methods for training eccentric viewing, the
Research Report
A Simplified Method of Identifying
the Trained Retinal Locus for
Training in Eccentric Viewing
Meri Vukicevic, Anh Le, and James Baglin
I n the typical human visual system, the mac-
ula allows for high visual resolution. Damage
to this area from diseases, such as age-related
macular degeneration (AMD), causes the loss
of central vision in the form of a central
scotoma (Kanski, 2008). Since no treatment is
available to reverse AMD, providing low vi-
sion rehabilitation to compensate for the loss
of central vision is invaluable for individuals
with this condition. Teaching persons with a
central scotoma the technique of eccentric
viewing to use their remaining peripheral ret-
ina to read and perform tasks of daily living
has been shown to be effective (Nilsson,
Frennesson, & Nilsson, 2003; Petre, Hazel,
Fine, & Rubin, 2000; Vukicevic & Fitzmau-
rice, 2002).
It has been reported that persons with AMD
can unconsciously adopt an eccentric area of
the uncompromised retina, allowing them to
achieve better vision. This eccentric area acts
as a pseudo-fovea and is termed the preferred
retinal locus (PRL) (Schuchard, 1995; Tim-
berlake et al., 1986). Although useful, this
spontaneous choice of location may not pro-
vide optimal vision for individuals to perform
various visual tasks, such as reading, recog-
nizing faces, or performing activities of daily
living. Optimizing the location of the retinal
area used can be addressed with formal train-
ing in eccentric viewing to teach individuals
to use a more suitable part of their retina to
see by introducing a trained retinal locus
(TRL) (Culham, Silver, & Bird, 1990;
Fletcher, Schuchard, & Watson, 1999;
Nilsson et al., 2003; Vukicevic & Fitzmau-
rice, 2005, 2009). Although there are many
©2012 AFB, All Rights Reserved
fundamental principles are equivocal and in-
volve two stages:
1. Identification of the residual areas of the
healthy retina by mapping the individual’s
visual field and
2. Location of the most suitable area to be
used as the TRL on the basis of the prox-
imity to the fovea.
A number of methods and apparatuses are
available to chart the visual field, but the
preferred method is by microperimetry with
such devices as the Macular Integrity Assess-
ment Microperimeter (CenterVue SpA, Pa-
dova, Italy) or the Nidek MP-1 Micro Perim-
eter (Nidek Technologies Srl, Padova, Italy).
Alternately, the visual field can be mapped by
tangent screen perimetry, such as the Bjerrum
tangent screen. Microperimetry allows clini-
cians to precisely delineate the borders of the
scotoma and the corresponding visible pathol-
ogy on the retina. The technique is also ca-
pable of displaying direct, real-time observa-
tion of the retina, and stimuli can be placed on
the retina for the purposes of training in ec-
centric viewing. For this reason, microperim-
etry is useful (Sunness, Bressler, & Maguire,
1995; Timberlake et al., 1986). Nevertheless,
microperimetry is not widely used clinically
because it is considered to be the least popular
method of identifying the retinal locus for
eccentric viewing training (Weisser-Pike,
2008). Low vision practitioners have reported
that microperimeters are difficult to use and
difficult for clients to understand how to per-
form the required task. The preference is for
simpler methods, such as the Amsler grid or
the Bjerrum tangent screen. Clinicians’ pref-
erence is not the only issue that restricts the
clinical use of microperimetry in a low vision
setting: it is expensive equipment and hence
is generally reserved for research purposes
(Manivannan et al., 2001).
Journal of Visual Impairment & Blindness, September 2012 555
 Low vision practitioners commonly use the
Bjerrum tangent screen as a method of map-
ping the central visual field or the central
scotoma or both. The Bjerrum tangent screen
is a black felt screen that evaluates the central
30 degrees of the retina at a one- or two-meter
(about 3 feet or 6.5 feet) testing distance. The
Bjerrum has statico-kinetic properties that al-
low the borders of the scotoma to be accu-
rately charted (kinetically) and individual test
points to be grossly quantified (statically).
The Bjerrum tangent screen can also be mod-
ified using a white cross for persons with
central field defects to assist them to fixate
centrally and steadily (Garber, 1994; West,
1988). Although the Bjerrum tangent screen
is still considered a valuable tool in clinical
settings, the large dimensions of the test
screen and the need for an accurate setup each
time render it difficult to use during domicil-
iary visits when this information is required
by low vision therapists for mapping the field
for training in eccentric viewing.
Limited portability and the lack of access to
a microperimeter or a tangent screen have led
to the development of more simplified meth-
ods of testing the boundaries of a central
scotoma for training in eccentric viewing.
Wright and Watson (1996) developed the
“clock face” method to determine the size of
a scotoma and to assist in determining the
direction of the TRL. The desk-based Cali-
fornia Central Visual Field Test (Mattingly
Low Vision, Escondido, California), which
uses laser dots of various brightness to map
central scotomas has been developed. Be-
cause of import restrictions in Australia, this
tool was unavailable to the researchers during
the time of data collection. Another method is
contained in the Eccentric Viewing Resources
Kit (EV Kit) (Fitzmaurice, 2002), which was
also developed to address the issue of porta-
bility and ease of use in determining the TRL.
The test consists of three screening cards that
help identify the retinal locus closest to the
fovea that the low vision practitioner can use
556 Journal of Visual Impairment & Blindness, September 2012
for teaching eccentric viewing. The test has
been reported to be useful in determining the
TRL, and individuals who received training in
eccentric viewing after the TRL was identi-
fied using this kit made significant improve-
ments in their near vision, reading speed,
reading comprehension, and performance of
activities of daily living (Vukicevic & Fitz-
maurice, 2005, 2009). The consistency of the
EV Kit tools compared to conventional pe-
rimetry tests has not yet been substantiated.
(The EV Kit is available from Associate
Professor Kerry Fitzmaurice, e-mail: ⬍k.
fitzmaurice@latrobe.edu.au⬎).
The EV Kit contains a smiley face card (see
Figure 1a) made from an A4 size laminated
card with two perpendicular lines bisecting
each other to form a cross. A smiley face (15
mm, or about 0.6 inch, in diameter) is situated
at the end of each line. When the card is held
at the testing distance of 30 centimeters
(about 12 inches), the distance between each
face and the center of the cross corresponds to
7 degrees eccentricity from the fovea. Each
eye is tested independently, and the person is
asked to look at the center of the card, using
the lines as a guide to where the center is. The
person should be aware of the faces above,
below, and to the side. If the person can see
any of these faces, he or she then determines
which is the clearest. The clearest smiley face
should give an indication of the best area for the
TRL. For example, if the person indicates that
the top smiley face is the clearest, this is the area
to be stimulated, so the person will be required
to look approximately 7 degrees inferiorly for
the purposes of training in eccentric viewing.
The girl’s face card (see Figure 1b) is com-
prised of two separate laminated strips with
the dimensions of 80 millimeters by 300 mil-
limeters (about 3 inches by 12 inches). Each
card contains a black-and-white photo of a
girl’s face centered on top of a 260-millimeter
(about 10-inch) black line. Markings on either
side of the picture extend out to 20 degrees
and are placed at 10-degree increments along
©2012 AFB, All Rights Reserved
Figure 1. Eccentric Viewing Resource Kit screening cards (not to scale): (a) smiley face card and (b)
girl’s face card. Copyright 1993 and 2000, respectively, by Kerry Fitzmaurice. Reprinted with permission.

the line. Both cards are essentially the same
but are oriented perpendicular to each other to
allow testing of the vertical and horizontal
retina. The individual is asked to look at the
lines away from the girl’s face to identify the
best gaze position that allows him or her to
see the girl’s face most clearly.
The aim of the study was to compare the
results of the smiley face and the girl’s face to
estimate an appropriate TRL with that of the
Bjerrum tangent screen. We did not have ac-
cess to a microperimeter for comparison.
an absolute central scotoma as a result of uni-
lateral or bilateral atrophic AMD, which was
diagnosed by an ophthalmologist. There were
no restrictions on the level of visual acuity re-
quired for the study. The participants were ex-
cluded if they presented with another ocular
pathology or with visual field loss from an oc-
ular disease other than AMD. All the proce-
dures in the study were approved by the La
Trobe University Faculty Human Ethics Com-
mittee (08/32), and all the participants gave
written consent prior to participation.

PARTICIPANTS METHODS
The participants were recruited by convenience The participants’ best-corrected distance acu-
criterion sampling from a private ophthalmol- ity was measured using a rear-illuminated
ogy clinic in Melbourne, Australia. They all had Snellen chart at 6 meters (about 20 feet, or

©2012 AFB, All Rights Reserved Journal of Visual Impairment & Blindness, September 2012 557
Table 1
Demographic data and visual acuity.
Eye Age Sex
Right ⫽ 9 74 – 88 Female ⫽ 6
Left ⫽ 5 (M ⫽ 81; SD ⫽ 5) Male ⫽ 3
closer if the participant was not able to read
the 6/60 optotype) and converted to LogMAR
notation for the purposes of analysis. Near
vision was tested at 40 centimeters (about 1.3
feet) using the Bailey-Lovie Word Reading
Chart (Bailey & Lovie-Kitchin, 1980). Perim-
etry was performed using a 1-meter Bjerrum
tangent screen to map the border of the par-
ticipant’s central scotoma and blind spot. Be-
cause of the loss of central vision, it was
difficult for the participants to locate and
steadily fix at the middle target on the Bjer-
rum screen. The screen was therefore adapted
by placing two white strings in a cross over
the chart to provide a guide for the center.
Tangent screen perimetry was performed
using the smallest white stimulus that the
participant could see, ranging from 1 to 7
millimeters (about 0.4 to 0.27 inch; M ⫽ 3.75
millimeters, or about 0.15 inch). Central field
loss was determined kinetically. The blind
spot was mapped first to provide the partici-
pants with an understanding of the concept of
a missing area in the field (Bailey, 1978). The
scotoma was then mapped by randomly as-
sessing each meridian (every 15 degrees). The
peripheral visual field was charted at every
second meridian (every 30 degrees). The
Bjerrum visual field results were shown to an
experienced clinician who was not related to
the study, and she was asked to select the
preferred area for training the TRL by placing
a cross on the visual field recording. The area
selected was identical to that of the re-
searcher, thus only one set of results for this
variable are included. No participants were
found to have a preferred TRL in a diagonal
location using the Bjerrum. The testing order
558 Journal of Visual Impairment & Blindness, September 2012
Distance visual acuity Near visual acuity
0.5 – 1.8 12.5 – 80
(M ⫽ 1.01, SD ⫽ 0.3) (M ⫽ 38.7, SD ⫽ 20.8)
with the smiley face card, the girl’s face card,
or Bjerrum tangent screen was randomized.
RESULTS
Nine participants (14 eyes) were recruited for
the study; the participants’ demographic data
and visual acuity are shown in Table 1. An
example of the results for the Bjerrum, girl’s
face card, and smiley face card are shown in
Figures 2a– c. The “X” indicates the most
optimal area on the Bjerrum recording se-
lected by the examiner and the preferred area
chosen by the participant on the screening
cards (see Figure 2a). With the girl’s face card
(Figure 2b), the scotoma is placed on the
10-degree line inferiorly, and the girl’s face
falls onto the healthy area of the retina (de-
noted by the “X”). Conversely, with the smi-
ley face card (see Figure 2c), the scotoma is
placed in the center of the cross (at the “X”),
and the superior smiley face falls onto the
healthy area of the retina.
Table 2 shows the results for each eye for all
three tests. A high degree of agreement was
found between the location of the best retinal
area, as defined by the Bjerrum tangent screen
and that of the smiley face card (13/14, 92.8%),
and between the Bjerrum tangent screen and the
girl’s face card (11/14, 78.6%). A kappa statistic
was also calculated for each comparison to the
Bjerrum tangent screen. The kappa statistic is a
measure of interrater reliability that takes into
account chance agreement (Cohen, 1975). Ac-
cording to the results of the kappa statistic, there
was a statistically significant level of agreement
between the Bjerrum and the smiley face
(kappa ⫽ 0.90, p ⬍ .001) and between the
Bjerrum and the girl’s face (kappa ⫽ 0.71,
©2012 AFB, All Rights Reserved
Figure 2. Examples of test results with the (a) Bjerrum tangent screen, (b) the girl’s face card,
and (c) the smiley face card. Figures 2b and 2c are copyright 2000 and 1993, respectively, by
Kerry Fitzmaurice. Reprinted with permission.

p ⬍ .001). According to Landis and Koch CONCLUSIONS

(1977), a kappa statistic of kappa ⫽ 0.90 for the
smiley face is regarded as almost perfect agree-
ment, while a kappa statistic of kappa ⫽ 0.71
for the girl’s face is regarded as substantial
agreement.
This study showed a high degree of reliability
between using the tools from the EV Kit to
identify a TRL and mapping the central sco-
toma with a Bjerrum tangent screen. A defi-
nite advantage of both the smiley face card

Table 2
Results for all three tests for each participant.
Bjerrum tangent screen: Location Smiley face card: Location Girl’s face card: Location
Eye of the best retinal area of the best retinal area of the best retinal area

1 Right Right Right

2 Superior Superior Superior
3 Right Right Right
4 Inferior Inferior Inferior
5 Left Left Left
6 Right Right Right
7 Left Left Superior
8 Left Right Inferior
9 Left Left Left
10 Bottom Bottom Superior
11 Right Right Right
12 Superior Superior Superior
13 Left Left Left
14 Left Left Left

©2012 AFB, All Rights Reserved Journal of Visual Impairment & Blindness, September 2012 559
and the girl’s face card is that they are por-
table, easily administered by a low vision
practitioner, and easy for a person to under-
stand. Nevertheless, there are disadvantages,
which include the inability to identify a TRL
in a diagonal location and a gross estimation
of the best area on which to place the TRL.
The kit identifies an approximate location in
terms of superior, inferior, nasal, or temporal,
but is less sensitive to locating the optimum
degree for the TRL. Some persons require the
TRL at a closer or further proximity to the
fovea than what the EV Kit tools can identify.
However, this tool, like the clock face
method, is not meant to be used in isolation.
In a previous study (Vukicevic & Fitzmau-
rice, 2005), when the TRL was identified with
the smiley face card, the distance from the
fovea was refined using the EccVUE
computer-generated method for training ec-
centric viewing (Fitzmaurice, Kinnear, &
Chen, 1994), and the participants significantly
improved on all the parameters that were
tested (near vision, reading speed, reading
comprehension, and performance of activities
of daily living). In conclusion, the almost-
perfect agreement between the Bjerrum tan-
gent screen and the smiley face card and the
substantial agreement with the girl’s face card
that were found in this study indicate that
these tools from the EV Kit are a useful
resource for low vision practitioners who are
training persons with a bilateral absolute cen-
tral scotoma in eccentric viewing, especially
if the assessment and training occur outside
the clinical environment.
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