C L I N I C A L A N D E X P E R I M E N T A L

Acuity predictions from VEP Heravian, Douthwaite and Jenkins

OPTOMETRY

Acuity predictions from visually evoked

potential to checkerboard pattern reversal
stimuli: the effect of reversal rate

Shandiz J Heravian* MSc PhD
WA Douthwaite† MSc PhD FCOptom
DCLP
TCA Jenkins† MSc PhD FCOptom DCLP
*Department of Optometry, Mashhad
University of Medical Sciences
†
Department of Optometry, University
of Bradford
Accepted for publication: 19 October
1999
Introduction: A pattern reversal stimulus (check size 5.5 minutes of arc) was used to
elicit the visually evoked potential (VEP).
Methods: The peak to trough amplitude of the VEP wave was measured and compared
to subjective visual acuity (Landolt C). The recordings were made at three, six and 12
pattern reversals per second.
Results: The correlation between VEP amplitude and visual acuity was found to decrease
at higher temporal frequencies. The decrease is not confined to the use of a television
system reversing checkerboard pattern stimulus as suggested by previous workers.
Discussion: It may well be concerned with a change in processing of the visual informa-
tion as could be expected at these higher frequencies.
(Clin Exp Optom 1999; 82: 6: 244–249)

Keyboards: amplitude, reversal rate, visual acuity, visually evoked potential

The visually evoked potential (VEP) has
been used by a number of investigators
for non-invasive assessment of visual acuity
in human infants.1,2 Marg and coworkers,1
Towle and Harter 3 and Skalka 4 used a
target where the detail size was reduced
until a threshold was reached with the
visual signal no longer discernible from
noise. One of the problems with this
approach is that including targets which
produce noisy signals into a subsequent
regression will alter the slope of that
regression5 -7 and yield different resolu-
tions. Although there are techniques avail-
able for dealing with this problem (for
example, sweep VEP), they require com-
plex data processing. An alternative
approach 1,8,9 is to take supra-threshold
measurements of wave amplitudes at a
fixed checkerboard target size.
Jenkins and colleagues7 discovered that
the predicted acuity derived from a sin-
gle amplitude measurement of the small-
est check size stimulus used in the inves-
tigation (5.5 minutes of arc) was
reasonable. It has been shown previously
that when a small check stimulus of 5.5
minutes of arc is used, there is a signifi-
cant correlation between evoked potential
amplitude and subjective visual acuity in
non-amblyopic subjects. This correlation
decreases when checks of increasing size
are used.7 However, such measurements
have the benefit of needing only a single
observation, making them clinically fast
and easy to achieve.
Amplitude measurements have been
questioned in the past due to variability
on successive measurement, although
generally these criticisms have been lev-
elled at work that used check sizes three
or four times larger than the 5.5 minutes
of arc check used above. Shors and col-
leagues 10 suggested that the run-to-run
variability can be minimised by averaging
over a number of runs. Repeatability of
the VEP amplitude and subjective acuity
has been studied by Douthwaite and col-
leagues. 11 They found a better repea-
tability at slow pattern reversal rates. In a
further study, Douthwaite and Jenkins12
used the two check sizes of 5.5 and 40
minutes of arc and suggested that a single
run of 65 sweeps produced a representa-
tive amplitude for a 40 minutes of arc
check, whereas the 5.5 minutes of arc
check required more runs to be averaged
before the amplitude was stable. Jenkins
and colleagues7 noted that the correlation
between visual acuity and VEP wave
amplitude decreased as the check size was
increased. This latter point must cast
doubt on any approach that uses the VEP

Clinical and Experimental Optometry 82.6 November–December 1999

244
 Acuity predictions from VEP Heravian, Douthwaite and Jenkins

METHODS

Visual acuity assessment

Landolt Cs were used to measure the sub-
ject’s visual acuity.7 A walk-back technique
was employed. The Landolt Cs were pre-
sented in a rectangular matt white field,
of size 14 by 10 degrees. Each Landolt C
test card consisted of one row of 10 Cs with
each C separated by a space one C wide.
The direction of the gap was confined to
the four cardinal positions. The back-
Figure 1. A typical set of three VEP recordings made from an ground luminance of the test card, and
individual subjects showing P1and N2 for the waves analysed the screen in which it was held, was
in this study. A is the three reversals per second wave, B is the 258 cd/m 2. The mean contrast of the
six reversals per second wave, C is the 12 reversals per second Landolt C targets was 85 per cent (where
wave. The waves have been displaced vertically for clarity. Note contrast = L max - L min/L max + L min).
the isolated (transient) waveform in A and the steady state Subjects were required to estimate their
waveform in C. own threshold for a trial test card by ad-
justing the target-to-eye distance until they
felt they were at the limit of their acuity.
The measuring procedure then started
under forced-choice conditions, although
no limit to time was given. The distance
response to large check sizes (generated and 12 reversals per second) found a good of the subject was increased (in steps,
by visual cells eccentric to the fovea) to correlation between the P1N2 amplitude which produced five seconds of arc
estimate visual acuity. Thus, any regression and visual acuity at three and six reversals changes in the gap size of the Cs) in a
technique using supra-threshold measure- per second, but a lower correlation at 12 bracketing method until they failed to call
ments that involves large checks for the reversals per second. the pass criterion of eight correct out of a
purpose of predicting visual acuity via a Lovasik and Ahmedbhai 14 described row of 10 Cs. The test card was changed
regression line or curve and an intercept VEP artefacts arising from the mean at each viewing distance. In this fashion,
is questionable. screen luminance variations with time the resolution threshold was determined
The optimal temporal characteristics of which occurred with their television stimu- and was considered to be equal to the
the VEP stimulus used for acuity assays lus. On such a screen, the check reversal angular subtense of the gap in the small-
have received comparatively little atten- does not occur at the same time in all parts est C that produced a pass.
tion. Regan13 reviewed studies by inde- of the screen as it takes a finite time for
pendent workers which suggested that each frame to be presented. We wanted The VEP measurement
spatial selectivity in infants may be con- to determine if the decrease in correla- The VEP stimulus was a black and white
founded with temporal selectivity. His own tion with the fast reversal rate found by pattern reversal checkerboard produced
work 13 suggests that infants as old as Douthwaite and colleagues11 using a mov- by a moving mirror back projection system
four to six years possess pattern-evoked ing mirror stimulus, which reverses all the (Digitimer Model No 112) with a mean
responses tuned to temporal frequencies checks simultaneously, might resolve the screen luminance of 130 cd/m2 and a con-
well outside the adult range. Sokol2 sup- uncertainty. Hence, the purpose of this trast of 80 per cent. A single check size of
ported the notion that the temporal char- study was to determine the relationship 5.5 minutes of arc was used over an 8° x 7°
acteristics of the visual system of infants between visual acuity and VEP amplitude field at a working distance of 2.19 m. The
must be considered when investigating its for a 5.5 minutes of arc checkerboard tar- small 5.5 minutes of arc check encourages
spatial properties. The latencies of the get at three temporal frequencies. We also a response mainly from the central five
infant waves were found to be longer than considered it necessary to repeat the degrees of the visual field.7 The evoked
those of the adult but decrease with the Douthwaite and colleagues11 experiment potential was recorded on a Digitimer
passage of time and reach adult levels in order to establish whether their results D200 averager and signal analyser with the
around the age of six years. Douthwaite could only be applied to the television analysis time of 300 ms. The band pass fil-
and colleagues11 using a 5.5 minutes of arc stimulus or if the results apply equally well ters were set at 0.16 Hz and 300 Hz with a
check and three reversal rates (three, six to a moving mirror stimulus. sensitivity of 100 mv per volt. The active

Clinical and Experimental Optometry 82.6 November–December 1999

245
Acuity predictions from VEP Heravian, Douthwaite and Jenkins
electrode was positioned 2.5 cm above the
inion on the midline and referenced to
the centre of the forehead with a ground
electrode on the right of the forehead. An
interelectrode impedance of five Kohm,
or less, was acceptable.
At the start of recording, the subject was
instructed to fixate the centre of the field
and to concentrate on keeping the pat-
tern clear. All the recordings were mo-
nocular, and the eye not being investi-
gated was covered by a white septum which
gave a homogenous field to the occluded
eye, and that adapted it to approximately
the same light level as the eye under test.
The occluder was placed as close to the
eye as possible. All subjects were volun-
teers who were fully informed of the
nature of the experiments. The pattern
reversal alternation rates used were three,
six and 12 reversals per second (1.5, 3, 6
Hz). The extreme values were chosen to
give a definite transient and a definite
steady-state VEP response, with the inter-
mediate temporal frequency lying in the
boundary region between the other two.
Three runs of approximately 85 sweeps
were recorded to give a 256 sweep result.
The pattern reversal rate was changed at
this point and the procedure was re-
peated. The three, six and 12 reversal rates
examined in this work were selected in a
random sequence.
The peak-to-trough amplitude (P1N2)
with the peak and trough latencies (P1
and N2) were measured for the 256 sweep
waves. The P1N2 amplitudes were used in
this experiment because the negative
trough has been observed to be sensitive
to contour density (detail size) and im-
age clarity when using small checks.15,16
This trough has a latency of around 150
msec under these recording conditions.
SUBJECTS
Thirty-three subjects were recruited; their
ages ranged from 19 to 38 years (median,
23 years). The right eye from each sub-
ject was used, after a precise refraction,
with the refractive correction worn
throughout. The visual acuity range for the
group was from 6/3 to 6/9 (Landolt C),
which was restricted to acuity levels likely
Clinical and Experimental Optometry 82.6 November–December 1999
to generate a VEP wave from a 5.5 minute
check stimulus. However, many of the sub-
jects who took part in the experiment had
acuities of 6/6 or better and to allow a
better approximation of the regression,
blurring lenses, +0.25 to +0.75 dioptre
were used to obtain a spread of acuities.
The acuities at the lower end of the range
arose from subjects with a defocusing lens
before the right eye only. Defocusing was
achieved with spherical convex lenses
placed in the trail frame and the lenses
were worn throughout the procedure
described below. The lenses were carefully
centred to avoid induced prismatic effects.
RESULTS
Figure 1 illustrates a typical set of results
from an individual subject with peak and
trough of interest labelled to indicate
where the measurements were made. The
VEP wave generally consisted of a nega-
tive trough N1 (peak latency around 88 ms),
followed by the positive peak P1 (122 ms),
followed by a negative trough N2 (172 ms).
Figure 1 waveform A shows the VEP re-
cording obtained with three reversals per
second. Figure 1 waveform B obtained at
six reversals per second and Figure 1 wave-
form C is the 12 reversals per second wave-
form. The waveforms have been displaced
vertically for clarity. Note the steady-state
C waveform in Figure 1.
Figure 2, Figure 3 and Figure 4 show
the scatter plots for peak-to-trough ampli-
tudes against Landolt C acuities. The cor-
relation coefficient for the three revers-
als per second rate was r = -0.56 (p < 0.001)
and the intercept on the X axis was 133
seconds of arc, which is equivalent to
6/13.3, the 95 per cent confidence limits
for the slope -0.76 < r < -0.27. For the six
reversals per second rate the correlation
coefficient was r = -0.40 (p < 0.01) with an
intercept on the X axis of 158 seconds of
arc equivalent to 6/15.8. The 95 per cent
confidence limits for this slope were -0.66
< r < -0.07. The correlation coefficient
for the 12 reversals per second rate was
r = -0.32 (p < 0.5) with an intercept on
the X axis of 206 seconds of arc equiva-
lent to 6/20.6. The 95 per cent confidence
limits for this slope were -0.60 < r < 0.02.
246
Table 1 shows the mean and standard
deviations of resolution (seconds of arc)
and peak to trough amplitudes and the
peak and trough latencies for all subjects
for three, six and 12 reversals per second.
From this table, it can be seen that the
mean amplitude for the three reversal rate
is 5.32 mv and that for the six reversal rate
it is 5.06 mv. The 12 reversal rate has a
mean amplitude of 4.25 mv which indi-
cates a reduction in amplitude at this re-
versal rate (see Figure 1 waveform C). The
absence of values for the latencies at 12
reversals per second is due to the fact that
the response at this temporal frequency
is a steady-state response and in these con-
ditions the temporal measurements made
on the waves are those of a phase angle.
When considering the complete set of
results there seemed to be a wide range
of amplitudes produced for any single
acuity level. This variation in amplitude
is due to a number of factors such as
fatigue and concentration and will be
discussed later.
It was sometimes difficult to find the
exact positions of peak-to-trough ampli-
tude for each wave, as some waves had very
small signal/noise ratios. The smallest
amplitude obtained for the 12 reversal
rate was 1.05 mv and was more likely to
be noise rather than a visual response. As
the high frequency signals contain the
smallest amplitudes, these can be ex-
pected to provide the least reliable
estimates for acuity as is evident by the
large spread in their confidence limits.
The measured peak-to-trough latencies
showed no significant correlation with
subjective visual acuity for all three
reversal rates.
DISCUSSION
The technique described in this paper
represents a rapid and convenient method
for predicting the corrected visual acuity
in an eye capable of near normal resolu-
tion. It should provide a useful and easy
screening tool for amblyopia or for the
measurement of potential acuity.
This work supports the findings of
Jenkins and colleagues7 that the peak-to-
trough amplitude measurement from a
 Acuity predictions from VEP Heravian, Douthwaite and Jenkins

Figure 2. The scatter plot of peak to trough amplitude
(P1N2) against visual acuity at three reversals per second
for 33 subjects. A linear regression gives Y = -0.7 X + 9.32,
where Y is the amplitude in mv and X is the resolution in
sec arc with r = -0.56.
Figure 3. The scatter plot of peak to trough amplitude (P1N2) against
visual acuity at six reversals per second for 33 subjects. The equation of
the regression line is Y = -0.05 X + 8.03, where Y is the amplitude in mv
and X is the resolution in sec arc, r = -0.40.

Figure 4. The scatter plot of peak to trough amplitude (P1N2) against visual
acuity at 12 reversals per second for 33 subjects. The equation of the regression
line is Y = -0.03 X + 6.25, where Y is the amplitude in mv and X is the resolution
in sec arc, r = -0.32.

Reversals Spatial acuity Standard Mean peak Standard Mean latency Standard Mean latency Standard
(per sec ) (sec arc ) deviation to trough deviation of positive deviation of negative deviation
amplitude (mv) peak (m sec) trough (m sec)
3 60.15 ±19 5.32 ± 2.25 122.5 ± 16 177.4 ± 18
6 5.06 ± 2.2 113.5 ± 14 175.4 ± 19
12 4.25 ± 2.0

Table 1. Mean and standard deviation of spatial resolution and VEP peak to trough amplitude (P1N2) and the peak and trough latency
for the 33 subjects at the three reversal rates

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Acuity predictions from VEP Heravian, Douthwaite and Jenkins
5.5 minute check can be used as an indi-
cator of subjective visual acuity for peo-
ple with acuities within the range 6/3 to
6/9 (Landolt C). However, the results of
the experiment suggest that there was a
lower correlation between the VEP wave
amplitude and subjective visual acuity
(r = - 0.56) for all three reversal rates com-
pared to previous work.11 Douthwaite and
coworkers11 found much higher correla-
tions of r = - 0.81 for three and six reversal
rates with a lower correlation of r = - 0.54
for the 12 reversal rates. Nevertheless, the
same relation between the reversal rate
and the acuity in the two studies still holds
true.
Douthwaite and coworkers11 and oth-
ers17 suggested that the lower correlation
to the faster reversal rate might be due to
artefacts produced by the television screen
such as unequal luminance, unequal
number of black and white checks, distor-
tion at the edge of the television screen
and different phases at the top and bot-
tom of the screen.17 However, the present
study used a moving mirror back projec-
tion system to eliminate the artefacts pro-
duced by a television system. Despite using
this equipment, there was still a reduction
in correlation for the 12 reversals per sec-
ond stimulus. Therefore, it may be that
this reduction in correlation is concerned
with factors other than the stimulus limi-
tations in the earlier experiments. Towle
and Harter 3 acquired a correlation coeffi-
cient of r = -0.86 when comparing their
VEP acuity prediction with subjective
visual acuity. Weiner and colleagues 18
found a value of r = -0.98 for the same
relation. However, in both cases a wider
spread of visual acuities was used and this
will inevitably improve the correlation
coefficient where a linear relationship is
present.
There are physiological reasons, which
may be responsible for the loss of correla-
tion with fast reversal rates. Kulikowski
and Tolhurst19 proposed the concept of
sustained and transient processing by the
visual system, in which spatial patterns are
considered to be processed by sustained
channels whereas the transient channels
process movement. Watson and Robson20
have argued that the high temporal fre-
Clinical and Experimental Optometry 82.6 November–December 1999
quency mechanisms provide information
only about motion or temporal change.
Their experimental work demonstrated
that although these high temporal fre-
quency detectors can also relay spatial in-
formation, it was much poorer at spatial
discrimination than was the low temporal
frequency system. This finding is consist-
ent with proposals that temporal modula-
tion is served by at least two distinct sets
of mechanisms. It is likely that the VEP
waveforms obtained in this study at the
slow flicker rates (three reversals per
second) reflect the high acuity sustained
channels described above.
Although there is some dispute about
the precise mechanism involved, it is con-
ceivable that the poor correlation at the
12 reversals per second rate may be due
to a significant contribution from the tran-
sient system, which is less effective at the
slower reversal rate. Stromeyer and
coworkers21 suggested that there is a shift
from form to movement mechanisms
when the reversal rate is increased from
5.4 reversals per second to 16 reversals per
second and this is evident in experiments
reported by Panish and colleagues.22 They
showed that there is a dissociation in the
processing of spatial and temporal detail
as reversal rate increases. Thompson 23
proposed that a change occurs in the
dominance of these two independent
channels and that this change becomes
manifest at eight reversals per second.
Thus, the reduction in the correlation
coefficient between slow and fast reversal
rates in the present work is in agreement
with the psychophysical evidence.
However, although this cause will apply
to all studies, the correlations obtained for
this study (r = -0.56) were considerably
lower than those (r = -0.81) obtained by
Douthwaite and colleagues.11 The reason
for this could be due to the fact that the
previous work used subjects with natural
acuities ranging from 6/2.5 to 6/8.5,
whereas some of the subjects in this
experiment were artificially blurred to
obtain a range of acuities from 6/3 to 6/9.
According to Jenkins and coworkers7 the
use of a blurring lens means that the in-
vestigation is concerned with the relation-
ship between the VEP and blur and is not
248
a true assay of the acuity effect. They sug-
gest that it may be unwise to infer that this
situation provides any useful information
for the prediction of corrected visual acu-
ity where the optical image may be formed
clearly on the retina of a visual system that
has reduced resolving ability. Obviously,
such a relationship will only apply if the
cause of acuity loss is optical in nature.
Studies show that VEP amplitudes de-
crease in an orderly fashion as retinal blur
increases up to three dioptres where a dif-
ferent relationship exists.15,24,25 Waveforms
can still be detected in the presence of
large amounts of blur and these are due
to the flicker component of the reversing
pattern. However, the amount of blurring
used in this experiment ranged from
+0.25 to +0.75 D and this is unlikely to
alter amplitude significantly. Thus, the
subjects in the experiment described
above are mixed in the sense that some
use blurring lenses representing optical
defocus but others do not, and this would
have reduced the true correlation coeffi-
cient, consistent with our finding. It is also
possible that a number of other factors will
have affected the results. These include
noise, attention, accommodation, eye
movements, artefacts, electrode place-
ment and trend (an increase or decrease
in amplitude with repeated measure-
ments).26 Variability in amplitude between
runs on the same occasion has been
studied by Fagan and colleagues 26 They
concluded that the major contribution to
amplitude variability arises from noise,
with sequential (trend) effects also mak-
ing a significant contribution. Weiner and
coworkers18 found that the amplitude and
threshold of the wave can be altered by
fatigue. The effect of this factor on our
readings has not been established.
CONCLUSION
It has been found that the amplitude of a
VEP waveform elicited by a 5.5 minutes
of arc check at three reversals per second
correlates with the subjective visual acuity
of people with relatively good spatial reso-
lution and is consistent with the findings
of others.1,7,11 This correlation decreases
at higher temporal frequencies and this

decrease is not confined to the use of a
television system reversing checkerboard
pattern stimulus. It may be due to a
change in the processing of the visual in-
formation known to occur at these higher
temporal frequencies. We propose that
such a technique can be used as a first
estimate of potential acuity in normal
observers. As a consequence, it would pro-
vide a useful screening test for amblyopia.
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Author’s address:
Dr J Heravian Shandiz
Department of Optometry
Pirapezeshki Faculty
Mashhad University of Medical Sciences
Ahmadabad St
Parastar Ave
Mashhad
IRAN
249