PURPOSE: Reading is vital to full participation in modern society. To millions of people suffering from macular disease that results in a central scotoma, reading is difficult and inefficient, rendering reading as the primary goal for most patients seeking low vision rehabilitation. The goals of this review paper are to summarize the dependence of reading speed on several key visual and typographical factors and the current methods or technologies for improving reading performance for people with macular disease. IMPORTANT FINDINGS: In general, reading speed for people with macular disease depends on print size, text contrast, size of the visual span, temporal processing of letters and oculomotor control. Attempts at improving reading speed by reducing the crowding effect between letters, words or lines; or optimizing properties of typeface such as the presence of serifs or stroke-width thickness proved to be futile, with any improvement being modest at best. Currently, the most promising method to improve reading speed for people with macular disease is training, including perceptual learning or oculomotor training. SUMMARY: The limitation on reading speed for people with macular disease is likely to be multi-factorial. Future studies should try to understand how different factors interact to limit reading speed, and whether different methods could be combined to produce a much greater benefit.

Reading is slow and difficult for many people with central vision loss. A previous study showed that the temporal threshold for letter recognition is a major factor limiting reading speed for people with central vision loss. Here, we asked whether the temporal threshold for letter recognition for people with central vision loss could be improved through training and, if so, whether that would benefit reading. Training consisted of six sessions (3000 trials) of recognizing letter trigrams presented at fixation. Trigrams were initially presented at a baseline temporal threshold that was decreased by 0.1 log step when observers letter recognition accuracies reached 80% or higher for four consecutive blocks. Before and after training, we measured observers visual acuity, preferred retinal locus for fixation, fixation stability, reading speeds using the rapid serial visual presentation (RSVP) paradigm, the MNREAD Acuity Chart and 100-word passages, the baseline temporal threshold for letter recognition at 80% accuracy, and a visual-span profile. After training, the temporal threshold was decreased by 68%. This improvement was accompanied by a higher RSVP maximum reading speed (but no change in MNREAD and passage reading speeds) and a larger visual span. A mediation analysis showed that the relationship between the temporal threshold and RSVP maximum reading speed was mainly mediated by the information transfer rate (size of visual span/temporal duration). Our results showed that the temporal threshold for letter recognition is amenable to training and can improve RSVP reading speeds, offering a practical means to improve reading speed for people with central vision loss.

Recent evidence suggests a double dissociation of size and spacing limit on letter recognition-it is limited by size in the fovea and critical spacing in the normal periphery. Here, we evaluated whether size or spacing limits letter recognition in people with age-related macular degeneration (AMD) who must use their peripheral vision. We measured the size threshold for recognizing lowercase letters presented alone, or flanked by two letters at various center-to-center nominal letter spacings (multiples of letter size) for 11 observers with AMD. For comparison, similar measurements were obtained at 5° and 10° eccentricity in the nasal and lower visual fields in three older adults with normal vision. Single-letter size thresholds were worse for observers with AMD than at comparable retinal locations in the normal periphery. For flanked letters, size threshold improved with larger nominal spacing up to the critical spacing, beyond which size threshold was unaffected by the flankers. Seven AMD observers had a nominal critical spacing between 1.25× and 1.80×, values close to those in the normal fovea, suggesting that their letter recognition is size-limited; two had a nominal critical spacing of 3-4×, values close to those in the normal periphery, implying that their letter recognition is limited by spacing; and another two had a nominal critical spacing of ∼2.3×, implying that their letter recognition is limited by both size and spacing. The wide range of nominal critical spacings observed in our AMD observers may reflect the degree of completeness of their adaptation process to vision loss.

PURPOSE: Patients with central vision loss face daily challenges on performing various visual tasks. Categorizing facial expressions is one of the essential daily activities. The knowledge of what visual information is crucial for facial expression categorization is important to the understanding of the functional performance of these patients. Here we asked how the performance for categorizing facial expressions depends on the spatial information along different orientations for patients with central vision loss. METHODS: Eight observers with central vision loss and five age-matched normally sighted observers categorized face images into four expressions: angry, fearful, happy, and sad. An orientation filter (bandwidth = 23°) was applied to restrict the spatial information within the face images, with the center of the filter ranged from horizontal (0°) to 150° in steps of 30°. Face images without filtering were also tested. RESULTS: When the stimulus visibility was matched, observers with central vision loss categorized facial expressions just as well as their normally sighted counterparts, and showed similar confusion and bias patterns. For all four expressions, performance (normalized d), uncorrelated with any of the observers visual characteristics, peaked between -30° and 30° filter orientations and declined systematically as the filter orientation approached vertical (90°). Like normally sighted observers, observers with central vision loss also relied mainly on mouth and eye regions to categorize facial expressions. CONCLUSIONS: Similar to people with normal vision, people with central vision loss rely primarily on the spatial information around the horizontal orientation, in particular the regions around the mouth and eyes, for recognizing facial expressions.

Following the onset of central vision loss, most patients develop an eccentric retinal location outside the affected macular region, the preferred retinal locus (PRL), as their new reference for visual tasks. The first goal of this article is to present behavioral evidence showing the presence of experience-dependent plasticity in people with central vision loss. The evidence includes the presence of oculomotor re-referencing of fixational saccades to the PRL; the characteristics of the shape of the crowding zone (spatial region within which the presence of other objects affects the recognition of a target) at the PRL are more "foveal-like" instead of resembling those of the normal periphery; and the change in the shape of the crowding zone at a para-PRL location that includes a component referenced to the PRL. These findings suggest that there is a shift in the referencing locus of the oculomotor and the sensory visual system from the fovea to the PRL for people with central vision loss, implying that the visual system for these individuals is still plastic and can be modified through experiences. The second goal of the article is to demonstrate the feasibility of applying perceptual learning, which capitalizes on the presence of plasticity, as a tool to improve functional vision for people with central vision loss. Our finding that visual function could improve with perceptual learning presents an exciting possibility for the development of an alternative rehabilitative strategy for people with central vision loss.

Purpose

Reading is vital to full participation in modern society. To millions of people suffering from macular disease that results in a central scotoma, reading is difficult and inefficient, rendering reading as the primary goal for most patients seeking low vision rehabilitation. The goals of this review paper are to summarize the dependence of reading speed on several key visual and typographical factors and the current methods or technologies for improving reading performance for people with macular disease.

Important findings

In general, reading speed for people with macular disease depends on print size, text contrast, size of the visual span, temporal processing of letters and oculomotor control. Attempts at improving reading speed by reducing the crowding effect between letters, words or lines; or optimizing properties of typeface such as the presence of serifs or stroke-width thickness proved to be futile, with any improvement being modest at best. Currently, the most promising method to improve reading speed for people with macular disease is training, including perceptual learning or oculomotor training.

Summary

The limitation on reading speed for people with macular disease is likely to be multi-factorial. Future studies should try to understand how different factors interact to limit reading speed, and whether different methods could be combined to produce a much greater benefit.

Single-unit recordings demonstrated that the adult mammalian visual cortex is capable of reorganizing after induced retinal lesions. In humans, whether the adult cortex is capable of reorganizing has only been studied using functional magnetic resonance imaging, with equivocal results. Here, we exploited the phenomenon of visual crowding, a major limitation on object recognition, to show that, in humans with long-standing retinal (macular) lesions that afflict the fovea and thus use their peripheral vision exclusively, the signature properties of crowding are distinctly different from those of the normal periphery. Crowding refers to the inability to recognize objects when the object spacing is smaller than the critical spacing. Critical spacing depends only on the retinal location of the object, scales linearly with its distance from the fovea, and is approximately two times larger in the radial than the tangential direction with respect to the fovea, thus demonstrating the signature radial-tangential anisotropy of the crowding zone. Using retinal imaging combined with behavioral measurements, we mapped out the crowding zone at the precise peripheral retinal locations adopted by individuals with macular lesions as the new visual reference loci. At these loci, the critical spacings are substantially smaller along the radial direction than expected based on the normal periphery, resulting in a lower scaling of critical spacing with the eccentricity of the peripheral locus and a loss in the signature radial-tangential anisotropy of the crowding zone. These results imply a fundamental difference in the substrate of cortical processing in object recognition following long-term adaptation to macular lesions.

Purpose

Crowding, the difficulty in recognizing a letter in close proximity with other letters, has been suggested as an explanation for slow reading in people with central vision loss. The goals of this study were (1) to examine whether increased letter spacing in words, which presumably reduces crowding among letters, would benefit reading for people with central vision loss and (2) to relate our finding to the current account of faulty feature integration of crowding.

Methods

Fourteen observers with central vision loss read aloud single sentences, one word at a time, using rapid serial visual presentation. Reading speeds were calculated based on the rapid serial visual presentation exposure durations yielding 80% accuracy. Letters were rendered in Courier, a fixed-width font. Observers were tested at 1.4× the critical print size (CPS), three were also tested at 0.8× CPS. Reading speed was measured for five center-to-center letter spacings (range: 0.5-2× the standard spacing). The preferred retinal locus for fixation was determined for nine of the observers, from which we calculated the horizontal dimension of the integration field for crowding.

Results

All observers showed increased reading speed with letter spacing for small spacings, until an optimal spacing, beyond which reading speed either showed a plateau, or dropped as letter spacing further increased. The optimal spacing averaged 0.95 ± 0.06× [±95% confidence interval] the standard spacing for 1.4× CPS (similar for 0.8× CPS), which was not different from the standard. When converted to angular size, the measured values of the optimal letter spacing for reading show a good relationship with the calculated horizontal dimension of the integration field.

Conclusions

Increased letter spacing beyond the standard size, which presumably reduces crowding among letters in text, does not improve reading speed for people with central vision loss. The optimal letter spacing for reading can be predicted based on the preferred retinal locus.

Crowding between adjacent letters has been investigated primarily as a spatial effect. The purpose of this study was to investigate the spatio-temporal properties of letter crowding. Specifically, we examined the systematic changes in the degradation effects in letter identification performance when adjacent letters were presented with a temporal asynchrony, as a function of letter separation and between the fovea and the periphery. We measured proportion-correct performance for identifying the middle target letter in strings of three lowercase letters at the fovea and 10° in the inferior visual field, for a range of center-to-center letter separations and a range of stimulus onset asynchronies (SOA) between the target and flanking letters (positive SOAs: target preceded flankers). As expected, the accuracy for identifying the target letters reduces with decreases in letter separation. This crowding effect shows a strong dependency on SOAs, such that crowding is maximal between 0 and ∼100 ms (depending on conditions) and diminishes for larger SOAs (positive or negative). Maximal crowding does not require the target and flanking letters to physically coexist for the entire presentation duration. Most importantly, crowding can be minimized even for closely spaced letters if there is a large temporal asynchrony between the target and flankers. The reliance of letter identification performance on SOAs and how it changes with letter separations imply that the crowding effect can be traded between space and time. Our findings are consistent with the notion that crowding should be considered as a spatio-temporal, and not simply a spatial, effect.

Purpose

Perceptual learning has been shown to be effective in improving visual functions in the normal adult visual system, as well as in adults with amblyopia. In this study, the feasibility of applying perceptual learning to enhance reading speed in people with long-standing central vision loss was evaluated.

Methods

Six observers (mean age, 73.8) with long-standing central vision loss practiced an oral sentence-reading task, with words presented sequentially using rapid serial visual presentation (RSVP). A pre-test consisted of measurements of visual acuities, RSVP reading speeds for six print sizes, the location of the preferred retinal locus for fixation (fPRL), and fixation stability. Training consisted of six weekly sessions of RSVP reading, with 300 sentences presented per session. A post-test, identical with the pre-test, followed the training.

Results

All observers showed improved RSVP reading speed after training. The improvement averaged 53% (range, 34-70%). Comparisons of pre- and post-test measurements revealed little changes in visual acuity, critical print size, location of the fPRL, and fixation stability.

Conclusions

The specificity of the learning effect, and the lack of changes to the fPRL location and fixation stability suggest that the improvements are not due to observers adopting a retinal location with better visual capability, or an improvement in fixation. Rather, the improvements are likely to represent genuine plasticity of the visual system despite the older ages of the observers, coupled with long-standing sensory deficits. Perceptual learning might be an effective way of enhancing visual performance for people with central vision loss.