Reviewer #2 (Public review):
Summary
This study uses functional MRI to evaluate visual contrast sensitivity across the visual field at the level of the visual cortex, testing the method as a proof of principle in a small group of normally sighted individuals, modelling both normal vision and simulated vision loss, as well as a patient with independently verified vision loss. The results suggest a promising technique to measure vision objectively across the visual field and overcomes the requirement for careful fixation which is often challenging in those with low vision or sight loss.
Strengths
• Objective measure of central vision: The proposed method may provide a more comprehensive and objective assessment of residual visual function in individuals with sight loss. This may be particularly useful for those with central visual field loss without the requirement of stable fixation or subjective motor responses.
• More sensitive measure: The use of slope to calculate contrast sensitivity across a range of contrasts within the brain is clever and likely more sensitive than single threshold measurements or standard clinical measures of visual acuity using letter charts. Standard supra-threshold (high contrast) tests are not ideal for capturing residual vision or partial vision loss.
• Good agreement with standard atlas: The Benson atlas provides a good estimate of visual field maps within V1 based on anatomical landmarks, and the authors take steps to refine this informed by cortical magnification and V1 surface area (brain size) for each individual participant. This could allow the technique to be generalised without the need to collect lengthy individual mapping data from every participant.
• Within-subject reproducibility: The measurements appear to be sensitive and reproducible, particularly in those with normal vision, and are consistent with known features of visual sensitivity differences in different parts of the visual field.
• Potential tool to measure visual field sensitivity in controls: Even if the proposed methods are not ideal for widespread clinical translation, they do offer an exciting tool to test hypotheses about visual field differences in healthy controls. For example, there seems to be an increase in sensitivity on either side of the simulated ring scotoma (Fig 6 - perhaps due to the release of lateral inhibition?). Reliability measures suggest that individual differences are consistent in healthy controls (although not tested statistically, perhaps due to the small sample size?). Whether they reflect behaviourally meaningful differences in visual field sensitivity could be tested in individuals by comparing them to behavioural measures across the visual field.
• Potential tool to test novel treatments: The proposed techniques could be used to test within-subject changes in visual function in environments that are equipped to measure and analyse fMRI data, including clinical trials aimed at determining the success of novel treatments. Preliminary testing in healthy controls with eye movements also suggests that the method is suitable for testing low vision patients with unstable fixation (e.g., nystagmus), and the authors have modelled the effects of varying amounts and types of eye movements on functional outcome measures.
Weaknesses
• Questionable sensitivity to differences in patients. The variability in heat maps across healthy control participants is somewhat surprising, and it is uncertain whether they represent actual visual sensitivity differences or an artifact of the measurement technique, e.g., due to signal-to-noise differences introduced by local variations in brain anatomy. Thus, it is uncertain whether the substantial variance across controls will allow for a sufficiently stable baseline to detect meaningful differences in individual patients. Also, as the authors rightly point out, Benson atlas does not model differences along meridians, so that upper/lower field differences might not be detectable. However, the authors acknowledge that this is a pilot study, and further testing a wider range of scotoma types in patients and simulated in controls will only improve the methods. Furthermore, the ability to capture visual field representations in human visual cortex is also likely to improve with computational advances, making the use of atlases more feasible, obviating the need for individualised population receptive field mapping.
• Potential for clinical translation. Although it is a sensitive measure, functional MRI is costly, is not available in all clinical settings, requires significant post-processing analyses, and may be contraindicated in some individuals due to safety (e.g., metallic implants) or other concerns (e.g., claustrophobia). These could present significant barriers to widespread clinical translation, if this were the ultimate goal of the study.
• Limited range of spatial frequencies. The spatial frequencies tested were still quite low (0.3 and 3cpd) compared to measures such a visual acuity. Extending the measurements to higher spatial frequencies could allow better characterization of central vision, although necessarily for peripheral vision. However, this may depend on the typical visual abilities of the patient population of interest.
Appraisal and Impact:
The authors used appropriate and robust methods to assess and model known features of visual sensitivity differences across the visual field in sighted controls. In addition, the assessment technique successfully captured sensitivity changes due to simulated and actual partial field loss but was also fairly resilient to eye movements and fixation instability, typical of patients with sight loss. Although currently providing a proof of principle, the method is likely to improve with further testing and increasing normative sample sizes, and as computational methods continue to advance visual field map predictions. Although it may not be adopted widely as a standard clinical assessment technique due to the expense and other obstacles, it would provide a valuable tool in assessing clinical populations, for example in the context of clinical trials to assess suitability for treatment interventions or monitor treatment outcomes.