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Review Article

Refractive errors and their effects on visual evoked potentials

Ruchi Kothari, Pradeep Bokariya1, Smita Singh2, Purvasha Narang2, Ramji Singh3

In view of the increasing use of visual evoked potentials (VEP) technique in neuro-ophthalmological diagnosis, it was Access this article online
thought pertinent to appraise the changes brought about in VEPs in the presence of refractive error (RE) as studied by Website:
the vision researchers and neurophysiologists. The purpose of this review was to provide a comprehensive quintessence www.jcor.in
of the work carried out in this field with an attempt to summarize the previous concepts, recent perspective and current DOI:
notion about the value of RE in electrophysiologic testing particularly the VEP technique. 10.4103/2320-3897.122625
Quick Response Code:
Key words: Defocus, refractive errors, visual evoked potential

Visually evoked cortical response testing has been one of the
most exciting clinical tools to be developed from neurophysiologic
research and has provided us with an objective method of
identifying abnormalities of the afferent visual pathways.
Visual evoked potentials (VEPs) reflect electrical phenomena
occurring during the visual processing and are a graphic
illustration of the cerebral electrical potentials generated by the
occipital cortex evoked by a defined visual stimulus.[1] Therefore,
VEPs can be used both in research and in clinical practice to
elucidate the function of the visual system.
It is known that the technical and physiological factors such
as pupil diameter, refractive errors (REs), type of stimulus, age
and sex, electrode position and anatomical variations may affect
VEP.[2] It is assumed that RE cause defocus. Defocusing may affect
the VEP, which if allowed to persist, can result in corresponding
neurological changes.
It was perceived that there was no clear cut presumption
with regards to how actually does the RE alters the visually
evoked response of the brain, whether the VEPs are more
affected by myopia or hypermetropia and to what extent the
degree of RE would affect the VEPs. Therefore, we made an
attempt to review the various aspects related to the effects
of RE on VEPs.
Beginning with background reading about the topic, we
traced the specific resources, extensively searched the literature,
analyzed the shortcomings and strengths of various workers,
tabulated their methodologies and findings in chronological
manner and tried to derive at an inference incorporating the
Departments of Physiology, 1Anatomy, and 2Ophthalmology, MGIMS,
Sevagram, Wardha, Maharashtra, 3Department of Physiology, AIIMS,
Patna, Bihar, India
Address for correspondence: Dr. Ruchi Kothari, Department of
Physiology, MGIMS, Sevagram, Wardha - 442 102, Maharashtra,
India. E-mail: prachi1810@yahoo.com
Manuscript received: 15.05.2013; Revision accepted: 25.06.2013
previous, recent and finally our own perspective regarding the
relationship of VEPs with REs.
Multiple database searches using MedLine, Google scholar,
EMBASE and PubMed were conducted to identify all the previous
as well as the recent studies and publications pertinent to this
issue. All identified documents were examined and those that
were relevant were retrieved for inclusion in the review. The
relevant reports were skimmed, retrieved; compiled and important
conclusions from the studies were laid down in proper chronology.
The methodologies and findings of various authors were tabulated
for a quick glance and to make easy comparisons between them.
Reference lists of retrieved documents were hand searched to
identify the additional publications. Then a critical analysis of the
relationship among different works was performed and finally
this research was coupled to our own work.
Perception Decades Ago
Minute neural discharges that occur in visual cortex upon brief
exposure of the eye to patterned stimuli after monitoring by
topical scalp electrodes, amplification and summation produce
characteristic waveform that exhibits a relationship to retinal
image clarity. A systematic relationship was first established long
back.[3] They observed that the amplitude for both a negative
wave appearing at 80-100 ms after a flash of patterned target and
a positive wave following this flash by 180-200 ms was greater
with retinal image clarity and lessened with its degradation over
a wide range of dioptic values.
The amplitude of the response in a pattern reversal VEP is
dependent on the visual systems ability to resolve the pattern
and on the degree of retinal image focus. Small errors of refraction
tend to reduce the average amplitude of the waves of VEPs. A
quantified documentation was provided[4] who found the VEP
amplitude to be decreased 25% per diopter (D) of defocus and
the effect was appreciable for 0.25 D. They employed a rotating
polaroid in conjunction with a checker pattern made of polaroid
strips, in which the intensity for each neighboring check varied
sinusoidally in time. The overall intensity of light transmitted

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Kothari, et al.: Refractive errors and VEP
through the pattern therefore remained constant. The subjects
eye was situated 85 cm from the plane of the pattern.
The VEP is more sensitive to small refractive changes than
electroretinogram (ERG), perhaps because the VEP heavily
emphasizes the foveal region while the ERG is more broadly
representative of the entire stimulus field.
Considerable attention was given in the past to the use
of checkerboard-pattern stimuli in the study of the VEPs
in subjects as a technique for determining REs. Duffy and
Rengstorff.[5] electronically subtracted the response to light
from the response to pattern plus light that yielded a residual
contour response. Working at a 20 feet refraction distance,
they performed an initial scan over a wide range of spherical
lens values with large increments on relatively large checker
squares, 10 min of arc. They finalized the spherical lens
measurement by use of small lens increments on a finer checker
square pattern (2.5). They claimed precision of spherical
refraction of 0.25 D. The value determined was found to be
more myopic or less hyperopic than that established by the
conventional refractive techniques.
Reduction in amplitude of the VEP with RE was also reported.[6]
They showed that there is consistently greater reduction in VEP
amplitude for small amounts of plus lens defocus than for minus
and it showed that subjects partially accommodated for minus
lens. They found that decrease in amplitude in non-cycloplegic
refraction measurements seem to occur more rapidly for plus lens
than for minus and it is thought to be due to the partial correction
of defocus brought about by accommodative effort of the subject.
The REs blur the stimulus and blurred vision also has been
shown to decrease the amplitude of the conventional pattern
reversal VEP.[7] Large REs, introduced by the use of ophthalmic
lenses, cause the waves to approach zero amplitude. Collins et al.[8]
studied the effect of introduced REs on the VEP on five women
and eight men aged 19-45 years.
REs were created by introducing the following combined
standard lenses: (+2.00 DS + 2.00 DC 90), (+1.00 DS + 1.00
DC 90), (1.00 DS 1.00 DC 90) and (2.00 DS 2.00 DC stimulation of receptors in the central retina, but the same effect
90) diopters. Using 3 radius field stimulation and 12-min checks,
monocular pattern-reversal VEPs were recorded without and then
with each introduced RE by a computer-based data collection
system and compared with previously established normal values.
There was a pronounced effect on the P100 component of the VEP
with these introduced REs.
The P100 latency was abnormally prolonged in 31% (5/16) of
recordings with the (2.00 DS 2.00 DC 90) diopter lens and
in 87.5% (14/16) with the (+2.00 DS + 2.00 DC 90) diopter
lens. The maximum P100 latency was 126 ms. For all other
recordings, the P100 latency was less than 113 ms, but there was
considerable temporal dispersion and reduction in amplitude of
the P100 component, especially for the convex lenses. Indeed,
the VEP was almost abolished in some of the recordings when a
(+2.00 DS + 2.00 DC 90) diopter lens was used. Their study,
using the pattern-reversal method, illustrated the significant
changes in absolute and relative latency of the P100 component
when Res, which approximated to those found in the population
4 Journal of Clinical Ophthalmology and Research - Jan-Apr 2014 - Volume 2 - Issue 1
at large, were introduced to defocus a small stimulus field and
high spatial frequency pattern. This effect was seen to be greatest
for REs of + 2.00 DS + 2.00 DC 90 diopters.
Pattern defocusing has been used to evaluate the contribution
of different spatial frequency components in checks to VEP
latency. Latency shifts with increasing blur (2.50 to +2.50)
were determined[9] for sinusoidal grating and check patterns.
The effect of blur was found to be more for the higher spatial
frequencies. Zislina et al.[10] in their studies with congenital
myopia have shown significant deviations from reference of
component P100.
REs were induced[11] in normal subjects by means of positive
D lenses to reduce visual acuity (VA) from an initial level of 20/20
to 20/100 and then to 20/200. Pattern visual evoked potentials
(PVEPs) were recorded at each of these three levels of VA using
high contrast checkerboard stimuli subtending 11 and 42
of visual arc. Their findings confirmed the need to take REs
into account because latencies fell outside normal limits with
decreased VA.
Reduction of VA or of the contrast of the stimulus induces
a prolongation of the pattern reversal visual evoked potential
(PR-VEP) latencies, perhaps because these conditions cause
deterioration of the visual capacity to recognize objects and
may preferentially activate the slower central retina channel.
The PR-VEP was obtained[12] with a video stimulator and three
kinds of stimuli: Total video field, video with a central scotoma
and a restricted central stimulus. The subjects were tested under
conditions of normal (20/20) and reduced VA (20/200) with 14 and
56 checks and 60% contrast and under conditions of normal VA
(20/20) with 14 checks and with stimulus contrast of 60% and
25%. Blurring increased latencies and decreased amplitudes only
with the 14 checks stimulus but not with 56 checks and the
amplitudes obtained with the central stimulus became greater
than those obtained with a central scotoma. Reducing contrast
increased only latency and there was no difference between
amplitudes obtained with a central stimulus or a central scotoma.
They deduced that blurring small checks induces a preferential
was not observed when stimulus contrast was reduced. Thus,
prolongation of latency and decreased amplitude with a reduction
in VA was established in their study.
Recent Perspective
In their study, Perlman et al.[13] investigated the correlation
between reduced VA and VEP in volunteers with normal corrected
VA and in patients suffering from inherited macular degeneration
or from age related macular degeneration. In both groups of
patients suffering from macular dysfunction, pattern reversal
VEP was very subnormal and was characterized by prolonged
implicit time. These findings indicated that the PVEP directly
correlates with foveal function. Therefore, they suggested that
recordings of PVEP can be used to differentiate between RE and
macular disorders as causing reduction in VA when other clinical
signs are missing or not available.
Lee et al.[14] tried to evaluate the P100 latency of VEP according
to refraction. They studied 28 patients (12 males, 16 females) with
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Kothari, et al.: Refractive errors and VEP
myopia. Subjects were divided into three groups (mild, moderate,
severe myopia) according to refraction and they evaluated the
results of VEP studies. The Mean values of refraction and latency
(P100) of naked eyes were 4.27 DS, 103.95 ms and those of
corrected eyes (in glasses) were 0.25 DS, 100.59 ms. Respectively,
in mild, moderate, and severe myopia, the P100 latency of naked
eyes were 101.27 ms, 102.59 ms, 107.99 ms and those of corrected
eyes were 98.33 ms, 100.58 ms, 102.19 ms respectively (P < 0.05).
There was significant negative correlation between refraction and
P100 latency in myopia.
Marr et al.[15] undertook a retrospective case review and
recruited 112 children with age less than 10 years presenting
over 3 years who were found to have high myopia (defined as
one or both eyes demonstrating six diopters spherical equivalent
or more of myopic RE on retinoscopy). They concluded that
high myopia in early childhood is strongly associated with
systemic and ocular problems. In 54%, there was an underlying
systemic association with or without further ocular problems
(e.g., developmental delay, pre-maturity, Marfan, Stickler,
Noonan, Down syndrome) and in the remaining 38% there were
further ocular problems associated with the high myopia (e.g.,
lens subluxation, coloboma, retinal dystrophy, anisometropic
amblyopia).
Marr et al.[16] reviewed 114 consecutive children under 10 years
of age with high hypermetropia (greater than + 5.00 DS) during
a 5-year period and reported that high hyperopia has a similar
incidence of associated ocular abnormalities as high myopia.
To understand how REs affect multifocal visual evoked
potential (mfVEP) responses, monocular mfVEP responses were
obtained using a pattern reversal dartboard display.[17] The
right eye was tested under simulated RE. For the simulated
RE condition, significant centrally located abnormalities
were seen for all subjects. They concluded that factors such
as uncorrected REs can produce apparent field defects on the
mf VEP.
A very recent study conducted by Anand et al.[18] examined
effects of uncorrected REs in a short-duration transient visual
evoked potential system and investigated their role for objective
measurement of RE. REs were induced by means of trial lenses
in 35 emmetropic subjects. A synchronized single-channel
electro encephalogram was recorded for emmetropia and each
simulated refractive state to generate 21 VEP responses for
each subject. P100 amplitude (N75 trough to P100 peak) and
latency were identified by an automated post-signal processing
algorithm. They construed that induced hypermetropia and
myopia correlated strongly with both P100 amplitude and
latency.
Most of these studies have been reported in western
populations and no such comparative study is available in
Indian population. Since, there are differences as regards to
the age of detection, accuracy of correction and regularity of
usage of correcting glasses, a recent study[19] was conducted to
estimate the effect of RE on VEP recordings in Indian population.
To test the hypothesis that the changes in VEP due to REs
in Indian population are different from western population,
pattern reversal VEP recordings were performed in a total of
Journal of Clinical Ophthalmology and Research - Jan-Apr 2014 - Volume 2 - Issue 1
50 hypermetropics and 50 myopics having age in the range of
18-40 years. The subjects having astigmatism (>0.5 DC) and
RE of more than 5 D were excluded in the study. They were
investigated for VEP recordings with and without glasses. Their
results were compared with those of 50 age and sex matched
controls. P100 latency was increased and amplitude decreased
with and without correction of RE. The statistical analysis
revealed a significant difference (P < 0.05) in latency of P100 and
amplitude of P100 between controls and myopics with glasses
and highly significant difference (P < 0.001) between controls
and myopics without glasses; so, VEPs were affected in Indian
subjects with RE irrespective of correction given, but more so
without correction.
The difference in P100 latency and amplitude between controls
and hyperopics with glasses and those without glasses were found
to be non-significant in this study.
A RE develops when there is lack of coordination among the
factors required for the growth of the eye and for the eye to
become emmetropic like changes in refractive components and
in eye size. A myopic eye is generally larger than emmetropic
or hyperopic eyes and changes in scleral tissue may be the
factor when emmetropization does not occur. Animal studies
have shown that poor image quality on the retina can elicit a
signal to sclera tissue components to strengthen or weaken
in an attempt to move the retina to the best location for a
clear image.
Scleral remodeling causes axial lengthening that occurs in
myopia; the scleral tissue is weakened and thins. In progressive
myopia existing collagen is degraded, the production of new
collagen is reduced and matrix proteoglycans are lost.[20,21] So in
this way, if we recollect the physiological changes occurring in
the development of myopia, substantial explanation to the above
finding unfurls.
Conclusion
To conclude, the observations of the studies [Table 1] in the past
as well as the recent research in this field suggest that the RE
blur the stimulus and cause defocus, which lead to significant
changes in VEP (P100 latency and amplitude) in the presence
of RE. As per our perspective, among the REs, VEPs seem to be
more affected by myopia than hypermetropia. However, the
principal cause in both is the degree of defocusing of the image
produced by the RE.
Since no clear inference could be drawn with regards to
whether the VEPs seem to be more affected by myopia or
hypermetropia as higher degrees of the REs were excluded; so,
further longitudinal studies on a larger sample of ametropic
population are required to confirm the contributions of the retinal
defocus associated with particular RE to the alterations in pattern
reversal VEPs.
Implication
If pattern stimuli are to be used in VEP investigation, it is
important that a patient be tested with RE corrected. REs tend
to affect the interpretation of the VEP results. Therefore in
performing the VEP study, one should consider the refraction
and VA.
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Kothari, et al.: Refractive errors and VEP

Table 1: Comparative account of the studies on relationship between VEP and refractive error
Researchers Year Methodology Findings
Millodot and Riggs 1970 Rotating polaroid with checker pattern of polaroid strips with 25% in VEP amplitude per diopter of
constant overall intensity of light and individual elements of defocus
pattern show sinusoidal fluctuations of luminance
Ludlam and Meyers 1972 Amplitude for +lens
Collins et al. 1979 Introduced refractive errors 12 min checks Latency
3 degree radius field 31% (5/16) with 2.00 DS 2.00 DC 90
87.5% (14/16) with 2.00 DS 2.00 DC 90
Amplitude for +lens temporal dispersion
Bobak et al. 1987 Sinusoidal gratings Effect for smaller checks
Checks with sing blur from 2.5 DS to +2.5 DS
Bartel and Vos 1994 + Lens to visual acuity, checks of 11 and 42 Latency with sing visual acuity
Tumas et al. 1997 20/20 14 60% contrast 5660% contrast Amplitude Latency
20/200 Amplitude Latency
1460% contrast
20/20 ~ Latency
1425% contrast
Winn et al. 2005 Monocular mfVEP responses, using a pattern reversal dartboard For simulated refractive error, centrally
display located abnormalities were found
Anand et al. 2011 Uncorrected refractive errors in a short-duration transient visual Induced hypermetropia and myopia correlated
evoked potential (single channel EEG) strongly with P100 latency and amplitude
Kothari et al. 2013 Pattern reversal VEP using 88 checkerboard display generated P100 latency, amplitude with and
by evoked potential recorder (RMS EMG EP MARK II) without correction of refractive error
VEP: Visual evoked potentials, EEG: Electro encephalogram, mfVEP: Multifocal visual evoked potential,: Prolonged : Reduced

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Cite this article as: Kothari R, Bokariya P, Singh S, Narang P, Singh
R. Refractive errors and their effects on visual evoked potentials. J Clin
Ophthalmol Res 2014;2:3-6.
Source of Support: Nil. Conflict of Interest: No.

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