Analysis of the application of computerized optokinetic nystagmus analyzer in vision examination

Analysis of the application of computerized optokinetic nystagmus analyzer in vision examination | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Analysis of the application of computerized optokinetic nystagmus analyzer in vision examination 梅夏 蒋介石, 云云 周日, 杰 洪, 鲍恩 赵, 赵军 孟, 南 马, 程 切, 兰娜 张, 荆 福 This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7451342/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Objective To investigate the practicability, accuracy, and consistency of the computerized optokinetic nystagmus (OKN) analyzer for visual acuity (VA) measurement. Method Consistency evaluation study. A total of 219 subjects (13.48±12.89 years, 115 males, 104 females) underwent bilateral VA testing using a computerized OKN analyzer and a traditional OKN drum. Additionally, 104 subjects (12.58±12.05 years, 54 males, 50 females) were tested bilaterally with the computerized OKN analyzer and a standard lightbox VA chart (random order), including 80 myopic eyes (spherical equivalent [SE] ≤ -0.5 D) and 63 hyperopic eyes (SE ≥ +0.5 D); VA was recorded in logMAR. Concordance rates between the OKN analyzer and OKN drum were calculated. Intraclass correlation coefficients (ICC) and Bland-Altman plots were used to assess the consistency between the OKN analyzer and lightbox VA chart. Subjects completing the lightbox test were stratified by age (3–4 years, 5 years, 6 years, 7–15 years, 18–58 years), refractive error, and VA range to compare inter-method correlations. Results Compared with the OKN drum, the computerized OKN analyzer achieved a concordance rate of 74.00% (right eye) and 77.08% (left eye), indicating good agreement. For VA measurements, mean VA (logMAR) of the right eye was -0.24±0.29 (OKN analyzer) vs. -0.24±0.28 (lightbox); left eye was -0.25±0.28 vs. -0.24±0.29. ICC values were 0.92 (right eye) and 0.88 (left eye, both P<0.001), confirming significant consistency. Bland-Altman analysis showed 95% limits of agreement of -0.232 to 0.228 (right eye) and -0.293 to 0.266 (left eye). Bland-Altman analysis showed 95% limits of agreement of -0.232 to 0.228 (right eye) and -0.293 to 0.266 (left eye). Inter-method consistency improved with age (highest in ≥18 years) and was stronger in myopic vs. hyperopic eyes. Notably, correlation weakened as VA improved, with the highest concordance in the 0.1–0.5 logMAR range. Conclusion The computerized OKN analyzer exhibits favorable reliability, accuracy, and practicability for VA testing in patients aged ≥6 years across different refractive errors, with superior performance in myopic patients. Its utility in children aged 3–4 years and individuals with normal VA (≤0.1 logMAR) requires further validation. Computerized OKN analyzer Visual acuity Children Accuracy Optokinetic drum Figures Figure 1 Figure 2 Figure 3 Introduction The 0–6 years age window is critical for pediatric visual development: abnormal visual experiences during this period can disrupt visual system maturation and impair visual function [ 1 – 3 ] . Thus, early refractive screening and comprehensive vision assessment in infants and young children are essential for timely intervention in developmental visual disorders and optimal clinical outcomes. Current pediatric visual function assessment includes qualitative (behavioral observation, no quantitative VA data) and quantitative methods. Quantitative VA tests, based on the Preferential Gaze principle (e.g., forced preferential looking, enhanced preferential looking), rely on psychophysical paradigms but require repeated trials, prolonging examination and limiting clinical utility [ 4 ] . Visual Evoked Potential, an electrophysiological method, objectively evaluates retinocortical pathway function but cannot reflect subjective visual perception or assess high-level visual processing centers [ 5 , 6 ] . Young children’s immature cognitive, motor, and language abilities hinder objective, accurate VA measurement. While quantitative methods provide numerical data, their correlation with traditional VA charts is weak, partly due to the lack of a standardized framework for infant/young child vision assessment [ 7 ] . For children at risk of amblyopia or visual impairment, reliable quantitative VA tools are urgently needed—especially for those unable to complete traditional VA tests. The computerized OKN analyzer was initially developed for VA testing in mouse models and later adapted for humans [ 8 ] . It enables quantitative VA assessment and is particularly suitable for children and patients with language disorders. Previous studies have validated a computer-based OKN device with infrared eye-tracking for subjective VA correlation, but small sample sizes limited its clinical applicability [ 9 , 10 ] . Further validation of its accuracy against standard VA charts is required. This study compared the computerized OKN analyzer with the traditional OKN drum and standard lightbox VA chart. Objectives included: (1) evaluating the performance of the computerized OKN analyzer vs. traditional tools; (2) establishing correlations between OKN responses and standardized VA measurements; (3) exploring the clinical feasibility of the computerized OKN analyzer for VA assessment. The goal was to provide clinicians with a new vision assessment tool for children and patients with language disorders. Methods 1. Study Population A total of 219 subjects (438 eyes) were enrolled from Beijing Tongren Eye Center between October 31 and December 31, 2023. Refractive data were converted to SE, subjects were categorized as myopic (SE ≤ -0.5 D) or hyperopic (SE ≥ + 0.5 D). Subjects completing the lightbox VA chart test were stratified into five age groups: 3–4 years, 5 years, 6 years, 7–15 years, and 18–58 years. Inclusion criteria: Ability to complete lightbox VA chart testing during routine outpatient visits; no concurrent ocular disease. Exclusion criteria: Congenital/secondary nystagmus; recent ocular infection/active lesions; head shaking during testing. 2. Instruments and Procedures 2.1 Optotype vision screening A 21-inch display (1.5 m from the subject) presented scrolling black-and-white striped gratings (resolution: 2560×1440; contrast: 100%). Stimulus parameters: stripe width 0.5–8.7 mm, inter-grating distance 12–26 mm, rolling speed 5°/s (Fig. 1 ). The optokinetic “wheel effect” was mitigated by optimizing inter-stripe spacing. Each test cycle included 3.5 seconds of left-to-right scrolling and 3.5 seconds of right-to-left scrolling. An infrared camera recorded nystagmus in real time, transmitting data to a computer for waveform generation (Fig. 2 ). A “positive response” was defined as ≥ 2 distinct nystagmus waveforms per cycle; fewer waveforms indicated failure to perceive the target. 2.2 Stimulus Sequence for OKN Testing Visual stimuli were presented in a binary sequence. The initial stimulus corresponded to 0.5 decimal Snellen VA (logMAR equivalent). If ≥ 2 typical nystagmus waveforms were recorded, the next stimulus was adjusted to 0.3 decimal Snellen VA; if not, the next stimulus was 0.7 decimal Snellen VA. This iterative process continued until the smallest VA eliciting nystagmus was identified as the OKN analyzer-measured VA. 2.3 Ocular Examinations Computerized OKN test: Subjects rested their chin on a chin rest and forehead against the device. One eye was occluded; the subject viewed screen animations to ensure ocular relaxation. The infrared system recorded nystagmus, and the computer filtered waveforms to determine valid responses, adjusting stimuli until the minimum responsive VA was identified. OKN drum test: The drum was rotated slowly in front of the subject to observe OKN presence. Lightbox VA chart test: A standard logarithmic VA chart was used (2.5 m test distance). The right eye was tested first, followed by the left. Testing proceeded downward from the top line; if > 50% of optotypes in a line were identified correctly, the next line was tested. The last successfully identified line was recorded as VA. 3. Statistical Analysis Intraclass correlation coefficients (ICC) was performed using SPSS 21 to examine the relationship between the results obtained by the two methods. ICC: Assessed inter-method consistency (interpretation: 0.9 = excellent). Bland-Altman plots: Evaluated agreement by plotting the mean difference between methods against the mean of the two measurements. The paired t-test was used to detect the differences between the two groups, with P > 0.05 considered no statistically significant. Results 1. Consistency Between Computerized OKN Analyzer and OKN Drum Of 219 subjects (age distribution: Table 1 ), 167 (right eye) and 171 (left eye) showed consistent results between the two methods. Concordance rates were 74.00% (right eye) and 77.08% (left eye), indicating good agreement. Table 1 Age Distribution of Subjects Age (years) Case Rate 3ཞ4 23 10.5% 5 29 13.2% 6 33 15.1% 7ཞ18 81 37.0% > 18 53 24.2% 2. Consistency Between Computerized OKN Analyzer and Traditional VA chart A total of 104 subjects were included (age distribution: Table 2 ). Mean VA (logMAR) was comparable between methods: Right eye: -0.24 ± 0.29 (OKN analyzer) vs. -0.24 ± 0.28 (lightbox); Left eye: -0.25 ± 0.28 (OKN analyzer) vs. -0.24 ± 0.29 (lightbox). ICC values were 0.92 (right eye) and 0.88 (left eye, both P < 0.001), confirming good consistency. Bland-Altman analysis showed mean differences of -0.003 ± 0.12 (right eye) and − 0.01 ± 0.14 (left eye), with 95% limits of agreement of -0.233 to 0.228 (right eye) and − 0.293 to 0.266 (left eye) (Fig. 3 ). Paired t-tests showed no significant differences (all P > 0.05). Table 2 Age Distribution of Subjects Age (years) Case Rate 3ཞ4 14 13.5% 5 13 12.5% 6 17 16.3% 7ཞ15 37 35.6% > 18 23 22.1% 3. Subgroup Analyses (Age, Refractive Error, VA Range) 3.1 Age Groups Inter-method consistency improved with age (Table 3 ). The ≥ 18 years group showed the highest ICC, while the 3–4 years group had the lowest. No significant differences were observed via paired t-tests (all P > 0.05). Table 3 Inter-Method Consistency by Age Group (logMAR, ICC, P-Values) Age(years) Case (eye) Computerized OKN (logMAR, x̅±s) Traditional VA chart (logMAR, x̅±s) ICC p-value t-test (p-value) 3ཞ4 14 Right -0.17 ± 0.12 -0.22 ± 0.1 0.45 p < 0.05 0.11 Left -0.18 ± 0.16 -0.15 ± 0.14 0.55 p < 0.05 0.48 5 13 Right -0.14 ± 0.1 -0.15 ± 0.15 0.61 p < 0.01 0.86 Left -0.22 ± 0.23 -0.15 ± 0.18 0.67 p < 0.01 0.17 6 17 Right -0.18 ± 0.30 -0.15 ± 0.25 0.91 p < 0.001 0.30 Left -0.21 ± 0.29 -0.20 ± 0.27 0.87 p < 0.001 0.74 7ཞ15 37 Right -0.20 ± 0.27 -0.20 ± 0.29 0.92 p < 0.001 0.82 Left -0.22 ± 0.27 -0.22 ± 0.28 0.89 p 18 23 Right -0.46 ± 0.36 -0.43 ± 0.35 0.94 p < 0.001 0.22 Left -0.38 ± 0.36 -0.39 ± 0.37 0.92 p < 0.001 0.75 3.2 Refractive Error Groups Both myopic and hyperopic groups showed good inter-method consistency, but the myopic group had higher ICC values than the hyperopic group (Table 4 ). No significant differences were found via paired t-tests (all P > 0.05). Table 4 Inter-Method Consistency by Refractive Error (logMAR, ICC, P-Values) Group Case (eye) Computerized OKN (logMAR, x̅±s) Traditional VA chart (logMAR, x̅±s) ICC p-value t-test (p-value) Myopia Right 39 -0.41 ± 0.35 -0.41 ± 0.34 0.94 p < 0.001 0.96 Left 41 -0.36 ± 0.33 -0.36 ± 0.33 0.93 p < 0.001 0.79 Hyperopia Right 33 -0.13 ± 0.15 -0.14 ± 0.16 0.77 p < 0.001 0.76 Left 30 -0.16 ± 0.19 -0.11 ± 0.17 0.72 p < 0.001 0.08 3.3 VA Ranges Inter-method correlation weakened as VA improved (Table 5 ). The highest ICC was observed in the 0.1–0.5 logMAR range, while the 1.0–1.5 logMAR range showed the lowest. Paired t-tests revealed significant differences in the 1.0–1.5 logMAR range (all P < 0.0001). Table 5 Inter-Method Consistency by VA Range (logMAR, ICC, P-Values) VA Case (eye) Computerized OKN (logMAR, x̅±s) Traditional VA chart (logMAR, x̅±s) ICC p-value t-test (p-value) 0.1ཞ0.5 Right 39 -0.50 ± 0.30 -0.53 ± 0.23 0.84 p < 0.001 0.25 Left 40 -0.48 ± 0.30 -0.53 ± 0.24 0.80 p < 0.001 0.13 0.5 ~ 1.0 Right 51 -0.12 ± 0.12 -0.11 ± 0.10 0.66 p < 0.001 0.65 Left 53 -0.13 ± 0.14 -0.09 ± 0.09 0.51 p 0.05 < 0.0001 Left 12 -0.001 ± 0.04 0.10 ± 0.04 0.51 p < 0.05 < 0.0001 Discussion Throughout the past few years, a lot of researchers have investigated how modifying the shape and position of stimuli impacts OKN development [ 11 – 13 ] . The OKN can detect visually significant deficits that require medical treatment by responding to a stimulus that is effectively developed [ 14 , 15 ] . OKN is an involuntary response and, thus, requires less assistance from participants. Since OKN is involuntary, it provides a rapid and accurate method for assessing patients' VA, especially for young non-verbal patients or those with anxiety or language barriers [ 16 ] . It might be challenging to adequately measure young VA of children in order to identify early childhood vision abnormalities because children tend to move around and lose focus while testing, as it is standard practice to assess VA in children using the same procedures as adults. A possible solution to the challenge of reliably evaluating visual function in this age range with objective approaches may be the detection of OKN. Since these procedures don’t rely on the capacity and desire to communicate, objective assessments of VA may be helpful when testing becomes challenging due to anxious participants or a language barrier. Furthermore, irrespective of behavioral responses, OKN testing in response to a patterned rotating drum or a computer-generated drifting stimulus can be utilized to objectively assess visual function [ 17 ] . To establish a connection between subjective and objective VA, the results of optokinetic VA in an OKN apparatus and traditional VA charts findings have been compared [ 18 ] . Camera-based eye tracking is one non-invasive electronic technique for eye monitoring; most of the time, this includes extracting the ocular signal from infrared video footage. The contrast and spatial dimensions of the stimuli may both be precisely adjusted using computer-assisted equipment. Computer-aided assessment and analysis may enable a fast, accurate, and controlled clinical examination of visual function [ 19 , 20 ] . The OKN test has been shown to be a viable method for assessing visual function in several studies [ 21 ] . These days, hand-held OKN drums are mostly replaced by computer-assisted OKN testing instruments that provide the ability to alter stripe width and contrast. The computer screen stimulates a bigger visual area, which makes it simpler to focus the youngster on the stimuli in the first place. This is crucial because, particularly in young children, a negative reaction to OKN may be misinterpreted due to a simple lack of attention to the stimuli. Additionally useful features of the computer-based system include consistent space-average brightness, uniform rate of movement, and precisely regular, smooth stripes on the screen. This study revealed that 219 of the 222 individuals that completed the screening requirements passed the test, and the testability rate was 98.6%, demonstrating the good operability of this method. A number of factors contributed to the failure of the nystagmus test, including tension esotropia, crying throughout the test, and being unable to finish it due to vertigo. The consistent brightness of the nystagmus equipment, the stable optotype movement speed throughout the test, and the lack of distraction from the surroundings of the examination room might be the reason for the good repeatability of the vision assessed by the nystagmus meter. The disadvantage of the wheel effect brought on by the tympanic method is minimized in this research by varying the width between the gratings, and the speed of grating is designed to steadily produce nystagmus in the participants. In this study, we considered recognition VA levels as the standard and wondered whether the new technology would allow a more precise clinical evaluation of visual function in preverbal children. We selected patients between the ages of 3 and 6 for our research group, clinicians may be able to more easily, quickly, and accurately assess visual function in this age group with the use of computer-assisted assessment and analysis. VA testing was additionally conducted in adult subjects to further validate the accuracy of this method. Results demonstrated that the correlation between the two assessment methods strengthened with increasing age, which may be attributed to improved patient compliance: older individuals showed better cooperation, thereby enhancing the accuracy of the test results. When using recognition VA as the reference standard, we found that the computerized OKN analyzer showed age-dependent performance: in children aged 6 years and older, the intraclass correlation coefficient (ICC) between OKN-derived VA and chart VA exceeded 0.87 (right eye: 0.91; left eye: 0.87), indicating good consistency. In contrast, the ICC was significantly lower in children aged 3–4 years (right eye: 0.45; left eye: 0.55), which may be explained by age-related differences in OKN maturation. The subcortical pathway mediating OKN continues to develop until approximately 6 years of age, and younger children may exhibit weaker or more variable nystagmus responses to the same stimulus [ 6 ] . Additionally, improved compliance in older children and adults likely contributed to the stronger correlation observed in these groups. A key finding of this study was the inverse relationship between VA quality and inter-method consistency: as VA improved, the correlation between the computerized OKN analyzer and the traditional lightbox chart weakened. Specifically, the highest ICC was observed in the 0.1–0.5 logMAR range (right eye: 0.84; left eye: 0.80), whereas in the 1.0–1.5 logMAR range, the ICC dropped to 0.31–0.51, with a significant difference in mean VA between the two methods (paired t-test, P < 0.0001) [ 22 ] . This phenomenon is consistent with previous reports and may be attributed to the limited spatial resolution of the OKN stimulus: for individuals with normal VA, the fine stripes required to discriminate high logMAR values may not provide sufficient contrast to induce detectable nystagmus. Future iterations of the device could address this limitation by increasing the maximum spatial frequency of the stimulus (e.g., narrowing stripe width to < 0.5 mm) or adjusting contrast dynamically based on initial VA estimates. In terms of refractive status, the computerized OKN analyzer showed stronger consistency with the lightbox chart in myopic patients (right eye ICC: 0.94; left eye ICC: 0.93) than in hyperopic patients (right eye ICC: 0.77; left eye ICC: 0.72). Further analysis revealed that hyperopic patients had lower OKN-derived VA (mean logMAR: -0.13 to -0.16) compared to chart-derived VA (mean logMAR: -0.11 to -0.14), a discrepancy that may be explained by differences in accommodative engagement. During traditional chart testing, hyperopic individuals can use active accommodation to compensate for refractive error and resolve distant optotypes; in contrast, the high-contrast black-and-white stripes of the OKN stimulus may suppress accommodative effort, leading to underestimation of VA [5]. This finding suggests that the computerized OKN analyzer may require refractive correction for hyperopic patients to improve measurement accuracy—an important consideration for clinical application. Beyond diagnostic precision, the intrinsic advantages of OKN-based assessment including operator simplicity, minimal infrastructure requirements and language-independent administration define compelling use scenarios. In preschool vision screening programs where traditional acuity charts face implementation barriers such as limited child cooperation and literacy demands, automated OKN systems enable rapid evaluations in less than 2 minutes per test and objective assessments without verbal responses. For special-needs populations such as non-verbal autism, intellectual disabilities and stroke survivors, the passive nature of OKN stimuli circumvents communication-dependent testing, offering critical access to vision assessment previously constrained by behavioral factors. Most significantly, in global health contexts characterized by resource limitations such as community health worker settings and mobile clinics, OKN platforms demonstrate distinct viability. Their portability with devices weighing less than 1 kg, low power consumption with solar-chargeable capabilities and elimination of refractive correction needs during screening align with WHO recommendations for tiered eye care delivery. Field validation studies in these scenarios should prioritize environmental robustness particularly against variable ambient lighting while establishing locally-relevant referral thresholds based on established VA correlation gradients. This study has three key limitations that should be considered when interpreting the results. First, the cross-sectional design precluded longitudinal assessment of the computerized OKN analyzer’s performance. For pediatric patients, in particular, longitudinal data are needed to determine whether OKN-derived VA can track changes in visual function over time (e.g., before and after amblyopia treatment), which is critical for evaluating its utility in monitoring treatment response. Second, children under 3 years of age were excluded from the study due to difficulties in obtaining reliable chart VA measurements, leaving the device’s applicability in this high-risk group unvalidated. Third, the reduced accuracy in individuals with normal VA (1.0–1.5 logMAR) limits the device’s use in general population screening, as it may misclassify individuals with normal vision as having subnormal VA. In summary, the computerized OKN analyzer represents a promising tool for objective VA assessment, with particular utility in children aged 6 years and older and myopic patients. However, its performance in younger children, hyperopic patients, and individuals with normal VA requires further optimization—including adjustments to stimulus parameters and validation in larger, more diverse cohorts. Future research should also explore the integration of refractive correction into the testing protocol for hyperopic patients and evaluate the device’s longitudinal performance in tracking visual development and treatment outcomes. Conclusion The computerized OKN analyzer demonstrates reliable performance for VA testing in patients aged ≥ 6 years, with superior accuracy in myopic individuals. It provides a convenient, objective alternative for children and patients with language disorders. However, its utility in children aged 3–4 years and individuals with normal VA requires further validation. Future studies should focus on longitudinal data collection and stimulus optimization to expand its clinical applicability. Abbreviations VA visual acuity OKN optokinetic nystagmus SE spherical equivalent ICC intraclass correlation coefficients Declarations Ethics approval and consent to participate This study was conducted in accordance with the Declaration of Helsinki and received ethical approval from the Ethics Committee of Beijing Tongren Hospital, affiliated with Capital Medical University (Ethics Approval Number: TRECKY2021-174). Informed consent was obtained from all participants’ parents or legal guardians. Consent for publication Not applicable. Competing interests The authors declare that they have no conflict of interest. Funding This work was supported by the “Yangfan” clinical technology innovation project, Beijing Municipal Administration of Hospitals (YGLX202506); High-Level Public Health Technical Talents Construction Project of Beijing Municipal Health Commission, (2023-1-2025.12). Author Contribution JF and MXJ designed the study. YYS, JH, BWZ, ZJM and NM joined the data collection. MXJ analyzed the data and drafted the manuscript. CC and ZL provided the instruments. YYS and JF contributed to the interpretation of the results and critical revision of the manuscript for important intellectual content and approved the final version of the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors would like to thank the Beijing Tongren Hospital for their support and contributions to this research. We really appreciate the help in this study from Pengfengcheng Medical technology, Qingdao, Shandong, China. Data Availability The data supporting the findings of this study are included in the manuscript. References Xia M, Faisal Ul R, Wang J, Chen N, Che C, Song Y. Preliminary study on the computer-based optokinetic nystagmus analyzer to detect the visual acuity of preschool children. Indian J Ophthalmol 2024, 72(0). David Edward H, Stephen R, Dan G. Optokinetic nystagmus: six practical uses. Pract Neurol 2024, 24(4). 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马","email":"","orcid":"","institution":"Beijing Tongren Eye Center","correspondingAuthor":false,"prefix":"","firstName":"南","middleName":"","lastName":"马","suffix":""},{"id":521668632,"identity":"46a8e195-2c6e-4f15-b689-7bb9d460ba9b","order_by":6,"name":"程 切","email":"","orcid":"","institution":"University of Petroleum Huadong","correspondingAuthor":false,"prefix":"","firstName":"程","middleName":"","lastName":"切","suffix":""},{"id":521668633,"identity":"035118b5-97f5-428c-abea-8bbfae2ac34e","order_by":7,"name":"兰娜 张","email":"","orcid":"","institution":"Department of Research and Development, Pengfengcheng Medical Technology","correspondingAuthor":false,"prefix":"","firstName":"兰娜","middleName":"","lastName":"张","suffix":""},{"id":521668634,"identity":"559e0446-3167-4c2f-a7fd-3cd8119d13e7","order_by":8,"name":"荆 福","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAt0lEQVRIiWNgGAWjYBAC9gYGBoMEBgY5NvbmA8Rp4TkA0WLMx3MsgXgtIJA4TyJHgUgtEgkMBQ931Ka3MeQwMPyo2EacFoPEM8dz2xjOHmDsOXObsBZ7sJa2Y7ltjH0JzIxtRGjhgWpJZ2PmMSBJS00CGxvRWngegLQcMGzjYUs4SJRfeNgT2Ax/ttXJy89/fPDBjwoitDAw8H8zYGA4DGYeIEY9CDA/YGCoI1bxKBgFo2AUjEQAAMtgN3K9s8sMAAAAAElFTkSuQmCC","orcid":"","institution":"Beijing Tongren Eye Center","correspondingAuthor":true,"prefix":"","firstName":"荆","middleName":"","lastName":"福","suffix":""}],"badges":[],"createdAt":"2025-08-25 08:23:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7451342/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7451342/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":92446145,"identity":"302b165a-68a8-43fd-8623-420336d7fe88","added_by":"auto","created_at":"2025-09-29 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1","display":"","copyAsset":false,"role":"figure","size":357220,"visible":true,"origin":"","legend":"\u003cp\u003eA. Computerized OKN analyzer; B. Scrolling screen bars.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7451342/v1/b2b537c0bb5bb5d8aede6e7b.png"},{"id":92445123,"identity":"599577eb-2685-428e-ac92-865d8b33beed","added_by":"auto","created_at":"2025-09-29 19:59:08","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":141493,"visible":true,"origin":"","legend":"\u003cp\u003eThis shows the nystagmus waveform captured by computer, where A is the left eye and B is the right eye. The vertical axis shows the eye movement, and the horizontal axis shows the time duration.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7451342/v1/14c69a31b381924fa64e3e50.png"},{"id":92445669,"identity":"0bb1e853-b0bd-4604-a695-39ec1f096308","added_by":"auto","created_at":"2025-09-29 20:07:08","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":121046,"visible":true,"origin":"","legend":"\u003cp\u003eA. Bland-Altman analysis of right eyes; B. Bland-Altman analysis of left eyes；C. Scatter plots and related lines of right eyes; D. Scatter plots and related lines of left eyes\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7451342/v1/49af91210a0c6973e20ece1a.png"},{"id":92446378,"identity":"9860223d-8cf5-467a-83ec-0f6df14ec1b0","added_by":"auto","created_at":"2025-09-29 20:23:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1477149,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7451342/v1/4973b0a4-3e64-4600-99f0-5e2de43948af.pdf"},{"id":92445128,"identity":"57d6f53c-c778-42f8-9214-559654f47da8","added_by":"auto","created_at":"2025-09-29 19:59:08","extension":"xlsx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":27326,"visible":true,"origin":"","legend":"","description":"","filename":"rawdata.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7451342/v1/81bbf9886dadd0fa2ad95380.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Analysis of the application of computerized optokinetic nystagmus analyzer in vision examination","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe 0\u0026ndash;6 years age window is critical for pediatric visual development: abnormal visual experiences during this period can disrupt visual system maturation and impair visual function \u003csup\u003e[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Thus, early refractive screening and comprehensive vision assessment in infants and young children are essential for timely intervention in developmental visual disorders and optimal clinical outcomes.\u003c/p\u003e\u003cp\u003eCurrent pediatric visual function assessment includes qualitative (behavioral observation, no quantitative VA data) and quantitative methods. Quantitative VA tests, based on the Preferential Gaze principle (e.g., forced preferential looking, enhanced preferential looking), rely on psychophysical paradigms but require repeated trials, prolonging examination and limiting clinical utility \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Visual Evoked Potential, an electrophysiological method, objectively evaluates retinocortical pathway function but cannot reflect subjective visual perception or assess high-level visual processing centers \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eYoung children\u0026rsquo;s immature cognitive, motor, and language abilities hinder objective, accurate VA measurement. While quantitative methods provide numerical data, their correlation with traditional VA charts is weak, partly due to the lack of a standardized framework for infant/young child vision assessment \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. For children at risk of amblyopia or visual impairment, reliable quantitative VA tools are urgently needed\u0026mdash;especially for those unable to complete traditional VA tests.\u003c/p\u003e\u003cp\u003eThe computerized OKN analyzer was initially developed for VA testing in mouse models and later adapted for humans \u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. It enables quantitative VA assessment and is particularly suitable for children and patients with language disorders. Previous studies have validated a computer-based OKN device with infrared eye-tracking for subjective VA correlation, but small sample sizes limited its clinical applicability \u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. Further validation of its accuracy against standard VA charts is required.\u003c/p\u003e\u003cp\u003eThis study compared the computerized OKN analyzer with the traditional OKN drum and standard lightbox VA chart. Objectives included: (1) evaluating the performance of the computerized OKN analyzer vs. traditional tools; (2) establishing correlations between OKN responses and standardized VA measurements; (3) exploring the clinical feasibility of the computerized OKN analyzer for VA assessment. The goal was to provide clinicians with a new vision assessment tool for children and patients with language disorders.\u003c/p\u003e\u003cp\u003e"},{"header":"Methods","content":"\n\u003ch3\u003e1. Study Population\u003c/h3\u003e\n\u003cp\u003eA total of 219 subjects (438 eyes) were enrolled from Beijing Tongren Eye Center between October 31 and December 31, 2023. Refractive data were converted to SE, subjects were categorized as myopic (SE \u0026le; -0.5 D) or hyperopic (SE\u0026thinsp;\u0026ge;\u0026thinsp;+\u0026thinsp;0.5 D). Subjects completing the lightbox VA chart test were stratified into five age groups: 3\u0026ndash;4 years, 5 years, 6 years, 7\u0026ndash;15 years, and 18\u0026ndash;58 years.\u003c/p\u003e\u003cp\u003eInclusion criteria: Ability to complete lightbox VA chart testing during routine outpatient visits; no concurrent ocular disease.\u003c/p\u003e\u003cp\u003eExclusion criteria: Congenital/secondary nystagmus; recent ocular infection/active lesions; head shaking during testing.\u003c/p\u003e\n\u003ch3\u003e2. Instruments and Procedures\u003c/h3\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Optotype vision screening\u003c/h2\u003e\u003cp\u003eA 21-inch display (1.5 m from the subject) presented scrolling black-and-white striped gratings (resolution: 2560\u0026times;1440; contrast: 100%). Stimulus parameters: stripe width 0.5\u0026ndash;8.7 mm, inter-grating distance 12\u0026ndash;26 mm, rolling speed 5\u0026deg;/s (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The optokinetic \u0026ldquo;wheel effect\u0026rdquo; was mitigated by optimizing inter-stripe spacing. Each test cycle included 3.5 seconds of left-to-right scrolling and 3.5 seconds of right-to-left scrolling. An infrared camera recorded nystagmus in real time, transmitting data to a computer for waveform generation (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A \u0026ldquo;positive response\u0026rdquo; was defined as \u0026ge;\u0026thinsp;2 distinct nystagmus waveforms per cycle; fewer waveforms indicated failure to perceive the target.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Stimulus Sequence for OKN Testing\u003c/h2\u003e\u003cp\u003eVisual stimuli were presented in a binary sequence. The initial stimulus corresponded to 0.5 decimal Snellen VA (logMAR equivalent). If\u0026thinsp;\u0026ge;\u0026thinsp;2 typical nystagmus waveforms were recorded, the next stimulus was adjusted to 0.3 decimal Snellen VA; if not, the next stimulus was 0.7 decimal Snellen VA. This iterative process continued until the smallest VA eliciting nystagmus was identified as the OKN analyzer-measured VA.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Ocular Examinations\u003c/h2\u003e\u003cp\u003eComputerized OKN test: Subjects rested their chin on a chin rest and forehead against the device. One eye was occluded; the subject viewed screen animations to ensure ocular relaxation. The infrared system recorded nystagmus, and the computer filtered waveforms to determine valid responses, adjusting stimuli until the minimum responsive VA was identified.\u003c/p\u003e\u003cp\u003eOKN drum test: The drum was rotated slowly in front of the subject to observe OKN presence.\u003c/p\u003e\u003cp\u003eLightbox VA chart test: A standard logarithmic VA chart was used (2.5 m test distance). The right eye was tested first, followed by the left. Testing proceeded downward from the top line; if\u0026thinsp;\u0026gt;\u0026thinsp;50% of optotypes in a line were identified correctly, the next line was tested. The last successfully identified line was recorded as VA.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e3. Statistical Analysis\u003c/h3\u003e\n\u003cp\u003eIntraclass correlation coefficients (ICC) was performed using SPSS 21 to examine the relationship between the results obtained by the two methods. ICC: Assessed inter-method consistency (interpretation: \u0026lt;0.5\u0026thinsp;=\u0026thinsp;poor; 0.5\u0026ndash;0.75\u0026thinsp;=\u0026thinsp;moderate; 0.75\u0026ndash;0.9\u0026thinsp;=\u0026thinsp;good; \u0026gt;0.9\u0026thinsp;=\u0026thinsp;excellent). Bland-Altman plots: Evaluated agreement by plotting the mean difference between methods against the mean of the two measurements. The paired t-test was used to detect the differences between the two groups, with P\u0026thinsp;\u0026gt;\u0026thinsp;0.05 considered no statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\n\u003ch3\u003e1. Consistency Between Computerized OKN Analyzer and OKN Drum\u003c/h3\u003e\n\u003cp\u003eOf 219 subjects (age distribution: Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), 167 (right eye) and 171 (left eye) showed consistent results between the two methods. Concordance rates were 74.00% (right eye) and 77.08% (left eye), indicating good agreement.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAge Distribution of Subjects\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCase\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRate\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3ཞ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15.1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7ཞ18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e24.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003e2. Consistency Between Computerized OKN Analyzer and Traditional VA chart\u003c/h3\u003e\n\u003cp\u003eA total of 104 subjects were included (age distribution: Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Mean VA (logMAR) was comparable between methods: Right eye: -0.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29 (OKN analyzer) vs. -0.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28 (lightbox); Left eye: -0.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28 (OKN analyzer) vs. -0.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29 (lightbox).\u003c/p\u003e\u003cp\u003eICC values were 0.92 (right eye) and 0.88 (left eye, both P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), confirming good consistency. Bland-Altman analysis showed mean differences of -0.003\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12 (right eye) and \u0026minus;\u0026thinsp;0.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14 (left eye), with 95% limits of agreement of -0.233 to 0.228 (right eye) and \u0026minus;\u0026thinsp;0.293 to 0.266 (left eye) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Paired t-tests showed no significant differences (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAge Distribution of Subjects\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCase\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRate\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3ཞ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16.3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7ཞ15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e35.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22.1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003e3. Subgroup Analyses (Age, Refractive Error, VA Range)\u003c/h3\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Age Groups\u003c/h2\u003e\u003cp\u003eInter-method consistency improved with age (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The \u0026ge;\u0026thinsp;18 years group showed the highest ICC, while the 3\u0026ndash;4 years group had the lowest. No significant differences were observed via paired t-tests (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eInter-Method Consistency by Age Group (logMAR, ICC, P-Values)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge(years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCase\u003c/p\u003e\u003cp\u003e(eye)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComputerized OKN (logMAR, x̅\u0026plusmn;s)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTraditional VA chart (logMAR, x̅\u0026plusmn;s)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eICC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003et-test\u003c/p\u003e\u003cp\u003e(p-value)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3ཞ4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.17\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.86\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.21\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.74\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7ཞ15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.82\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.22\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.46\u0026thinsp;\u0026plusmn;\u0026thinsp;0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Refractive Error Groups\u003c/h2\u003e\u003cp\u003eBoth myopic and hyperopic groups showed good inter-method consistency, but the myopic group had higher ICC values than the hyperopic group (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). No significant differences were found via paired t-tests (all P\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eInter-Method Consistency by Refractive Error (logMAR, ICC, P-Values)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCase (eye)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComputerized OKN (logMAR, x̅\u0026plusmn;s)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTraditional VA chart (logMAR, x̅\u0026plusmn;s)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eICC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003et-test\u003c/p\u003e\u003cp\u003e(p-value)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMyopia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.36\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.79\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHyperopia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.77\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.3 VA Ranges\u003c/h2\u003e\u003cp\u003eInter-method correlation weakened as VA improved (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The highest ICC was observed in the 0.1\u0026ndash;0.5 logMAR range, while the 1.0\u0026ndash;1.5 logMAR range showed the lowest. Paired t-tests revealed significant differences in the 1.0\u0026ndash;1.5 logMAR range (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eInter-Method Consistency by VA Range (logMAR, ICC, P-Values)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCase\u003c/p\u003e\u003cp\u003e(eye)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eComputerized OKN (logMAR, x̅\u0026plusmn;s)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTraditional VA chart (logMAR, x̅\u0026plusmn;s)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eICC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003et-test\u003c/p\u003e\u003cp\u003e(p-value)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0.1ཞ0.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.48\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.13\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0.5\u0026thinsp;~\u0026thinsp;1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.12\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.65\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e-0.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e0.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1.0\u0026thinsp;~\u0026thinsp;1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e0.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e0.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e-0.001\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e\u003cp\u003e0.10\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThroughout the past few years, a lot of researchers have investigated how modifying the shape and position of stimuli impacts OKN development \u003csup\u003e[\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. The OKN can detect visually significant deficits that require medical treatment by responding to a stimulus that is effectively developed \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. OKN is an involuntary response and, thus, requires less assistance from participants. Since OKN is involuntary, it provides a rapid and accurate method for assessing patients' VA, especially for young non-verbal patients or those with anxiety or language barriers \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. It might be challenging to adequately measure young VA of children in order to identify early childhood vision abnormalities because children tend to move around and lose focus while testing, as it is standard practice to assess VA in children using the same procedures as adults. A possible solution to the challenge of reliably evaluating visual function in this age range with objective approaches may be the detection of OKN. Since these procedures don\u0026rsquo;t rely on the capacity and desire to communicate, objective assessments of VA may be helpful when testing becomes challenging due to anxious participants or a language barrier. Furthermore, irrespective of behavioral responses, OKN testing in response to a patterned rotating drum or a computer-generated drifting stimulus can be utilized to objectively assess visual function \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. To establish a connection between subjective and objective VA, the results of optokinetic VA in an OKN apparatus and traditional VA charts findings have been compared \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eCamera-based eye tracking is one non-invasive electronic technique for eye monitoring; most of the time, this includes extracting the ocular signal from infrared video footage. The contrast and spatial dimensions of the stimuli may both be precisely adjusted using computer-assisted equipment. Computer-aided assessment and analysis may enable a fast, accurate, and controlled clinical examination of visual function \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. The OKN test has been shown to be a viable method for assessing visual function in several studies \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. These days, hand-held OKN drums are mostly replaced by computer-assisted OKN testing instruments that provide the ability to alter stripe width and contrast. The computer screen stimulates a bigger visual area, which makes it simpler to focus the youngster on the stimuli in the first place. This is crucial because, particularly in young children, a negative reaction to OKN may be misinterpreted due to a simple lack of attention to the stimuli. Additionally useful features of the computer-based system include consistent space-average brightness, uniform rate of movement, and precisely regular, smooth stripes on the screen.\u003c/p\u003e\u003cp\u003eThis study revealed that 219 of the 222 individuals that completed the screening requirements passed the test, and the testability rate was 98.6%, demonstrating the good operability of this method. A number of factors contributed to the failure of the nystagmus test, including tension esotropia, crying throughout the test, and being unable to finish it due to vertigo. The consistent brightness of the nystagmus equipment, the stable optotype movement speed throughout the test, and the lack of distraction from the surroundings of the examination room might be the reason for the good repeatability of the vision assessed by the nystagmus meter. The disadvantage of the wheel effect brought on by the tympanic method is minimized in this research by varying the width between the gratings, and the speed of grating is designed to steadily produce nystagmus in the participants. In this study, we considered recognition VA levels as the standard and wondered whether the new technology would allow a more precise clinical evaluation of visual function in preverbal children. We selected patients between the ages of 3 and 6 for our research group, clinicians may be able to more easily, quickly, and accurately assess visual function in this age group with the use of computer-assisted assessment and analysis. VA testing was additionally conducted in adult subjects to further validate the accuracy of this method. Results demonstrated that the correlation between the two assessment methods strengthened with increasing age, which may be attributed to improved patient compliance: older individuals showed better cooperation, thereby enhancing the accuracy of the test results.\u003c/p\u003e\u003cp\u003eWhen using recognition VA as the reference standard, we found that the computerized OKN analyzer showed age-dependent performance: in children aged 6 years and older, the intraclass correlation coefficient (ICC) between OKN-derived VA and chart VA exceeded 0.87 (right eye: 0.91; left eye: 0.87), indicating good consistency. In contrast, the ICC was significantly lower in children aged 3\u0026ndash;4 years (right eye: 0.45; left eye: 0.55), which may be explained by age-related differences in OKN maturation. The subcortical pathway mediating OKN continues to develop until approximately 6 years of age, and younger children may exhibit weaker or more variable nystagmus responses to the same stimulus \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Additionally, improved compliance in older children and adults likely contributed to the stronger correlation observed in these groups.\u003c/p\u003e\u003cp\u003eA key finding of this study was the inverse relationship between VA quality and inter-method consistency: as VA improved, the correlation between the computerized OKN analyzer and the traditional lightbox chart weakened. Specifically, the highest ICC was observed in the 0.1\u0026ndash;0.5 logMAR range (right eye: 0.84; left eye: 0.80), whereas in the 1.0\u0026ndash;1.5 logMAR range, the ICC dropped to 0.31\u0026ndash;0.51, with a significant difference in mean VA between the two methods (paired t-test, P\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e. This phenomenon is consistent with previous reports and may be attributed to the limited spatial resolution of the OKN stimulus: for individuals with normal VA, the fine stripes required to discriminate high logMAR values may not provide sufficient contrast to induce detectable nystagmus. Future iterations of the device could address this limitation by increasing the maximum spatial frequency of the stimulus (e.g., narrowing stripe width to \u0026lt;\u0026thinsp;0.5 mm) or adjusting contrast dynamically based on initial VA estimates.\u003c/p\u003e\u003cp\u003eIn terms of refractive status, the computerized OKN analyzer showed stronger consistency with the lightbox chart in myopic patients (right eye ICC: 0.94; left eye ICC: 0.93) than in hyperopic patients (right eye ICC: 0.77; left eye ICC: 0.72). Further analysis revealed that hyperopic patients had lower OKN-derived VA (mean logMAR: -0.13 to -0.16) compared to chart-derived VA (mean logMAR: -0.11 to -0.14), a discrepancy that may be explained by differences in accommodative engagement. During traditional chart testing, hyperopic individuals can use active accommodation to compensate for refractive error and resolve distant optotypes; in contrast, the high-contrast black-and-white stripes of the OKN stimulus may suppress accommodative effort, leading to underestimation of VA [5]. This finding suggests that the computerized OKN analyzer may require refractive correction for hyperopic patients to improve measurement accuracy\u0026mdash;an important consideration for clinical application.\u003c/p\u003e\u003cp\u003eBeyond diagnostic precision, the intrinsic advantages of OKN-based assessment including operator simplicity, minimal infrastructure requirements and language-independent administration define compelling use scenarios. In preschool vision screening programs where traditional acuity charts face implementation barriers such as limited child cooperation and literacy demands, automated OKN systems enable rapid evaluations in less than 2 minutes per test and objective assessments without verbal responses. For special-needs populations such as non-verbal autism, intellectual disabilities and stroke survivors, the passive nature of OKN stimuli circumvents communication-dependent testing, offering critical access to vision assessment previously constrained by behavioral factors. Most significantly, in global health contexts characterized by resource limitations such as community health worker settings and mobile clinics, OKN platforms demonstrate distinct viability. Their portability with devices weighing less than 1 kg, low power consumption with solar-chargeable capabilities and elimination of refractive correction needs during screening align with WHO recommendations for tiered eye care delivery. Field validation studies in these scenarios should prioritize environmental robustness particularly against variable ambient lighting while establishing locally-relevant referral thresholds based on established VA correlation gradients.\u003c/p\u003e\u003cp\u003eThis study has three key limitations that should be considered when interpreting the results. First, the cross-sectional design precluded longitudinal assessment of the computerized OKN analyzer\u0026rsquo;s performance. For pediatric patients, in particular, longitudinal data are needed to determine whether OKN-derived VA can track changes in visual function over time (e.g., before and after amblyopia treatment), which is critical for evaluating its utility in monitoring treatment response. Second, children under 3 years of age were excluded from the study due to difficulties in obtaining reliable chart VA measurements, leaving the device\u0026rsquo;s applicability in this high-risk group unvalidated. Third, the reduced accuracy in individuals with normal VA (1.0\u0026ndash;1.5 logMAR) limits the device\u0026rsquo;s use in general population screening, as it may misclassify individuals with normal vision as having subnormal VA.\u003c/p\u003e\u003cp\u003eIn summary, the computerized OKN analyzer represents a promising tool for objective VA assessment, with particular utility in children aged 6 years and older and myopic patients. However, its performance in younger children, hyperopic patients, and individuals with normal VA requires further optimization\u0026mdash;including adjustments to stimulus parameters and validation in larger, more diverse cohorts. Future research should also explore the integration of refractive correction into the testing protocol for hyperopic patients and evaluate the device\u0026rsquo;s longitudinal performance in tracking visual development and treatment outcomes.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe computerized OKN analyzer demonstrates reliable performance for VA testing in patients aged\u0026thinsp;\u0026ge;\u0026thinsp;6 years, with superior accuracy in myopic individuals. It provides a convenient, objective alternative for children and patients with language disorders. However, its utility in children aged 3\u0026ndash;4 years and individuals with normal VA requires further validation. Future studies should focus on longitudinal data collection and stimulus optimization to expand its clinical applicability.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eVA visual acuity\u003c/p\u003e\n\u003cp\u003eOKN optokinetic nystagmus\u003c/p\u003e\n\u003cp\u003eSE spherical equivalent\u003c/p\u003e\n\u003cp\u003eICC intraclass correlation coefficients\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e This study was conducted in accordance with the Declaration of Helsinki and received ethical approval from the Ethics Committee of Beijing Tongren Hospital, affiliated with Capital Medical University (Ethics Approval Number: TRECKY2021-174). Informed consent was obtained from all participants\u0026rsquo; parents or legal guardians.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work was supported by the \u0026ldquo;Yangfan\u0026rdquo; clinical technology innovation project, Beijing Municipal Administration of Hospitals (YGLX202506); High-Level Public Health Technical Talents Construction Project of Beijing Municipal Health Commission, (2023-1-2025.12).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJF and MXJ designed the study. YYS, JH, BWZ, ZJM and NM joined the data collection. MXJ analyzed the data and drafted the manuscript. CC and ZL provided the instruments. YYS and JF contributed to the interpretation of the results and critical revision of the manuscript for important intellectual content and approved the final version of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eThe authors would like to thank the Beijing Tongren Hospital for their support and contributions to this research. We really appreciate the help in this study from Pengfengcheng Medical technology, Qingdao, Shandong, China.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data supporting the findings of this study are included in the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eXia M, Faisal Ul R, Wang J, Chen N, Che C, Song Y. Preliminary study on the computer-based optokinetic nystagmus analyzer to detect the visual acuity of preschool children. Indian J Ophthalmol 2024, 72(0).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDavid Edward H, Stephen R, Dan G. Optokinetic nystagmus: six practical uses. Pract Neurol 2024, 24(4).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSoheil MD, Philip RKT, Steven CD. The Effect of Simulated Visual Field Loss on Optokinetic Nystagmus. Transl Vis Sci Technol 2020, 9(3).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJames RD, Lauren MW, David RS, Eileen EB. The teller acuity cards are effective in detecting amblyopia. Optom Vis Sci 2009, 86(6).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMarcelo Fernandes C, Dora Fix V. Visual impairment in children with spastic cerebral palsy measured by psychophysical and electrophysiological grating acuity tests. Dev Neurorehabil 2012, 15(6).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJanette A, Oliver B. Inferences about infants' visual brain mechanisms. Vis Neurosci 2014, 30(0).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eClaudia P, Gina M, Jean RS, Emmanuel O, Dave S-A. Similarities and differences between behavioral and electrophysiological visual acuity thresholds in healthy infants during the second half of the first year of life. Doc Ophthalmol 2017, 134(2).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eB E, L M BLRT. O: The effect of toluene on the vestibulo- and opto-oculomotor system in rats. A computerized nystagmographic study. Acta Otolaryngol 1986, 101(0).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNoemie S, Anja P-W. Establishing an Objective Measurement of Visual Acuity with a Computerised Optokinetic Nystagmus Suppression Test. Klin Monbl Augenheilkd 2020, 237(4).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSang Beom H, Hee Kyung Y, Joon Young H, Jong-Mo S, Jin Hak L. In Bum L, Jeong-Min H: Efficacy of a computerized optokinetic nystagmus test in prediction of visual acuity of better than 20/200. Invest Ophthalmol Vis Sci 2011, 52(10).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eD H, V H, P H W: Experimental studies of optokinetic nystagmus. IV. Rabbits. Ann Otol Rhinol Laryngol 1971, 80(3).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eI P H MO. The efficiency of the central and peripheral retina in driving human optokinetic nystagmus. Vis Res 1984, 24(9).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSiobhan G, Yanning H, Arun NK, Mark H, Chris MH, John R. L: Vertical optokinetic nystagmus and saccades in normal human subjects. Invest Ophthalmol Vis Sci 2003, 44(9).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEleni P, Michael C. B: Is there a role for optokinetic nystagmus testing in contemporary orthoptic practice? Old tricks and new perspectives. Am Orthopt J 2014, 64(0).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGiovanni B, Fausto R, Dominik S, Katharine K, Antonella P, Nina F-D. Measuring optokinetic after-nystagmus: potential for detecting patients with signs of visual dependence following concussion. J Neurol 2020, 268(5).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eM J D JES, J T E, I G, H J G, C H. H L, J O, J S, F S : Management of nystagmus in children: a review of the literature and current practice in UK specialist services. Eye (Lond) 2020, 34(9).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSara TW, Joseph F 3rd, David RM. B, Conrad 3rd W: Optokinetic nystagmus as a measure of visual function in severely visually impaired patients. Invest Ophthalmol Vis Sci 2007, 48(10).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYa-Lan W, Jia-Jun W, Xi-Cong L, Han Z, Yun-E Z. Clinical usefulness of the baby vision test in young children and its correlation with the Snellen chart. Int J Ophthalmol 2024, 17(2).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMills M, Ciner E, Ying G-s, Daniel E, Martin ER, Meiyeppen S, DeSouza E, Peirish L. Quantitative visual acuity measurement in young children using tablet-based optokinetic nystagmus videography. Investig Ophthalmol Vis Sci. 2019;60(9):4416\u0026ndash;4416.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNo\u0026eacute;mie S, Anja P-W. Objective measurement of visual acuity by optokinetic nystagmus suppression in children and adult patients. J AAPOS 2019, 23(5).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShin YJ, Park KH, Hwang JM, Wee WR, Lee JH, Lee IB. Objective measurement of visual acuity by optokinetic response determination in patients with ocular diseases. Am J Ophthalmol. 2006;141(2):327\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJason T, Zaw L, Mohammad N, Misty E, Rebecca F, Joanna B, Benjamin T. OKN-Fast: Objective visual acuity threshold measurement using the optokinetic response(). Annu Int Conf IEEE Eng Med Biol Soc 2023, 2023(0).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Computerized OKN analyzer, Visual acuity, Children, Accuracy, Optokinetic drum","lastPublishedDoi":"10.21203/rs.3.rs-7451342/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7451342/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e To investigate the practicability, accuracy, and consistency of the computerized optokinetic nystagmus (OKN) analyzer for visual acuity (VA) measurement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod \u003c/strong\u003eConsistency evaluation study. A total of 219 subjects (13.48±12.89 years, 115 males, 104 females) underwent bilateral VA testing using a computerized OKN analyzer and a traditional OKN drum. Additionally, 104 subjects (12.58±12.05 years, 54 males, 50 females) were tested bilaterally with the computerized OKN analyzer and a standard lightbox VA chart (random order), including 80 myopic eyes (spherical equivalent [SE] ≤ -0.5 D) and 63 hyperopic eyes (SE ≥ +0.5 D); VA was recorded in logMAR. Concordance rates between the OKN analyzer and OKN drum were calculated. Intraclass correlation coefficients (ICC) and Bland-Altman plots were used to assess the consistency between the OKN analyzer and lightbox VA chart. Subjects completing the lightbox test were stratified by age (3–4 years, 5 years, 6 years, 7–15 years, 18–58 years), refractive error, and VA range to compare inter-method correlations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e Compared with the OKN drum, the computerized OKN analyzer achieved a concordance rate of 74.00% (right eye) and 77.08% (left eye), indicating good agreement. For VA measurements, mean VA (logMAR) of the right eye was -0.24±0.29 (OKN analyzer) vs. -0.24±0.28 (lightbox); left eye was -0.25±0.28 vs. -0.24±0.29. ICC values were 0.92 (right eye) and 0.88 (left eye, both P\u0026lt;0.001), confirming significant consistency. Bland-Altman analysis showed 95% limits of agreement of -0.232 to 0.228 (right eye) and -0.293 to 0.266 (left eye). Bland-Altman analysis showed 95% limits of agreement of -0.232 to 0.228 (right eye) and -0.293 to 0.266 (left eye). Inter-method consistency improved with age (highest in ≥18 years) and was stronger in myopic vs. hyperopic eyes. Notably, correlation weakened as VA improved, with the highest concordance in the 0.1–0.5 logMAR range.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e The computerized OKN analyzer exhibits favorable reliability, accuracy, and practicability for VA testing in patients aged ≥6 years across different refractive errors, with superior performance in myopic patients. Its utility in children aged 3–4 years and individuals with normal VA (≤0.1 logMAR) requires further validation.\u003c/p\u003e","manuscriptTitle":"Analysis of the application of computerized optokinetic nystagmus analyzer in vision examination","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-29 19:59:00","doi":"10.21203/rs.3.rs-7451342/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-01T17:34:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-16T15:31:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-06T18:38:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"71493493234451230503815744375564648796","date":"2026-02-03T10:52:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"6488821706545404232246805041454338397","date":"2026-02-02T11:04:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"89641740771418099515257476897663513439","date":"2026-02-02T10:18:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-05T08:34:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"159571323330174023313590034465525799680","date":"2025-09-25T14:57:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"47320665672731439761085857839907155592","date":"2025-09-18T11:31:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-18T05:48:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-16T18:54:29+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-28T13:05:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-28T12:01:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Ophthalmology","date":"2025-08-28T11:58:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-ophthalmology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"boph","sideBox":"Learn more about [BMC Ophthalmology](http://bmcophthalmol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/boph","title":"BMC Ophthalmology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"519e9f2e-9614-483e-b054-e3d3946a17de","owner":[],"postedDate":"September 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-21T14:53:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-29 19:59:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7451342","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7451342","identity":"rs-7451342","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}