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

OPTOMETRY
cxo_753 410..420

RESEARCH PAPER

A novel apparatus for interocular interaction evaluation in

children with and without anisometropic amblyopia

Clin Exp Optom 2012; 95: 410–420 DOI:10.1111/j.1444-0938.2012.00753.x

Xin Jie (Angela) Lai*§ PhD MOptom Background: Dichoptic visual stimulation may be achieved using shutter goggles and
Jack Alexander* PhD FAAO mirror systems. These methods vary in their feasibility for use in children. This study
Ming Guang He† MD PhD aims to investigate the feasibility of use of a simple trial frame-based system to evaluate
Zhi Kuan Yang†¶ MD PhD interactions in children.
Catherine Suttle* PhD MCOptom Methods: Low contrast acuity, contrast sensitivity and alignment sensitivity were mea-
* School of Optometry and Vision sured in the non-dominant eye of 10 normally-sighted children, 14 anisometropic
Science, The University of New South children without amblyopia and 14 anisometropic amblyopic children (aged
Wales, Sydney, Australia 5–11 years) using goggles and a trial frame apparatus (TFA). The dominant eye was
†
Zhongshan Ophthalmic Centre, either fully or partially occluded. The difference in visual functions in the non-dominant
Guangzhou, China eye between the full and partial occlusion conditions was termed the ‘interaction index’.
§
Smith-Kettlewell Eye Research Institute, Agreement between the TFA and goggles in terms of visual functions and interactions
San Francisco, CA, USA was assessed in anisometropic children with and without amblyopia using the Bland-
¶
Changsha Aier Eye Hospital, Hunan, Altman method and t-test. Training sessions allowed subjects to become accustomed to
China the systems and tasks. The duration of training, the number of breaks requested by
E-mail: xinjie.lai@gmail.com subjects and their willingness to attend further experiments were recorded in 10 sub-
jects from each group and were compared between groups and between systems.
Results: Both Bland-Altman and t-test methods indicated acceptable agreement between
the TFA and goggles in visual function and interaction measures (p > 0.05), except for
contrast sensitivity measured in anisometropic children without amblyopia (p = 0.042).
For all subject groups, contrast sensitivity training was significantly longer using goggles
than using the TFA (p ⱕ 0.001). Significantly more breaks were requested in acuity and
contrast sensitivity testing, when goggles were used than when the TFA was used (p <
Submitted: 26 March 2011 0.045). Anisometropic children without amblyopia showed a significantly greater willing-
Revised: 8 January 2012 ness to attend more experiments using the TFA than using goggles (p = 0.025).
Accepted for publication: 18 January Conclusion: The TFA may be a useful tool in studies of interactions in amblyopes,
2012 particularly in studies of children’s vision.

Key words: amblyopia, children, contrast sensitivity, vision, visual acuity

Dichoptic visual masking occurs when a
target is presented to one eye and a mask
is presented to the fellow eye. The stimu-
lus and masking configurations may take
various forms, including ‘masking light by
light’, ‘masking a pattern by light’ and
‘masking a pattern by a pattern’.1 The
mask may be presented either coincident
with or adjacent to the stimulus.2–10 In
the normal visual system, the target
and the mask are processed binocularly
and the mask can affect the perception of
the target, resulting in an increment or a
decrement in visual function thresholds of
the tested eye.2,3,8–10 These masking effects

Clinical and Experimental Optometry 95.4 July 2012 © 2012 The Authors
410 Clinical and Experimental Optometry © 2012 Optometrists Association Australia

Figure 1. The trial frame apparatus (TFA), 1.0 mm pinhole, opaque
occluder and the star-shaped occluder used with the TFA. The
star-shaped occluder was made using a +5.00 DS trial lens with four
strips of 5.0 mm wide black masking tape. The opaque occlusion at
the centre of the star-shaped occluder was 13 mm in diameter.
are underpinned by interactions in the
visual system that take place between
signals from the two eyes, known as
interocular interactions. In dichoptic
masking studies, the impact of the
masking stimulus on perception of the test
stimulus is assessed. Comparison between
visual functions measured under dichop-
tic and monocular viewing conditions
allows the nature and the strength of
interocular interactions to be investigated.
Mirror or prism devices and shutter
goggles have been used in dichoptic
masking studies;3,11–13 however, equipment
of this kind may not be feasible for use in
some populations.14 For this reason, a
simple and portable viewing system, a ‘trial
frame apparatus’ (TFA) was designed and
validated in a previous study.14 The TFA
consisted of a trial frame adjusted to
the individual’s interpupillary distance, a
© 2012 The Authors
Clinical and Experimental Optometry © 2012 Optometrists Association Australia
Interocular interaction evaluation in children Lai, Alexander, He, Yang and Suttle
pinhole aperture (1.0 mm in diameter)
placed in front of the tested eye and a
partial occluder placed in front of the
non-tested eye. The occluder was made
using a +5.00 DS trial lens, on which four
strips of 5.0 mm wide opaque black
masking tape were placed to form a
‘star-shaped’ occlusion (Figure 1). Visual
function and interocular interaction mea-
surements made using this method were
found to agree with those made using
shutter goggles in children and adults with
normal vision.14
Amblyopia is often known as ‘lazy eye’.
It refers to a disorder of the visual system
that is characterised by unilateral or
bilateral loss of visual acuity without
pathology.15 Anisometropia, which has a
prevalence of two to six per cent in school
children,16,17 is one of the major causes of
amblyopia. Previous studies indicate that
in humans, about one-third of cases of
amblyopia are caused by anisometropia,
one-third by strabismus and one-third by a
combination of both.18,19 Deprivation due
to conditions such as congenital cataracts
can also lead to amblyopia.20
Numerous studies have demonstrated
that interocular interactions differ be-
tween amblyopic and normal observers.
For example, binocular summation is
reduced or absent in amblyopes.21,22 Hol-
opigian, Blake and Greenwald23 found that
stereoacuity and binocular summation are
absent at high spatial frequencies only,
while Hood and Morrison24 found a higher
level of binocular contrast summation in
amblyopes with binocular single vision
than in normal observers, for both low and
high spatial frequencies. Baker and col-
leagues25 found that binocular contrast
summation is normal in amblyopes when
contrast sensitivity is normalised across the
amblyopic and the fellow eyes. Studies by
Sengpiel and Blakemore26, and Smith and
colleagues27 have demonstrated inhibitory
interaction in animals with amblyopia and
Vedamurthy and colleagues2 found signifi-
cant inhibitory interaction in anisome-
tropic amblyopic adults.2 Most of these
findings suggest that abnormal interac-
tions occur in anisometropic amblyopia.
Studying interactions in anisometropic
amblyopes may provide information on
visual processing in these subjects and the
mechanisms underlying this disorder.
Comparison between interactions in
anisometropes with and without amblyo-
pia may be informative because both
groups have significant differences in
refractive error between eyes but only one
of these groups has developed amblyopia.
The aim of this study is to investigate the
feasibility of use of the TFA as a means of
studying interocular interactions in chil-
dren with and without anisometropic
amblyopia. Specifically, to investigate:
1. Agreement in visual function and
interocular interaction measures
between the TFA and shutter goggles
in anisometropic children with and
without amblyopia and
2. The feasibility of use of the TFA as a
viewing system to evaluate interactions
in children.
Clinical and Experimental Optometry 95.4 July 2012
411
Interocular interaction evaluation in children Lai, Alexander, He, Yang and Suttle

(a) Anisometropic amblyopic children

Subject Sex Age Prescription VA (logMAR) IDVA Stereoacuity
(years) (logMAR) (arcsec)
Right eye Left eye DE NDE

1 M 6.4 plano +3.00 -0.2 0.1 0.3 50

2 M 6.5 +0.25 +6.50/-2.00 ¥ 180 -0.1 0.5 0.6 400
3 M 7.4 +6.25 +7.00 0.1 0.3 0.2 400
4 F 8.3 0/-1.75 ¥ 95 -1.00 0 0.1 0.1 30
5 F 8.4 +2.25/-0.50 ¥ 170 +0.50/-1.00 ¥ 10 -0.2 0.2 0.4 70
6 M 8.4 -4.00/-2.25 ¥ 50 -2.50/-0.50 ¥ 170 0 0.15 0.15 50
7 F 8.5 +0.75/-0.50 ¥ 130 +3.75 0 0.5 0.5 100
8 F 8.6 +4.25/-0.50 ¥ 155 +0.25/-0.50 ¥ 15 -0.1 0.3 0.4 70
9 F 9.1 +4.50/-1.00 ¥ 160 plano -0.1 0.2 0.3 50
10 M 9.2 +0.50 +7.00/-2.00 ¥ 45 -0.2 0.2 0.4 400
11 F 9.3 -4.50/-1.50 ¥ 10 -1.25 -0.2 0.4 0.6 50
12 M 9.5 -3.25/-0.75 ¥ 170 plano 0 0.15 0.15 30
13 M 9.8 -6.00/-1.75 ¥ 40 -4.25/-1.00 ¥ 130 0 0.1 0.1 40
14 M 10.1 +2.50/-2.50 ¥ 180 +4.50/-2.50 ¥ 180 0 1.0 1.0 400

(b) Anisometropic children without amblyopia

Subject Sex Age Prescription VA (logMAR) Stereoacuity
(years) (arcsec)
Right eye Left eye DE NDE

1 M 7.1 -1.75 -1.75/-1.00 ¥ 85 0 0 40

2 F 7.2 0/-3.25 ¥ 175 0/-2.25 ¥ 5 0 0 70
3 F 8.3 -2.50 -2.75/-1.25 ¥ 165 -0.1 -0.1 40
4 M 8.3 -2.25 -1.00 -0.2 -0.2 30
5 F 8.8 -4.75/-0.50 ¥ 180 -3.25/-0.50 ¥ 170 0 0 30
6 F 8.9 -0.25 -1.50 0 0 30
7 M 9.0 -6.50 -4.75/-0.50 ¥ 30 0 0 30
8 F 9.3 -5.00/-1.50 ¥ 35 -6.25/-2.00 ¥ 150 0 0 40
9 F 9.3 +0.50 +1.25/-0.75 ¥ 155 -0.1 -0.1 30
10 F 9.3 +1.00/-1.00 ¥ 165 +2.00/-2.25 ¥ 175 -0.2 -0.2 140
11 F 9.6 -12.50 -10.50 0 0 30
12 F 9.7 -4.50 -4.50/-1.00 ¥ 160 0 0 40
13 F 9.8 +3.00/-0.75 ¥ 180 -1.00/-0.50 ¥ 175 0 0 140
14 M 9.8 -3.75 -2.25/-0.75 ¥ 160 0 0 30

Table 1 Clinical characteristics of anisometropic children with [a] and without [b] amblyopia. VA, visual acuity measured in the
screening program (using a high contrast E chart); DE, dominant eye; NDE, non-dominant eye; IDVA, interocular difference in high
contrast acuity. No monocular suppression or diplopia was reported in any of these subjects (Worth four dot test).

⫾ 1.5 years; seven male, three female), 14
METHODS
anisometropic children without amblyo-
pia (mean age: 8.8 ⫾ 0.8 years; six male,
Subjects eight female) and 14 anisometropic
Subjects were 5–11 years old, including 10 amblyopic children (mean age: 8.8 ⫾
normally sighted children (mean age: 9.2 1.0 years; eight male, six female). These
three subject groups are referred to as
‘controls’, ‘anisometropes’ and ‘ambly-
opes’, respectively. All subjects were
recruited through a school-based screen-
ing program in Huadu, China. Table 1
shows the clinical characteristics of the

Clinical and Experimental Optometry 95.4 July 2012 © 2012 The Authors
412 Clinical and Experimental Optometry © 2012 Optometrists Association Australia

anisometropes and amblyopes. Ethical
approval for the present study was
obtained from the Human Research
Ethics Committee of the University of New
South Wales in Australia and the ethics
committee of the Zhongshan Ophthalmic
Center in China. Written, informed
consent was obtained before recruitment
from parents of all subjects. Assent was
obtained from each subject. This study
adhered to the tenets of the Declaration of
Helsinki.
A series of vision screening tests was
conducted as part of the screening
program, including a clinical acuity test
for distance (a high-contrast E chart at
5 m), cover test for distance and near
(with refractive correction if needed;
correction was prescribed by one of the
authors [XJL] based on both cycloplegic
[1% cyclopentolate] and non-cycloplegic
refractions28,29 and was applied through-
out this study), binocularity (Worth four
dot test at 6 m), stereopsis (Randot stere-
oacuity test at 40 cm), sighting dominance
test30,31 and fundus examination, includ-
ing assessment of central fixation (direct
ophthalmoscopy). No ocular deviation or
eccentric fixation was found in any of the
subjects.
Subjects were included only if they had
no history of ocular trauma and/or ocular
pathology, no systemic disease (by self-
report), no strabismus (based on cover
test), no previous or current treatment of
anisometropia and/or amblyopia (refrac-
tive correction or occlusion), no eccentric
fixation and they met the following
criteria:
CONTROLS
1. Uncorrected vision of 0.0 logMAR or
better in each eye, with an interocular
difference of less than 0.1 logMAR
2. spherical and cylindrical refractive
error of 0.50 D or less for distance
3. stereopsis of equal to or better than 40
seconds of arc (arcsec).
ANISOMETROPES AND AMBLYOPES
1. Visual acuity for anisometropes:
0.1 logMAR or better in each eye, with
an interocular difference of less than
0.1 logMAR
© 2012 The Authors
Clinical and Experimental Optometry © 2012 Optometrists Association Australia
Interocular interaction evaluation in children Lai, Alexander, He, Yang and Suttle
2. visual acuity for amblyopes: 0.1 logMAR
or worse in one eye and 0.1 logMAR
or better in the other eye, with an
interocular difference of 0.1 logMAR
or more
3. interocular difference in spherical
refractive error of 0.75 DS or more for
hyperopic children, 1.25 DS or more
for myopic children and cylindrical
refractive error of 1.00 DC or more for
children with astigmatism (refractive
errors were defined using negative
cylinder).32
Apparatus
Visual stimuli were generated using a VSG
2/5 graphics card (Cambridge Research
Systems, Rochester, UK) externally con-
nected to an HP 8530P laptop computer
and were displayed on a gamma-corrected
21-inch Trinitron Sony GDM-F520 cathode
ray tube monitor. The refresh rate was
120 Hz. The mean room illuminance was
4.78 ⫾ 2.76 Lux (Konica Minolta T-10 illu-
minance meter). Three visual functions
were measured in each subject, namely,
low contrast acuity (-0.20 Weber contrast),
contrast sensitivity and alignment sensitiv-
ity. Two viewing systems were used, namely,
ferro-electric shutter goggles (FE-1, Cam-
bridge Research Systems) and the TFA.
Using each of these viewing systems, each
visual function was measured under both
full and partial occlusion conditions (see
below). For anisometropes and amblyopes,
refractive error was always corrected using
trial lenses.
SHUTTER GOGGLES
The shutter goggles were synchronised
with the monitor so that alternate frames
were presented to each eye (for example,
odd-numbered frames to right eye, even-
numbered frames to left eye). Thus, each
eye viewed the stimuli at a refresh rate of
60 Hz. The background luminance of the
monitor was fixed at 170 cd/m2 and this
level was reduced to about 21 cd/m2 at
each eye by the goggles. The goggles were
worn using an elasticated strap and were
held in place by an assistant to reduce
their weight and to minimise discomfort.
In the full occlusion (monocular) condi-
tion, an opaque eye-patch was used to
cover the non-tested eye, with a trial frame
holding the subject’s refractive correction
over it (if needed) and with the shutter
goggles outermost. In the partial occlu-
sion condition, subjects wore a trial frame
with refractive correction (if needed) and
the goggles, with no eye-patch.
TRIAL FRAME APPARATUS
The design and validation of the TFA
(Figure 1) are described elsewhere.14 In
both full and partial occlusion, a pinhole
aperture (1.0 mm in diameter) was placed
in front of the tested eye. The non-tested
eye was covered using the star-shaped
occluder in the partial occlusion condi-
tion and using an opaque cover for full
occlusion. The star-shaped occluder con-
sisted of one opaque black masking tape at
horizontal, one at vertical and the other
two at 45° and 135°. Depending on the
vertex distance, the opaque occlusion at
the centre of the star-shaped occluder
blocked out between 22° and 24° of the
central visual field of the non-tested eye
but light transmission from the periphery
was allowed.14 The pinhole transmits
approximately 10° of central field to the
tested eye and the field more peripheral to
this was vignetted. Thus, in partial occlu-
sion, the view consists of the target pre-
sented to the tested eye coincident with
the central occlusion of the non-tested
eye. While the experiments were con-
ducted in a darkened room, even with a
pupil diameter of 8.0 mm, the field of view
through the pinhole remained below 20°
and always below the peripheral field
angle of the star-shaped occluder.
Stimuli and experimental tasks
A training session was conducted for each
subject before the main experiments, to
allow the subject to become accustomed to
the tasks with each viewing system. The
stimuli and tasks described here apply to
the main experiments. Any differences
for the training sessions are indicated in
Procedures.
On each trial, a central target was pre-
sented to the tested eye only for a period of
140 ms (400 ms in training sessions), to
minimise the impact of eye movements.33
With full occlusion, the non-tested eye was
Clinical and Experimental Optometry 95.4 July 2012
413
Interocular interaction evaluation in children Lai, Alexander, He, Yang and Suttle

per degree [cpd]) subtending 3.5° at a

viewing distance of 2 m, with the standard
deviation of the Gaussian envelope 0.65°.
Alignment sensitivity was assessed with
three Gabor patches at 65 per cent Mich-
elson contrast (vertical, at six cycles per
degree, presented at a viewing distance of
1 m) with the upper and lower patches in
vertical alignment and the central patch
displaced to the left or right relative to this
alignment on each trial.

SQUARE PARTIAL OCCLUSION

The square partial occlusion was at -0.78
Weber contrast, subtending 2.3°, 3.5° and
9.5° of the visual field for acuity, contrast
sensitivity and alignment sensitivity tests,
respectively. This form of partial occlusion
applied only to the shutter goggles.

FUSION LOCK
The fusion lock, intended to maintain in
the dichoptic, partial occlusion condi-
tions, was a ring target at -0.78 Weber con-
trast with a width of 0.1°, subtending 4° for
acuity, 8° for contrast sensitivity and 15°
for alignment sensitivity.

SUPPRESSION MARKERS
Suppression markers were four lines, two
presented to each eye (subtending 0.3°,
2.5° and 1° at locations 6°, 10° and 19.5° in
the periphery for acuity, contrast sensitiv-
Figure 2. Examples of stimuli presented to the tested eye [i] and the non-tested eye [ii] ity and alignment sensitivity measure-
with partial occlusion for the acuity [A], contrast sensitivity (central target at 4 cpd is ments, respectively). These markers were
presented here, virtual target was at 6 cpd) [B] and alignment sensitivity (central target presented in the goggle square partial
at 2 cpd is presented here, virtual target was at 6 cpd) [C] measurements when shutter occlusion condition only.
goggles were used as a viewing system The experimental tasks were identical
in the training and the main experiments.
These tasks were:
1. in the acuity test, to indicate by point-
fully occluded, while with partial occlu- (not with the TFA) in partial occlusion ing the orientation of the E target
sion, the non-tested eye was masked with only to check for suppression of either eye. 2. contrast sensitivity was measured using
either a square low-luminance patch a temporal two-alternative forced
(viewed via shutter goggles and referred to CENTRAL TARGET choice method, in which subjects ver-
as ‘square partial occlusion’; Figure 2) or a Acuity was assessed with a single letter E bally reported whether the Gabor
star-shaped occluder (viewed via the TFA; presented at one of four possible orienta- patch was presented in interval ‘one’ or
Figure 1). A fusion lock was constantly pre- tions (right, left, up or down) at a viewing ‘two’ after each trial and
sented to both eyes. It was visible to the distance of 4 m. The letter was constructed 3. in the alignment sensitivity test, the task
tested eye only in the full occlusion condi- in a 5 ¥ 5 grid, in which each stroke and was to point to the offset direction (left
tion when the shutter goggles were used gap was one-fifth of the dimension of the or right) of the central Gabor patch.
and in both viewing conditions when the square grid. All responses were input to the program
TFA was used. Suppression markers (see The contrast sensitivity test consisted of a by the examiner (author XJL). No feed-
below) were used with the shutter goggles circular Gabor patch (vertical, at six cycles back was given.

Clinical and Experimental Optometry 95.4 July 2012 © 2012 The Authors
414 Clinical and Experimental Optometry © 2012 Optometrists Association Australia

Procedures
In the training session, the dominant eye
of each subject was tested in all three visual
functions with partial occlusion only, using
both viewing systems (all tests were con-
ducted in a pseudo-random order). In
these sessions, a two-down one-up (2/1)
single staircase method was used for acuity
and contrast sensitivity testing, while a 1/1
double staircase method was used for
alignment sensitivity testing. Start levels
were based on previous findings to ensure
subjects could easily detect the stimuli, and
the step sizes were sufficiently small to
ensure the stimuli were always supra-
threshold during training.2,34,35 The square
partial occlusion used with shutter goggles
in this training session subtended 3°, 5°
and 7° in the acuity, contrast sensitivity and
alignment sensitivity tests, respectively.
Subjects who could give 10 consecutively
correct answers were regarded as having
passed the training for each visual function
and viewing system. Duration of training
sessions for each visual function test were
recorded using a stopwatch in 10 subjects
of each group, for the TFA and the
goggles, respectively.
The main experiments were conducted
within three days of the training. The
three visual functions were measured in
the non-dominant eye only in each
subject. Four testing conditions were used:
1. shutter goggles with full occlusion
2. shutter goggles with partial occlusion
3. trial frame with full occlusion and
4. trial frame with partial occlusion.
Different viewing systems were tested
on separate days and all tests using each
viewing system were conducted in a
pseudo-random order. Initially, individual
start level was determined using a 1/1
single staircase method in the acuity and
contrast sensitivity tests and a 1/1 double
staircase method in the alignment sensi-
tivity test. Following this, thresholds were
measured using a 2/1 double staircase
method in the acuity and contrast sensi-
tivity tests and a 1/1 double staircase
method in the alignment sensitivity test.
The step sizes were 0.08 logMAR, 3.5 dB
and 1.5 arcmin in the acuity, contrast
sensitivity and alignment sensitivity tests,
respectively.
© 2012 The Authors
Clinical and Experimental Optometry © 2012 Optometrists Association Australia
Interocular interaction evaluation in children Lai, Alexander, He, Yang and Suttle
In both training and main experiments,
an ‘unforced-choice method’36 (allowing
‘don’t know’ answers) was used in
acuity and contrast sensitivity tests due
to long experimental duration (up to
eight minutes), to enhance subjects’ co-
operation and to increase the likelihood
of test completion.36,37 Although subjects
were not forced to give a response to each
trial, they tended to give as many answers
as they could, with an average of only one
‘don’t know’ answer given by each subject
during each test. An ‘incorrect’ response
was recorded for the ‘don’t know’ answers.
A ‘forced-choice method’38 was used in the
alignment sensitivity test to reduce the
variability of the subjects’ judgment of
alignment.
A game-like atmosphere39 was
employed. At the beginning of the experi-
ments, the child was asked to add his/her
name to a list of ‘challengers’ pasted on a
wall and was told that he/she was going to
play three games (three visual function
tests) that day. Each game included two
stages (two viewing conditions) and he/
she was allowed to paste a little red flag
after his/her name when he/she passed a
stage of a game. At the end of each day,
the child who had most flags would be the
‘champion of red flags’. The examiner
(XJL) frequently praised and encouraged
the subjects throughout the experiments
and words were carefully used in experi-
mental task instructions to ensure they
were easily understood by the subjects.
Subjects were tested in groups of two
during the main experiments and thus
they were tested in turns and a break was
given after each visual function test under
one viewing condition. Subjects were also
allowed to take breaks by request at any
time during a test. The number of breaks
requested by subjects (excluding those
given after each visual function test) was
recorded in 10 subjects of each group, for
the TFA and shutter goggles respectively.
After all tests, 10 subjects of each group
were given a slip of paper with one ques-
tion and two response options. They were
asked to mark one or both of the option
boxes. The question was:
‘Do you want to play some more games
with us in the next semester? Please check
the box to tell us which game you would
like to play and cross the one you don’t
like. Check both of them if you like both
of them and cross both of them if you
don’t like either of them.’
Response options were: ‘(A) Glasses
with spider web or (B) Diving mask’, rep-
resenting (A) TFA and (B) shutter
goggles, respectively.
Data analysis
THRESHOLDS AND INTERACTION INDEX
In the single and double staircase
methods, trials up to the first reversal on
each track were excluded. In the acuity
and contrast sensitivity tests, the mean of
mid-points of peaks and valleys of the
remaining reversals were taken to repre-
sent threshold. In the alignment sensitivity
test, the standard deviation (SD) of the
mid-points was taken to represent the vari-
ability of a subject’s judgment of align-
ment and the reciprocal of this was
recorded as alignment sensitivity.
The difference in non-dominant eye
visual function between the full and
partial occlusion is termed the ‘interac-
tion index’. As a threshold measure, the
acuity ‘interaction index’ was calculated
by the following normalising function:
Acuity(Partial ) - Acuity(Full )
Interaction Index =
Acuity(Partial ) + Acuity(Full )
As sensitivity measures, contrast and
alignment sensitivity interaction indices
were calculated as follows:
Interaction Index
Sensitivity(Full ) - Sensitivity(Partial )
=
Sensitivity(Full ) + Sensitivity(Partial )
For each visual function measurement,
a positive index value indicates poorer
non-dominant eye visual function (stron-
ger inhibitory impact) with partial relative
to full occlusion of the dominant eye. The
interaction index of each visual function
evaluated using the TFA was compared
between anisometropes and amblyopes
using the repeated measures analysis of
variance (ANOVA).
Clinical and Experimental Optometry 95.4 July 2012
415
Interocular interaction evaluation in children Lai, Alexander, He, Yang and Suttle
Agreement between shutter goggles and
the trial frame was examined for ani-
sometropes and amblyopes, in terms of:
1. absolute measures of each visual func-
tion with partial occlusion and
2. interaction index for each of these
three visual functions. Two methods
were used to test for agreement: the
paired-samples t-test and the Bland-
Altman method.40 The Bland-Altman
method includes the following four
steps:
1. The means and the differences
between measures using two viewing
systems were calculated for each
subject,
2. the differences were plotted as a func-
tion of the means,
3. the mean and standard deviation of the
differences were calculated and
4. the lower and upper ‘limits of agree-
ment’ (LOA) were calculated:
LOA = Mean difference ± 1.96 × SD
where
Mean difference =
∑ (TFA - Shutter goggles )
n Feasibility of use of the shutter
1 n ⎡(TFA - Shutter goggles )i ⎤
2 Visual functions and interocular
SD = ∑
n i =1 ⎢⎣ - Mean difference ⎥⎦
n = number of subjects
The trial frame and shutter goggles
were considered to show very good agree-
ment if:
1. ninety per cent of the differences (n =
14) between the goggles and the trial
frame were within the two limits of
agreement and
2. the standard deviation of the differ-
ences was less than the SD of the results
(visual function or interaction index)
obtained using the goggles.
They were considered to show lower but
acceptable agreement if the SD of the dif-
ferences was more than the SD of the
results obtained using the goggles but
equal to or less than 1.96 ¥ SD of the
results obtained using the goggles. They
were considered to show poor agreement
if the SD of the differences was more than
1.96 ¥ SD of the results obtained using the
goggles.
Clinical and Experimental Optometry 95.4 July 2012
416
FEASIBILITY OF THE SHUTTER
GOGGLES AND TRIAL FRAME
The duration of each subject training
session, the number of breaks requested
by subjects in the main experiments and
the willingness to attend further experi-
ments were recorded in 10 subjects from
each group to assess the feasibility of the
two viewing systems. Based on the chil-
dren’s answers to the question of willing-
ness to attend further experiments, a tick
to a viewing system was marked as ‘1’,
while a cross to a viewing system was
marked as ‘0’. For each test of visual func-
tion, these scores, duration of training and
the number of breaks requested by sub-
jects were each compared among the
three groups of subjects for data obtained
using the trial frame and shutter goggles,
respectively, using the one-way ANOVA or
the Kruskal-Wallis analysis of variance and
were each compared between the TFA and
shutter goggles using the repeated mea-
sures ANOVA or the Wilcoxon signed-
rank test.
RESULTS
interactions in anisometropes
and amblyopes
For anisometropes and amblyopes, mea-
sures of visual function with partial occlu-
sion using the trial frame and shutter
goggles are presented in Figure 3. The
‘interaction indices’ of each visual func-
tion evaluated using the TFA and shutter
goggles are presented in Figure 4. High
inter-individual variation was found in all
three visual functions and in interaction
index of these visual functions in both ani-
sometropes and amblyopes. The limits of
agreement and the number of subjects
showing differences beyond these limits
and the results of agreement assessment
between these two viewing systems (Bland-
Altman and t-test methods) are shown in
Table 2. The agreement between these
two viewing systems in control subjects is
discussed elsewhere.14
For both anisometropes and amblyopes,
the Bland-Altman method indicated
acceptable or very good agreement
Clinical and Experimental Optometry © 2012 Optometrists Association Australia
between shutter goggles and the TFA in all
three visual function measures and in
their interaction index evaluations. The
t-test indicated that in each visual func-
tion, interaction index was not signifi-
cantly different when evaluated using
shutter goggles or the trial frame (p >
0.05). Absolute measures of acuity and
alignment sensitivity also did not differ sig-
nificantly between the two viewing systems
(p > 0.05). Contrast sensitivity was not
significantly different between viewing
systems in the amblyopes (p > 0.05) but it
was significantly lower (poorer) when
measured using the trial frame than using
goggles in the anisometropes (p = 0.042).
Acuity interaction index evaluated using
the trial frame was significantly higher in
amblyopes than in anisometropes (F1,13 =
5.000, p = 0.044) but there was no signifi-
cant difference between these two groups
in contrast sensitivity (F1,13 = 0.025, p >
0.05) or alignment sensitivity (F1,13 = 2.483,
p > 0.05) interaction index. The interac-
tion index evaluated using shutter goggles
is discussed elsewhere.41
goggles and the trial frame
The training duration of each visual func-
tion for each group is presented in
Figure 5. No significant difference was
found among subject groups in any mea-
surement of visual function, using either
the TFA (acuity: c2[2] = 2.754; contrast
sensitivity: c2[2] = 5.292; alignment sensi-
tivity: F2,27 = 0.263; p > 0.05) or shutter
goggles (acuity: c2[2] = 4.055; contrast
sensitivity: F2,27 = 3.021; alignment sensitiv-
ity: F2,27 = 0.477; p > 0.05). For all three
groups of subjects, the durations of train-
ing sessions for acuity (Z = -0.930, p > 0.05)
and alignment sensitivity (Z = -0.154, p >
0.05) tests were not significantly different
when using the trial frame and the goggles
as viewing systems. The training sessions
for contrast sensitivity testing were signifi-
cantly longer using goggles than using
the trial frame in all groups of subjects
(controls: F1,9 = 21.423, p = 0.001; ani-
sometropes: Z = -2.703, p = 0.007; ambly-
opes: F1,9 = 30.146, p < 0.001).
The number of breaks requested by
each group is shown in Table 3. The
© 2012 The Authors
 Interocular interaction evaluation in children Lai, Alexander, He, Yang and Suttle

Anisometropes Amblyopes
Anisometropes Amblyopes A
A

TFA acuity Interaction Index

1.2 0.45
TFA acuity (logMAR)

1.1 0.35
1.0
0.9 0.25
0.8 0.15
0.7
0.6 0.05
0.5
-0.05
0.4
0.3 -0.15
0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.1 -0.15 -0.05 0.05 0.15 0.25 0.35 0.45

Shutter goggle acuity (logMAR)

Shutter goggle acuity Interaction Index

B B
Shutter goggle contrast sensitivity (dB)
TFA contrast sensitivity (dB)

0.2

TFA contrast sensitivity

-40 -35 -30 -25 -20 -15 -10 0.15

Interaction Index
-10
0.1
-15
-20 0.05

-25
0

-30 -0.05
-35 -0.1
-40 -0.1 -0.05 0 0.05 0.1 0.15 0.2

Shutter goggle contrast sensitivity Interaction Index

C C
TFA alignment sensitivity
TFA alignment sensitivity

0.8
1.0
Interaction Index

0.6
0.8
0.4
(arcmin-1)

0.6 0.2
0.0
0.4
-0.2
0.2 -0.4
-0.6
0
0 0.2 0.4 0.6 0.8 1.0 -0.6 -0.4 -0.2 0.0 0.2 0.4 0.6 0.8

-1
Shutter goggle alignment sensitivity (arcmin ) Shutter goggle alignment sensitivity Interaction Index

Figure 3. Non-dominant eye acuity (logMAR) [A], contrast Figure 4. Acuity [A], contrast sensitivity [B] and alignment
sensitivity (dB) [B] and alignment sensitivity (arcmin-1) [C] sensitivity [C] interaction indices evaluated using the trial
measured using the trial frame and shutter goggles with frame and shutter goggles in the non-dominant eye of 14
partial occlusion on the dominant eye of 14 anisometropic anisometropic children without amblyopia (anisometropes;
children without amblyopia (anisometropes; solid circles) solid circles) and 14 anisometropic amblyopic children
and 14 anisometropic amblyopic children (amblyopes; open (amblyopes; open squares). Index towards the positive y-axis
squares) indicates poorer non-dominant eye visual function with partial
relative to full occlusion of the dominant eye.

number was not significantly different sitivity testing did not differ significantly Z = -2.165, p = 0.030; amblyopes: Z =
among subject groups, using either the between the trial frame and goggle -2.041, p = 0.041) when goggles were used,
trial frame (acuity: c2[2] = 1.036; contrast viewing systems (Z = -1.265, p > 0.05). Sig- compared to when the TFA was used.
sensitivity: c2[2] = 0.558; alignment sensi- nificantly more breaks were requested by The total scores indicated by each
tivity: c2[2] = 0.558; p > 0.05) or shutter controls (Z = -2.070, p = 0.038) and ambly- group of subjects for willingness to attend
goggles (acuity: c2[2] = 0.180; contrast opes (Z = -2.111, p = 0.035) during the further sessions using the trial frame and
sensitivity: c2[2] = 0.201; alignment sensi- acuity test and by all groups of subjects shutter goggles are shown in Table 4. The
tivity: c2[2] = 0.330; p > 0.05). The number during the contrast sensitivity test (con- scores did not differ significantly among
of breaks requested during alignment sen- trols: Z = -2.070, p = 0.038; anisometropes: subject groups (TFA: c2[2] = 2.000;

© 2012 The Authors Clinical and Experimental Optometry 95.4 July 2012
Clinical and Experimental Optometry © 2012 Optometrists Association Australia 417
Interocular interaction evaluation in children Lai, Alexander, He, Yang and Suttle

Agreement test
LOA Outlier Agreement
Bland–Altman t-test

Anisometropic Acuity Function -0.07 ⫾ 0.50 1 Acceptable p = 0.338

amblyopic children Index -0.02 ⫾ 0.24 1 Acceptable p = 0.644
Contrast Function -0.54 ⫾ 11.81 0 Acceptable p = 0.745
sensitivity Index 0 ⫾ 0.11 0 Good p = 0.874
Alignment Function -0.09 ⫾ 0.55 0 Good p = 0.241
sensitivity Index 0.10 ⫾ 0.64 0 Good p = 0.254
Anisometropic Acuity Function 0.04 ⫾ 0.46 0 Acceptable p = 0.540
children without Index 0.05 ⫾ 0.23 1 Good p = 0.120
amblyopia
Contrast Function 4.59 ⫾ 14.90 0 Acceptable p = 0.042
sensitivity Index -0.02 ⫾ 0.09 0 Good p = 0.133
Alignment Function 0 ⫾ 0.58 0 Acceptable p = 0.954
sensitivity Index 0.05 ⫾ 0.50 1 Acceptable p = 0.495

Table 2 Agreement between the two viewing systems. 1. The limits of agreement (LOA) for absolute measures and ‘interaction
indices’ measured using the two viewing systems (the trial frame and shutter goggles) in anisometropic children with and without
amblyopia. 2. The number of subjects in whom differences between the two viewing systems (the trial frame versus shutter goggles)
exceeded the two LOA (outliers) and 3. The agreement between the two viewing systems (Bland-Altman and t-test methods). For the
t-test, p > 0.05 indicates no significant difference between measurements using shutter goggles and the trial frame apparatus.
Differences between these two viewing systems were found only in contrast sensitivity measurements for anisometropic children
without amblyopia.

4.0 goggles: c2[2] = 1.050; p > 0.05). They

Duration of training session (minutes)

3.5
were significantly higher for the trial
3.0
2.5 frame than for goggles in anisometropes
2.0 (Z = -2.236, p = 0.025), indicating that
1.5
1.0 these subjects had significantly greater
0.5 TFA willingness to attend more experiments
0.0 Shutter goggles using the TFA than using goggles. The
Amblyopes

Amblyopes

Amblyopes
Anisometropes

Anisometropes

Anisometropes
Controls

Controls

Controls

scores from controls (Z = -1.633, p > 0.05)

and amblyopes (Z = -1.732, p > 0.05) did
not differ significantly between the two
viewing systems.
Acuity test Contrast sensitivity test Alignment sensitivity test

Figure 5. Duration of training sessions (minutes) using shutter goggles and the trial DISCUSSION
frame as viewing systems in acuity, contrast sensitivity and alignment sensitivity testing Shutter goggles and the trial frame gener-
in normally sighted children (controls) and anisometropic children with (amblyopes) ally show acceptable to good agreement in
and without (anisometropes) amblyopia. Error bars represent 95 per cent confidence visual function measures and in interac-
intervals. tion index evaluations in anisometropes
and amblyopes, with one exception. Con-
trast sensitivity in anisometropes showed
poor agreement between the two viewing
systems based on the paired t-test (but

Clinical and Experimental Optometry 95.4 July 2012 © 2012 The Authors
418 Clinical and Experimental Optometry © 2012 Optometrists Association Australia
 Interocular interaction evaluation in children Lai, Alexander, He, Yang and Suttle

system.41 This may be due to the use of the

Controls Anisometropes Amblyopes pinhole in front of the tested eye that
Acuity Trial frame 0 1 1 resulted in the reduction in retinal illumi-
nance.14,41 The present study found a sig-
Shutter goggles 8 7 8
nificantly higher acuity interaction index
Contrast sensitivity Trial frame 2 1 1
in amblyopes than in anisometropes
Shutter goggles 9 10 10
(evaluated using the trial frame). This sug-
Alignment Trial frame 1 1 2 gests that the extent to which acuity of the
sensitivity Shutter goggles 3 2 3 non-dominant eye is influenced by stimu-
lation of the dominant eye is greater in
Table 3 Total numbers of breaks requested by normally sighted children (controls) and anisometropic children with amblyopia
anisometropic children with (amblyopes) and without (anisometropes) amblyopia than in those without. This finding agrees
during acuity, contrast sensitivity and alignment sensitivity testing using the trial frame with previous work using shutter goggles;41
and shutter goggles as viewing systems however, the sample size in the present
study is small and the statistical power in
this sample is only 38 per cent (PS Power
and Sample Size Program42). Further
experiments with a larger sample may
improve understanding of the relation-
ship between interactions and anisome-
tropic amblyopia.
Subject group Trial frame Shutter goggles Two amblyopic subjects had negative
Controls 9 5 acuity interaction index (Figure 4), indi-
Anisometropes 10 5 cating better acuity with partial rather
Amblyopes 10 7 than full occlusion in these subjects. This
suggests that the relationship between
interocular interaction and anisometropic
Table 4 Total scores from normally sighted children (controls) amblyopia may vary in amblyopic subjects.
and anisometropic children with (amblyopes) and without (ani- The reason for this inconsistency is
sometropes) amblyopia indicating willingness to attend further unclear due to the lack of information
experiments using the trial frame and shutter goggles about the history of the development of
amblyopia and about the deficits at sub-
cortical and cortical levels in amblyopic
subjects. Similar studies on subjects with a
clear history of development of amblyopia
and accompanied by objective measures of
acceptable agreement was shown based on to the non-tested eye was 22° to 24° using amblyopia-related deficits would provide a
the Bland-Altman method). These find- the trial frame and 3.5° using goggles, it is better understanding of this relationship.
ings agree with previous work in controls,14 possible that the size of the central occlu- The pool of subjects tested here was
and suggest that the trial frame may be sion and the amount of light transmitted recruited from a larger group of 106 chil-
applicable in the evaluation of interocular from the periphery had a strong impact dren.43 While parents of all children gave
interaction in children and in investiga- on contrast sensitivity but a less significant consent for them to be tested using the
tion of these interactions in amblyopes, in impact on acuity or alignment sensitivity. TFA, consent for testing with the shutter
populations where more complex devices Perhaps better agreement in contrast goggles was received from parents of only
cannot be used. It is important to note sensitivity measurement may be found 42 of these children. Some of the parents
that the TFA does not have the flexibility between these two systems if similar sizes expressed concern that the use of unfamil-
of shutter goggles and mirror or prism of central occlusion were used. iar equipment could be harmful to their
devices and it may be used to study limited As shown in Figure 3, it is interesting to children’s vision. In addition, not all of the
forms of dichoptic masking. note that the acuity of the non-dominant 42 children were able to complete the
The poor agreement between shutter eye measured with partial occlusion did experimental processes using the goggles.
goggles and the trial frame in contrast sen- not differ significantly between amblyopes Three children in the anisometropes
sitivity measurement in anisometropes is and anisometropes (one-way ANOVA, p > group and one child in the amblyopes
consistent with findings in controls.14 As 0.05), which is consistent with previous group did not complete testing with
the size of the central occlusion presented findings using shutter goggles as a viewing goggles due to discomfort when wearing

© 2012 The Authors Clinical and Experimental Optometry 95.4 July 2012
Clinical and Experimental Optometry © 2012 Optometrists Association Australia 419
Interocular interaction evaluation in children Lai, Alexander, He, Yang and Suttle
the goggles and their parents were not
able to persuade them to continue with
the tests. Thus, only 38 of the 106 children
underwent all tests with both viewing
systems, due to difficulties encountered in
using the shutter goggles.
In addition to discomfort and parental
concerns about the shutter goggles,
another complication with this viewing
system was that the lenses were occasion-
ally affected by condensation. This compli-
cation is related to the fact that the
present study was conducted in a warm
environment, in high humidity and might
not arise in cooler, less humid conditions.
This factor may in part explain the differ-
ences between the two viewing systems in
terms of duration of training, number of
breaks and willingness to participate in
further test sessions.
SUMMARY
Our findings indicate acceptable agree-
ment between shutter goggles and the
trial frame in acuity, contrast sensitivity
and alignment sensitivity testing and in
evaluation of a form of interocular inter-
action for these visual functions, in ani-
sometropic children with and without
amblyopia. The trial frame is better
accepted by anisometropic children
without amblyopia than the shutter
goggles. The TFA may be a useful system
in studies of interocular interaction in
amblyopes, particularly in children.
ACKNOWLEDGEMENT
The authors thank Jinping Zheng for assis-
tance with data collection.
REFERENCES
1. Norton TT, Corliss DA, Bailey JE. The Psycho-
physical Measurement of Visual Function.
Woburn: Butterworth-Heinemann, 2002. p 201–
204.
2. Vedamurthy I, Suttle CM, Alexander J, Asper LJ. A
psychophysical study of human binocular interac-
tions in normal and amblyopic visual systems.
Vision Res. 2008; 48: 1522–1531.
3. Meese TS, Hess RF. Interocular suppression is
gated by interocular feature matching. Vision Res
2005; 45: 9–15.
4. Paradiso MA, Nakayama K. Brightness perception
and filling-in. Vision Res 1991; 31: 1221–1236.
5. Agrawal R, Conner IP, Odom JV, Schwartz TL,
Mendola JD. Relating binocular and monocular
Clinical and Experimental Optometry 95.4 July 2012
420
vision in strabismic and anisometropic amblyopia.
Arch Ophthalmol 2006; 124: 844–850.
6. McKee SP, Bravo MJ, Taylor DG, Legge GE. Stereo
matching precedes dichoptic masking. Vision Res
1994; 34: 1047–1060.
7. Brown RJ, Candy TR, Norcia AM. Development of
rivalry and dichoptic masking in human infants.
Invest Ophthalmol Vis Sci 1999; 40: 3324–3333.
8. Baker DH, Meese TS. Binocular contrast interac-
tions: dichoptic masking is not a single process.
Vision Res 2007; 47: 3096–3107.
9. Baker DH, Meese TS, Hess RF. Contrast masking
in strabismic amblyopia: attenuation, noise,
interocular suppression and binocular summa-
tion. Vision Res 2008; 48: 1625–1640.
10. Vedamurthy I, Suttle CM, Alexander J, Asper LJ.
Interocular interactions during acuity measure-
ment in children and adults, and in adults with
amblyopia. Vision Res 2007; 47: 179–188.
11. Borra T, Hooge IT, Verstraten FA. A dichoptic
study of the oblique effect. Perception 2010; 39:
909–917.
12. Meese TS, Hess RF. Low spatial frequencies are
suppressively masked across spatial scale, orienta-
tion, field position, and eye of origin. J Vis 2004; 4:
843–859.
13. Meese TS, Georgeson MA, Baker DH. Binocular
contrast vision at and above threshold. J Vis 2006;
6: 1224–1243.
14. Lai XJ, Alexander J, Ho A, Yang ZK, He MG, Suttle
C. Design and validation of a method for evalua-
tion of interocular interaction. Optom Vis Sci 2011.
[Epub ahea of print]
15. Moseley M, Fielder A. Amblyopia: A Multidisci-
plinary Approach. Woburn: Butterworth-
Heinemann, 2002.
16. Hirsch MJ. Anisometropia: a preliminary report of
the Ojai Longitudinal Study. Am J Optom Arch Am
Acad Optom. 1967;44:581–585.
17. Blum HL. Vision Screening for Elementary
Schools: The Orinda Study. Berkeley: University of
California Press, 1959.
18. Pediatric Eye Disease Investigator Group. The
clinical profile of moderate amblyopia in children
younger than 7 years. Arch Ophthalmol 2002; 120:
281–287.
19. Pediatric Eye Disease Investigator Group. A ran-
domized trial of atropine vs. patching for treat-
ment of moderate amblyopia in children. Arch
Ophthalmol 2002; 120: 268–278.
20. Ruth AL, Lambert SR. Amblyopia in the phakic
eye after unilateral congenital cataract extraction.
J AAPOS 2006; 10: 587–588.
21. Levi DM, Harwerth RS, Manny RE. Suprathresh-
old spatial frequency detection and binocular
interaction in strabismic and anisometropic
amblyopia. Invest Ophthalmol Vis Sci 1979; 18: 714–
725.
22. Sireteanu R, Fronius M, Singer W. Binocular inter-
action in the peripheral visual field of humans
with strabismic and anisometropic amblyopia.
Vision Res 1981; 21: 1065–1074.
23. Holopigian K, Blake R, Greenwald MJ. Selective
losses in binocular vision in anisometropic ambly-
opes. Vision Res 1986; 26: 621–630.
24. Hood AS, Morrison JD. The dependence of bin-
ocular contrast sensitivities on binocular single
vision in normal and amblyopic human subjects. J
Physiol 2002; 540: 607–622.
25. Baker DH, Meese TS, Mansouri B, Hess RF. Bin-
ocular summation of contrast remains intact in
Clinical and Experimental Optometry © 2012 Optometrists Association Australia
strabismic amblyopia. Invest Ophthalmol Vis Sci
2007; 48: 5332–5338.
26. Sengpiel F, Blakemore C. The neural basis of sup-
pression and amblyopia in strabismus. Eye (Lond)
1996; 10: 250–258.
27. Smith EL, Chino YM, Ni J, Cheng H, Crawford
MLJ, Harwerth RS. Residual binocular interac-
tions in the striate cortex of monkeys reared with
abnormal binocular vision. J Neurophysiol 1997; 78:
1353–1362.
28. Scheiman MM, Hertle RW, Beck RW, Edwards AR,
Birch E, Cotter SA, Donahue S et al. Randomized
trial of treatment of amblyopia in children aged 7
to 17 years. Arch Ophthalmol 2005; 123: 437–447.
29. Grosvenor TP. Primary Care Optometry. Boston:
Butterworth-Heinemann, 2002.
30. Coren S, Kaplan CP. Patterns of ocular domi-
nance. Am J Optom Arch Am Acad Optom 1973; 50:
283–292.
31. Roth HL, Lora AN, Heilman KM. Effects of
monocular viewing and eye dominance on spatial
attention. Brain 2002; 125: 2023–2035.
32. Weakley DRJ. The association between nonstrabis-
mic anisometropia, amblyopia, and subnormal
binocularity. Ophthalmology 2001; 108: 163–171.
33. Bartz AE. Eye-movement latency, duration, and
response time as a function of angular displace-
ment. J Exp Psychol 1962; 64: 318–324.
34. France TD, France LW. Low-contrast visual acuity
cards in pediatric ophthalmology. Graefes Arch Clin
Experiment Ophthalmol 1988; 226: 158–160.
35. Skoczenski AM, Norcia AM. Late maturation of
visual hyperacuity. Psychol Sci 2002; 13: 537–541.
36. Kaernbach C. Adaptive threshold estimation with
unforced-choice tasks. Percept Psychophys 2001; 63:
1377–1388.
37. Green DM. A maximum-likelihood method for
estimating thresholds in a yes-no task. J Acoust Soc
Am 1993; 93: 2096–2105.
38. Leek MR. Adaptive procedures in psychophysical
research. Percept Psychophys 2001; 63: 1279–1292.
39. Carkeet A, Levi DM, Manny RE. Development of
vernier acuity in childhood. Optom Vis Sci 1997; 74:
741–750.
40. Bland JM, Altman DG. Statistical methods for
assessing agreement between two methods of clini-
cal measurement. Lancet 1986; 1: 307–310.
41. Lai XJ, Alexander J, He M, Yang Z, Suttle C. Visual
functions and interocular interactions in anisome-
tropic children with and without amblyopia. Invest
Ophthalmol Vis Sci 2011; 52: 6849–6859.
42. Dupont WD, Plummer WD. Power and sample size
calculations. A review and computer program.
Control Clin Trials 1990; 11: 116–128.
43. Lai XJ. Visual Functions and Interocular Interac-
tions in Normally Sighted Children and Anisome-
tropic Children with and Without Amblyopia.
School of Optometry and Vision Science. 2010,
The University of New South Wales: Sydney, 2010.
Corresponding author:
Dr Xin Jie (Angela) Lai
School of Optometry and Vision Science
The University of New South Wales
Kensington
NSW 2051
AUSTRALIA
E-mail: xinjie.lai@gmail.com
© 2012 The Authors
Copyright of Clinical & Experimental Optometry is the property of Wiley-Blackwell and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.