Name: Workflows for the Photopic Negative Response and the Baby Vision Test (Video) | JoVE Journal
Uploaded: 2026-08-07T14:30:00.000+00:00
Duration: 5 min 44 s
Description: Learn standardized workflows for the photopic negative response and Baby Vision Test to improve clinical electrophysiology success rates. This 6E protocol enhances efficiency in pediatric ophthalmology and glaucoma diagnostics.

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The authors would like to express gratitude to all the participants and the people working on these workflows.

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	<li>Frishman L et al. ISCEV extended protocol for the photopic negative response (PhNR) of the full-field electroretinogram. Documenta Ophthalmologica. 2018;136(3):207-211.</li>
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The authors have no conflicts of interest to disclose.

While the photopic negative response (PhNR) and automated eye-tracking&#8211;based grating acuity assessments offer substantial promise for the objective evaluation of inner retinal function and infant visual acuity (VA), with the PhNR requiring neither refractive correction nor fixation monitoring5 and eye-tracking methods providing reliable acuity measurements without verbal responses7, both techniques remain underutilized in many clinical settings.
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Visual electrophysiology provides an objective, quantitative means of assessing visual pathway function from the retina to the cortex1,2. Conventional tests such as full&#8209;field electroretinography (ERG) and visual evoked potentials (VEPs) are widely used in clinical ophthalmology3,4. However, several specialized techniques with proven clinical value remain underutilized in routine practice.
Two such techniques are the photopic negative response (PhNR), a negative wave that follows the b-wave of the light-adapted electroretinogram (ERG) and reflects retinal ganglion cell function5,6, and the Baby Vision Test, a visual assessment modality that uses a dynamic target-based testing approach. The baby vision test uses a horizontally drifting grating (with luminance matched to the background) while recording eye movements. Spatial resolution is increased progressively, and visual acuity (VA) is estimated from the highest resolution that elicits stable tracking7. Although both techniques have demonstrated utility in research settings7,8, their widespread clinical adoption remains limited.
Several factors contribute to this gap. Electrophysiological recordings are susceptible to numerous confounds, including electromagnetic interference, grounding, electrode type and placement, stimulation parameters, patient factors (age, pupil, refraction, anesthesia), and environmental variables9,10,11,12. Procedural variability and lack of consistent reference data further undermine clinical confidence13.
To address these challenges, detailed, standardized workflows for PhNR and Baby Vision examinations are presented. These workflows are built upon a structured, checklist&#8209;based 6E framework (Environment, Equipment, Examinee, Electrode, Examination, and Exit) that explicitly specifies environmental conditions, standardizes each testing phase from patient preparation to electrode placement, and translates technical parameters into practical, step&#8209;by&#8209;step actions. By reducing operator&#8209;dependent variability and minimizing omitted steps, the 6E approach directly improves intra&#8209; and inter&#8209;subject reproducibility compared to conventional, less protocol&#8209;driven methods.&#160;The protocol is designed for routine clinical settings such as pediatric ophthalmology and electrophysiology laboratories. The aim is to facilitate broader clinical adoption of these valuable tools.

<table><tbody><tr><td>Compound tropicamide eye drops</td><td>Kingyork Group Hebei Univision Pharmaceutical,Tianjin, China</td><td>8327304</td><td>Fixed combination ophthalmic solution containing 0.5% tropicamide and 0.5% phenylephrine hydrochloride. Used for pupillary dilation and cycloplegia.&amp;nbsp;</td></tr><tr><td>Durapore</td><td>3M Deutschland GmbH,Neuss,Germany</td><td>108099995</td><td>High strength, non stretch silk like cloth medical tape.</td></tr><tr><td>GT20 Conductive Paste</td><td>GREENTEK, Wuhan, China</td><td>20142072064</td><td>Water soluble conductive paste for non adhesive electrodes in electrophysiological examination</td></tr><tr><td>GT5 Conductive Gel</td><td>GREENTEK, Wuhan, China</td><td>20152072150</td><td>Combined skin prep and conductive gel for electrophysiological recordings</td></tr><tr><td>MonpackOne instrument</td><td>Metrovision, Perenchies, France</td><td>20162160840,K211643</td><td>Integrated electrodiagnostic system for visual electrophysiology. Supports full field flash ERG, pattern ERG, multifocal ERG, VEP, multifocal VEP, and sensory EOG et al. Used in hospitals and clinics by trained ophthalmologists and medical professionals.</td></tr><tr><td>Vision Monitor Software</td><td>Metrovision, Perenchies, France</td><td>Mon2018F,K211643</td><td>Integrated software platform for visual electrophysiology. Controls stimulus generation (flash, pattern, multifocal), acquires bioelectrical signals via up to 5 channels, and processes raw data using spatial filtering and artifact rejection algorithms. Produces digitized ERG, VEP, EOG waveforms et al.&amp;nbsp;</td></tr></tbody></table>

workflows for the photopic negative response and the baby vision test

Workflows for the Photopic Negative Response and the Baby Vision Test

Visual electrophysiological tests are noninvasive, objective tools widely used in clinical ophthalmology. However, two promising modalities, the photopic negative response (PhNR), which assesses inner retinal and retinal ganglion cell function, and the dynamic target-based Baby Vision Test, remain underutilized in clinical practice despite their ability to provide valuable objective functional data. Limited adoption is primarily due to procedural variability, numerous confounding factors, and challenges in result interpretation. To address these barriers, clear and standardized operational protocols are essential for maximizing their diagnostic potential. Here, a standardized 6E workflow is proposed, encompassing Environment, Equipment, Examinee, Electrode, Examination, and Exit, designed to improve the clinical feasibility and implementation of these tests. In a retrospective analysis, implementation of the 6E protocol significantly increased the proportion of infants who successfully completed testing. Specifically, the PhNR test success rate increased from 61.54% to 86.45% (p &#60; 0.05), while the average duration of the Baby Vision Test decreased from 17.44 &#177; 9.89 min to 13.28 &#177; 9.24 min (p &#60; 0.05). These findings demonstrate that the 6E workflow enhances the clinical utility and efficiency of PhNR and Baby Vision testing, supporting their broader application in the diagnosis and management of glaucoma and pediatric visual disorders.

The clinical utility of the 6E workflow was evaluated by comparing examination outcomes before and after its implementation. Specifically, PhNR data were analyzed during the one-year period before and the one-year period after adoption of the 6E protocol (Figure 8), as well as Baby Vision Test data collected during the two-year periods before and after implementation (Figure 9).
Following implementation of the 6E protocol, the number ...

This article presents standardized workflows for the photopic negative response (PhNR) and the Baby Vision Test, two underutilized but clinically valuable electrophysiological modalities, to reduce procedural variability and enhance their diagnostic utility in glaucoma and pediatric visual disorders.

Visual electrophysiological tests are noninvasive, objective tools widely used in clinical ophthalmology. However, two promising modalities, the photopic ...

Our research focuses on standardizing PhNR and baby vision workflows to improve their clinical utility for diagnosing and monitoring ocular disease. This protocol is applicable to children&#039;s eye care, electrophysiology laboratories, and routine clinics for visual disorders.To begin, perform the routine calibration and verification of all stimuli and recording instruments according to the ISCEV recommendations. Verify that the electroretinography system is properly connected to the visual stimulator. Inspect all cable connections and confirm that they are intact and functioning correctly. Using alcohol soaked cotton swabs, disinfect the headrest and the chin rest before testing. Next, turn on the computer and wait until the desktop is fully loaded. Switch the stimulator rocker switch from O to I. Launch the acquisition software. Select the VEP and ERG menu and choose the PhNR protocol. Next, ensure that the camera is functioning properly.Explain the procedure to the parent or guardian, emphasizing that the examination is non-invasive and painless. Confirm that the child is awake and calm. Avoid testing children who are drowsy, dozing, or actively crying. Confirm the baseline pupil s

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Learn standardized workflows for the photopic negative response and Baby Vision Test to improve clinical electrophysiology success rates. This 6E protocol enhances efficiency in pediatric ophthalmology and glaucoma diagnostics.

Workflows for the Photopic Negative Response and the Baby Vision Test

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