Oculomotor Training Improves Binocular Vision with ... · Oculomotor Training & Binocular Vision ....

Oculomotor Training & Binocular Vision

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Oculomotor Training Improves Binocular Vision with Improved Symptoms 1

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Melissa Hunfalvay, RightEye LLC, 7979 Old Georgetown Rd, Suite 801, Bethesda, MD 20814, 6

U.S.A. (301) 979 7970 [email protected] 7

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Ankur Tyagi, RightEye LLC, 7979 Old Georgetown Rd, Suite 801, Bethesda, MD 20814, 9

U.S.A. (301) 979 7970 [email protected] 10

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Jason Whittaker, 38 Proulx Place, Winnipeg, MB R3X 0C5, CANADA. (204) 230 5743; 12

[email protected] 13

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Cedric Noel, [email protected] 15

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*Please direct all correspondence to Dr. Melissa Hunfalvay 18

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mailto:[email protected]





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Oculomotor Training Improves Binocular Vision with Improved Symptoms 26

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41 Key words: Vision therapy, eye tracking, binocular vision, functional vision 42

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Participants 45

The total number of participants considered for this study were 96. Out of the total, 48 46

participants completed the “EyeQ Trainer Exercise” assigned to them. They are categorized as 47

“Intervention Group” for the purpose of this study. Other 48 participants did not do the “EyeQ 48

Trainer Exercise” assigned to them. They are categorized as “Control Group” for the purpose of 49

this study. Participants in the Control group are matched with Intervention group on Age, 50

Functional Vision EyeQ Score, and Time interval between pre and post assessment. Table 1 51

shows the information about participants. 52

Table 1 53

Summary of participant Age, Functional EyeQ Score and time interval between pre and post 54

assessments, for Intervention Vs Control group. 55

Variable Control

Intervention

Mean ± SD Range Mean ± SD Range

Age 30 ± 21 [8, 85]

42 ± 24 [5, 85]

Functional Vision EyeQ Score 57 ± 19 [11, 82]

55 ± 17 [21, 83]

Days difference between

Pre and Post Assessment 16 ± 8 [5, 35] 15 ± 7 [6, 35]

Note. Mean, Standard Deviation and Range of values for Age, Functional Vision EyeQ Score, 56

and Time interval between pre and post assessment for Intervention and matched Control group. 57

There were 12 males (25%) and 36 females (75%) in the Intervention Group. In 58

comparison, there were 19 males (40%) and 29 females (60%) in the Control Group. 59

Apparatus 60


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Testing and training interventions were done on the same apparatus. Stimuli were presented 61

using the RightEye tests on a Tobii I15 vision 15” monitor fitted with a Tobii 90 Hz remote eye 62

tracker and a Logitech (model Y-R0017) wireless keyboard and mouse. The participants were 63

seated in a stationary (nonwheeled) chair that could not be adjusted in height. They sat in front of 64

a desk in a quiet, private room. Participants’ heads were unconstrained. The accuracy of the 65

Tobii eye tracker was 0.4◦ within the desired headbox of 32 cm × 21 cm at 56 cm from the 66

screen. For standardization of testing, participants were asked to sit in front of the eye 67

tracking system at an exact measured distance of 56 cm (ideal positioning within the headbox 68

range of the eye tracker). 69

Oculomotor Testing Tasks. Pre and post-tests were conducted using the same set of 70

oculomotor tasks, collectively call Functional Vision EyeQ. These tasks included three smooth 71

pursuit tests, 2 saccade tests, one fixation test, two reaction time tests. 72

Pursuit Tests: Three types of pursuit tests were run. A Circular Smooth Pursuit (CSP), 73

Horizontal Smooth Pursuit (HSP) and Vertical Smooth Pursuit (VSP). Participants were asked to 74

“follow the dot, on the screen, as accurately as possible with their eyes.” The dot is 0.2 degrees 75

in diameter and moved at a speed of 25 degrees of visual angle per second. The tests were taken 76

with a black background with white dot and lasted 20s. The diameter of movement of the CSP 77

circle was 20 degrees. 78

Self-Paced Saccade Tests (see Hunfalvay, Roberts, Murray, Tyagi, Kelly & Bolte, 2019): 79

In the Horizontal Saccade (HS) test, participants were asked to look at a countdown of three, 80

two, one in the center of the screen before moving their eyes back and forth between two dots. 81

Their goal was to ‘target each dot’ on the left and right of the screen as quickly and accurately as 82

possible. The targets were 10 cm apart and 1 cm in diameter. The tests were taken with a black 83


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background with white dots and lasted 10s. The protocol for the Vertical Saccade (VS) test was 84

the same as that for the HS test. However, the VS test was in a vertical plane. 85

Fixation Test: In the Fixation Test (FX), participants are asked to look at three different 86

optotypes for 7 seconds each with a 3 second break between. Optotype 1 is a cross of 1 degree in 87

size. Optotype 2 is a circular dot, 1 degree in size. Optotype 3 is a small four-point diamond, that 88

is 3 cm in size on the edge. The tests were taken with a white background with black dots and 89

lasted a total of 30 seconds, including the breaks 90

Reaction Time Tests: Two reaction time tests were given; a Choice Reaction Time test 91

(CRT) and Discriminate Reaction Time test (DRT; see Lange, Hunfalvay, Murray, Roberts, 92

Bolte, 2018). In brief, the CRT test, the participant viewed three stimuli and was asked to 93

provide one of three responses. In the DRT test, the participant viewed three stimuli and was 94

required to respond to only one stimulus. 95

The Functional Vision EyeQ Score (FVEQ): includes a linear combination of saccade, 96

pursuit, fixation and reaction time oculomotor variables. A total of 142 metrics make up the 97

model. Weights range from X to Y across metrics. More about the individual tests and metrics 98

can be found in published papers. 99

Oculomotor Training Task. Training exercises took 5 minutes and were conducted 100

twice a day, once in the morning and once in the evening, for a total of five days. The training 101

exercises assigned took participants through a series of exercises including: Down-gaze Central 102

No-No, Up-gaze Central No-No, Down Right-Diagonal Saccades followed by Upward Pursuit, 103

and Down Left-Diagonal Saccades followed by Upward Pursuit. 104


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For Down-gaze Central No-No, participants are asked to tilt their head to the top line and 105

then back to center, when they see the target presented on screen. They have to repeat the 106

process, each time the target jumps. 107

For Up-gaze Central No-No, participants are asked to move their head one time to the bottom 108

line and then back to the center, when they see the target presented on screen. They have to 109

repeat the process, each time the target jumps. 110

Procedure 111

Participants were recruited through advertisements placed on the internet, social media, 112

bulletin boards, and word of mouth and RightEye clients. The nature of the study was explained 113

to the participants, and all participants were provided a written University Approved informed 114

consent to participate. Following informed consent, participants were asked to complete a pre-115

screening. Participants were excluded from the study if they reported past head injury, any 116

neurological condition, or static visual acuity of greater than 20/400. Participants were also 117

excluded if they were unable to pass a 9-point calibration sequence. 118

Following pre-screening, participants completed the Neurobehavioral Symptom Inventory 119

(NSI) and then took the oculomotor tests. Once testing was complete, they were randomly 120

assigned to the oculomotor training (Intervention Group) or to a Control group. Therapy was 121

assigned based on oculomotor deficiency. In this study, participants were selected if their vertical 122

smooth pursuits deviated greater than 7mm off the anticipated path. The goal of the therapy was 123

to realign the eyes so they more accurately followed the straight up and down plane of the VSP 124

target. The pattern could be one of the following: V or Y pattern, A or Lambda (λ) pattern, which 125

can be in either left eye or right eye or both eyes. 126


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Participants were randomly assigned to the Control or Intervention groups. The 127

intervention group did the RightEye EyeQ Trainer exercises and no other interventions. The 128

control group did not do the RightEye EyeQ Trainer exercises nor any no other intervention. 129

After training was complete the participant returned for a post-test Functional Vision 130

EyeQ and completed the NSI and debriefing of the study. 131

Data Analysis 132

Separate 2 (Group) x 2 (Time) repeated measures ANOVAs were used to determine 133

differences in RightEye Test Metrics: Functional Vision EyeQ Score (#), Discriminate Reaction 134

Time (DRT): Response Accuracy (%), Choice Reaction Time (CRT): Distractibility (#), Vertical 135

Saccades (VS): Saccadic Recovery (mm), Horizontal Saccades (HS): Saccadic Recovery (mm), 136

Horizontal Smooth Pursuit (HSP): Pathway Length Difference (mm), and Circular Smooth 137

Pursuit (CSP): Predictive Smooth Pursuit (%) between the two Groups (Control and 138

Intervention) and over Time (Pre and Post Assessments). 139

Results 140

1. Functional Vision EyeQ Score (#) 141

The ANOVA results for Functional Vision EyeQ Score demonstrated a non-significant main 142

effect for Group (Intervention, Control) (p = .524); however there was a significant main effect 143

for Time (Pre, Post), F(1, 94) = 6.04, p = .016, η2g = .01 and a significant interaction (Group x 144

Time), F(1, 94) = 8.17, p = .005, η2g = .02. Simple effects revealed a decrease in the Functional 145

Vision EyeQ Score for control from pre (57.06) to post (56.38); however, the intervention 146

group’s metric value improved from pre (54.50) to post (63.65) (See Table 2). 147


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2. Discriminate Reaction Time (DRT): Response Accuracy (%) 149

The ANOVA results for DRT: Response Accuracy demonstrated significant main effect for 150

Group (Intervention, Control), F(1,94) = 5.45, p = .022, η2g = .04, significant main effect for 151

Time (Pre, Post), F(1, 94) = 13.78, p = .000, η2g = .04 and a significant interaction (Group x 152

Time), F(1, 94) = 14.73, p = .000, η2g = .04. Simple effects revealed a slight decrease in the 153

DRT: Response Accuracy for control from pre (91.85) to post (91.65); however, the intervention 154

group’s metric value increased from pre (79.06) to post (91.65) (See Table 2). 155

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3. Choice Reaction Time (CRT): Distractibility (#) 157


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The ANOVA results for CRT: Distractibility demonstrated a non-significant main effect for 158

Group (Intervention, Control) (p = .132); however there was a significant main effect for Time 159

(Pre, Post), F(1, 94) = 12.48, p = .001, η2g = .04 and a significant interaction (Group x Time), 160

F(1, 94) = 4.32, p = .040, η2g = .01. Simple effects revealed a decrease in the CRT: Distractibility 161

for control from pre (3.19) to post (2.46) and the intervention group’s metric value decreased 162

from pre (5.33) to post (2.52) (See Table 2). 163

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4. Vertical Saccades (VS): Saccadic Recovery (mm) 165

The ANOVA results for VS: Saccadic Recovery demonstrated a non-significant main effect 166

for Group (Intervention, Control) (p = .129) and non-significant main effect for Time (Pre, Post), 167

(p = 0.472); however there was a significant interaction (Group x Time), F(1, 90) = 5.12, p = 168

.026, η2g = .01. Simple effects revealed an increase in VS: Saccadic Recovery for control from 169

pre (1.58) to post (1.74); however, the intervention group’s metric value reduced from pre (2.09) 170

to post (1.79) (See Table 2). 171


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5. Horizontal Saccades (HS): Saccadic Recovery (mm) 173

The ANOVA results for HS: Saccadic Recovery demonstrated a non-significant main effect 174

for Group (Intervention, Control) (p = .676) and non-significant main effect for Time (Pre, Post), 175

(p = 0.175); however there was a significant interaction (Group x Time), F(1, 90) = 4.05, p = 176

.047, η2g = .01. Simple effects revealed an increase in HS: Saccadic Recovery for control from 177

pre (1.65) to post (2.02); however, the intervention group’s metric value reduced from pre (1.80) 178

to post (1.73) (See Table 2). 179

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6. Horizontal Smooth Pursuit (HSP): Pathway Length Difference (mm) 181


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The ANOVA results for HSP: Pathway Length Difference demonstrated a non-significant 182

main effect for Group (Intervention, Control) (p = .423) and non-significant main effect for Time 183

(Pre, Post), (p = 0.202); however there was a significant interaction (Group x Time), F(1, 90) = 184

5.17, p = .025, η2g = .02. Simple effects revealed an increase in HSP: Pathway Length Difference 185

for control from pre (2.89) to post (3.37); however, the intervention group’s metric value reduced 186

from pre (2.87) to post (1.69) (See Table 2). 187

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7. Circular Smooth Pursuit (CSP): Predictive Smooth Pursuit (%) 189

The ANOVA results for CSP: Predictive Smooth Pursuit demonstrated a non-significant 190

main effect for Group (Intervention, Control) (p = .865); however there was a significant main 191

effect for Time (Pre, Post), F(1, 94) = 5.65, p = .019, η2g = .01 and a significant interaction 192

(Group x Time), F(1, 94) = 7.30, p = .008, η2g = .02. Simple effects revealed an increase in the 193

CSP: Predictive Smooth Pursuit for control from pre (8.65) to post (8.87); however, the 194

intervention group’s metric value reduced from pre (10.29) to post (6.80) (See Table 2). 195


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Table 2 shows the mean test metric values for Intervention and Control groups, over pre 197

and post assessments. The test metric values have directional aspect of improvement; meaning, 198

for some metrics, a lower value is a better indicator of Oculomotor health and for some, a higher 199

value is better. 200

Test metrics where a lower value is better are: 201

a. CRT: Distractibility (#) 202

b. VS: Saccadic Recovery (mm) 203

c. HS: Saccadic Recovery (mm) 204

d. HSP: Pathway Length Difference (mm) 205

e. CSP: Predictive Smooth Pursuit (%) 206

Test metrics where a higher value is better are: 207

a. Functional Vision EyeQ Score 208

b. DRT: Response Accuracy (%) 209

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Table 2 213

Metric values for pre and post assessments in Intervention group and Control group. 214

Variable Control

Intervention

Pre Post Pre Post

(Mean ± SD) (Mean ± SD) (Mean ± SD) (Mean ± SD)

Functional Vision EyeQ Score 57.06 ± 18.96 56.38 ± 22.14

54.50 ± 17.30 63.65 ± 20.90

DRT: Response Accuracy (%) 91.85 ± 12.50 91.65 ± 12.09

79.06 ± 22.57 91.65 ± 13.25

CRT: Distractibility (#) 3.19 ± 4.29 2.46 ± 2.69

5.33 ± 6.46 2.52 ± 2.74

VS: Saccadic Recovery (mm) 1.58 ± 0.65 1.74 ± 0.91

2.09 ± 1.30 1.79 ± 1.08

HS: Saccadic Recovery (mm) 1.65 ± 0.98 2.02 ± 1.24

1.80 ± 0.82 1.73 ± 0.78

HSP: Pathway Length Difference (mm) 2.89 ± 9.96 3.37 ± 9.90

2.87 ± 10.56 1.69 ± 5.67

CSP: Predictive Smooth Pursuit (%) 8.65 ± 5.72 8.87 ± 6.53 10.29 ± 8.66 6.80 ± 6.72

SD: Standard Deviation, Pre: Pre-Assessment metric value, Post: Post-Assessment metric value 215

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