Introduction The ocular surface provides a unique opportunity to study hemodynamics since the vessels can be visualized directly, without treatment and non-invasively. The availability of instruments to measure various hemodynamic parameters on the ocular surface in an objective manner are lacking. The quantification of red blood cell velocity, blood oxygen saturation and conjunctival redness on the ocular surface using novel, validated techniques has the potential of providing useful information about vascular physiology. The specific aims of each chapter are as follows: Chapter 3: The objective was to design, develop and validate a system that would non-invasively quantify the red blood cell velocity in the conjunctival vessels. A tool was developed to automatically analyze video sequences of conjunctival vessels, digitally imaged with high enough magnification to resolve movement of the blood within the vessel. Chapter 4: The objective was to: a) design and develop a method in order to non-invasively quantify the changes in blood oxygen saturation (SO2) in the conjunctival vessels and demonstrate reliability of the measures and, b) demonstrate the application of the method by showing a response to an isocapnic hyperoxic provocation and compare those values to the results from a valid instrument. Chapter 5: The aim of this experiment was to examine variations in ocular redness levels, red blood cell velocities and oxygen saturation levels over time in clinically healthy participants and also to compare differences between two age groups. Chapter 6: The aim of this experiment was to examine the ocular redness levels, red blood cell velocities and oxygen saturation levels in clinically healthy participants when a topical ophthalmic decongestant was instilled onto the eye and to demonstrate the validity of the use of two novel techniques. Chapter 7: The aim of this experiment was to examine ocular redness, red blood cell velocity and oxygen saturation in participants who were habitual soft contact lens wearers (study) compared to those that did not (control) and also to compare differences in silicone (SH) and non-silicone hydrogel wearers. Methods Chapter 3: Simulations representing moving RBCs within a vessel and the random variation of each cell in terms of speed, shape and intensity were created in order to evaluate the performance of the algorithm. For each vessel, a signal that correlated to blood cell position was extracted from each frame, and the inter-frame displacement was estimated through a modified dynamic time warping (DTW) algorithm. This provided the red blood cell velocity over time in each point of the vessels. Thus, from these estimates, the mean red blood cell velocity for each vessel was easily evaluated. The true mean velocity from the simulation with the one estimated by the algorithm was compared and the system accuracy was determined. Chapter 4: a) Conjunctival vessels were imaged with two narrow-band interference filters with O2-sensitive and O2-insensitive peak transmissions using a Zeiss slit lamp at 32x magnification. Optical densities were calculated from vascular segments using the average reflected intensities inside and outside the vessels. Optical density ratios were used to calculate relative oxygen saturation values. Video images of the bulbar conjunctiva were recorded at three times of the day. Measurement repeatability was assessed over location at each time and across consecutive frames. b) Subjects initially breathed air for 10 minutes followed by pure oxygen (O2) for 20 minutes, and then air for a final 10 minute period using a sequential re-breathing circuit. Simultaneously, SO2 values measured with a pulse oximeter ear clip and finger clip were recorded. The validity of the dual wavelength method was demonstrated by comparing the values to those from the ear clip pulse oximeter. Chapter 5: Participants attended eight separate visits over the course of a day. Levels of bulbar conjunctival redness, red blood cell velocity and blood oxygen saturation were measured on a vessel of interest. Chapter 6: Participants attended three separate visits during an allotted 60 minute session. Bulbar conjunctival redness, red blood cell velocity and blood oxygen saturation were measured on a vessel of interest, pre-insertion, just after insertion and, 10 minutes after insertion of a topical ocular decongestant. Significant differences between the three measures were assessed and correlations between the three parameters were reported. Chapter 7: Participants were measured 8 times over the course of a day with their contact lenses in place. Bulbar conjunctival redness, red blood cell velocity and blood oxygen saturation were measured. Results Chapter 3: Results for the simulated videos demonstrated a very good concordance between the estimated and actual velocities supporting its validity. The mean relative error for the modified Dynamic Time Warping (DTW) method is 6%. Chapter 4: The intraclass correlations (ICCs) between the three locations at each time point were 0.93, 0.56 and 0.86 respectively. Measurements across 5 consecutive frames showed no significant difference for all subjects (ICC = 0.96). The ICCs between the two methods at each time point were 0.45, 0.10 and 0.11 respectively. a) There was no significant difference in SO2 between the three locations measured using the dual wavelength method for all subjects. There was also no significant difference between the three locations at any of the time points for the dual wavelength method. b) In response to isocapnic hyperoxic provocation using the dual wavelength method, blood oxygen saturation was increased from control values and subsequently recovered after withdrawal of hyperoxia. Blood oxygen saturation values recorded from the ear clip and finger clip of the pulse oximeter also showed an increase from control values and subsequently recovered after withdrawal of hyperoxia. SO2 comparison between the dual wavelength method and the ear-clip pulse oximeter method did not show a significant difference. The interaction between the two methods and time on SO2 was not significant. Chapter 5: From baseline, the group mean redness and oxygen saturation did not change significantly over time. There was a significant difference in the group mean red blood cell velocity values over time. There was no significant difference between age strata for all three measures. Chapter 6: After drop instillation redness values decreased significantly. There was no change in red blood cell velocity and oxygen saturation over time. There was a moderate significant correlation between SO2 and red blood cell velocity just after drop insertion. Chapter 7: When comparing the study and control groups, no significant difference in redness or SO2 over time was found. RBC velocity over time was found to be significantly different between groups. When comparing the two study groups (SH vs. hydrogel) no significant difference across either measure over time was found. Conclusions Chapter 3: Signal displacement estimation through the DTW algorithm can be used to estimate mean red blood cell velocity. Successful application of the algorithm in the estimation of RBC velocity in conjunctival vessels was demonstrated. Chapter 4: The application of the dual wavelength method was demonstrated and optical density ratios can be used in a reliable manner for relative oxygen saturation measurements. This valid method promises to enable the study of conjunctival O2 saturation under various experimental and physiological conditions. Chapter 5: The results of this study support the theory of metabolic regulation. The lack of any significant change across time for redness and oxygen saturation along with significant changes in red blood cell velocity substantiates this notion. Chapter 6: This study supports the literature regarding metabolic regulation of the microvasculature during the use of various stimuli. The results demonstrated that oxygen saturation levels remain stable even when a significant decrease in ocular redness is measured. The novel techniques used in this experiment demonstrated the expected action of the decongestant further contributing to their application and validity. Chapter 7: In summary, the participants in the study group were habitual contact lens wearers that had lower RBC velocities when compared to the control group supporting the notion that contact lenses initiate a hypoxic response. The lack of change in SO2 in either group supports the theory of metabolic regulation.

The global aim of this thesis was to assess retinal vascular reactivity in glaucoma patients using a standardised hypercapnic stimulus. There is a suggestion of disturbance in the regulation of retinal and optic nerve head (ONH) hemodynamics in patients with Primary Open Angle Glaucoma (POAG), although much of the work to-date has either been equivocal or speculative. Previous studies have used non-standardised hypercapnic stimuli to assess vascular reactivity. To explain, hypercapnia induces hyperventilation which disturbs arterial oxygen concentration, an effect that varies between individuals resulting in the non-standardised provocation of vascular reactivity. Therefore, a normoxic hypercapnic provocation was developed to avoid additional and potentially uncontrolled vasoconstriction in what is thought to be a vasospastic disease. The development of a safe, sustained and stable normoxic hypercapnic stimulus was essential for the assessment of retinal arteriolar vascular reactivity so that repeated hemodynamic measurements could be obtained. Furthermore, most techniques used to measure vascular reactivity do not comprehensively assess retinal hemodynamics, in terms of the simultaneous measurement of vessel diameter and blood velocity in order to calculate flow. In this respect, this study utilized a technique that quantitatively assesses retinal blood flow and vascular reactivity of the major arterioles in close proximity to the ONH. The stimulus and vascular reactivity quantification technique was validated in healthy controls and then was clinically applied in patients with POAG. Newly diagnosed patients with untreated POAG (uPOAG) were recruited in order to avoid any confounding pharmacological effects and patients with progressive POAG (pPOAG) were also selected since they are thought to likely manifest vascular dysregulation. Finally, the results of the functional vascular reactivity assessment were compared to those of systemic biochemical markers of endothelial function in patients with untreated and progressive POAG and in healthy controls. Overall summary A safe, sustained, stable and repeatable normoxic hypercapnic stimulus was developed, evaluated and validated. In terms of the physiology of retinal vascular regulation, the percent magnitude of vascular reactivity of the arterioles and capillaries was found to be comparable in terms of flow. The new stimulus was successfully applied in POAG and in healthy controls to assess vascular reactivity and was also compared to plasma levels of ET-1 and cGMP. In terms of the patho-physiology of POAG, the study revealed a clear impairment of vascular reactivity in the uPOAG and pPOAG groups. There were reduced levels of plasma ET-1 in the uPOAG and ntPOAG groups. In addition, treatment with Dorzolamide improved vascular reactivity in the ntPOAG group in the absence of any change in the expression of plasma ET-1 or cGMP. Future work will address this apparent contradiction between the outcome of the functional vascular reactivity assessment and the biochemical markers of endothelial function in newly diagnosed POAG patients treated with Dorzolamide. Aims of chapters  Chapter 3: To determine the effect of hypercapnia on retinal capillary blood flow in the macula and ONH using scanning laser Doppler flowmetry (SLDF) in young healthy subjects.  Chapter 4: To describe a new manual methodology that permits the comprehensive assessment of retinal arteriolar vascular reactivity in response to a sustained and stable hypercapnic stimulus. The secondary aim was to determine the magnitude of the vascular reactivity response of the retinal arterioles to hypercapnic provocation in young healthy subjects.  Chapter 5: To compare the magnitude of vascular reactivity of the retinal arterioles in terms of percentage change of flow to that of the retinal capillaries using a novel automated standardized methodology to provoke normoxic, or isoxic, hypercapnia.  Chapter 6: To determine the magnitude of retinal arteriolar vascular reactivity to normoxic hypercapnia in patients with untreated POAG (uPOAG), progressive POAG (pPOAG) and controls. The secondary aim was to determine retinal vascular reactivity in newly treated POAG (ntPOAG, i.e. after treatment with 2% Dorzolamide, twice daily for 2 weeks).  Chapter 7: To compare plasma endothelin-1 (ET-1) and cyclic guanosine monophosphate (cGMP) between groups of patients with untreated primary open angle glaucoma (uPOAG), progressive POAG (pPOAG), newly treated POAG (ntPOAG) and controls. The effect of normoxic hypercapnia on plasma ET-1 and cGMP was also assessed. The functional measures of retinal blood flow and vascular reactivity were correlated with systemic biochemical markers of endothelial function. Methods Chapters 3, 4 and 5 were conducted on young healthy control subjects, where as Chapters 6 and 7 were conducted on patients with glaucoma and healthy controls.  Chapter 3: Subjects breathed unrestricted air for 15 minutes (baseline) via a sequential gas delivery circuit and then the fractional (percent) end-tidal concentration of CO2 (FETCO2) was manually raised for 15 minutes by adding a low flow of CO2 to the inspired air. For the last 15 minutes, FETCO2 was returned to baseline values to establish a recovery period. Heidelberg Retina Flowmeter (HRF) images centered on both the ONH and the macula were acquired during each phase.  Chapter 4: Subjects breathed air via a sequential gas delivery circuit for 15 minutes and the air flow was then manually decreased so that subjects inspired gases from the rebreathing reservoir until a stable 10-15% increase in FETCO2 concentration was achieved for 20 minutes. Air flow rate was then manually elevated so that subjects breathed primarily from the fresh gas reservoir to return FETCO2 back to baseline for the last 15 minutes. Retinal arteriolar hemodynamics was assessed using the Canon Laser Blood Flowmeter (CLBF) during all three breathing phases.  Chapter 5: Normoxic, or isoxic, hypercapnia was induced using an automated gas flow controller (RespirActTM, Thornhill Research Inc. Toronto, Canada). Subjects breathed air with PETCO2 normalized at 38 mmHg. An increase in PETCO2 of 15% above baseline, whilst maintaining normoxia, was then implemented for 20 minutes and then PETCO2 was returned to baseline conditions for 10 minutes. Retinal and ONH hemodynamic measurements were performed using the CLBF and HRF in random order across sessions.  Chapter 6: Retinal arteriolar vascular reactivity was assessed in patients with uPOAG, pPOAG (defined by the occurrence of optic disc hemorrhage within the past 24 months) and controls during normoxic hypercapnia. Using the automated gas flow controller, patients breathed air for 10 mins and PETCO2 was maintained at 38mmHg. Following this normoxic hypercapnia (a 15% increase in PETCO2 while PETO2 was maintained at resting levels) was induced for 15 mins and then for the last 10 mins PETCO2 was returned to baseline (post-hypercapnia) to establish recovery blood flow values. Retinal arteriolar diameter, blood velocity and blood flow was assessed using the CLBF in both patient groups and controls. A similar paradigm was repeated in the newly treated POAG group (ntPOAG, i.e. after treatment with 2% Dorzolamide, twice daily for 2 weeks).  Chapter 7: Blood samples were collected from the cubital vein of all participants (uPOAG, pPOAG, ntPOAG and controls) during baseline conditions (PETCO2=38mmHg) and then during normoxic hypercapnia (i.e. a 15% increase in PETCO2 relative to the baseline) using the paradigm described for Chapter 6. ET-1 and cGMP was assessed using immunoassay. Results  Chapter 3: The group mean nasal macula capillary blood flow increased from 127.17 a.u. (SD 32.59) at baseline to 151.22 a.u. (SD 36.67) during hypercapnia (p=0.028), while foveal blood flow increased from 92.71 a.u. (SD 28.07) to 107.39 a.u. (SD 34.43) (p=0.042). There was a concomitant and uncontrolled +13% increase in the group mean PETO2 during the hypercapnic provocation of +14% increase in PETCO2.  Chapter 4: Retinal arteriolar diameter, blood velocity and blood flow increased by 3.2% (p=0.0045), 26.4% (p<0.0001) and 34.9% (p<0.0001), respectively during hypercapnia. There was a stable ¬+12% increase in PETCO2 during hypercapnia and a concomitant -6% decrease in PETO2.  Chapter 5: Using an automated gas flow controller the co-efficient of repeatability (COR) was 5% of the average PETCO2 at baseline and during normoxic hypercapnia. The COR for PETO2 was 10% and 7% of the average PETO2 at baseline and during normoxic hypercapnia, respectively. Group mean PETCO2 increased by approximately +14.4% and there was only a +4.3% increase in PETO2 during hypercapnia across both study sessions. Retinal arteriolar hemodynamics increased during hypercapnia (p<0.001). Similarly, there was an increase in the capillary blood flow of the temporal rim of the ONH (p<0.001), nasal macula (p<0.001) and foveal areas (p<0.006) during hypercapnia. A non-significant trend for capillary blood flow to increase in the macula temporal area (+8.2%) was noted. In terms of percentage change of blood flow, retinal capillary vascular reactivity (i.e. all 4 analyzed areas = 22.4%) was similar to the magnitude of arteriolar (= 24.9%) vascular reactivity.  Chapter 6: Retinal arteriolar diameter, blood velocity and flow did not increase during normoxic hypercapnia in uPOAG compared to controls. Diameter and blood velocity did not change in pPOAG during normoxic hypercapnia but there was a significant increase in blood flow (+9.1%, p=0.030). After treatment with 2% Dorzolamide for 2 weeks there was a 3% (p=0.040), 19% (p<0.001) and 26% (p<0.001) increase in diameter, velocity and flow, respectively, in the ntPOAG group. Group mean PETCO2 increased by approximately +15% in all the groups and there was only a +3% increase in PETO2 during hypercapnia.  Chapter 7: Plasma ET-1 levels were significantly different across groups at baseline (one way ANOVA; p=0.0012) and this was repeated during normoxic hypercapnia (one way ANOVA; p=0.0014). ET-1 levels were lower in uPOAG compared to pPOAG and controls at baseline and during normoxic hypercapnia (Tukey’s honestly significant difference test). Similarly, ntPOAG group also showed lower ET-1 levels compared to the pPOAG and controls at baseline and during normoxic hypercapnia (Tukey’s honestly significant difference test). The cGMP at baseline and during normoxic hypercapnia across all groups was not different. In the control group, the change in ET-1 during normoxic hypercapnia was negatively correlated with change in retinal arteriolar blood flow (r = -0.52, p=0.04), that is, as the change in ET-1 reduced, the change in blood flow increased. A weak correlation was noted between change in cGMP during normoxic hypercapnia and the change in arteriolar blood flow (r = +0.45, p=0.08). Conclusions  Chapter 3: Hypercapnia resulted in a quantifiable capillary vascular reactivity response in 2 of the 3 assessed retinal locations (i.e., nasal macula and fovea). There was no vascular reactivity response of the ONH. It is critical to minimise the concomitant change in PETO2 during hypercapnia in order to obtain robust vascular reactivity responses.  Chapter 4: A technique to comprehensively assess vascular reactivity during stable and sustained hypercapnia was described. Retinal arteriolar diameter, blood velocity and blood flow increased in response to hypercapnia. The vascular reactivity results of this study served as a reference for future studies using the hypercapnic provocation and CLBF. Also, the concomitant change in PETO2 using the partial rebreathing technique was reduced compared to the manual addition of CO2 technique described in Chapter 3 but was still greater than optimal.  Chapter 5: A new automated gas flow controller was used to induce standardised normoxic, or isoxic, hypercapnia. The magnitude of vascular reactivity in both retinal arterioles and capillaries in response to the new hypercapnic stimulus was robust compared to the previous stimuli. There was a clear ONH vascular reactivity response in this study, unlike the result attained in Chapter 3. Although theoretically it is predictable that the percent magnitude of vascular reactivity of the arterioles and capillaries should be similar, this is the first study to show that they are indeed comparable. The magnitude of hypercapnia was repeatable and the concomitant change in PETO2 was minimal and physiologically insignificant.  Chapter 6: The normal response of the retinal arterioles and capillaries to normoxic hypercapnia is impaired in both uPOAG and pPOAG compared to controls. Short term treatment with 2% topical Dorzolamide for two weeks improved retinal vascular reactivity in ntPOAG. However, it is still unclear whether this improvement is a direct effect of Dorzolamide or as a secondary effect of the decrease in intraocular pressure (IOP).  Chapter 7: We found a reduction in the plasma ET-1 at baseline and during normoxic hypercapnia in the uPOAG and in the ntPOAG groups. This is the first study to show a lower plasma ET-1 level in uPOAG. The fact that this finding was repeated after 2 weeks treatment with Dorzolamide in the ntPOAG group further validates these results. It also suggests that Dorzolamide treatment does not impact ET-1 and cGMP measures, although it clearly results in an improvement of vascular reactivity. Correlation results suggest that as the change in ET-1 reduced during normoxic hypercapnia, the change in blood flow increased in the controls.

Aim The experiment proposed to study the effect of sustained visual attention in an effective visual field of 40 degrees, in cued and uncued conditions with different set-sizes. Methods The participants had a normal contrast and visual acuity with normal ocular/general health. The experiments were performed both for central (0 - 20degrees) and peripheral (>20 – 50 degrees) visual fields. The targets were presented with valid and invalid cued conditions in different set-sizes of 500, 1000 and 2000. The targets were Gabor gratings oriented at 90 or 180deg subtending a minimum angle of resolution (MAR) ranging from 1.5-10minarc at 25cm. The spatial frequency of the Gabor ranged from 1- 29cycles/degrees and contrast from 20-100%. The observer had to identify the Gabor with horizontal grating and register the response. The accuracy and the reaction times for the targets were evaluated. Results The central targets had lower reaction times and high accuracy compared to the peripheral targets. There was a significantly increasing eccentricity effect as the targets were displayed much peripherally. It was less with presentation of valid sustained cues but it was not eliminated. The diminishing contrast of the target had a significant increase in reaction times and reduced accuracy. The effect of increasing number of items in the display didn’t show any significant increase in reaction time, i.e. there was no “set-size effect” seen both central and peripheral targets. The valid cues improved the performance with lower reaction times, compared to the neutral cued conditions, in each of the different experiments and resulted in an improved accuracy in both the central and peripheral visual field. Conclusion Visual attention is affected by contrast, target size and spatial gratings. Reaction time is high and accuracy less for low contrast targets, high spatial frequency and larger set-size, except for set-size 2000 in the central field where it was seen that the reaction times were reduced. The effect is consistent in both central and peripheral visual fields. The set-size also has an effect on the reaction times and on accuracy. The effects are more pronounced in the peripheral visual field.

Purpose: Hyper-reflective superficial cells were an unexpected finding while examining the corneal epithelium using confocal microscopy (CM), during an MSc thesis conducted in 2006 at the University of Waterloo, Canada. The author1 suggested that the appearance of these hyper-reflective cells could be associated with solution induced corneal staining (SICS) that was also observed in those participants who had manifested these hyper-reflective cells. However, this hypothesis has not been reported in the literature. This thesis aimed to investigate variables that could possibly predict the appearance of hyper-reflective superficial cells. These investigated variables were the effect of: contact lenses, contact lens solutions, lens/solution combinations, long-term use of certain contact lenses and solutions, age, dry eye symptom, topical anaesthetics and sodium fluorescein. In addition to this, the normal superficial epithelium of controls was defined. Methods: CM images of the superficial epithelium were obtained during the various experiments from: 32 non-contact lens wearing participants, 18 post-menopausal participants symptomatic of dry eye and 18 post-menopausal age-matched asymptomatic women and 147 adapted soft contact lens wearers. For one experiment CM was performed with the contact lens in situ, making the use of a topical anaesthetic unnecessary. Superficial cellular appearance of CM images was graded using a custom grading scale. Hyper-reflective cells were counted. Corneal staining was assessed using sodium fluorescein. Results: Results obtained during the various experiments revealed that hyper-reflective cells predominately appeared with the use of a specific lens/solution combination. Also, the number of hyper-reflective cells peaked after two hours of lens wear. It was also shown that when hyper-reflective cells occurred during an experiment, not every participant who was exposed to that specific lens/solution combination manifested hyper-reflective cells. Also, a great deal of inter-subject variability in observed numbers of hyper-reflective cells was noted. Conclusion: In conclusion, this thesis established that the hyper-reflective cells that were observed by Harvey were reproducible and may co-occur with corneal staining induced by a specific lens/solution interaction

Introduction Retinal vascular reactivity is impaired in patients with diabetes and is thought to be involved in the onset and progression of diabetic retinopathy (DR). Previous studies that have utilized hyperoxia to assess retinal vascular reactivity have been limited due to confounding factors associated with the administration of oxygen and have used a variety of different instruments to measure retinal blood flow. The influence of blood glucose at the time of blood flow assessment has also not been systemically investigated. The specific aims of each Chapter are as follows: Chapter 3: To compare three systems used to administer hyperoxia to human subjects. Chapter 4: To quantify the magnitude and timeline of change of retinal hemodynamic parameters induced by an isocapnic hyperoxic stimulus. Chapters 5, 6 and 7: To quantify the magnitude of change of retinal hemodynamic parameters induced by hyperoxia, hyperglycemia and combined hyperoxia / hyperglycemia, respectively, in groups of diabetic patients with no clinically visible, and mild-to-moderate, DR and in age-matched subjects without diabetes. Methods Chapter 3: Subjects breathed air followed by oxygen, or oxygen plus carbon dioxide using a non-rebreathing system, or air followed by oxygen using a sequential rebreathing system. The magnitude of change and variability of CO2 concentrations was compared between systems. Chapter 4: Baseline retinal blood flow data was acquired while the subjects breathed air using a sequential rebreathing system. An isocapnic hyperoxic stimulus was initiated and maintained for 20 minutes. Air was then re-administered for 10 minutes. Retinal blood flow measurements were acquired every minute over the course of the study. The magnitude of change of each hemodynamic parameter was determined by fitting individual data with a sigmoidal function. For Chapter 5, 6 and 7 diabetic patients with no clinically visible, and mild-to-moderate, DR were stratified into groups based upon their retinopathy status. Age-matched non-diabetic subjects were recruited as controls. Baseline retinal blood flow data was acquired while subjects breathed air. Retinal blood flow measurements were then acquired after exposure to (a) hyperoxia, (b) hyperglycemia and (c) combined hyperoxic / hyperglycemic stimuli. Change in hemodynamic parameters was compared between groups and correlated with objective measures of retinal edema. Results Chapter 3: The difference in group mean end-tidal CO2 levels between baseline and hyperoxia was significant for oxygen administration using a non-rebreathing system. The sequential rebreathing technique resulted in a significantly lower variability of individual CO2 levels than either of the other techniques. Chapter 4: An ~11% decrease of diameter, ~36% decrease of velocity and ~48% decrease of blood flow was observed in response to isocapnic hyperoxia in young, healthy subjects. A response time of 2.30±0.53 minutes and 2.62±0.54 minutes was observed for diameter and velocity, respectively. Chapter 5: Retinal blood velocity, flow, and WSR significantly decreased in response to isocapnic hyperoxia in all groups. The magnitude of the reduction of blood flow was significantly reduced with increasing severity of retinopathy. There was a significant relationship between baseline objective edema index values and retinal vascular reactivity. Chapter 6: A significant change in blood glucose level was observed for all groups. No significant change in any hemodynamic parameter was found in patients with diabetes and in age-matched subjects without diabetes. Chapter 7: Retinal blood velocity and flow significantly decreased in all groups in response to combined hyperoxic / hyperglycemic provocation. The vascular reactivity response was not significantly different across the groups. Conclusions Chapter 3: Control of CO2 is necessary to attain standardized, reproducible hyperoxic stimuli for the assessment of retinal vascular reactivity. Chapter 4: Arteriolar retinal vascular reactivity to isocapnic hyperoxic provocation occurs within a maximum of 4 minutes. Although there was a trend for diameter to respond before velocity, the response characteristics were not significantly different between diameter and velocity. Different response characteristics of the retinal vasculature to transmural pressure mediated autoregulation as opposed to metabolic mediated vascular reactivity are suggested. Chapter 5: The vascular reactivity response in terms of the reduction of blood flow relative to baseline was significant in all groups but the magnitude of the change in flow was significantly reduced with increasing severity of retinopathy. A loss of retinal vascular reactivity is indicated in patients with moderate DR without clinically evident diabetic macular edema (DME), and in patients with DME. Chapter 6: Unaltered retinal arteriolar blood flow was found 1 hour after glucose ingestion in patients with diabetes and in age-matched subjects without diabetes. These results do not support the theory that retinal blood flow is affected by an acute increase of blood glucose in diabetic patients and in subjects without diabetes. Chapter 7: The vascular reactivity response to a combined hyperoxic / hyperglycemic provocation produced a pronounced reduction in blood flow. Unlike the response to hyperoxia alone, the vascular reactivity response was not significantly different across the groups. This suggests that hyperglycemia may influence the retinal vascular reactivity response to hyperoxia.

Ongoing efforts to quantify changes in quality of life attributable to low vision rehabilitation have focused on the utility of a single test instrument to measure this multidimensional concept. It is hypothesized that quality of life is best assessed using multiple instruments to capture some of its component facets, including functional status and psychosocial impact. Low vision devices have a predictably spontaneous impact on functional vision status, but associated psychosocial impact occurs with different magnitudes and over more protracted time intervals. The National Eye Institute Visual Function Questionnaire (NEI VFQ-25) measures the functional status of individuals in key vision areas that are associated with quality of life. The Psychosocial Impact of Assistive Devices Scale (PIADS) is an instrument that measures the psychosocial impact of assistive device intervention in three quality of life domains: competence, adaptability, and self-esteem. 68 participants were obtained from an ongoing parent study. These participants were recruited through the Low Vision Clinic at the University of Waterloo. They had a primary diagnosis of age-related macular degeneration (ARMD) and were obtaining a CCTV system for the first time. Assessments from the parent study used in this thesis included follow-up from 2 weeks, 1 month, 3 months, and 6 months post-adoption of the CCTV. The two tests administered were to measure functional vision status (NEI VFQ-25) and perceived psychosocial impact (PIADS), according the framework outlined by the Consortium for Assistive Technology Outcomes Research (CATOR). Multivariate repeated-measures ANVOA results confirmed that CCTV systems have an immediate and robust effect on the daily visual functioning of their users, and that this effect is stable over long periods of device use. The psychosocial impact of CCTV device use peaks in the shorter term and then seems to wane in the longer term for reasons that are not yet understood. The NEI VFQ-25 and the PIADS appear to have differential sensitivity to important influences on low vision rehabilitation outcomes. This project has demonstrated the value of longitudinal outcomes research in low vision rehabilitation. After obtaining a CCTV, visual function status remains static while psychosocial impact is dynamic during 6-months of follow-up.

Purpose: Previous studies have shown that some digital filters can enhance picture-image visibility for people with visual impairment. The ultimate purposes of this study are to determine the improvement of picture-image visibility for people with maculopathy using digital image enhancement, and to compare the enhancement effects of generic filters and custom-devised filters. The secondary interests are to investigate the effect of age and maculopathy on supra-threshold contrast matching and to investigate the spatial frequency characteristics of picture-images. Methods: In order to develop effective custom-devised filters, supra-threshold contrast matching and contrast thresholds for two age groups of subjects with normal vision (14 aged 20-50 years and 15 aged 51+ years) and three groups of people with maculopathy (13 with atrophic ARMD, 14 with exudative ARMD, and 8 with JMD) were measured. Amplitude spectrum at each spatial frequency and the slope of amplitude versus spatial frequency were measured to investigate the spatial frequency characteristics of single face and general scene images. To investigate the preference for filters, 7 generic filters and 4 custom-devised filters were applied to single faces and general scenes. The generic filters were high-pass/unsharp masking, contrast enhancement, Sobel edge enhancement, DoG convolution, DoG FFT, Peli’s adaptive enhancement, and a band-pass filter with equi-emphasis of spatial frequencies. The custom-devised filters were band-pass filters based on contrast sensitivity (CS) loss, contrast matching at 3.6% and 27.9%, and emphasis of the peak of the CS curve. Subjects with maculopathy were required to rate the visibility of each image with and without filtering. Nine subjects with maculopathy participated to assess the enhancement quantitatively during which the recognition of facial expression and details in general scenes was tested with and without filtering. Results: Contrast constancy was demonstrated in age-matched controls and people with maculopathy. Single faces were found to be of significantly lower average amplitude than the other groups of images. Eight filters were found to be effective in improving perceived visibility; contrast enhancement, Peli’s adaptive enhancement, DoG convolution, high-pass/unsharp masking, Sobel edge enhancement, band-pass based on 3.6% and 27.9% contrast matching and equi-emphasis band-pass filters. These filters specifically were found to be effective for one or more combinations of maculopathy type and image category. The most commonly preferred filters were the generic filters, contrast enhancement and Peli’s adaptive enhancement. The two highest rated filters for each subject significantly reduced the number of errors of facial expression and errors of recognition of detail within general scene images. Conclusions: The visual system adjusts to compensate for CS loss with aging and maculopathy. Single faces are unique in spatial frequency characteristics. Some generic and custom-devised filters are effective in enhancing image visibility. The custom-devised filters are not superior to the generic filters. Visibility enhancement can be assessed quantitatively.

Accommodation and vergence, the two important oculomotor systems, exhibit the property of adapation which maintains the response for comfortable prolonged viewing. Several mathematical models have been developed to describe the basic underlying mechanism of accommodation and vergence. Currently used models contradict with each other in the placement of critical elements in the model. This thesis addressed this controversy and empirically verified these models. The effect of vergence adaptation and its influence on certain critical oculomotor parameters have been evaluated in two studies. The specific aims, methods, results and conclusions of each chapter are as follows: Chapter 3 Aim To evaluate the effect of vergence adaptation on convergence accommodation (CA) response and the effect of CA stimulation on accommodative adaptation to determine the model that best fits human accommodation and vergence interaction. Methods This study investigated the effect of vergence adaptation on the convergence accommodation (CA) response as a function of vergence stimulus magnitude and duration in 10 emmetropes. Convergence was induced using no prism, 6, and 12 prism dioptres as stimuli at 0.4m, viewed for 5, 10 & 15 minutes of duration in randomized separate sessions. Phoria measures and CA responses were recorded at the baseline, immediately following prism insertion and following specific durations of viewing through the prism (post-task). Also the effect of CA cross-link on the tonic accommodation (TA) adaptation was investigated where TA response was measured before and after the convergence task. Results & conclusions Repeated measures of ANOVA showed no significant (p > 0.05) phoria adaptation or CA response change with no prism as the stimulus. For 6 and 12 prism dioptres, there were significant reductions (p< 0.01) in CA with phoria adaptation. No significant (p>0.05) phoria adaptation or reduction in the CA response between 5, 10 and 15 minutes of viewing showing no effect of duration. No significant difference (p = 0.85) between the pre and post task TA response while vergence was adapted. The results of the study show that vergence adaptation reduces CA response supporting models which predict the CA crosslink to reduce its output as tonic vergence adaptation progresses. However the convergence accommodation does not appear to lead to increased output of tonic accommodation. Chapter 4 Aim The purpose of this study was to evaluate certain critical parameters of vergence and accommodation under vergence adaptation (induced with a BO Δ), before and after positive fusional vergence training. Methods Eleven emmetropes with normal binocular vision participated in the study. Distance & near phoria, AC/A & CA/C ratios, & positive fusional amplitude at near were evaluated before and after two weeks of positive fusional vergence training. Phoria adaptation and CA responses were monitored every 3 minutes for 15 minutes while the subjects viewed through 12Δ BO under open-looped accommodation at 0.4m before and after training. On a separate vergence adaptation session (before training), phoria adaptation was induced under dual closed-loop condition using 12Δ BO at 0.4m. Cross-link ratios, BO fusional amplitude at 0.4m and near phoria were measured following 15 minutes of prism adaptation. Subjects underwent 2 weeks of positive fusional vergence training using variable tranaglyphs and aperture rule at 0.4m. Phoria adaptation and CA responses monitored over time were exponentially fit and were compared before and after training. AC/A & CA/ C ratios and BO to blur value at 0.4m taken before training, under the vergence adapted state and after training were analyzed using repeated measures ANOVA. Results & conclusions No significant difference (p > 0.05) in the cross-link ratios were found before and after training. However, there was a significant (p < 0.01) increase and decrease in the AC/A and CA/C ratios respectively under the vergence adapted state. BO to blur value at 0.4m was significantly increased (p < 0.01) from the pre training value under both vergence adapted condition and following training. Rate constants and magnitudes of phoria adaptation and CA response reduction were significantly (p < 0.01) different following training demonstrating robust and greater magnitude of vergence adaptation in the BO direction reducing the CA response faster. However, this improved vergence adaptability is not reflected in the static measures of AC/A and CA/C ratios. The increased BO to blur value following training is caused by the increased speed of prism adaptation reducing the CA response during BO fusional amplitude testing.

Purpose and hypothesis: The purpose of this study was to optimize and standardize the following parameters of sweep Visually Evoked Potential (sVEP) in adults: criteria for fitting the regression line to estimate threshold, luminance, electrode placement, temporal frequency, sweep direction, presence of fixation target and stimulus area. The hypothesis is that the parameters chosen will have an impact on the measured visual acuity, contrast threshold and on the number of viable sVEP plots. Methods: The Power Diva software, Version 1.9 was used for this study. Five gold cup active electrodes, one reference electrode and one ground electrode were used to measure the Electroencephalography (EEG) signals. Six adult participants (aged 17 to 35 years), with corrected to normal visual acuity and no history of ocular disease took part in each experiment, except for the repeatability experiment in which 3 subjects participated. Four criteria for regression line fitting were compared. Psychophysical thresholds were used to validate the sVEP measures for the different criterion and repeatability of sVEP was estimated for 10 sessions. The effect of luminance (25 cd/m2, 50 cd/m2, 100 cd/m2), electrode placement (Power Diva and ISCEV), temporal frequency (6 Hz, 7.5 Hz, 10 Hz), sweep direction, fixation target and stimulus area were investigated. A repeated measure ANOVA statistical method was used to analyze the average threshold and the number of viable plots out of five active channels for all subjects. Results: Criterion 2 and 3 gave better visual acuity, higher contrast sensitivity, better repeatability and gave results that were closer to the psychophysical threshold than criterion 0 and 1. Luminance of 25 cd/m2 gave significantly fewer viable readings than 50 and 100 cd/m2 while measuring visual acuity (F = 5.11, df = 2, p = 0.0295). Temporal frequency of 7.5 Hz gave significantly more viable readings than 6 and 10 Hz while measuring visual acuity (F = 50.53, df = 2, p < 0.0001) and contrast threshold (F = 9.87, df = 2,p = 0.0043). There was a highly significant interaction of criterion with temporal frequency (F = 1536.98, df = 6, p < 0.0001) while measuring contrast threshold. There was a significant interaction of criterion with sweep direction (F = 4.26, df = 3, p = 0.0231) and for the number of readings (F = 3.75, df = 3, p = 0.0343) while measuring visual acuity. There was an interaction of criterion with sweep direction (F = 4.97, df = 3, p = 0.0136) while measuring contrast threshold at a spatial frequency of 1 cpd. There was a significant effect of fixation target (F = 7.64, df = 1, p = 0.0396) while measuring visual acuity. There was a significant effect of stimulus area (F = 11.78, df = 4, p < 0.0001) on the number of readings while measuring contrast threshold. Conclusion: The sVEP parameters chosen do have a significant effect on visual acuity, contrast threshold and on the number of viable readings. The following parameters are recommended in adults on the basis of results; Criterion 2 or 3 for fitting regression line (C2 - regression line fitted from the signal peak amplitude to the last data point with a signal to noise ratio (SNR) >1; C3 – similar to criterion 2, but the threshold should be within sweep range used), luminance of 50 or 100 cd/m2 , either Power Diva (PD) or International Society for Clinical Electrophysiology of Vision (ISCEV) electrode placement, temporal frequency of 7.5 Hz, either sweep direction, measurement with the central fixation target, larger stimulus area.

Abstract Both in the closed and open eye state the superior limbus is covered by the upper lid. This region is of physiological interest and clinical importance because in chronic hypoxia, neovascularization of the cornea commonly occurs here. The limbal region in general is additionally of importance as the stem cells which are the source of the new corneal cells are located in the epithelium of the limbus and these are vital for normal functioning and are affected under certain adverse conditions. Purpose: In this experiment I examined corneal morphology in the limbal area and in particular under the upper lid in order to primarily examine the variation in the corneal limbal epithelial and total thickness as well as epithelial and endothelial cell density. Methods: I measured 30 eyes OD/OS (chosen randomly) of thirty healthy subjects aged from 18 to 55 years in the first study and twelve participants in the second study, with refractive error ≤ ±4 D and astigmatism ≤ 2 D. The thickness and cell density of five positions: superior, inferior, temporal, nasal limbal and central cornea was determined with optical coherence tomography (OCT) and confocal microscopy. At least three scans of each position were taken in both studies with OCT. At least 40 of 100 adjacent sagittal scans of each image were measured using OCT software program. In the confocal study, image J software was used to determine cell densities. Results: The epithelial and corneal limbal thickness were significantly thicker than the epithelial and central corneal thickness (p<0.05). The limbal, inferior cornea is thinner than the three other positions and the temporal region of the cornea is the thickest both in epithelial and total cornea. Epithelial cell density was significantly lower in the superior cornea than the four other positions. There was no significant difference in the endothelial cell density. Conclusions: Using OCT with high resolution and cross-sectional imaging capability and confocal microscope with high magnification, I found that the limbal cornea is significantly thicker than the central cornea both in total and in epithelial thickness. In the limbus, one might expect the superior cornea (under the lid) to be thickest (because of the expected hypoxia) whereas I found the temporal cornea was thickest. The epithelial cell density was lower in the superior cornea but there was no significant difference in cell densities in the endothelium. Further morphological investigation is of interest.