Improving Reading Speed for People with Central Vision Loss through Perceptual Learning

Reading is difficult and slow for many low vision patients, especially those with central vision loss who are obligated to use their peripheral retina to read. The leading cause of visual impairment in developed countries is age-related macular degeneration (AMD),1–3 which is also the leading cause of central vision loss. Because reading is the most common clinical complaint as well as the primary goal for patients with central vision loss seeking visual rehabilitation,1,4,5 improving the reading performance for these patients is a key challenge facing low vision rehabilitation. Previous studies have examined a number of ways to improve reading performance in people with central vision loss. For instance, in low vision clinics, patients are routinely prescribed with magnifiers for reading tasks. However, even with magnification, reading speed in people with central vision loss is still lower than that at the normal fovea.5–8 Substantial effort has been invested to determine the mode of text presentation that offers people with central vision loss the fastest reading speed, including page format, scrolling-text in the horizontal or the vertical direction, and rapid serial visual presentation (RSVP), where words are presented one at a time on a display. Most studies found no significant differences in reading speed for different text presentation modes for people with central vision loss.9–11 A handful of studies found a small advantage of using RSVP,12 especially if the word presentation rate varied with word length13 or when observers were allowed to adjust their own presentation rate.14 Other attempts have explored whether simple manipulation of text typography and typesetting such as increasing letter spacing15,16 and line spacing,17 which presumably reduces the crowding effect among text, could improve reading speed. Unfortunately, none of these simple manipulations of text typography or typesetting improve reading speed for people with central vision loss.16,17 In this study, I explored the feasibility of using perceptual learning, a method that has proven to be effective in improving visual functions in normal and amblyopic visual systems, to improve reading speed for people with central vision loss. Perceptual learning is defined as “any relatively permanent and consistent change in the perception of a stimulus array, after practice or experience with this array”.18 Practically, perceptual learning is synonymous with “training” or “practice.”19 Previous studies have shown that visual performance improves with practice for a variety of tasks,19–25 in younger as well as in older adults,26,27 and in the normal fovea and periphery alike.19,27–31 In addition, perceptual learning has also shown effectiveness in improving visual functions in adults with amblyopia (monocular sensory loss of vision in the absence of an organic origin).32–38 In many cases, adults with amblyopia improved not only on the trained task, but their visual acuities (an untrained task) also improved as a result of training.33–37 Considering the effectiveness of perceptual learning in improving visual functions in the normal visual system and in adults with amblyopia, I asked whether perceptual learning would also be effective in improving reading performance for people with central vision loss. Clearly, there are many challenges facing the use of perceptual learning in improving visual functions in people with central vision loss. Specifically, the most common cause of central vision loss is AMD,1–3 which primarily afflicts people older than 65 years of age. It is well known that even though visual performance of older adults can improve with practice, more training may be required before the improvement reaches a plateau26 and that there may be more day-to-day lapses in improvement, which would lead to an overall reduction in the amount of learning.27 Also, in contrast to amblyopia, the majority of people with central vision loss suffer from bilateral vision loss and their functioning retina may not be healthy; whether these would impact the effectiveness of perceptual learning for people with central vision loss is unknown. Hence, despite the promising benefits that perceptual learning can deliver, it remains unclear if people with central vision loss can benefit from it. To my knowledge, there exists no published paper on using perceptual learning to improve visual functions in people with central vision loss, although previous studies have examined whether or not reading performance could be improved by training comprehension,39 or training patients to use a CCTV or stand magnifier to read.40,41 Comprehension training is a cognitive task, and the use of a CCTV or stand magnifier requires motor skills, making it unclear that any improvement from these training represents genuine improvement in the sensory system, which is the basis of perceptual learning. The goal of this study was to determine the feasibility of using perceptual learning to improve reading speed for people with central vision loss. Previous works have established that reading performance in the normal periphery benefits from perceptual learning based on the following training tasks: identifying random sequences of three letters at various positions across the visual field,19,27,31 performing a lexical decision task,31 and reading.31 The greatest improvement in reading speed was obtained using reading as the training task.31 Consequently, reading was used as the training task in this study.