Ramkumar Sabesan

Vision improvement by correcting higher-order aberrations with customized soft contact lenses in keratoconic eyes

Higher-order aberration correction in abnormal eyes can result in significant vision improvement, especially in eyes with abnormal corneas. Customized optics such as phase plates and customized contact lenses are one of the most practical, nonsurgical ways to correct these ocular higher-order aberrations. We demonstrate the feasibility of correcting higher-order aberrations and improving visual performance with customized soft contact lenses in keratoconic eyes while compensating for the static decentration and rotation of the lens. A reduction of higher-order aberrations by a factor of 3 on average was obtained in these eyes. The higher-order aberration correction resulted in an average improvement of 2.1 lines in visual acuity over the conventional correction of defocus and astigmatism alone.

Visual performance after correcting higher order aberrations in keratoconic eyes

Keratoconic eyes are affected by an irregular optical blur induced by significant magnitude of higher order aberrations (HOAs). Although it is expected that correction of ocular aberrations leads to an improvement in visual performance, keratoconic eyes might not achieve the visual benefit predicted by optical theory because of long-term adaptation to poor retinal image quality. To investigate this, an adaptive optics (AO) system equipped with a large-stroke deformable mirror and a Shack-Hartmann wavefront sensor was used to correct the aberrations and measure high contrast tumbling E visual acuity (HCVA) in 8 keratoconic eyes. Eight normal eyes were employed as control. Aberrations were dynamically corrected with closed-loop AO during visual acuity testing, with residual root-mean-square error of around 0.1 microm in both groups over 6-mm pupil (p = 0.11). With AO correction, the HCVA in logMAR was -0.26 +/- 0.063 in normal eyes, and in keratoconic eyes, it was -0.07 +/- 0.051 (p = 0.0001) for the same pupil size. There was no correlation in the AO-corrected HCVA for normals with the magnitudes of their native HOA. However, within keratoconic eyes, poorer AO-corrected HCVA was observed with an increase of the native magnitudes of HOA (R(2) = 0.67). This may indicate that long-term visual experience with poor retinal image quality, induced by HOA, may restrict the visual benefit achievable immediately after correction in keratoconic eyes.

Neural compensation for long-term asymmetric optical blur to improve visual performance in keratoconic eyes.

Purpose. To investigate whether long-term visual experience with irregular optical blur compensates for the impact of higher-order aberration on visual performance in keratoconic (KC) eyes. Methods. The aberrations and high (100%)- and low (20%)-contrast tumbling E visual acuity (VA) were measured in four moderate KC eyes in which the subjects were wearing their own prescribed soft toric contact lenses over a 6-mm pupil. VA was measured in three emmetropic normal eyes for comparison with each of the four KC eyes. An adaptive optics system was used to correct the aberration of the normal eye and to induce the aberration of the KC eye simultaneously during vision testing. The magnitude of neural compensation was defined as improvement in VA in each KC eye compared with the normal eyes with KC aberrations. Results. Mean total and higher-order root mean square errors in the KC eyes with contact lenses were 2.72 +/- 0.83 mum and 1.36 +/- 0.29 mum, respectively, for a 6-mm pupil. Residual RMS wavefront error in induction of KC aberrations on normal eyes was approximately 0.1 mum in all cases. Each KC eye had statistically better high (P < 0.02)- and low (P < 0.03)-contrast VA than the three normal eyes. Mean compensation for high-contrast VA in logMAR was 0.12 +/- 0.09, corresponding to an improvement of 23.8%. A similar result was obtained for low-contrast VA. The magnitude of compensation increased with the severity of KC aberrations. Conclusions. In KC eyes, the neural visual system compensates for long-term visual experience with an asymmetrically blurred retinal image, resulting in improved visual performance.

Wavefront-Guided Scleral Lens Prosthetic Device for Keratoconus

Purpose To investigate the feasibility of correcting ocular higher order aberrations (HOAs) in keratoconus (KC) using wavefront-guided optics in a scleral lens prosthetic device (SLPD). Methods Six advanced KC patients (11 eyes) were fitted with an SLPD with conventional spherical optics. A custom-made Shack-Hartmann wavefront sensor was used to measure aberrations through a dilated pupil wearing the SLPD. The position of SLPD, that is, horizontal and vertical decentration relative to the pupil and rotation were measured and incorporated into the design of the wavefront-guided optics for the customized SLPD. A submicron-precision lathe created the designed irregular profile on the front surface of the device. The residual aberrations of the same eyes wearing the SLPD with wavefront-guided optics were subsequently measured. Visual performance with natural mesopic pupil was compared between SLPDs having conventional spherical and wavefront-guided optics by measuring best-corrected high-contrast visual acuity and contrast sensitivity. Results Root mean square of HOA in the 11 eyes wearing conventional SLPD with spherical optics was 1.17 ± 0.57 &mgr;m for a 6-mm pupil. Higher order aberrations were effectively corrected by the customized SLPD with wavefront-guided optics, and root mean square was reduced 3.1 times on average to 0.37 ± 0.19 &mgr;m for the same pupil. This correction resulted in significant improvement of 1.9 lines in mean visual acuity (p < 0.05). Contrast sensitivity was also significantly improved by factors of 2.4, 1.8, and 1.4 on average for 4, 8, and 12 cycles/degree, respectively (p < 0.05 for all frequencies). Although the residual aberration was comparable to that of normal eyes, the average visual acuity in logMAR with the customized SLPD was 0.21, substantially worse than normal acuity. Conclusions The customized SLPD with wavefront-guided optics corrected the HOA of advanced KC patients to normal levels and improved their vision significantly.

Binocular visual performance and summation after correcting higher order aberrations

Although the ocular higher order aberrations degrade the retinal image substantially, most studies have investigated their effect on vision only under monocular conditions. Here, we have investigated the impact of binocular higher order aberration correction on visual performance and binocular summation by constructing a binocular adaptive optics (AO) vision simulator. Binocular monochromatic aberration correction using AO improved visual acuity and contrast sensitivity significantly. The improvement however, differed from that achieved under monocular viewing. At high spatial frequency (24 c/deg), the monocular benefit in contrast sensitivity was significantly larger than the benefit achieved binocularly. In addition, binocular summation for higher spatial frequencies was the largest in the presence of subject’s native higher order aberrations and was reduced when these aberrations were corrected. This study thus demonstrates the vast potential of binocular AO vision testing in understanding the impact of ocular optics on habitual binocular vision.

Correcting Highly Aberrated Eyes Using Large-stroke Adaptive Optics

PURPOSE To investigate the optical performance of a large-stroke deformable mirror in correcting large aberrations in highly aberrated eyes. METHODS A large-stroke deformable mirror (Mirao 52D; Imagine Eyes) and a Shack-Hartmann wavefront sensor were used in an adaptive optics system. Closed-loop correction of the static aberrations of a phase plate designed for an advanced keratoconic eye was performed for a 6-mm pupil. The same adaptive optics system was also used to correct the aberrations in one eye each of two moderate keratoconic and three normal human eyes for a 6-mm pupil. RESULTS With closed-loop correction of the phase plate, the total root-mean-square (RMS) over a 6-mm pupil was reduced from 3.54 to 0.04 microm in 30 to 40 iterations, corresponding to 3 to 4 seconds. Adaptive optics closed-loop correction reduced an average total RMS of 1.73+/-0.998 to 0.10+/-0.017 microm (higher order RMS of 0.39+/-0.124 to 0.06+/-0.004 microm) in the three normal eyes and 2.73+/-1.754 to 0.10+/-0.001 microm (higher order RMS of 1.82+/-1.058 to 0.05+/-0.017 microm) in the two keratoconic eyes. CONCLUSIONS Aberrations in both normal and highly aberrated eyes were successfully corrected using the large-stroke deformable mirror to provide almost perfect optical quality. This mirror can be a powerful tool to assess the limit of visual performance achievable after correcting the aberrations, especially in eyes with abnormal corneal profiles.

Post-DSAEK optical changes: a comprehensive prospective analysis on the role of ocular wavefront aberrations, haze, and corneal thickness.

Purpose: The aim was to assess the visual impact of ocular wavefront aberrations, corneal thickness, and corneal light scatter prospectively after performing a Descemet stripping automated endothelial keratoplasty (DSAEK) in humans. Methods: Data were obtained prospectively from 20 eyes preoperatively and at 1, 3, 6, and 12 months post-DSAEK. At each visit, the best spectacle-corrected visual acuity and visual acuity with glare (brightness acuity testing) were recorded, and ocular wavefront measurements and corneal optical coherence tomography (OCT) were performed. The magnitude and the sign of individual Zernike terms [higher-order aberrations (HOAs)] were determined. Epithelial, host stromal, donor stromal, and total corneal thicknesses were quantified. The brightness and intensity profiles of OCT images were generated to quantify light scatter in the whole cornea, subepithelial region, anterior and posterior host stroma, interface, and donor stroma. Results: The mean best spectacle-corrected visual acuity and glare disability at low light levels improved from 1 to 12 months post-DSAEK. All corneal thicknesses and ocular lower-order aberrations and HOAs were found to be stable from 1 to 12 months, whereas total corneal, host stromal, and interface brightness intensities decreased significantly over the same period. A repeated measures analysis of variance performed across the follow-up period revealed that the change in scatter, but not the change in the HOAs, could account for the variability occurring in the acuity from 1 to 12 months post-DSAEK. Conclusions: Although ocular HOAs and scatter are both elevated over normal values post-DSAEK, our results demonstrate that the improvements in visual performance occurring over the first year post-DSAEK are associated with decreasing light scatter. In contrast, there were no significant changes in the ocular HOAs during this time. Because corneal light scatter decreased between 1 and 12 months despite there being stable corneal thicknesses over the same period, we conclude that factors that induced light scatter, other than tissue thickness or swelling (corneal edema), significantly impacted the visual improvements that occurred over time post-DSAEK. A better understanding of the cellular and extracellular matrix changes of the subepithelial region and interface, incurred by the surgical creation of a lamellar host–graft interface, and the subsequent healing of these tissues, is warranted.

Visual Performance with Wave Aberration Correction after Penetrating, Deep Anterior Lamellar, or Endothelial Keratoplasty

PURPOSE To investigate the contribution ocular aberrations have on visual performance by quantifying improvements in best-corrected visual acuity (VA) and contrast sensitivity (CS) obtained with higher-order aberration (HOA) correction after penetrating (PK), deep anterior lamellar (DALK), or Descemets stripping automated endothelial keratoplasty (DSAEK). METHODS Sixteen eyes were evaluated from 14 subjects who underwent PK (n = 5), DALK (n = 6), or DSAEK (n = 5) greater than 1 year prior to study enrollment. Ocular aberrations were measured and an adaptive optics system was used to correct ocular lower-order aberration (LOA) and HOA. VA and CS were measured for each subject with LOA or full-aberration correction. CS was measured at each of three spatial frequencies: 4, 8, and 12 cycles/deg. RESULTS All keratoplasty groups had more aberration than that of a normal myopic population and experienced significant VA gains with full-aberration correction (P < 0.0013). PK subjects had better VA than that of DSAEK subjects with LOA correction (logMAR VA 0.03 ± 0.05 vs. 0.25 ± 0.05; P = 0.0870). After HOA correction this trend persisted (P = 0.1734). DSAEK subjects also experienced less VA benefit from full-aberration correction than that of PK and DALK subjects. All keratoplasty groups demonstrated similar CS benefits from full-aberration correction despite differing higher-order root-mean-square magnitudes. CONCLUSIONS PK eyes had better logMAR VA than that of DSAEK eyes with LOA correction, whereas DALK eyes performed intermediate between the two. When full correction was applied, the same trend persisted. The findings suggest that factors other than aberration contribute to decrements in VA with DSAEK compared with PK.

Active eye-tracking for an adaptive optics scanning laser ophthalmoscope

We demonstrate a system that combines a tracking scanning laser ophthalmoscope (TSLO) and an adaptive optics scanning laser ophthalmoscope (AOSLO) system resulting in both optical (hardware) and digital (software) eye-tracking capabilities. The hybrid system employs the TSLO for active eye-tracking at a rate up to 960 Hz for real-time stabilization of the AOSLO system. AOSLO videos with active eye-tracking signals showed, at most, an amplitude of motion of 0.20 arcminutes for horizontal motion and 0.14 arcminutes for vertical motion. Subsequent real-time digital stabilization limited residual motion to an average of only 0.06 arcminutes (a 95% reduction). By correcting for high amplitude, low frequency drifts of the eye, the active TSLO eye-tracking system enabled the AOSLO system to capture high-resolution retinal images over a larger range of motion than previously possible with just the AOSLO imaging system alone.

The elementary representation of spatial and color vision in the human retina

The origins of spatial and color vision in the human retina. The retina is the most accessible element of the central nervous system for linking behavior to the activity of isolated neurons. We unraveled behavior at the elementary level of single input units—the visual sensation generated by stimulating individual long (L), middle (M), and short (S) wavelength–sensitive cones with light. Spectrally identified cones near the fovea of human observers were targeted with small spots of light, and the type, proportion, and repeatability of the elicited sensations were recorded. Two distinct populations of cones were observed: a smaller group predominantly associated with signaling chromatic sensations and a second, more numerous population linked to achromatic percepts. Red and green sensations were mainly driven by L- and M-cones, respectively, although both cone types elicited achromatic percepts. Sensations generated by cones were rarely stochastic; rather, they were consistent over many months and were dominated by one specific perceptual category. Cones lying in the midst of a pure spectrally opponent neighborhood, an arrangement purported to be most efficient in producing chromatic signals in downstream neurons, were no more likely to signal chromatic percepts. Overall, the results are consistent with the idea that the nervous system encodes high-resolution achromatic information and lower-resolution color signals in separate pathways that emerge as early as the first synapse. The lower proportion of cones eliciting color sensations may reflect a lack of evolutionary pressure for the chromatic system to be as fine-grained as the high-acuity achromatic system.