Name: A Gaze-Contingent Display Framework for Perceptual Learning Research with Simulated Central Vision Loss (Video) | JoVE Journal
Uploaded: 2025-04-11T13:20:00.000+00:00
Duration: 7 min 12 s
Description: Learn a gaze-contingent display framework for studying perceptual learning and oculomotor adaptations in simulated central vision loss. This method enables researchers to investigate compensatory visual strategies and rehabilitation approaches.

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5 minutes

This work is supported by NIH NEI 1 U01 R01EY031589 and 1R21EY033623-01.

All participants were healthy individuals with visual acuity of 20/40 or above and no known vision issues. Both the representative participants are females, and their ages are 27 and 24. All participants provided informed consent, and the study received approval from the Institutional Review Board (IRB) at the University of Alabama at Birmingham.
1. Identifying an ideal system for simulated central vision loss research
<ol>
	<li>Identify a system that efficiently transmits information from the eye tracker to the stimulus generation software in a continuous loop. Use methods described in37 to measure the latency of different combinations of systems to identify the one with the lowest latency. 
	​NOTE: A comparison of the combined latency of four different combinations of systems comprising two eye trackers (EyeLink 1000 Plus Tower Mount and TRACKPixx3), two display devices (CRT Monitor (refresh rate = 100Hz) and Display++ (refresh rate = 120Hz)) along with two operating systems (Windows 10 and Mac iOS) is shown in Figure 3. Each combination was measured 20 times. Results showed that system latency was the lowest when Vpixx TrackPixx3 eye tracker was used in combination with the Windows 10 operating system.</li>
</ol>
<img alt="System latency comparison graph showing latency in milliseconds for E1000 and TP setups on Mac and Win." class="xfigimg" src="/files/ftp_upload/67596/67596fig03.jpg" data-altupdatedat="1788304762000" data-alt="Figure 3"> 
Figure 3: Latency comparison across different combinations of monitors, eye-tracking devices, and operating systems. Bars represent the ± 1 standard deviation across the 20 repetitions per combination. Measures were taken with a Mac operating system phone in slow motion mode, reaching a refresh rate of 240Hz. TP/CRS/Win is statistically different from E1000/CRT/Mac (t(38)=9.53, p&lt;0.001), E1000/CRS/Mac (t(38)=16.24, p&lt;0.001) and E1000/CRS/Win (t(38)=3.94, p&lt;0.001). <a href="https://www.jove.com/files/ftp_upload/67596/67596fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
2. Participant familiarization with simulated central vision loss through gaze-contingent display
NOTE: A fundamental component in simulating central vision loss is to familiarize participants with the gaze-contingent display. Without proper familiarization, measures of abilities can be conflated by the participants' effort to navigate the gaze-contingent display. Several key steps in the protocol ensure sufficient familiarization with the gaze-contingent display to be able to measure visual performance reliably.
<ol>
	<li>Provide participants with audiovisual instructions about the task that they will be performing during a particular session. For each task, have dedicated video instructions with screen captures from the actual task. Then, explain the instructions verbally to ensure that the participant has a good understanding of what to expect in a given task.</li>
	<li>Provide participants with practice trials before beginning each of the main tasks. This provides an opportunity to clarify any questions related to the task.</li>
	<li>During the initial visit, before conducting gaze-contingent tasks, carry out fixation training on participants, where they learn to place their simulated scotoma within a white central box on the screen for varying durations with spatial tolerance increasing across trials, while they ignore distractors that may appear on the screen.</li>
	<li>Additionally, carry out a PRL induction task on participants, which is designed to promote the development of PRL-like behavior. In this task, make participants view an opaque disk randomly placed on the screen that covers a target (for example, a Landolt C) and move the scotoma close to the opaque disk to reveal the target. 
	NOTE: Oculomotor analysis of this task can indicate an early PRL-like location that can later be used as a training locus. In this experimental paradigm, the circular central scotoma subtended 10° visual angle. These steps allow participants to familiarize themselves with the gaze-contingent display and prepare them to perform a wide range of perceptual assessments and training tasks using their peripheral vision.</li>
</ol>
3. Development of effective instructions
NOTE: Instructions play a crucial role in guiding participants on how to respond to stimuli and manage their simulated scotoma during different tasks. Appropriate instructions must be thorough and clear to avoid any confusion. Instructions should be reiterated as needed to ensure understanding.
<ol>
	<li>Instructional videos
	<ol>
		<li>Visual demonstration: Provide videos that visually demonstrate each step of the task. Videos should clearly illustrate how to manage the simulated scotoma appropriately during the task and how to respond to stimuli.</li>
		<li>Narration: Deliver a concise script developed to accompany the visual demonstration that explains the process in simple terms. Ensure that language is easy to understand and avoid technical terminology.</li>
	</ol>
	</li>
	<li>Scripted verbal instructions
	<ol>
		<li>Consistency: Use a standardized script for verbal instructions to ensure consistency across different sessions and participants. Example: Throughout the task, there will be multiple breaks to rest your eyes. During these breaks, make sure to keep your head on the chin rest. When you are ready to continue the task, press the spacebar, and the task will begin again.</li>
		<li>Clarity: Speak slowly and clearly - make sure to emphasize all important aspects of the task.</li>
	</ol>
	</li>
	<li>Visual instructions
	<ol>
		<li>On-screen instructions: Provide written guidance on the screen that participants can read before and during the completion of tasks. Use short sentences for clarity with visual aids to demonstrate stimuli that the participant may encounter during each task.</li>
	</ol>
	</li>
</ol>
4. Assessment tasks' design and implementation
NOTE: Tasks designed within this framework are broadly divided into two main categories: (1) Free eye movement tasks and (2) Fixation-constrained tasks. In the free-eye movement tasks, let participants make eye movements across the screen to identify targets appearing at random locations on the screen (or to read text), whereas, in fixation-constrained tasks, ask participants to maintain fixation within a central white box throughout the task and use their peripheral vision to make judgments. Figure 4 shows example tasks and descriptions for each category. More detailed information about the tasks can be found in38.
<img alt="Oculomotor task diagram with stability tests, acuity measures, attention assessment, visual skills." class="xfigimg" src="/files/ftp_upload/67596/67596fig04.jpg" data-altupdatedat="1788304762000" data-alt="Figure 4"> 
Figure 4: A visual representation of different assessment tasks designed using the framework. The tasks are broadly categorized into Free eye movement tasks, where the scotoma follows the eye movements of the participants to view targets freely (top panel), and Fixation-constrained tasks, where the scotoma needs to be placed within a central white box throughout the task (bottom panel). This figure has been modified from38. <a href="https://www.jove.com/files/ftp_upload/67596/67596fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol>
	<li>Free eye movement tasks 
	NOTE: Free eye movement tasks measure participants' eye movement behavior while they perform tasks. These promote understanding of the eye's movements in the context of naturalistic tasks such as reading and visual search.
	<ol>
		<li>Instructional video/verbal instructions
		<ol>
			<li>Present an instructional video and scripted verbal instructions to the participant prior to the calibration.</li>
		</ol>
		</li>
		<li>Calibration
		<ol>
			<li>Run validations of previous calibrations between tasks and additional calibrations when validations are poor, or when participants take breaks between tasks.</li>
		</ol>
		</li>
		<li>Free-viewing task specific methods
		<ol>
			<li>Perform free-viewing tasks that instruct participants to do a variety of actions using their gaze rather than fixating on one area. Choose to perform the task with one of the following variants.</li>
			<li>Bring the scotoma near a cue, causing a stimulus to appear. Maintain fixation on a specific screen location for a period of time. Perform a standard task, like reading or visual search, with central vision occluded by the scotoma.</li>
			<li>At the beginning of tasks, provide participants with on-screen instructions followed by a set of practice trials. Following the completion of the practice trials, give reminder instructions before moving on to the task. Ensure that the participants understand and have shown proficiency using the visual layouts, the required oculomotor actions, and the response characteristics of each task prior to measuring performance.</li>
			<li>Provide participants with auditory feedback indicating the accuracy of their responses as they complete each task, as visual feedback can be missed due to the use of a scotoma.</li>
			<li>Incorporate breaks of up to 1 min into each task to reduce the chance of testing fatigue. Incorporate breaks of 3 min or longer for days that include longer sessions of assessments to reduce the chances of testing fatigue.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Fixation-constrained tasks 
	NOTE: Fixation-constrained tasks are useful to test or train peripheral vision at specific visual field locations. These tasks are suitable for testing both early- and mid-level visual processing, including visual acuity, contrast sensitivity, crowding, etc., as well as high-level visual processing, including exogenous and endogenous attention. For these tasks, it is important that participants learn to maintain steady fixation to avoid task performance being confounded by attentional resources dedicated to steady fixation. During these tasks, participants are asked to keep their central vision focused on the center of the screen with the help of fixation aids (Figure 5B) while responding to stimuli that appear in their peripheral vision.
	<ol>
		<li>Instructional video/verbal instructions
		<ol>
			<li>Present an instructional video and scripted verbal instructions to the participant prior to the calibration.</li>
		</ol>
		</li>
		<li>Calibration
		<ol>
			<li>Run validations of previous calibrations between tasks and additional calibrations when validations are poor, or when participants take breaks between tasks.</li>
		</ol>
		</li>
		<li>Fixation-constrained task-specific methods
		<ol>
			<li>During fixation-constrained tasks, ask participants to maintain their head position in the chinrest for the duration of the task, ensuring that the calibration remains as accurate as possible to the original position throughout the process.</li>
			<li>Provide participants with on-screen instructions followed by a set of practice trials. Following the completion of the practice trials, give a reminder set of on-screen instructions before moving on to the task.</li>
			<li>During these tasks, ask participants to keep their central vision focused on the center of the screen with the help of fixation aids (white rectangular fixation box) while responding to stimuli that appear in their peripheral vision to either side of the fixation box.</li>
			<li>Ask participants to respond using their right index finger on a five-button response box located to their right during the assessment. If fixation is not maintained, the stimulus will not be presented and will time out unless fixation is resumed.</li>
			<li>Provide participants with auditory feedback indicating the accuracy of their responses as they complete each task, as, again, visual feedback can be missed due to the use of a scotoma.</li>
			<li>Incorporate breaks of up to 1 min into each task to reduce the chance of testing fatigue. Incorporate breaks of 3 min or longer for days that include longer sessions of assessments to reduce the chances of testing fatigue.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Development of appropriate fixation displays 
	NOTE: Tasks involving peripherally presented targets and simulated scotoma obstructing central vision present challenges when trying to estimate performance in a retinotopically defined location. Indeed, even in foveal tasks, the eyes make small, involuntary movements in the form of drift and microsaccades). Thus, in order to optimize fixation stability, careful thought should go into designing fixation aids.
	<ol>
		<li>Develop a fixation aid design that incorporates both a large fixation cross and a fixation box (Figure 5). Instruct participants to maintain the opaque occluder within the fixation box and use the long arms of the fixation cross as a reference for the center of the screen. 
		NOTE: This design combines both bullseye- and crosshair- types of visual aids, which have been shown to lead to the best fixation stability39. Additionally, by having both a fixation box and a fixation cross, this design can be easily used in translational contexts to test patients with central vision loss, as is the case of patients with MD.</li>
	</ol>
	</li>
	<li>Optimization of adaptive procedures to accurately measure performance 
	NOTE: A critical aspect of implementing different assessments is the ability to quickly and successfully estimate performance thresholds in a subset of these tasks (specifically visual acuity, contrast sensitivity, crowding, and contour integration). A challenge is that conventional staircases can be slow to converge and target performance close to the threshold, causing frustration and fatigue. To circumvent this, we implemented a three-stage procedure to estimate the performance of participants in these tasks.
	<ol>
		<li>In the first stage, ask participants to perform 12 practice trials before the actual experiment. During the second stage, utilize a 2-down 1-up staircase that terminates after 3 downward reversals (i.e., the direction of stimulus change, from down (hard) to up (easy), also refer to representative results section), followed by the third stage that consist of a conventional 3-down 1-up staircase that ends after 60 trials. 
		NOTE: Pilot studies indicated that this procedure achieves reliable thresholds for most tasks (visual acuity, crowding, and contrast sensitivity tasks). However, some tasks can require other methods, especially when performance can differ greatly across participants. For example, in the contour integration task, after the first stage of the procedure (practice), an additional procedure was implemented. The difficulty of the task was manipulated using a progressive staircase method where the orientation jitter (0°, 1°, 2°, 4°, 6°, 8°, 10°, 12°) increased every three trials for a total of 24 trials. Then, the second and third stages of the procedure (adaptive staircase) continued as normal. In general, different tasks may require slightly different adaptive procedures. However, the 3-stage approach allows participants to practice and quickly get within range of their threshold and provides detailed measurement within that range.</li>
	</ol>
	</li>
</ol>
<img alt="Static equilibrium diagrams with crossed vectors; visual perception experiment result, symmetrical design." class="xfigimg" src="/files/ftp_upload/67596/67596fig05.jpg" data-altupdatedat="1788304762000" data-alt="Figure 5"> 
Figure 5: Fixation aids used to promote fixation stability in participants. (A) Fixation cross and fixation box were used for fixation stability tasks. (B) The fixation cross, fixation box, and black cross at the center were used in low-level vision tasks. <a href="https://www.jove.com/files/ftp_upload/67596/67596fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Gaze-Contingent Framework for Studying and Training in Simulated Vision Loss

The authors declare that there is no conflict of interest regarding the publication of this paper.

In this methodological paper, we present a gaze-contingent framework for conducting perceptual research in simulated central vision loss that emphasizes hardware, design, and methodological considerations that are required to (1) choose the shortest system latency for gaze-contingent display, (2) administer a wide range of visual perception tasks, and (3) measure the oculomotor and perceptual performance of participants within this paradigm. Concerning (1), we emphasize the need for testing hardware and software reliabil...

Macular degeneration (MD) is the main cause of vision impairment globally, and it is projected to affect 248 million people worldwide by 20401. Late-stage MD is characterized by damage to the photoreceptors in the center of the visual field (fovea). Loss of central vision has severe effects on daily tasks that rely on central vision, such as navigation2, reading3, and recognizing faces4. Consequences of MD greatly impact the quality of life of these individuals5 and lead to negative psychological consequences6. Patients with MD, deprived of their central vision, may spontaneously develop compensatory oculomotor strategies involving the use of a peripheral retinal region to replace the fovea (Figure 1). This region, referred to as the preferred retinal locus (PRL)7, is often adopted by patients in tasks involving fixation, reading, and face recognition. There is evidence of the PRL, in patients with MD, taking over oculomotor referencing duties of the fovea8,9. Further, changes in attention and cognitive control are observed in patients with central vision loss, suggesting a relationship between vision loss and cognitive functions10. 
<img alt="Diagram of vision changes in macular degeneration; healthy, damaged fovea, retinal locus illustrated." class="xfigimg" src="/files/ftp_upload/67596/67596fig01.jpg" data-altupdatedat="1788304762000" data-alt="Figure 1"> 
Figure 1. Illustration of the perceptual experience of individuals with healthy vision and macular degeneration patients with foveal scotoma. Foveal scotoma leads to central vision loss in patients with macular degeneration. Some individuals can partially compensate for the loss of visual input to the fovea by using a peripheral retinal location, defined as  preferred retinal locus (PRL). In patients that developed a PRL, this is often used for eccentric fixation and during daily tasks. Retinal location, shape and size of the PRL can vary from person to person. <a href="https://www.jove.com/files/ftp_upload/67596/67596fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
While no gold standard intervention exists to recover vision loss or to compensate for loss of central vision, experimental approaches from optometry, occupational therapy and vision science are being tested to improve compensation through peripheral vision11,12. Oculomotor approaches focus on teaching patients to improve eye movement control and coordination, including teaching them to use a more adequate PRL11,12,13,14,15 while perceptual interventions focus on improving the general peripheral visual abilities or vision within the PRL, partially overcoming the limitation of peripheral vision16,17,18,19,20. Recent studies have used an eye-tracking based gaze-contingent display as a paradigm for the study of eye movements in central vision loss21,22,23,24,25,26,27,28,29. This approach, which utilizes a simulated scotoma (i.e., an occluder to obstruct the central region of the visual field) in healthy individuals (Figure 1), mitigates issues of recruitment and compliance, while providing high control on several parameters, such as the size and shape of the scotoma, thereby offering a promising alternative to the direct involvement of patients with MD. While there exists several differences between central vision loss and simulated scotoma30,31, some of the oculomotor behavior observed in the former, such as the development of a PRL, can be seen in the latter27,30,32, suggesting that some aspects of compensatory oculomotor strategies can be elicited by this gaze-contingent paradigm. Importantly, simulated central vision loss provides a broad framework for studying plasticity in both the healthy visual system and following central vision loss.
Here, we present the design, development, and use of a gaze-contingent framework that can be used to test perceptual, oculomotor, and attentional performances in healthy individuals and, with some modifications, in MD patients (Figure 2). We also detail the technical and psychophysical considerations that accompany gaze-contingent, peripheral training. A key technical challenge involves creating the perception of a smooth, short latency movement of the scotoma33. This short latency is obtained by selecting appropriate display devices, eye trackers, and operating systems34,35,36. Previous work has documented how each piece of hardware adds latency37 and strategies to reduce overall latency, accommodate blinks, and slow eye movements33. A novel aspect of our paradigm is the diverse set of training and assessment tasks within a single framework for perceptual research in both healthy and patient populations. The framework characterizes multiple levels of visual processing affected by central vision loss, specifically low-level vision, higher-level vision, attention, oculomotor control, and cognitive control. Preliminary tests conducted using a modified version of this approach showed evidence of improvement in visual acuity in both healthy controls and the patient population32. 
<img alt="Neuroscience diagram of cognitive and visual processes: oculomotor control, attention, visual acuity." class="xfigimg" src="/files/ftp_upload/67596/67596fig02.jpg" data-altupdatedat="1788304762000" data-alt="Figure 2"> 
Figure 2. Multidimensional approach to the study of plasticity in the visual system, and vision rehabilitation in Macular Degeneration. Illustration of interconnected dimensions such as visual perception, oculomotor, and cognitive control that contribute to visual processing and are affected in central vision loss. <a href="https://www.jove.com/files/ftp_upload/67596/67596fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

<table><tbody><tr><td>CRT Monitor</td><td>ViewSonic PF817 Professional Series CRT, ViewSonic Corp.</td><td></td><td>https://www.viewsonic.com/us/monitors.html?srsltid=&lt;br/&gt; AfmBOorEmjc67A5U2v2V&lt;br/&gt; wywNRHWzdrxcYx7Q3Y0&lt;br/&gt; 9tiNrnbs6FC4TPlc9</td></tr><tr><td>Display++ LCD Monitor</td><td>Cambridge Research Systems</td><td></td><td>https://www.crsltd.com/tools-for-vision-science/calibrated-displays/displaypp-lcd-monitor/</td></tr><tr><td>Eye Tracker</td><td>EyeLink 1000 Plus Tower Mount, SR Research</td><td></td><td>https://www.sr-research.com/eyelink-1000-plus/</td></tr><tr><td>Eye Tracker</td><td>Vpixx Technologies Inc.</td><td></td><td>www.vpixx.com</td></tr><tr><td>Macintosh IOS</td><td>Apple Inc.</td><td></td><td>https://www.apple.com/mac/</td></tr><tr><td>Windows 10</td><td>Microsoft Inc.</td><td></td><td>https://www.microsoft.com/en-us/</td></tr></tbody></table>

a gaze-contingent display framework for perceptual learning research with simulated central vision loss

A Gaze-Contingent Display Framework for Perceptual Learning Research with Simulated Central Vision Loss

Macular degeneration (MD) is one of the leading causes of vision impairment in the Western world. Patients with MD tend to develop spontaneous eye movement strategies to compensate for their vision loss, including adopting a preferred retinal locus, or PRL, a spared peripheral region that they use more frequently to replace the damaged fovea. However, not all patients are successful in developing a PRL, and even when they do, it might take them months. Currently, no gold standard rehabilitative therapy exists, and MD research is further hindered by issues of recruitment, compliance, and comorbidity. To help address these issues, a growing body of research has used eye tracking-guided, gaze-contingent displays in a simulated central vision loss paradigm in individuals with intact vision. While simulated vision loss is qualitatively different than pathological central vision loss, our framework provides for a highly controlled model through which to study compensatory eye movements and test possible rehabilitation interventions in low vision. By developing a comprehensive framework, rather than relying on isolated and disconnected tasks, we create a cohesive environment where we can test larger-scale hypotheses, allowing us to examine interactions between tasks, assess training effects across multiple measures, and establish a consistent methodology for future research. Furthermore, participants in simulated central vision loss studies show similarities in their oculomotor compensatory behaviors compared to patients with MD. Here, we present a framework for conducting gaze-contingent studies related to simulated central vision loss. We emphasize the utilization of the framework to test behavioral and oculomotor performance of healthy individuals on a wide range of perceptual tasks encompassing different levels of visual processing. We also discuss how this framework can be adapted for training MD patients.

In this section, we present illustrative data from both free eye movement and fixation-constrained tasks. The goal of this section is to illustrate data obtained using the framework and its ability to measure peripheral visual functions. The section is organized into four distinct categories, each highlighting critical elements necessary for accurate visual performance estimation under simulated central vision loss. These categories include performance on (1) low- and mid-level vision tasks, (2) attention measures in hig...

We present development of a gaze-contingent display framework designed for perceptual and oculomotor research simulating central vision loss. This framework is particularly adaptable for studying compensatory behavioral and oculomotor strategies in individuals experiencing both simulated and pathological central vision loss.

Macular degeneration (MD) is one of the leading causes of vision impairment in the Western world. Patients with MD tend to develop spontaneous eye ...

Below, we summarize key aspects of implementing a gaze-contingent framework for studying peripheral vision abilities.
1. Identifying an ideal system for simulated central vision loss research
<ol>
	<li>A first step is to identify a system that efficiently transmits information from the eye tracker to the stimulus generation software, in a continuous loop. We employed methods described in Saunders and Woods37 to measure latency of different combinations of systems, to identify the one with the lowest latency. A comparison of combined latency of four different combinations of systems comprising two eye trackers (EyeLink 1000 Plus Tower Mount and TRACKPixx3), two display devices (CRT Monitor (refresh rate = 100Hz) and Display++ (refresh rate = 120Hz)) along with two operating systems (Windows 10 and Mac iOS) is shown in Figure 3. Each combination was measured 20 times. Results showed that the system with the lowest latency was the Vpixx TrackPixx3 eye tracker in combination with the Windows 10 operating system.</li>
</ol>
<img alt="System latency comparison graph showing latency in milliseconds for E1000 and TP setups on Mac and Win." class="xfigimg" src="/files/ftp_upload/67596/67596fig03.jpg" data-altupdatedat="1788304762000" data-alt="Figure 3"> 
Figure 3. Latency comparison across different combinations of monitors, eye-tracking devices, and operating systems. (E1000: Eyelink 1000; CRT: Cathode-Ray Tube Display ++; Mac: Mac iOS; CRS: ViewSonicPF817; Win: Windows 10; TP: VPixx TrackPixx3). Bars represent the +/-1 standard deviation across the 20 repetitions per combination. Measures were taken with an Apple iPhone 12 in slow motion mode, reaching a refresh rate of 240Hz. TP/CRS/Win is statistically different from E1000/CRT/Mac (t(38)=9.53, p&lt;0.001), E1000/CRS/Mac (t(38)=16.24, p&lt;0.001) and E1000/CRS/Win (t(38)=3.94, p&lt;0.001). <a href="https://www.jove.com/files/ftp_upload/67596/67596fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
2. Participant familiarization with simulated central vision loss via gaze-contingent display
NOTE: A fundamental component in simulating central vision loss is to familiarize participants with the gaze-contingent display. Without proper familiarization, measures of abilities can be conflated by the participants' effort to navigate the gaze-contingent display. Several key steps in our protocol ensure sufficient familiarization with the gaze-contingent display to be able to measure visual performance reliably. These steps are summarized below:
<ol>
	<li>Participants are provided with audiovisual instructions about the task that they will be performing during a particular session. Each task has dedicated video instructions with screen captures from the actual task. This is followed by the experimenter explaining the instructions verbally to ensure that the participant has a good understanding of what to expect in a given task.</li>
	<li>Participants are provided with practice trials before beginning each of the main tasks. This provides an opportunity to clarify any questions related to the task.</li>
	<li>During the initial visit, before conducting gaze-contingent tasks, participants undergo fixation training, where they learn to place their simulated scotoma within a white central box on the screen for varying durations with spatial tolerance increasing across trials, while they ignore distractors that may appear on the screen.</li>
	<li>Additionally, participants undergo a 'PRL induction task', which is designed to promote development of PRL-like behavior. In this task, participants view an opaque disk randomly placed on the screen that covers a target (for example a Landolt C) and must move the scotoma close to the opaque disk to reveal the target. Oculomotor analysis of this task can indicate an early PRL-like location that can later be used as a training locus. In our experimental paradigm, the circular central scotoma subtended 10 degrees visual angle.</li>
	<li>These steps allow participants to familiarize themselves with the gaze-contingent display and prepare them to perform a wide range of perceptual assessments and training tasks by using their peripheral vision.</li>
</ol>
3. Development of effective instructions
NOTE: Instructions play a crucial role in guiding participants on how to respond to stimuli and manage their simulated scotoma during different tasks. Appropriate instructions must be thorough and clear to avoid any confusion. Instructions should be reiterated as needed to ensure understanding. The following methods are recommended to effectively convey task instructions:
<ol>
	<li>Instructional Videos:
	<ol>
		<li>Visual Demonstration: Videos visually demonstrate each step of the task. Videos should clearly illustrate how to manage the simulated scotoma appropriately during the task, and how to respond to stimuli.</li>
		<li>Narration: A concise script should be developed to accompany the visual demonstration that explains the process in simple terms. Ensure that language is easy to understand and avoid technical terminology.</li>
	</ol>
	</li>
	<li>Scripted Verbal Instructions:
	<ol>
		<li>Consistency: Use a standardized script for verbal instructions to ensure there is consistency across different sessions and participants.
		<ol>
			<li>Example: "Throughout the task, there will be multiple breaks to rest your eyes. During these breaks make sure to keep your head in the chin-rest. When you are ready to continue the task, press the spacebar and the task will begin again."</li>
		</ol>
		</li>
		<li>Clarity: Speak slowly and clearly – make sure to emphasize all important aspects of the task.</li>
	</ol>
	</li>
	<li>Visual Instructions:
	<ol>
		<li>On-screen instructions: Provide written guidance on the screen that participants can read before and during the completion of tasks. Use short sentences for clarity with visual aids to demonstrate stimuli that the participant may encounter during each task.</li>
	</ol>
	</li>
</ol>
4. Assessment Tasks' Design and Implementation
NOTE: Tasks designed within this framework are broadly divided into two main categories: (1) Free eye movement tasks and (2) Fixation-constrained tasks. In the free eye movement tasks, participants are allowed to make eye movements across the screen to identify targets appearing at random locations on the screen (or read text) whereas in fixation-constrained tasks participants are required to maintain fixation within a central white box throughout the task and use their periphery to make judgments. Figure 4 shows example tasks and descriptions for each category. More detailed information about the tasks can be found in Supplementary Material and Jayakumar (2024)38.
<img alt="Oculomotor task diagram with stability tests, acuity measures, attention assessment, visual skills." class="xfigimg" src="/files/ftp_upload/67596/67596fig04.jpg" data-altupdatedat="1788304762000" data-alt="Figure 4"> 
Figure 4. Perceptual Tasks: A visual representation of different assessment tasks designed using our framework. The tasks are broadly categorized into Free eye movement tasks where the scotoma follows the eye movements of the participants to view targets freely (top panel); and Fixation-constrained tasks where the scotoma needs to be placed within a central white box throughout the task (bottom panel). This task has been modified from38. <a href="https://www.jove.com/files/ftp_upload/67596/67596fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<ol>
	<li>Free Eye Movement Tasks 
	Free eye movement tasks measure participants' eye movement behavior while they perform tasks. These promote understanding of the eye movements in the context of naturalistic tasks such as reading and visual search. 
	General protocol for free-viewing tasks
	<ol>
		<li>Instructional Video/Verbal Instructions
		<ol>
			<li>An instructional video and scripted verbal instructions will be presented to the participant prior to the calibration.</li>
		</ol>
		</li>
		<li>Calibration
		<ol>
			<li>Validations of previous calibrations are run between tasks and additional calibrations are conducted when validations are poor, or when participants take breaks between tasks.</li>
		</ol>
		</li>
		<li>Free-Viewing task specific methods
		<ol>
			<li>Free-viewing tasks instruct participants to do a variety of actions using their gaze rather than fixating in one area. Some variants include:
			<ol>
				<li>Bring the scotoma near a cue, causing a stimulus to appear.</li>
				<li>Maintain fixation on a specific screen location for a period of time.</li>
				<li>Perform a standard task, like reading or visual search with central vision occluded by the scotoma.</li>
			</ol>
			</li>
			<li>At the beginning of tasks, participants are provided with on-screen instructions followed by a set of practice trials. Following the completion of the practice trials, they are given reminder instructions before moving on to the task. It is important the participants understand and have shown proficiency using the visual layouts, the required oculomotor actions, and the response characteristics of each task prior to measuring performance.</li>
			<li>Participants are provided with auditory feedback indicating the accuracy of their responses as they complete each task as visual feedback can be missed due to the use of a scotoma.</li>
			<li>Breaks up to one minute are built into each task to reduce the chance of testing fatigue. Breaks of 3 minutes or longer are built into days that include longer sessions of assessments to reduce the chances of testing fatigue.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Fixation-Constrained Tasks 
	Fixation-constrained tasks are useful to test, or train, peripheral vision at specific visual field locations. These tasks are suitable for testing both early- and mid-level visual processing, including visual acuity, contrast sensitivity, crowding, etc. as well as high-level visual processing including exogenous and endogenous attention. For these tasks it is important that participants learn to maintain steady fixation, to avoid task performance being confounded by attentional resources dedicated to steady fixation. During these tasks, participants are asked to keep their central vision focused on the center of the screen with the help of fixation aids (Figure 5B) while responding to stimuli that appear in their peripheral vision. 
	General protocol for fixation-constrained tasks 
	<ol>
		<li>Instructional Video/Verbal Instructions
		<ol>
			<li>An instructional video and scripted verbal instructions will be presented to the participant prior to the calibration.</li>
		</ol>
		</li>
		<li>Calibration
		<ol>
			<li>Validations of previous calibrations are run between tasks and additional calibrations are conducted when validations are poor, or when participants take breaks between tasks.</li>
		</ol>
		</li>
		<li>Fixation-constrained task specific methods
		<ol>
			<li>During fixation constrained tasks, participants are asked to maintain their head position in the chinrest for the duration of the task, ensuring that the calibration remains as accurate as possible to the original position throughout the process.</li>
			<li>Participants are provided with on-screen instructions followed by a set of practice trials. Following the completion of the practice trials, they are given a reminder set of on-screen instructions before moving on to the task.</li>
			<li>During these tasks, participants are asked to keep their central vision focused on the center of the screen with the help of fixation aids (white rectangular fixation box) while responding to stimuli that appear in their peripheral vision to either side of the fixation box.</li>
			<li>Participants respond using their right index finger on a five button response box, located to their right during assessment. If fixation is not maintained, the stimulus will not be presented, and will time out unless fixation is resumed.</li>
			<li>Participants are provided with auditory feedback indicating the accuracy of their responses as they complete each task, as again visual feedback can be missed due to the use of a scotoma.</li>
			<li>Breaks up to one minute are built into each task to reduce the chance of testing fatigue. Breaks of 3 minutes or longer are built into days that include longer sessions of assessments to reduce the chances of testing fatigue.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Development of appropriate fixation displays 
	Tasks involving peripherally presented targets and simulated scotoma obstructing central vision present challenges when trying to estimate performance in a retinotopically defined location. Indeed, even in foveal tasks, the eyes make small, involuntary movements, in the form of drift and microsaccades). Thus, in order to optimize fixation stability, careful thoughts should go into designing fixation aids. To do so, we developed a fixation aid design that incorporates both a large fixation cross and a fixation box (Figure 5). Participants are instructed to maintain the opaque occluder within the fixation box and use the long arms of the fixation cross as a reference for the center of the screen. This design combines both bullseye- and crosshair- types of visual aids, which have been shown to lead to the best fixation stability38. 
	Additionally, by having both a fixation box and a fixation cross, this design can be easily used in translational contexts to test patients with central vision loss</li>
	<li>Optimization of adaptive procedures to accurately measure performance 
	A critical aspect of the implementation of different assessments is the ability to quickly and successfully estimate performance thresholds in a subset of these tasks (specifically visual acuity, contrast sensitivity, crowding, and contour integration). A challenge is that traditional staircases can converge slowly and target performance that is close to the threshold might cause frustration and fatigue in participants. To circumvent this, we implemented a three-stage procedure to estimate performance of participants in these tasks. In the first stage, participants perform 12 practice trials before the actual experiment. During the second stage, we utilized a 2-down 1-up staircase that terminated after 3 downward reversals (i.e., direction of stimulus change, from down (hard) to up (easy), also refer to representative results section), followed by the third stage that consisted of a conventional 3-down 1-up staircase that ended after 60 trials. Pilot studies indicated that this procedure achieves reliable thresholds for most tasks (visual acuity, crowding, and contrast sensitivity tasks), however, some tasks can require other methods, especially when performance can differ greatly across participants. For example, in the contour integration task, after the first stage of the procedure (practice) additional procedure was implemented. Difficulty of the task was manipulated using a progressive staircase method where the orientation jitter (0°, 1°, 2°, 4°, 6°, 8°, 10°, 12°) increased every three trials for a total of 24 trials. Then the second and third stages of our procedure (adaptive staircase) continued as normal. In general, different tasks may require slightly different adaptive procedures, however, the 3-stage approach allows participants to practice, and then quickly gets within range of their threshold and provides detailed measurement within that range.</li>
</ol>
<img alt="Static equilibrium diagrams with crossed vectors; visual perception experiment result, symmetrical design." class="xfigimg" src="/files/ftp_upload/67596/67596fig05.jpg" data-altupdatedat="1788304762000" data-alt="Figure 5"> 
Figure 5. Fixation aids used to promote fixation stability in participants: A. Fixation cross and fixation box that were used for fixation stability tasks, B. Fixation cross, fixation box and black cross at the center that were used in low-level vision tasks. <a href="https://www.jove.com/files/ftp_upload/67596/67596fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
5. Adapting the framework for testing in MD patients
<ol>
	<li>While this framework is designed for simulated central vision loss in healthy individuals, it can be extended for research in MD patients, similar to previous gaze-contingent paradigms7,39,40. When adapting this framework for patients, it is important to keep in mind that their viewing strategies drastically differ from that of the sighted individuals. First, it is well known that patients with MD tend to have unstable fixations, thus despite recent attempts at calibrating eye-tracking devices used in vision research in this population41, this might prove challenging. To address this issue, we modified the nine-point calibration and validation process for MD patients by using larger calibration points combined with wedges and reducing the distance between the dots. This adjustment ensures that the targets appear closer to the center of the screen, preventing the need to view targets at extreme eccentricities. Additionally, because many tasks within our framework require stable central fixation, we included extra fixation aids, such as wedges that extend outward from the center of the fixation box to enhance detection. Secondly, it is also important to note that simulated and pathological scotomas differ in several key aspects, including the timeline of their formation, the development of compensatory strategies, and overall fixation stability, which may result in qualitatively different experiences. It is however possible to map the shape and size of the scotoma in MD patients through microperimetry testing and use this to define the shape of the scotoma in our tasks42. Finally, although the metrics we have presented may differ from those typically observed in patients, the ability to dissect eye movement behaviors and characterize the development of oculomotor strategies at various stages of simulated training offers a valuable tool. This approach enhances our understanding of how the visual system adapts to either simulated or pathological central vision loss.</li>
</ol>

a-gaze-contingent-display-framework-for-perceptual-learning-research

Research

JoVE Journal

Neuroscience

Neural control and cognitive processes can be studied through eye movements. The VisualEyes software allows an operator to program stimuli on two computer screens independently using a simple, custom scripting language. The system can stimulate tandem eye movements (saccades and smooth pursuit) or opposing eye movements (vergence) or any combination.

VisualEyes: A Modular Software System for Oculomotor Experimentation

Patients with visual deficits after stroke report about different constraints in daily life most likely due to variable compensatory strategies, which are difficult to differentiate in clinical routine. We present a clinical set-up which allows measurement of different compensatory head- and eye-movement-strategies and evaluating their effects on driving performance.

Driving Simulation in the Clinic: Testing Visual Exploratory Behavior in Daily Life Activities in Patients with Visual Field Defects

This article describes a novel method for simulating and studying adaptation in the visual system.

Visualizing Visual Adaptation

We recently proposed a method that allows dichoptic visual stimulus presentation and binocular eye tracking simultaneously1. The key is the combination of an infrared eye tracker and the corresponding infrared-transparent mirrors. This manuscript provides an in depth protocol for initial setup and everyday operation.

How to Build a Dichoptic Presentation System That Includes an Eye Tracker

Young children do not passively observe the world, but rather actively explore and engage with their environment. This protocol provides guiding principles and practical recommendations for using head-mounted eye trackers to record infants' and toddlers' dynamic visual environments and visual attention in the context of natural behavior.

Gaze in Action: Head-mounted Eye Tracking of Children's Dynamic Visual Attention During Naturalistic Behavior

This experimental protocol combined eye tracking and the assessment of presaccadic visual sensitivity in a dual task paradigm, consisting of a free choice saccade task and a visual discrimination task, to investigate the deployment of visual spatial attention before both, accurate and averaging saccades.

Investigating the Deployment of Visual Attention Before Accurate and Averaging Saccades via Eye Tracking and Assessment of Visual Sensitivity

Presented here is a protocol to improve stereoacuity using gamified perceptual learning software based on random-dot stimuli. Patients are stereo-deficient subjects without strabismus. The protocol combines optometry center visits with home exercises using software. Compliance and stereoacuity evolution are stored in the cloud.

Stereoacuity Improvement using Random-Dot Video Games

Presented here is a protocol for assessing binocular eye movements and gaze-controlled central visual field screening in participants with central vision loss.

Assessing Binocular Central Visual Field and Binocular Eye Movements in a Dichoptic Viewing Condition

The goal of our research is to correlate behavior to brain activity. Accurate behavioral measures and imaging techniques allow us to elucidate brain-behavior relationships.

Correlating Behavioral Responses to fMRI Signals from Human Prefrontal Cortex: Examining Cognitive Processes Using Task Analysis

We describe a novel methodology for creating naturalistic 3-D objects and object categories with precisely defined feature variations.  We use simulations of the biological processes of morphogenesis and phylogenesis to create novel, naturalistic virtual 3-D objects and object categories that can then be rendered as visual images or haptic objects.

Creating Objects and Object Categories for Studying Perception and Perceptual Learning

Learn a gaze-contingent display framework for studying perceptual learning and oculomotor adaptations in simulated central vision loss. This method enables researchers to investigate compensatory visual strategies and rehabilitation approaches.

A Gaze-Contingent Display Framework for Perceptual Learning Research with Simulated Central Vision Loss

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