Abstract:
In an embodiment of the disclosure, there is provided a handheld vision tester for vision self-testing by a user. The handheld vision tester comprises a touchscreen display, a control, and an interface port. The touchscreen display is configured to present different shapes, either statically or dynamically, to the user for the vision self-testing. One of the different shapes may be a modulated version of another similar shape displayed at the same time and includes a modulated edge. The control is configured to allow a user to trigger operations of the tester and allow the user to select one of the different shapes. The handheld vision tester is configured to determine results of the vision self-testing from the user selections and store the results in the handheld vision tester. The interface port is configured to transmit the stored results to a healthcare provider who uses the results to enhance treatment routines.

Description:
CROSS-REFERENCE TO RELATED APPLICATION 
       [0001]    This application is a continuation of U.S. application Ser. No. 13/319,305 filed on Nov. 7, 2011, entitled “Shape Discrimination Vision Assessment and Tracking System.” U.S. application Ser. No. 13/319,305 is the National Stage of, and therefore claims the benefit of, International Application No. PCT/US2010/034084 filed on May 7, 2010, entitled “Shape Discrimination Vision Assessment System,” which was published in English under International Publication Number WO 2010/132304 on Nov. 18, 2010, and has a priority date of May 9, 2009 based on provisional application No. 61/176,885 filed by Michael Bartlett, et al. and also has a priority date of Oct. 13, 2009 based on provisional application No. 61/251,159 filed by Michael Bartlett, et al. All of the above applications are commonly assigned with this National Stage application and are incorporated herein by reference in their entirety. 
     
    
     TECHNICAL FIELD OF THE INVENTION 
       [0002]    This invention relates to techniques for the design and implementation of a vision testing and assessment system. 
       BACKGROUND OF THE INVENTION 
       [0003]    Vision assessment today is most commonly carried out either with basic screening charts or by professional evaluation by a trained optometrist or ophthalmologist. Many well known screening tests are available. The well-known Snellen acuity chart is widely used, but other charts such as the “tumbling E” chart, the “Landolt C” chart, and the Amsler grid chart are also commonly used. Use of vision charts is suitable for analysis of common vision problems such as focusing disorders, but they are of limited value for monitoring more serious disorders such as diabetic retinopathy, age-related macular degeneration, and other serious disorders. These diseases have the potential to become active and degenerate rapidly. If not properly treated, permanent vision loss or even blindness may occur. 
         [0004]    Of course, methods exist for diagnosing and treating these more serious conditions. However, they generally require expensive and sophisticated equipment that must be operated by a specially trained technician, such as an optometrist or an ophthalmologist. In fact, the only commonly available tool for self-monitoring of most retinal disorders is the paper Amsler grid test. The Amsler grid is simply a square grid ruled on paper or cardboard. The user tests each eye individually by fixating on the grid and noting any grid segments that appear to be missing, wavy, or distorted. While simple and low cost, the Amsler grid is difficult to use since the individual must subjectively assess their own condition, it is not quantitative, and it can be very hard for patients to determine if missing, wavy, or distorted grid segments are slightly more or less pronounced from one test to the next. 
         [0005]    Hence, a low cost vision screening and assessment system that can detect the early signs of vision disorders, track their progress, and/or assess their relative severity is highly valuable. Such a system would allow persons to test their vision for serious vision disorders such as macular degeneration, diabetic retinopathy, glaucoma, and other disorders. Persons suffering from such disorders could use such a system to track their condition and validate the effects of their treatment in an objective and quantitative manner. And, of course, objective and quantitative vision testing can also be very useful to care providers in optimizing treatments for their patients. 
       SUMMARY OF THE INVENTION 
       [0006]    To address the above-discussed deficiencies of the prior art, in one embodiment, there is provided a method to self-test vision of a user for use with a handheld vision tester. In this particular embodiment, the method comprises: allowing the user to trigger operations of the handheld tester; employing a touchscreen of the handheld vision tester to present different shapes, either statically or dynamically, generated by the tester to the user for vision self-testing; receiving user input responses to the different shapes via the touchscreen display; determining results of the vision self-testing from the user input responses; storing the results in the handheld vision tester; and transmitting the stored results to a healthcare provider. One of the different shapes may be a modulated version of another similar shape displayed at the same time. The modulated version of the another similar shape includes a modulated edge. The healthcare provider uses the results to enhance treatment routines. 
         [0007]    In another embodiment, there is provided a handheld vision tester for vision self-testing by a user. The handheld vision tester comprises a touchscreen display, a control, and an interface port. The touchscreen display is configured to present different shapes, either statically or dynamically, to the user for the vision self-testing. One of the different shapes may be a modulated version of another similar shape displayed at the same time. The modulated version of the another similar shape includes a modulated edge. The control is configured to allow a user to trigger operations of the tester and allow the user to select, with the touchscreen display, one of the different shapes. The handheld vision tester is configured to determine results of the vision self-testing from the user selections and store the results in the handheld vision tester. The interface port is configured to transmit the stored results to a healthcare provider who uses the results to enhance treatment routines. 
         [0008]    The foregoing has outlined various features of the invention so that those skilled in the pertinent art may better understand the detailed description of the invention that follows. Additional features of the invention will be described hereinafter that form the subject of the claims of the invention. Those skilled in the pertinent art should appreciate that they can readily use the disclosed conception and specific embodiment as a basis for designing or modifying other structures for carrying out the same purposes of the invention. Those skilled in the pertinent art should also realize that such equivalent constructions do not depart from the scope of the invention. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0009]    For a more complete understanding of the invention, reference is now made to the following descriptions taken in conjunction with the accompanying drawings, in which: 
           [0010]      FIG. 1 a    shows a handheld device suitable for running a vision test; 
           [0011]      FIG. 1 b    shows an image of a user&#39;s face including key dimensions that may be used to determine the distance the user is away from the camera used to collect the image; 
           [0012]      FIG. 2 a    shows a Landolt C image for vision testing; 
           [0013]      FIG. 2 b    shows an Amsler grid image for vision testing; 
           [0014]      FIG. 2 c    shows an image for vision testing, including a reference circle and a circle with a modulated region; 
           [0015]      FIG. 3 a    shows an image for vision testing made up of multiple shapes in which one shape, a circle, is different from the other two, which are hexagons; 
           [0016]      FIG. 3 b    shows an image similar to the one of  FIG. 3 a   , but where the shapes have been moved to other locations on the screen to avoid creating a point of fixation; 
           [0017]      FIG. 4 a    shows a circle with pre-defined contrast as a function of radial dimension; 
           [0018]      FIG. 4 b    shows a modulated circle with pre-defined contrast as a function of radial dimension; 
           [0019]      FIG. 5 a    shows a first three-way selection test with two circles and one modulated circle, all the shapes having pre-defined contrast as a function of radial dimension, and the modulated circle having strong modulation; 
           [0020]      FIG. 5 b    shows a second three-way selection test with two circles and one modulated circle, all the shapes having pre-defined contrast as a function of radial dimension, and the modulated circle having moderate modulation; 
           [0021]      FIG. 5 c    shows a third three-way selection test with two circles and one modulated circle, all the shapes having pre-defined contrast as a function of radial dimension and the modulated circle having slight modulation; 
           [0022]      FIG. 6  shows a flow chart showing some elements of how a vision test routine may be controlled; 
           [0023]      FIG. 7 a    shows a graphical result of a shape discrimination vision test; 
           [0024]      FIG. 7 b    shows a graphical result of a shape discrimination vision test that includes freebies; 
           [0025]      FIG. 8 a    shows a quantitative result presentation for a shape discrimination vision test; 
           [0026]      FIG. 8 b    shows a numerical example of a quantitative result presentation for a shape discrimination vision test; and 
           [0027]      FIG. 8 c    shows a logMAR gray scale result presentation. 
       
    
    
     DETAILED DESCRIPTION 
       [0028]    In  FIG. 1   a,  an electronic handheld device  100  is shown. The handheld device  100  may include a case  102 , a display  104 , a cursor control  110 , a fingerprint sensor  114 , a camera  112 , a first button  106 , a second button  108 , a speaker  120 , a microphone  122 , a power connector  116 , and an interface port  118 . The display  104  may include touch-screen and/or multi-touch capability so that the handheld device  100  may be controlled by touching the display  104  in various locations or manners within certain timeframes. The fingerprint sensor  114  allows the handheld device  100  to identify the person using it (referred to as a user). Other techniques for positive identification such as voice analysis, passwords, biometric analysis, photographic analysis, and other possible techniques may also be implemented in the handheld device  100 . It is also possible to positively identify the specific handheld device  100  that was used to take a specific test by recording an identifying number or code specific to that handheld device  100  with the records for that test. In addition, the identifying number or code for the specific handheld device  100  might be beneficially marked or engraved somewhere on or inside the case  102  or other location of the handheld device  100 . Additional information regarding the user or the specific handheld device such as its date code, manufacturing date, serial number, and other information might also be beneficially marked, engraved, or otherwise indicated on or inside the handheld device  100 . Warning messages, reminders, safety warnings and other information may also be marked on or inside the case  102 . The cursor control  110  is a button that may be pressed to move a cursor across the display  104  and position it in a desired location. Pressing the cursor control  110  may also be used to trigger operations and to control the handheld device  100 . Alternative implementations of cursor controls including track balls, joysticks, touch pads, and other approaches may also be used in place of the cursor control  110  as shown in Figure la. The first button  106  and the second button  108  may be used to control the handheld device  100  and to operate functions of the handheld device  100 . It is noted that the handheld device  100  may be operated through manipulation of the display  104  if a touch-screen or multi-touch capability is included, through the cursor control  110 , through the fingerprint sensor  114 , through the first button  106  and through the second button  108 . Additional buttons and controls are possible including buttons and controls on the sides and back of the handheld device  100 . It is also possible that the handheld device may include only one button, or no buttons at all. In addition, some embodiments of the handheld device  100  may include accelerometers, gyroscopes, or tilt sensors to monitor motion, rotation, and orientation of the handheld device  100  so that the handheld device  100  may be responsive to how it is held and physically oriented or moved. As a simple example, the use of a tilt sensor would allow the device to monitor and/or respond to it&#39;s orientation to preferentially use the display  104  in a portrait or landscape orientation. The handheld device  100  may also include a microphone  122  and audio processing capability to so that voice or sound commands may be used to control it. Also, the handheld device  100  may include a speaker  120 , buzzer, vibrator, or other audible or physical signaling devices so that it can send messages and information to the user. Audible commands may benefit from use of a volume control that could be adjusted through the handheld device&#39;s  100  user control functions. And the camera  112  may be used to observe gestures, signals, sign language, and other symbols and movements of the user to control the handheld device  100  as well. Gestures involving actual motion of the handheld device  100  may be monitored with a motion sensor, accelerometer, or other techniques. It is also possible to include additional buttons, displays, an external mouse or trackball, and other forms of input devices. It is also noted that haptic, audible, or other feedback such as a click, buzz, vibration, jog, or other signal delivered on each button press, touch-screen or multi-touch press, or other activation of an input mechanism to the handheld device  100  may be beneficial to acknowledge the user&#39;s input and assure them that the handheld device  100  has or will respond to their inputs. 
         [0029]    The case  102  of the handheld device  100  may be constructed from metals, plastics, or other materials. While not shown in Figure la, the handheld device  100  may include removable panels on its front, back, or sides to allow batteries, memory cards, or optional accessories to be installed, connected, or removed. The power connector  116  allows the device to be powered from an external electrical power source that may supply AC or DC power to the handheld device  100 . Some interface ports  118  (such UNIVERSAL SERIAL BUS (USB®)) may also be capable of supplying power to the handheld device  100 . Interface port  118  allows the handheld device  100  to be connected to an external host computer, external cameras, external calibration or test equipment, external accessories, or other systems or devices the user may desire to connect it to. It is also possible that the interface port  118  or the power connector  116  could be configured to supply battery power from the handheld device  100  to an external device or interface connected to them. The interface port  118  may be constructed from multiple physical interfaces and protocols. Some examples are USB®, P1394, Ethernet, RS232, and many other possible interfaces. In addition to the interface port  118 , the handheld device  100  may include wireless connectivity. BLUETOOTH®, IEEE802.11, ZIGBEE®, and many other wireless communications protocols and radio electronics may be included in the handheld device  100 . The wired and or wireless connectivity of the handheld device  100  allows it to send information to a network service, host computer, or other computing device; and also allows for calibration, configuration, test protocols, software updates, and other useful information to be sent from a host computer or other data processing device or interface to the handheld device  100 . The procedure for allowing the handheld device  100  to either send data out over its wired or wireless interfaces or to receive information from other sources should normally include security features to ensure that the user&#39;s information and privacy are not compromised and also to ensure that configuration, calibration, and other important factors of the handheld device  100  operation cannot be compromised illicitly or accidentally. 
         [0030]    The handheld device  100  may be beneficially battery operated so that it can be used in a portable fashion in many locations when and where it is convenient for the user. Additionally, the handheld device may use power supplied to it over the interface port  118 , the power connector  116 , through wireless power sources, or through other possible ways of provide power to the handheld device  100 . In the case of operation from an internal or external battery, the handheld device  100  may beneficially include capability to alert the user of the amount of charge available from the battery and alert the user when battery charging is needed. The handheld device  100  may also check the battery level before a vision test is begun to ensure that adequate energy is available to complete the test so that a test is not interrupted due to loss of power. The handheld device  100  may also include software routines constructed so that in the event of a sudden power loss the information stored in the handheld device  100  such as prior vision test results and other information is not corrupted or lost. 
         [0031]    In this embodiment, the handheld device  100  is used to provide a vision test suitable for detected eye diseases and to monitor their present status or severity. As some vision tests are sensitive to the distance from the user under test to the display device being observed, it may be important that the handheld device  100  operate in a fashion that ensures that each test sequence is undertaken at an appropriate viewing distance. There are several options for how this can be achieved. First, the camera  112  may take a picture or even continuously monitor a video sequence of the user and make appropriate measurements from the image to ensure that the user is at an acceptable distance from the handheld device  100 . An example of use of a camera image  150  to determine viewing distance is illustrated in  FIG. 1   b.  In  FIG. 1   b,  a camera image  150  of a user&#39;s face  154  is shown inside the camera&#39;s  112  image boundary  152 . A horizontal image dimension  156  and vertical image dimension  158  are shown. Dimensions between some features of the user&#39;s face  154  are also shown. These are the distance between the pupils  160 , the distance between the outer eye sockets  162  and the dimension between the pupils and the bottom of the nose  164 . It is noted that for the purposes here of determining viewing distance that dimensions of the user&#39;s face  154  that are substantially unchanged by dress, mood, hairstyle, or other variable factors are preferred. That is, dimensions such as the distance between the pupils  160  are preferred over more variable dimensions such as the opening between the sides of the user&#39;s hair. Of course, many other dimensions of a user&#39;s face  154  may be used in addition to those shown specifically in  FIG. 1   b.  By monitoring the distance between the pupils  160  or other dimensions of the user&#39;s face  154 ; and with the knowledge of the magnification afforded by the camera&#39;s  112  optics, it can be readily computed whether the user is a suitable distance from the handheld device  100 . Such a technique for monitoring the distance the user is from the handheld device  100  may benefit from calibrating the actual dimensions of the user&#39;s face  154  to be used before testing begins. That is, if the handheld device  100  takes a photograph of the user when the user is at a known distance from the handheld device  100 , then the handheld device  100  can compensate for the actual size of the facial features of a specific user and more accurately estimate the distance the user is subsequently from the handheld device than would otherwise be possible. Alternatively, the camera  112  optics could be calibrated against an object of known physical size, for example a ruler, placed at a know distance from the camera so that a reference image can be collected against which images may be compared. It is noted that the size of a dimension of the user&#39;s face  154  (or any other object for that matter) in a camera image  150  may not be a linear function of the distance it is from the camera  112 . Consequently, use of non-linear correction factors or look-up tables may be beneficial in accurately computing the viewing distance from analysis of a given image  150 . Of course, if the camera  112  includes a zoom capability or other variable optics, it may be beneficial to take distance measurements with the camera  112  set to a known and fixed level of zoom every time such measurements are taken. Alternatively, variations in zoom could be accounted for in the distance computation. 
         [0032]    Of course, many other methods for measuring the distance from the handheld device  100  to the user are possible. Sonar, radar, light-based systems, and other electronic and photonic distance measurement devices can be incorporated into embodiments of the handheld device  100  to provide this function. Even simple mechanical techniques such as telescoping mechanical elements, strings that can be held from the user to the device, extendable chin rests, and many other techniques may be incorporated in to the handheld device  100  to ensure the user undertakes testing at an appropriate viewing distance. 
         [0033]    If the handheld device  100  detects that the user is not at a suitable distance for the test that is operating, the handheld device  100  may signal to the user through a visible, audible, or other way that he or she is either too close or too far away. The handheld device  100  may not continue operation of the testing until the user has positioned himself or herself at an appropriate distance so that accurate and reliable testing is substantially ensured. If the camera  112  or some other means of monitoring the distance to the user from the handheld device  100  that can generate an image of the user is used; then it is further possible for the handheld device  100  to ensure that the test is being undertaken correctly. For example, in some vision tests, it is critical that the user cover one eye and undertake the testing one eye at a time. In such a case, the camera  112  can be used to monitor the user and ensure that the user has the correct eye covered for each test. The camera  112  can also ensure that the same person is taking the test throughout the test sequence and the image of the user can be compared to images from past tests to ensure that the person taking the test is indeed the correct person. Other information, such as ensuring that the user taking the test is awake and upright and is holding the handheld device at a proper orientation can also be checked. 
         [0034]    It is noted that for some testing the handheld device  100  may automatically compensate for differences in desired viewing distances for some or all of the tests provided. That is, by monitoring how far the user is from the display  104 , the handheld device  100  may compensate for some variations in the viewing distance by adjusting the size of the test image presented in the display  104  or by varying other aspects of the test image (for example, viewing distance may also be compensated to some degree with the sharpness of the test image or by other factors). By automatically compensating for changes in viewing distance, the handheld device  100  may make it easier for a user to take their test. Instead of compensating for viewing distance by altering the size or other features of the test image, the handheld device  100  may also account for alternative viewing distances by scaling the user&#39;s resultant test score appropriately. And, of course, combinations of ways to automatically compensate for differences in viewing distance may also be applied. 
         [0035]    Visible glare that may appear on the display  104  of the handheld device  100  may be a substantial problem for accurate vision testing if it obscures test images and makes it difficult for the user to distinguish the images provided on the display  104 . Use of a matte finished display (or other type of display that reduces glare) to reduce glare may be beneficial. In addition, the camera  112  may be used to sense ambient light conditions and alert the user to reduce ambient light or move to another location if too much ambient light is present that may result in glare or otherwise cause issues with vision testing. Scratches, smudges, chips, and other damage or contamination of the display  104  may also make accurate vision testing difficult. Use of a display  104  with a hard coating to avoid damage or with a screen protection film may be beneficial. As noted previously, a matte finish may be beneficial, so a matte finished screen protection film (or other glare reducing film) may be desirable. Additionally, the handheld device  100  may at times remind the user to clean and wipe off the display  104 . 
         [0036]    It is also possible to add auxiliary displays to the handheld device  100  or to use the interface  118  or wireless connectivity to move images and/or video to an external video monitor. Auxiliary displays suitable for use with the handheld device  100  include LCD display panels, CRT displays, light processing display devices, head mounted displays, binocular display devices, virtual reality viewers, and many other types of displays. One example is use of the very small projectors that are now available and can be incorporated into small devices and allow images and video to be expanded for easy viewing. These small projectors are sometimes referred to as pico-projectors. Such a pico-projector may be physically integrated into the handheld device  100  or may be used as an external separate device connected to the handheld device  100  through a wired or wireless communication link. 
         [0037]    If an auxiliary display is used, the handheld device  100  may include hardware and software to ensure that proper viewing distance and display properties are available so that a reliable test may be completed. Hence, while images used for regular purposes may be displayed on a wide variety of available displays, the handheld device  100  might only send images or video for vision testing to displays that it can ensure are suitable for good quality testing. This requirement may impose the need for additional connectivity to an auxiliary display and also additional calibration and security features if the auxiliary display is to be used for vision testing. 
         [0038]    The functions of the handheld device  100  shown in  FIG. 1 a    may also be incorporated into electronic handheld devices that are already used for other functions. That is, the function delivered by the handheld device  100  may be implemented on a portable game console, a cellular phone, a personal digital assistant, a tablet computer, a netbook computer, a notebook computer, a blood glucose meter, or many other electronic devices. It is noted that there may be some benefit to using devices with somewhat larger displays as a greater area of the retina can be covered in vision testing (this may be more important for some vision disorders, but will be less important for others). However, larger devices with larger displays are normally less portable and may be more expensive, so tradeoffs of cost and convenience versus retina test coverage may need to be made. The ability to combine many functions together into a single device allows for convenience for the user and also allows for beneficial combined functionality in some cases. For example, if the handheld device  100  of  FIG. 1 a    includes the function of a glucometer, the user can record their blood glucose level when each vision test is taken so that a more complete record of vision capability and blood glucose can be generated (and this may be especially beneficial to users at risk with regard to diabetic retinopathy). If the handheld device includes a positioning technology such as the Global Positioning System (GPS), the records of vision testing can be location stamped so that the user can more easily remember where they took each test and what the testing conditions were. Of course, the handheld device  100  can easily include calendar and clock functions so that test results may also be time and date stamped. 
         [0039]    In  FIG. 2 a   , a Landolt C  408  test image is shown. The Landolt C  408  test is suitable for use with the handheld device  100  already described. The test image includes a display  104  outer boundary  402 , soft keys  404 , and reference lines  406 . In this test, the Landolt C  408  is rotated in 90 degree increments so that the “open” side of the “C” points to the right (as shown in  FIG. 2 a   ), to the left, upwards, or downwards. The user performs the test by pressing the soft key  404  in the direction in which the Landolt C  408  has its opening. The Landolt C  408  test provides for a vision acuity check. The test can be easily extended to include additional angles of orientation for the directions in which the “open” side of the “C” can appear in the course of a test. As noted previously, it is important that the Landolt C  408  test be conducted at an appropriate viewing distance. The display  104  outer boundary  402  is the limit of the display  104  area used for the test. It is noted that depending on the actual design of the handheld device  100 , the outer boundary  402  may be less than the physical limit of the display  104 . For example, to test for a high level of vision acuity, the Landolt C  408  may appear rather small in the handheld device  100  display  104 , so the entire display  104  area may not be used for some tests. The reference lines  406  are optional for the Landolt C  408  test and are included to better define the region in which the Landolt C  408  is rotated. Also, it is noted that the soft keys  404  may be pressed manually by the user with their fingers or with a stylus if that is preferred. And, instead of using the soft keys  404  for the user to provide their input on the orientation of the Landolt C  408 , this may be indicated by touching the touch-screen at a pre-defined location (perhaps in the “opening” of the C), by strokes on the touch-screen, by gestures monitored by the camera  112 , by movements of the handheld device  100 , through voice signals, or by other techniques. 
         [0040]    The Landolt C  408  test is based on a user&#39;s ability to distinguish the orientation of the “C” as a function of how large the image is presented. Of course, many other shapes may be used to create similar tests. Another common similar test is known as the “tumbling E” test. The “tumbling E” test is very similar to the Landolt C  408  test, the only key difference being the use of a letter E instead of a letter C. Of course, a very wide variety of shapes, such as circles, squares, triangles, and many other shapes that include some distortion, modulation, or other feature that allows their orientation to be specific so that a user can be challenged to identify it. 
         [0041]    In  FIG. 2 b    an Amsler Grid test image is shown. The Amsler Grid consists of grid segments  412  arranged in a regular rectangular grid within the outer boundary  402 . A center feature  414  is provided for the user under test to fixate on while identifying any missing, wavy, or distorted grid segments  412 . With a touch-screen capability in the display  104 , it is very easy for the user to indicate which grid segments  412  are missing, wavy, or distorted simply by pressing on the display  104  above such a grid segment  412 . With multi-touch capability in the display  104 , the user may be able to indicate the location of missing, wavy, or distorted grid segments even more quickly and conveniently. It is possible to separately track which grid segments  412  appear to be missing, wavy, or distorted and this information is useful in keeping track of the status of an eye disease over subsequent tests. That is, a missing grid segment  412 , may signal a more severe or advanced condition than a wavy or distorted grid segment  412 , so information for each level of condition can be collected separately and tracked automatically. The soft key  404  shown in  FIG. 2 b    can be used to indicate that the user sees all grid segments  412  normally. It is also noted, that the Amsler Grid test, like all tests described here, can be performed with different light intensities, colors, feature sizes, line weights, contrasts, and other image parameters to test the sensitivity and capability of the user&#39;s vision in a wide array of conditions. 
         [0042]      FIG. 2 c    shows an image for vision testing that includes a right circle  420  and a left circle  416  either of which may include a modulated region  418 . The outer boundary  402  serves the same function as in the prior figures. The soft key  404  is pressed by the user under test to indicate which of the two circles, the right circle  420  or the left circle  416  has a modulated region  418 . Of course, this selection can be done directly by touching the circle that has a modulated region  418  if a touch-screen display is used. And other methods of capturing this input from the user based on visible gestures, movement of the handheld device  100 , sounds, etc. are also possible. By changing the amplitude and location of the modulated region  418  and whether it appears on the left circle  416  or the right circle  420  it is possible to determine the user&#39;s ability to differentiate the presence or absence of a modulated region  418 . Of course, other shapes besides circles such as hexagons, squares, and other shapes can be used. And the modulated region  418  need not be a smooth curve as shown in  FIG. 2 c   , but may be triangular, rectangular, or of other shapes. The modulated region  418  may also appear at any angle around the circle including the top, the bottom, either side, or at other angles. And, of course, different colors, line weights, contrasts, brightness levels, and other factors may be varied so that the user under test&#39;s ability to distinguish the modulated region  418  under varying conditions can be determined. Depending on the display  104  size and format, the circles may be placed in any location on the display and not to the right and left as shown in  FIG. 2 c   . And additionally, while  FIG. 2 c    shows two circles, it is possible to create a similar test using three, four, or any number of circles or other shapes. With a larger number of circles or other shapes used in vision testing, the user selects from a broader number of choices and this may create a test with desirable attributes (the test may run faster, have more redundancy, be more accurate, or have other desirable attributes). It is also possible to use a single shape, such as the modulated left circle  416  shown in  FIG. 2 c    with modulated region  418  in the manner of the Landolt C  408  test already described. In such a test, the orientation of the modulated region  418  is changed along with the amplitude of the modulation  418  and/or the size of the left circle  416  as the user&#39;s ability to properly distinguish the orientation is monitored. 
         [0043]    In addition to the static images shown in the vision test in  FIGS. 2 a   - 2   c,  it is also possible to use dynamic images for vision testing on the handheld device  100 . Images that open or close (expand or contract), or move in other ways can be observed and/or compared to other dynamic or static images to help test for vision capability. 
         [0044]      FIG. 3 a    shows an image for vision testing suitable for use on a handheld device  100  made up of multiple shapes in which one shape, a circle  420 , is different from the other two, which are hexagons  424 . The display boundary  402  is shown for reference. In this vision test, the user selects the shape that is different from the other two by touching it on a touch-screen display  104 . Of course, this input could also be done with a keyboard, mouse, cursor controller  110 , soft keys, audible signals, gestures, movement of the handheld device  100 , or by other techniques. It is notable that in the image of  FIG. 3 a   , there is no point of fixation at which the user must concentrate their vision. In fact, the purpose of such a test is to force the user to employ their broader vision capability in identifying which of the three or more shapes is different from the others. 
         [0045]    Once the user selects which of the shapes in the image shown in  FIG. 3 a    is different from the others, in the embodiment as shown it is clearly the circle  420 , a subsequent test image may be presented to the user. This subsequent test image may be similar to the embodiment shown in  FIG. 3 b   . Note that  FIG. 3 b   , like  FIG. 3 a   , includes a display boundary  402 , a circle  420  and two hexagons  424 . However, the locations of the circle  420  and hexagons  424  have shifted inside the display boundary  402 . This is done intentionally to avoid the user fixating on one location in the test image and to encourage use of the user&#39;s broader vision. As with  FIG. 3 a   , the user when viewing  FIG. 3 b    would once again correctly select the circle  420  as the shape that is different from the other two. 
         [0046]    While  FIGS. 3 a  and 3 b    used circles  420  and hexagons  424  for shapes to be compared, may different shapes may be used. Squares, triangles, octagons, rectangles, and many other shapes can be applied. And while the circles  420  and hexagons  424  were relatively easy to distinguish from each other, shapes may be used that have only subtle differences so that the user is challenged to discriminate between them. In a vision test, a variety of easier and more difficult challenges in shape discrimination may be presented to the user so that the user&#39;s capability to detect small differences in shapes can be assessed. The subsequent images used for such testing may progressively become more difficult to distinguish as testing progresses, they may become more difficult based on some rules regarding the ability of the user to discriminate shapes in prior images, or may even be presented to the user randomly. Very many sequences for presenting more or less difficult shapes to discriminate are possible. It is also possible to make use of shapes that are turning, moving, changing size, rotating, or otherwise being altered in time as the test is taken. 
         [0047]    In  FIG. 4 a   , a circle  604  is shown that has pre-defined contrast as a function of radial dimension. The circle  604  is shown as a light circular region on a gray background. It also includes dark halos  610  and light halos  612  on both the inside and outside of the light circular region. It is noted that the contrast level of the dark halos  610  and the light halos  612  are a function of the radial dimension of the point of consideration on the halo to the center of the circle  604 . The use of a circle  604  that has pre-defined contrast as a function of radial dimension is beneficial in further encouraging the user of a vision testing system to avoid a specific point of fixation and instead employing their broader vision capability. Use of shapes with pre-defined contrast as a function of radial dimension also relaxes the dependence of test results on viewing distance. Hence, if shapes including pre-defined contrast such as the circle  604  of  FIG. 4 a    were used in the test described in  FIGS. 3 a  and 3 b   , some benefit in the accuracy of the testing may be achieved. Of course, many shapes including pre-defined contrast may be used instead of circles. Squares, triangles, ovals, ellipses, and many other shapes may be used. Also, the shapes need not be regular (that is, irregular shapes may also be used) and it is not even needed that they be closed curves. And, in addition to varying contrast with radial dimension, other aspects of the shape such as how sharp or fuzzy the lines are, brightness, color, and any other aspect of how the shape is presented may be varied. 
         [0048]    In  FIG. 4 b   , a modulated circle  608  is shown that has pre-defined contrast as a function of radial dimension. The modulated circle  608  is shown as a light region on a gray background. It includes dark halos  610  and light halos  612  on both the inside and outside the light region. The modulated circle  608  of  FIG. 4 b    is very similar to the circle  604  of  FIG. 4 a    with the exception that it has a modulated radius and is not a regular circle. Note that when the modulated circle  608  was formed, the pre-defined contrast as a function of radial dimension was applied first and the circular shape was then modulated so that both the light region and the dark halos  610  and light halos  612  were all modulated all together. The modulation applied in  FIG. 4 b    is a smooth curving change in radius as a function of angle, but many other modulations such as triangular modulations of radius, sinusoidal modulations of radius, and many other modulation functions can be applied. It is also possible to create irregular shapes and even shapes that are not closed curves for shape discrimination testing. 
         [0049]    In  FIGS. 5 a , 5 b , and 5 c    a sequence of vision test images  700  that may be utilized on the handheld device  100  are shown. These would normally be shown to a user in turn and the next image would be shown once the user responds to the image being shown to them presently. The test images  700  are three-way selection shape discrimination tests. In the first test image  700  shown in  FIG. 5 a   , two circles  604  and a modulated circle  608 , all of which have pre-defined contrast as a function of radial dimension, are shown. Similar to the vision test described in  FIGS. 3 a  and 3 b   , the three-way shape discrimination test image  700  is viewed by a user who selects which of the three or more shapes (in this embodiment three shapes are shown, but more can be used if desired) that is different from the others. This selection may be done by touching the display  104  over the shape being selected if a touch-screen or multi-touch display is used, or may be done with buttons, a mouse, cursor controls, audible inputs, gestures, or other techniques. In the embodiment shown, the different shape is clearly the modulated circle  608 . In  FIG. 5 b   , there are still two circles  604  and one modulated circle  608 , but the modulation level of the modulated circle  608  has been reduced so that it is harder to distinguish from the circles  604 . The order of the shapes has been changed so that the user must recognize that the modulated circle  608  is now to the right and no longer in the center location as it was in  FIG. 5 a    and the relative location of all the shapes has been shifted slightly upwards, downwards and/or side-to-side to avoid causing the user to fixate at a specific point in the image. In addition, the modulation phase has been changed randomly to minimize the cues of localized deviation from circularity from one test trial to another. That is, the modulated circle  608  has also been rotated randomly so that the phase of the modulation may not provide any visual cues. As testing progresses, the user may then be shown the test image of  FIG. 5 c    in which the modulated circle  608  is now to the far left and the modulation level is very small so that it is rather difficult to notice that it is different from the circles  604 . 
         [0050]    The vision testing approach shown in  FIGS. 5 a , 5 b   , and  5   c  offers several advantages. First, since it is desired that the user not fixate on a specific point in the images, there is no loss of accuracy if the user shifts their vision. In fact, it is desirable that the user make use of their broader vision. Second, the use of shapes such as the circle  604  and the modulated circle  608  that have contrast that varies with radial dimension makes the test less sensitive to small blurs in the display  104  that may be caused by manufacturing defects, dust, smudges, streaks, or other dirt and contamination. Also, since the shapes used in the images are intentionally blurred (by the radial variation of contrast), the test is less sensitive to imperfections of the visual accommodation of the user (that is, whether or not the user has good focusing ability and has a proper lens prescription if needed), and for substantially the same reasons, the test is also less sensitive to viewing distance from the user to the display  104 . The embodiment shown in  FIGS. 5 a , 5 b , and 5 c    used circles  604  and modulated circles  608 , but other shapes (such as squares, triangles, irregular closed and open curves, etc.) that are somewhat blurred, have halos, have variable contrast, have shading, have lighter and darker pixels, or are otherwise made somewhat fuzzy may also provide good results as vision test images. And, of course, such shapes may be presented in a wide variety of colors, contrast levels, brightness levels and with other alterations to their construction and presentation. 
         [0051]      FIG. 6  shows a flow chart  800  showing some elements of how a vision test routine may be controlled through a computer program. While many program control flows are possible for the operation of the handheld device  100 , several novel features of the flow chart  800  are included to help ensure accurate and reliable testing results. First step  802  indicates the beginning of the flow chart and the INPUT line  804  indicates that ID (identification) information for the user of the system and profile information about that person is made available to the program. This information may be received from prior inputs from the user, other programs, configuration information loaded by a health care provider or computer system administrator, over the internet, or via other means. First control step  806 , may check the user&#39;s ID against the information received by the program from the INPUT line  804  and may verify the user&#39;s identity. The identity information used may include a photograph of the user, a password, electronic fingerprints, or other methods of verifying identification. Since the handheld device  100  may include a camera, fingerprint sensor, fundus camera, and means to collect other biometric data, there are potentially many ways to verify the user&#39;s identification. In addition to purposes for verifying the user&#39;s identification, this biometric data may be collected and stored in the handheld device to note the user&#39;s condition of health. Additionally, the biometric data may be date-stamped so that it can be associated to the user&#39;s health condition at a particular time and associated with particular vision testing results. Examples of biometric data include, without limitation, pupil dilation, iris color, eyelash growth, heart rate, blood pressure, ptosis, and results of other health condition measurements. Much of this biometric data can be assessed with the camera, but some may require to be collected through other auxiliary devices as well. In second step  808 , user information may be updated once the user&#39;s identification has been verified. The user information may include information such as their preferred language, age, race, sex, blood pressure, glucose reading, resting heart rate, weight, medications, dosage levels, and other health related information. Biometric information, the results of health measurements and/or medical tests, the time and date of the dosage levels at which medications have been administered, side-effects the user may be experiencing from medications or treatments, and observations or comments the user may have regarding their state of health may be updated in second step  808  as well. Some of this information may come from an auxiliary device such as a glucometer, medication dosing aid, or other instruments and may be entered into the handheld device either manually by the user or automatically through an electronic interface. Medication dosing could also be recorded by the handheld device as a video to create a record of each medication dosing. The user information may also include other information about the user such as their email address, phone numbers, information regarding how to contact their health care provider, and other information the handheld device  100  may need to facilitate care for the user. It is noted that users may be likely to achieve the most accurate results when using their most comfortable language, hence, multilingual support based on the available user information may be important for the handheld device  100 . 
         [0052]    First control step  806  may also check to ensure that the software loaded on the handheld device  100  is a recent version and has not expired. The handheld device&#39;s  100  software may include expiration dates or a total number of times the software can be used before it is mandatory that the software be updated. This is an important safety feature as it ensures that old versions of the software cannot be used for a long time. Old software may have bugs that have been corrected in newer versions or newer software may have enhancements that make the vision testing more accurate, reliable, or beneficial in other ways. If the software version operating on the handheld device has expired or is not usable for some other reason, first control step  806  may pass control to exception handling service routine  828 , where the user may be directed to download updated software, request customer service, or otherwise address the situation. It is noted that automatic software updates may also be provided and the handheld device  100  may simply access the internet according to a regular schedule and check for possible updates to be downloaded and installed. Alternatively, if specific handheld devices  100  are registered with a host computer system, updates may be sent to the specific handheld devices  100  as soon as they are ready for use. 
         [0053]    Second control step  810  pretests, determines light levels, and self-tests handheld device  100 . The pretest may be included to verify that the user is in a correct state to allow a valid vision test to be completed. This may be important to ensure that the user is alert, awake, not under the influence of medications, drugs, or alcohol, and is generally ready for the vision test. The pretest may be a short game, coordination check, or other check where the result is compared to past results for the user from prior testing. At this point in the program, the handheld device  100  may check the ambient light levels to ensure that the user is in an environment adequate for the vision testing. This may normally be done using the camera  112  to sense the ambient light levels, but may also be done with other light detectors such as a photodiode. Second control step  810  may also include a device self-test. In a self-test, the handheld device  100  may check its memory for proper functionality, and may check its interfaces and operating parameters for acceptable conditions. The self-test may direct the user to further test or calibrate the handheld device  100  if a problem is detected. 
         [0054]    If second control step  810  has a valid outcome, a user-specific vision test or a standard test may be generated or accessed by the system software. The profile information from the INPUT line  804 , the user information received in the second step  808 , and possibly results from prior vision tests for the user may be used to determine what vision tests should be included. For example, a user with macular degeneration may benefit most from different tests than a patient with diabetic retinopathy. A user specific test generation is generated in third step  812  and once the user specific test is ready, fourth step  814  runs the test while monitoring the user&#39;s viewing distance, which eye the user has covered, and possibly other parameters. These other parameters might include monitoring an accelerometer or other motion sensor to sense if the user is shaking or otherwise moving more than would be acceptable for an accurate test result. It may also include monitoring of the ambient light levels, and/or checking for the presence of glare. The time the user takes for each test input may also be monitored so that interruptions of the testing or very long response times may be noted as possible indications of an invalid test. If any situations arise during the vision test that may compromise the accuracy of the results, the user may be notified to correct them. And if a correction is not made, the results may be marked to indicate they were received under questionable operating circumstances. 
         [0055]    Some means to allow the user to pause or abort testing may be included in fourth step  814  functions, and also, may be included in other areas of the flow chart  800  as well. This is beneficial as the user may be interrupted with a phone call, visitor, or have some other reason to want to stop testing immediately and resume later. The ability to pause and resume testing may be limited to short interruptions as the reliability of the test may be compromised if the user&#39;s condition, ambient conditions, or other factors have changed since testing was paused. Consequently, a time out function may be necessary if a pause feature is included. It is noted that records of partial tests, aborted tests, and paused tests (whether or not they timed out) may be stored in the handheld device  100 , but should be properly recorded to ensure that they are not confused with valid and complete test results. 
         [0056]    Third control step  816  checks to ensure that results from the test run in step  814  are reliable. This includes checking to ensure that all the parameters being monitored during the course of the test, such as viewing distance and proper eye coverage, etc., are nominal. And it may also include analysis of the test results to ensure consistency. That is, the vision test may be designed to include some redundancy in testing so that user responses on various tests are consistent with each other and indicate that the user took the test properly and was not guessing, making random inputs, or otherwise taking the test capriciously. One way this may be achieved is to occasionally present the user with a “freebie” test. That is, while the normal course of a vision test may be to subsequently make it more difficult for the user to distinguish the features of the test image (this was illustrated in the explanation of  FIGS. 5 a , 5 b , and 5 c   ), it may be beneficial to occasionally give the user a rather easy test image to respond to. This is referred to as a “freebie”. If the user doesn&#39;t quickly and accurately respond to the “freebie” it may be a sign that the user is not taking the test actively, is tired, or is somehow otherwise impaired. Additionally, occasionally offering the user a “freebie” test image may help the user maintain confidence and keep trying to master the test. 
         [0057]    Third control step  816  may also check specifically for false negative test results. False negative results are especially troublesome as they may indicate to the user that their condition is okay, when they may actually have a vision condition that needs attention. A false negative may be the result of the user cheating on the test by moving the handheld device  100  closer to them than they should for some test decisions, studying the test image for a long time, asking a person with them what answer to provide, and possibly other ways. Additionally, a false negative may occur if the test is not specifically sensitive to the user&#39;s condition or possibly for other reasons. For this reason, it may be important to ensure that all operating parameters (user condition, ambient light conditions, response timing, etc.) are consistent with accurate testing before a negative test result is provided. 
         [0058]    If the results appear to be reliable, third control step  816  passes control to fourth control step  818  which may determine whether the test results show a significant change in vision. As noted previously, a substantial benefit of vision monitoring may be gained in noting if changes in a user&#39;s vision have occurred from previous testing. Hence, fourth control step  818  may check specifically for this and direct the program to fifth control step  820  which checks if an additional test is needed if significant changes may have occurred. If fifth control step  820  finds that prior test results are not consistent (or if there are no prior results to compare to), a new user-specific test may be generated by third step  812  so that the user is not influenced by remembering how he or she responded to the prior test. That is, while the additional test may substantially test for the same conditions as the prior test, it may be presented so that the results are not influenced by the user&#39;s perceptions from the prior test. Fourth control step  818  and fifth control step  820  may also make other assessments. For example, if this is the first time a new user is receiving the test, it may direct control to complete multiple tests simply to verify consistency of the test readings and to more rapidly build a database of results for the user. 
         [0059]    If acceptable results are found so that no additional tests are needed, fourth control step  818  passes control to fifth step  822  where a data archive kept in the handheld device  100  may be updated with the new results and results may be provided to the user. Once again, if fourth control step  818  indicates a change in the users test results, control passes to fifth control step  820  where the results of the previous test, if one has already been completed, are compared to the results of the present test. If a sufficient number of tests (the system could be configured for any number of additional tests as desired) show consistent results, control also passes on to fifth step  822  for data archiving and presentation of the results to the user. 
         [0060]    Fifth step  822  may perform two very important functions. First, it updates the data archives kept in the handheld device  100 . The archives may include all information about the testing that was just completed. For example, the date and time the test was taken, identification of the handheld device  100  used, where the test was taken (if position information is available), how the user&#39;s identification was validated, a picture of the user, the room conditions, the distance from the user to the handheld when the test was taken, the time taken for and the result of each response the user gave in the course of the test, the length of any pauses in the testing, any invalid results, any special conditions that arose, the results of all tests given, and other information may be archived. Additional information such as screen shots of the handheld device&#39;s  100  display  104  at various points of the testing, and especially the screen shot presented to the user providing the results of their test, may also be archived. Of course, additional parameters may be archived, or for some embodiments, it may not be necessary to include all the information listed here. In any case, however, sufficient information may be archived so that a substantially complete and accurate record of the testing is kept. 
         [0061]    The second key function of fifth step  822  may be to notify the user of the results of his or her test. This may be done visually on the handheld device  100  display  104 , audibly, or by other means. But in any case, the results provided to the user may include their specific test scores and also some information about what the scores mean. That is, the handheld device  100  may assure the user that their scores are within reasonable bounds of their past scores. Or, if the user&#39;s vision has changed such that the handheld device  100  concludes that a professional evaluation is warranted, the handheld device  100  may direct the user to contact their health care provider for an evaluation. Of course, the handheld device  100  may also be used to keep track of the user&#39;s appointments including their scheduled visits with healthcare providers. So in some cases, the handheld device  100  may produce normal results for vision testing, but still remind the user that they have a regular appointment with a healthcare professional. 
         [0062]    Additionally, it may be beneficial to pass inspirational or encouraging messages to the user. As it has been scientifically demonstrated that a positive outlook leads to better physical health, the user may benefit if they are given positive encouragement in the course of their testing and especially when their results are provided to them. Other information that may be beneficial to the user such as recommendations for a healthy diet with exercise, advertising and branding information, or other information may also be passed to the user from the handheld device  100  at multiple points through the course of its use and, in particular, when the user is provided and/or is about to be provided their testing results. Of course, the inspirational and other messages may be tailored to the user&#39;s specific preferences through information stored in the handheld device  100 . For example, if it is known to the handheld device  100  that the user is trying lose weight, some encouragement consistent with this goal may be especially beneficial. Similarly, if the user&#39;s religion is known, inspirational messages can be tailored to be appealing to them more specifically. 
         [0063]    Control then passes from fifth step  822  to sixth step  824  where the testing results may be uploaded to a healthcare provider, clinical study coordinator, or other appropriate entity. The testing results may also be uploaded to a data server. Users with especially acute conditions, for example, may want a professional to review their testing results on an ongoing basis. Or, since the handheld device  100 , could be damaged, destroyed, lost, or stolen, the user may want their results to be stored on a computer system server so that they can be recovered if needed. In either case, wired or wireless networking technology such as DSL, fiber optics, wireless LAN, wireless WAN, or other wired or wireless data transmission technologies may be used to upload the data. Some user&#39;s may want email messages with their test results sent to specific email addresses and than can also be completed in sixth step  824  if desired. 
         [0064]    It is also possible for data uploaded from the handheld device  100  to be used in the construction of databases of information that may be used to enhance knowledge of various testing and treatment routines. That is, if a user is known to be taking certain medication, uploading and analyzing their vision testing results allows comparison of their results with others so that a substantially complete and accurate knowledge of the effectiveness of certain treatments may be assessed. This information may be beneficial to developers of treatments and especially in the conduction of medical trials to assess the efficacy of treatments. In addition to the scientific benefits of such data collection, business models in which companies or individuals wanting access to certain data may financially compensate a handheld device  100  user, or a provider of vision testing technology, may also be possible. As an example, a health insurance provider may incentivize users to take regular tests and possibly also upload their test results in the interests of making overall disease management and/or treatment more cost effective. 
         [0065]    In the course of the program running the vision testing on the handheld device  100  as shown in the flow chart  800  in  FIG. 6 , several control steps pass control to exception handling service routine  828 . First control step  806 , second control step  810 , and third control step  816  all include conditions for which negative or invalid results result in sending control to exception handling service routine  828 . Depending on the nature of the invalid or negative result, and depending on electronic diagnostics and self-testing the handheld device  100  performs on itself to ensure proper operation, exception handling service routine  828  may direct the user to perform different functions so that proper testing can resume or be initiated. For example, if the user&#39;s identification fails, exception handling service routine  828  may simply notify the user and allow them to try again. However, if the self-test of the handheld device  100  has failed, the user may be directed to test, service, or calibrate the handheld device  100 . Other conditions may be dealt with in appropriate manners as well. If the room ambient light is too bright, the user may be directed to change it. If inconsistent test results were determined and the test was deemed unreliable, the user may be notified and asked to take the test another time. If repeated unreliable results occur, the user may be directed to seek a professional evaluation from their healthcare provider. Since the handheld device  100  may make very many measurements and use very many techniques to ensure an accurate and reliable test, it is not practical to list many dozens or even hundreds of them here. However, the overall flow of the flow chart  800  makes it clear that the handheld device  100  will use many techniques to ensure accurate and dependable results. 
         [0066]    Once all testing, archiving, user notifications and other functions are completed, program control passes to seventh step  826  where operation is ended and the program ceases operation until it is restarted. In some cases, the handheld device  100  may include alarm functions to alert a user that they have a scheduled vision test to complete. In such a case, the handheld device  100  may start up automatically and send audible and/or visible or other signals to the user to remind them to take their test. The handheld device  100  may also include other calendar, appointment management, or other user convenience software. Additionally, it may be synchronized or updated by other calendar management software so that the user may conveniently keep track of their personal appointments along with their testing schedule, heath care provider appointments, medication schedule, reminders to take vitamins and/or exercise, and other aspects of their overall care. 
         [0067]      FIG. 7 a    shows a graphical result of a shape discrimination vision test  900 . The first trial image is represented by the first cross  901  which is shown at an elevated modulation level as it is positioned at a high level on the vertical axis  902 . Note that the vertical axis  902  represents modulation level and this is clear in  FIG. 7 a    as the words “Modulation Level” are shown as a title on the vertical axis  902 . Modulation level as shown in  FIGS. 7 a  and 7 b    refers to the amplitude of the modulation of a modulated shape such as the modulated circle  608  of  FIG. 4 b   , or  FIGS. 5 a , 5 b , and 5 c   . Subsequent trials are represented in  FIG. 7 a    as progressing to the right along the horizontal axis  904  that is also labeled with the word “Trial”. Each subsequent trial is also represented by a cross  908  and the modulation level for the next several trials are shown as decreasing with each subsequent trial. This approach is beneficial as a very large modulation level may be used for the first few trials so that the user intuitively learns that the modulation will decrease on subsequent trials if correct answers are provided. Of course, as explained with regard to  FIGS. 5 a , 5 b , and 5 c   , as the modulation level is decreased, it will eventually become difficult to accurately determine a modulated shape versus an un-modulated shape (i.e. a shape with no modulation) so the user will invariably make a mistake at some point. The mistake trial  912  illustrates this and shows that if a mistake is made, the modulation increases on a subsequent trial. Once correct responses to a trial resume, the modulation will again decrease on subsequent trials. It is noted that an amount modulation increases  914  when a mistake is made may be different from an amount modulation is decreased  916  when a correct answer is entered. After some number of trials, an accurate representation of the limit of the user&#39;s modulation threshold  906  may be estimated. The modulation threshold  906  may be determined from the data in a number of ways. One approach would be to take the modulation threshold  906  to be the level at which an equal number of decreasing and increasing modulation trials (i.e., an equal number of mistakes and correct result entries) are made over some number of past trials. For example, the modulation threshold  906  could be taken as the level at which an equal number of correct results and mistakes occurred over the last four trials. The modulation threshold  906  might also be taken as the modulation level that was crossed with correct (or incorrect) answers some fixed number of times. For example, in  FIG. 7 a   , the modulation threshold  906  is a level that was crossed three times with correct answers. The third correct crossing  918  in  FIG. 7 a    illustrates this. Or the modulation threshold might also be taken as the mean of several reversals (the level changes from correct to incorrect or from incorrect to correct). Another way to determine the threshold might be to fit a mathematical function that describes the threshold behavior of the visual system to the percent correct rates at various testing levels. The reliability of the threshold estimation may be assessed by analyzing fitting parameters and by comparing threshold values obtained with various threshold determination methods. 
         [0068]      FIG. 7 b    shows a similar graphical result of a shape discrimination vision test  900  to that shown in  FIG. 7 a   , but freebie  920  and freebie  922  are included. As previously described, a freebie trial is a trial in which the user is presented with a rather large modulation with the expectation that it should be an easy test for them to answer correctly. Hence, observation of the user&#39;s replies to a freebie is one way of ensuring that the user is actively engaged in the test and isn&#39;t just guessing. Another measure of the user&#39;s ability to correctly take the test is the consistency of the level at which mistakes occur as the test trials progress. In  FIG. 7 b   , the first mistake trial  912 , the second mistake trial  924  and the third mistake trial  926  all occur at similar modulation levels. Consequently, the confidence in the modulation threshold  906  level for the user is relatively high as the user appears to be consistent in the level of modulation reached before a mistake is made. Other ways of assessing the user&#39;s consistency include consistently correct answers for higher modulation levels above the modulation threshold  906 , and other possible statistical or other mathematical analysis techniques. It is noted that the amount the modulation is varied after the occurrence of a freebie may resume from the level of modulation prior to the freebie, may decrease from the level of modulation prior to the freebie assuming the freebie trial was answered correctly, or may follow other rules for variation of modulation including random variation of modulation rules and other rules. 
         [0069]      FIG. 8 a    illustrates a quantitative result presentation  1000  for providing results to the user and/or tabulating results of a shape discrimination test. The L  1010  indicates that the results above it are for the left eye and the R  1012  indicates that the results above it are for the right eye. The % Mod Result for the left eye  1002  is the modulation threshold  906  shown in  FIGS. 7 a  and 7 b    for the left eye of the user and the % Mod Result for the right eye  1006  is the modulation threshold  906  for the right eye of the user. The % Mod Result for the left eye  1002  and the % Mod Result for the right eye  1006  may be presented as simple percentages of modulation, proportions of modulation to circle radius (or another key dimension whatever shape is used), in the well-known MAR (Minimum Angle of Resolution) measure, or in log MAR (the logarithm of MAR), or in other quantitative or relative measurement formats. The left eye consistency score  1004  and the right eye consistency score  1008  are consistency measures as previously discussed for the users left eye and right eye tests respectively. Providing a consistency score of some sort to the user coaches them on their test taking ability and reinforces the need to take the vision test carefully and actively. The left eye consistency score  1004  and the right eye consistency score  1008  are much like video game scores in that they tell the user how well they took the test. Storing the left eye consistency score  1004  and the right eye consistency score  1008  in the handheld device&#39;s  100  memory and making it a part of the test archive for the user is useful as it provides an indication of how well the test was taken, and hence, to what level the result may be trusted. 
         [0070]    In  FIG. 8 b   , an example quantitative result presentation  1000  is provided with numerical example results for the % Mod Result for the left eye  1002  and the left eye consistency score  1004  shown above the L  1010 ; and with % Mod Result for the right eye  1006  and a right eye consistency score  1008  shown above the R  1012 . Note that the left eye consistency score  1004  and the right eye consistency score  1008  as presented in  FIG. 8 b    are not numerical, but are represented as ++ and +, respectively, indicating relatively how consistent the user was in taking the tests. Numerical scores are also possible, but relative scores using stars, smiling or frowning faces, different colors, or other approaches may be beneficial in providing a general indication of how consistently the user took the test. Additionally, the % Mod Result for the left eye  1002  and the % Mod Result for the right eye  1006  may also be provided as relative scores if desired. Relative scores such as good/moderate/poor, normal/borderline/abnormal, and many other relative scores are possible. 
         [0071]      FIG. 8 c    shows another example technique for result presentation. A logMAR gray scale  1030  is shown including a title  1038 , a lower gray scale limit  1036 , an upper gray scale limit  1034 , and a gray scale  1032 . In  FIG. 8 c   , the title  1038  identifies the result presentation of the logMAR gray scale  1030  as “logMAR Gray Scale”, the lower gray scale limit  1036  is illustrated as “−1.00” and the upper gray scale limit  1034  is illustrated as “1.00”. The gray scale  1032  shows a range from white for results near the lower gray scale limit  1036  to black for results near the upper gray scale limit  1034 . For example, a test score may be represented by using a gray level between the upper gray scale limit  1034  and the lower gray scale limit  1036 . The accuracy of the test score may be represented by the extension of that gray level, or a band of gray levels centered at the one that represents the test score. The narrower the gray level band, the more accurate or consistent the test score. A wide range of other options for using a segment of gray region within a gray scale  1032  include showing a result presentation in which the center of a gray region represents a test score and the size, shape or other aspects of the gray region represent the consistency of the user in taking the test. Of course, many variants including use of variable color shades instead of a gray scale  1032 , varying shapes, sizes, and other variations may be used. 
         [0072]    Although the description above contains many specificities, these should not be construed as limiting the scope of the invention, but as merely providing illustrations of some of the presently preferred embodiments of this invention. Thus the scope of the present invention should be determined by the appended claims and their legal equivalents, rather than by the examples given. Those skilled in the art to which this application relates will appreciate that other and further additions, deletions, substitutions and modifications may be made to the described embodiments.