
where it can be observed that vernier acu-
ity declines three to four times faster with
eccentricity than does high-contrast grat-
ing acuity. Subsequently, it has been sug-
gested that visual function thresholds that
require higher brain functions (beyond
the primary visual cortex) fall more rap-
idly with retinal eccentricity, suggesting
that the decline of visual functions with
increasing eccentricity is representative of
the complexity of visual information
processing of the periphery.
43
PRINT SIZE
It has been suggested that the differences
between central and peripheral reading
speed may be due to the increased con-
vergence of cone-photoreceptors on one
ganglion cell in the periphery. This in-
crease in convergence in the periphery
Figure 3. A schematic representation of reading speed in central
and peripheral vision as a function of print size, as measured using
the RSVP paradigm (modified after Chung, Mansfield and
Legge
47
). For both central and peripheral vision, reading speed
increases with larger print size until a critical print size is reached
(CPS), after which maximum reading speed (MRS) has been
reached. The different print sizes at which CPS is reached for
central and peripheral vision reflect the different resolution limits
for the two different eccentricities. However, the key difference
is that the MRS is lower for the peripheral retina, despite increased
print size. The peripher y cannot provide reading speed
comparable to the fovea.
Figure 2. A schematic representation of the ratio of peripheral to
foveal thresholds for high-contrast word recognition thresholds,
vernier acuity and grating acuity. The E
2
value is the eccentricity
at which foveal threshold has doubled (horizontal broken line).
The eccentricity for the word and vernier acuity is almost identical
(~0.7 degrees), whereas for grating acuity (similar to single letter
acuity), the eccentricity at which foveal threshold has doubled is
at ~2.5 degrees (shown by the vertical arrows). The figure is
modified after Abdelnour and Kalloniatis.
48
R
a
t
i
o

o
f

p
e
r
i
p
h
e
r
a
l

t
o

f
o
v
e
a
l

t
h
r
e
s
h
o
l
d
Eccentricity (deg)
0 2.5 5 7.5 10
10
16
8
6
2
4
0
12
14
Grating acuity
Vernier acuity
_
_
_
_
_
_
_
_
_ ___
High contrast word acuity
(E
2
~0.68)
10
(E
2
~0.70)
(E
2
~2.5) R
e
a
d
i
n
g

s
p
e
e
d

(
w
o
r
d
s
/
m
i
n
)
Print size (deg)
CPS
MRS
Central vision
Peripheral
vision (20)
_
_
_
__
1000
100
10
0.1 1

_
_
_
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Visual function Battista, Kalloniatis and Metha
explains why some spatial tasks result in
similar visual performance at different
retinal eccentricities provided that the
stimuli are scaled in size to equate with
the coverage of ganglion cells. The spatial
contrast sensitivity function is an example
because it remains shape-invariant at vari-
ous retinal eccentricities with the appro-
priate scaling of the size of the stimulus.
49,50
Following this idea, it is plausible to
question whether reading performance
can be equated by scaling print size in
peripheral vision.
47
Despite enlargement
of letter size to compensate for decreased
acuity with eccentric viewing, peripheral
reading speed in normal observers does
not approach that achieved using the
fovea.
2,18,21,47,51
Examination of the effect of
print size on reading speed in normal
peripheral vision using the RSVP presen-
tation paradigm by Chung, Mansfield and
Legge
47
showed that reading speed in-
creased with print size up to a critical print
size (CPS), beyond which reading speed
remained at a plateau level, termed the
maximum reading speed (MRS) as
shown schematically in Figure 3. The av-
erage values for maximum reading speed
decreased from the fovea to the periphery,
with larger print sizes required to achieve
maximum reading speed in peripheral vi-
sion in comparison to central vision. The
rate of change in reading speed as a func-
tion of print size remained invariant in cen-
tral and peripheral vision and even when
print size was not the limiting factor, maxi-
mum reading speeds were still lower in
peripheral vision compared to central
vision. In other words, we cannot simply
scale print size for the periphery to achieve
reading speeds attainable in the fovea.
CROWDING
Crowding, also known as lateral mask-
ing, refers to the decreased visibility of a
visual target in the presence of nearby
objects. In relation to reading, this refers
to the spatial interaction between adjacent
letters within the same word, with adjacent
letters obstructing each others recogni-
tion via the effect of crowding. It has been
suggested that crowding is a major factor
contributing to reduced reading speed in
peripheral vision because even when tar-
gets are scaled in size, the spatial ex-
tent
46,52,53
and magnitude
52,54
of the inter-
action are still greater in peripheral vision
than in central vision. It is well established
that resolution deteriorates more rapidly
with eccentricity for test targets sur-
rounded by flanking stimuli.
46,52,53
Thus, it
is suggested that the effect of crowding is
greater in the periphery than in the
fovea.
46,53,55
In other words, peripheral tar-
gets appear relatively more crowded and
less easily recognised than central targets
when letter separation is kept constant and
eccentricity is varied. Bouma
56
found that
if the adjacent letters were separated by a
distance equal to half the retinal eccen-
tricity, then the recognition of peripher-
ally presented letters flanked by adjacent
letters could reach that of unflanked let-
ters. Hence, the crowding phenomenon
has limited spatial extent.
Today, most printed material uses vari-
able or proportional spacing or pitch
because it is visually appealing. With this
type of spacing, the amount of horizon-
tal space that a character occupies
depends on the width of the individual
character, so that the letter i takes up
much less space than the letter w. For
fixed-width spacing, all characters occupy
the same amount of horizontal space, that
of the widest character, which is usually
the uppercase W. Despite the aesthetics
of proportionally-spaced fonts, Arditi,
Knoblauch and Grunwald
57
showed that
reading speed is fastest when fixed-width
fonts are used for both central and
peripheral vision.
Chung
55
suggested that if crowding
among individual letters contributes to
reduced reading speed in peripheral vi-
sion, then a solution may be to eliminate
or minimise crowding by increasing the
spacing between adjacent letters. She
found that increasing the letter spacing
beyond the standard size did not improve
reading speed in central or peripheral
vision and suggested that this may be
because the increased letter spacing
disrupted the word shape or word form
information. In addition, the increased
spacing would have reduced the visual
span.
THE VISUAL SPAN
When we read, we recognise only a few
letters with each glance. The visual span
was defined by ORegan
58,59
as the region
(or distance) around the point of fixation
within which characters of a given size can
be resolved. The extent of the visual span
is indicated by the retinal eccentricity at
which letters (in text) can no longer be
recognised. This limit is influenced by the
decline in visual acuity with increasing
distance from the fovea and also by the
effects of crowding between adjacent let-
ters.
56
The linear scaling laws that apply to
peripheral letter acuity and crowding
60
suggest that the size of the visual span is
approximately constant when measured in
letter spaces over a moderate range of
angular character size and as a conse-
quence, more letters cannot be squeezed
into the visual span by using smaller print.
Various studies have estimated the visual
span in normal central vision to be ap-
proximately 10 letters, measured over a
range of print sizes subtending between
approximately 0.3 and one degree.
19,58,59,61
In contrast, visual span estimates for pa-
tients with low vision range from normal
values to less than one character.
61
Due to the decreasing visual acuity from
the fovea to the periphery, larger print
sizes are required for peripheral viewing.
As a result, words presented in central vi-
sion will fit comfortably within the limits
of the visual span, as smaller print sizes
will be required for correct recognition.
At eccentric locations away from the fovea,
the letters of words with greater lengths
may fall outside the visual span because
larger print sizes are required for correct
recognition. The shrinking visual span
hypothesis as proposed by Legge,
Mansfield and Chung
62
states that the
number of letters recognised on each
glance shrinks in peripheral vision. As a
result, more time is required to recognise
words, the lengths of which exceed the size
of the visual span, as two or more glances
are necessary. The visual span estimates
from Legge, Mansfield and Chung
62
de-
creased from 10 letters in central vision to
1.7 letters at 15 degrees eccentricity. This
reduction in the size of the visual span with
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Visual function Battista, Kalloniatis and Metha
increasing eccentricity parallels reductions
in reading speed. In other words, the abil-
ity to process several letters in parallel
deteriorates in peripheral vision and this
smaller visual span is considered a funda-
mental limit to reading in peripheral
vision, especially due to the high magnifi-
cation required by low vision patients.
Therefore, further research examining the
visual span in peripheral vision may have
important implications for patients with
central visual loss.
WORD LENGTH
In reading materials, we encounter words
with different lengths and this is impor-
tant to consider when examining word
recognition in central and peripheral vi-
sion. It is important to investigate the ef-
fects of word length because of its role in
the word recognition and reading proc-
esses. The length of the word influences
saccades, with more saccades required
when word length information is re-
moved.
19,63-66
Word length experiments
show that perceived length directly influ-
ences word recognition responses, suggest-
ing that information regarding the length
of the word may contribute to word rec-
ognition providing a separate cue in the
recognition process.
66
In fact, word length
information aids word recognition, possi-
bly by adding information about word
shape or form. Increased word length also
hinders word recognition. This may be
because longer words require more eye
movements (because their letters do not
fit within the visual span), thus limiting
reading speed.
A simple demonstration of the difficul-
ties associated with reading words of
longer length (the letters of which fall
outside the limits of the visual span) with
peripheral vision is presented in Figure 4.
While maintaining fixation on the x
above the corresponding letters or words,
the individual letters are always easier to
recognise than the 12-letter words. This is
particularly clear with increasing distance
from fixation, even with larger print size.
As mentioned previously, distance sin-
gle letter acuity does not correlate with
reading acuity, especially for low vision
patients,
17,18
so from a clinical point of view,
it is not possible to predict reading per-
formance from distance visual acuity meas-
urements alone. This has prompted the
development of new tests of reading acu-
ity, for example the Bailey-Lovie word
reading chart
67
and the MNREAD (a Min-
nesota reading test) Acuity chart.
68
How-
ever, the question of how to measure read-
ing acuity effectively still remains. Future
studies may be directed at incorporating
systematic changes in word length in near
visual acuity charts, rather than single let-
ters alone. Investigating the effect of word
length in the periphery may have impor-
tant implications in predicting reading
performance and thus designing visual
rehabilitation programs for patients with
central visual loss.
In this review, we have presented evi-
dence showing that peripheral reading
performance does not reach that of cen-
tral vision, even when print size is scaled
for the periphery or when eye movements
are minimised. A summary of peripheral
visual function for reading, single letter
and word resolution is provided in Table 1.
Also, it has been mentioned that the visual
span is a fundamental limit to peripheral
reading, particularly due to the high mag-
nification required by low vision patients
and words of longer length. With less mag-
nification, more letters would fit within the
visual span and reading performance
would improve. Perhaps training may be
the answer to overcoming this problem, if
the size of print required for reading can
be reduced with practice. A question that
may arise before investigating training ef-
fects is whether perceptual learning would
be possible for reading, as training is not
observed for all visual functions.
PERCEPTUAL LEARNING
Perceptual learning involves an improve-
ment in the ability to discriminate simple
sensory attributes, such as pitch, texture,
visual acuity et cetera that does not involve
adaptations of the primary sensory end-
organs. Much of the interest generated by
studies of cortical plasticity stems from its
potential relevance to learning.
69
Profound
changes in cortical functional architecture
that follow retinal lesions may represent
the mechanisms of recovery after lesions
of the central nervous system. They may
also reveal adaptive mechanisms associ-
ated with normal processes such as per-
ceptual learning. The current view is that
Figure 4. A demonstration of the effects of the difference in
resolution of single letters versus words at different retinal
eccentricities. The angular subtense of each letter is identical for
the corresponding letter and word, however, the word is more
difficult to read than the single letter. The difference is likely to
be related to the reduced visual span in the periphery.
X
intersection
X
c
modification a
announcement e
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Clinical and Experimental Optometry 88.5 September 2005
319
Visual function Battista, Kalloniatis and Metha
the likely cause for learning is a sustained
and lasting change that has synaptic
plasticity as its basis.
69
Research on perceptual learning in
peripheral vision has shown that for an
adult with normal vision, spatial visual
functions including orientation discrimi-
nation, bisection and vernier acuity can be
improved by a factor as much as three.
70,71
The learning effects in peripheral hyper-
acuity are well established, however, re-
search on learning effects on visual acuity
and reading in the retinal periphery is
lacking and it remains unclear whether
visual acuity or reading performance in
the periphery can be improved with train-
ing. Beard, Levi and Reich
72
demonstrated
that both physiological and cognitive proc-
esses contribute to the improvement with
practice and Westheimer
73
showed that
learning effects or training can take place
in stereoscopic, orientation, vernier, bisec-
tion and time discriminations but not in
resolution and Landolt C acuities. It has
been suggested that failure to improve
with training is not a function of the ob-
server or the retinal location but is spe-
cific to the resolution task. In other words,
the tasks for which learning does not oc-
cur are considered to have a process which
is of a more primitive kind, more robust
and closer to sensory origins.
73
For exam-
ple, resolution tasks such as grating acuity
have a strong retinal basis and depend on
the spacing of retinal elements, while
other localisation tasks of the hyperacuity
kind have an element of cortical process-
ing.
43
Following this idea, if word acuity
thresholds follow the cortical magnifica-
tion factor,
48
such as vernier acuity, which
can be trained,
73
then it is plausible to pro-
pose that practice will also improve word
recognition thresholds.
While controversy surrounds the notion
that simple peripheral resolution perform-
ance can be improved with training,
73
re-
cent studies have demonstrated training-
related improvements in peripheral
reading performance,
74,75
Chung, Legge
and Cheung
75
specifically examined
whether visual span profiles (plot of letter
recognition accuracy as a function of letter
positions left or right of the midline) could
be modified through repeated training on
a letter recognition task in peripheral
vision. The results from this study showed
that training with a letter recognition task
at an eccentric location led to changes in
the visual span profiles. Letter recognition
accuracy increased and maximum reading
speed improved. These improvements
transferred to the untrained retinal loca-
tion and were retained for three months
after training. The authors suggested that
this confirmed that the visual span is a
bottleneck in peripheral reading but that
this can be improved with training.
Future studies aimed at determining
how we can better rehabilitate reading for
patients with AMD may be focused on over-
coming the problems associated with a
reduced visual span by examining the
effects of training on reading with periph-
eral vision. From a clinical perspective,
research in this field may trigger the
incorporation of training patients with
central visual loss to read with peripheral
vision in their visual rehabilitation pro-
grams.
ACKNOWLEDGEMENTS
Supported in part by the Robert G Leitl
Trust Professorship held by Michael
Kalloniatis. We would like to sincerely
thank Associate Professor Algis Vingrys for
providing the fundus photographs pre-
sented in this manuscript.
Peripheral visual function
Reading Slower reading rate (with scaled print size)
Increased critical print size (CPS)
Reduced maximum reading speed (MRS) attainable (with scaled print
size and reduced eye movements)
Reduced eye movement control
Greater effect of crowding
Reduced visual span:
central vision ~10 letters
peripheral vision ~1-2 letters
Single letter resolution Limited by changes in retinal elements:
Threshold declines slowly with increasing eccentricity
Eccentricity at which foveal threshold has doubled: E
2
~ 2.5
Word resolution Limited by the cortical magnification factor:
Threshold declines rapidly with increasing eccentricity
Eccentricity at which foveal threshold has doubled: E
2
~ 0.68
Table 1. Summary of peripheral visual function for reading, single letter and word resolution
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Corresponding author:
Dr Andrew Metha
Department of Optometry and Vision
Sciences
The University of Melbourne
Parkville VIC 3010
AUSTRALIA
E-mail: ametha@unimelb.edu.au
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