Methods, systems and devices for vision tests

Abstract

To provide methods, systems and devices for improving the assessment of the visual function and overcoming limitations of current methods for identifying the visual function that may potentially be reached by a given eye.SOLUTION: Multiple eye tests includes visual stimuli and optical measurement components, and methods of combining the results to identify and quantify sources of decreased vision resulting from optical sources, such as a lens and a cornea as distinguished from retinal sources. By identifying potentially correctable optical sources of decreased vision, and overcoming physiological limitations such as size of the eye's pupil, visual benefits of treatment such as cataract or corneal surgery are distinguished from retinal pathology that requires medical intervention. The devices and methods provide metrics that include an expected value of the visual function and sources of variability including both optical and neural components, to guide treatment and improve clinical trials.SELECTED DRAWING: Figure 1

Description

[Technical field]

[0001] STATEMENT REGARDING FEDERALLY SPONSORED RESEARCH OR DEVELOPMENT This invention was made with Government support under EY030829 awarded by the National Institutes of Health. The Government has certain rights in the invention.

[0002] Related Applications This application claims priority to U.S. patent application Ser. No. 17 / 554,703, entitled "METHODS, SYSTEMS, AND DEVICES FOR VISUAL INSPECTION," filed Dec. 17, 2021, which is incorporated by reference in its entirety herein. [Background technology]

[0003] Visual acuity and other visual functions guide the management of patients with retinal diseases and conditions. Such tests of visual function also serve as endpoints in clinical trials to test treatments. Printed and electronic charts for measuring visual acuity or other visual functions are commonly used because they are standardized, easy to use, and can be widely distributed, but they are inaccurate for the purpose of assessing retinal status. Such charts do not minimize or quantify optical factors that reduce ocular performance, such as stray light, insufficient transmittance, or lack of sharp focus due to problems with the tear film, cornea, or lens.

[0004] Additional optical factors include, but are not limited to, lack of proper refraction, especially when the correction of refractive errors is not simultaneous with the measurement using visual function charts, or is incorrect due to changes in the plane of the retina at the target location, such as by subretinal fluid. Furthermore, methods using visual function charts do not allow control of pupil size. Pupil size varies greatly among individuals, and with age the pupil often becomes smaller, which can greatly reduce the amount of light transmitted to the retina. When one or more sources of optical deterioration are present, the common clinical treatment of providing a pinhole to minimize the angle at which light can enter the eye and the cross section of the pupil through which light can pass can result in even greater variability in light transmission. Methods using visual function charts do not control or specify the fixation position of the eye, which aligns the visual stimulus to the retina, leading to a lack of information about the area of ​​the retina that is useful for visual function measurements. Furthermore, visual function charts do not specify the stability of fixation, which can affect vision when fixation stability is lacking.

[0005] Many optical devices provide one or more design features for visual display to control or determine information from these display features that influence the evaluation of ocular function. For visual acuity, which is closely related to retinal function, all of these display factors, including high resolution displays and models that combine information, are relevant to the determination of retinal function. Factors such as the precise stimulus and number of letters affect the performance of visual tests, including visual acuity tests. Although potentially important in estimating reading ability, such tests may compromise accuracy when assessing retinal status. Models used to improve the accuracy and testing efficiency of visual acuity and other visual functions include procedural details and stimulus parameters. However, these models do not adequately minimize or identify the effects on central tendency and variability of optical and performance factors on the measurements of visual function within the models. Measurements and models of the above non-retinal factors are necessary to identify retinal visual function and potential vision that may be achieved with treatment.

[0006] The present invention aims to improve and overcome some of these known deficiencies in the related art. It is intended. Summary of the Invention

[0007] The present invention relates to methods, systems and devices designed for diagnostic use by eye care professionals and researchers in clinical trials to more accurately identify the visual function of the eye and the potential for improvement through treatment. The methods, systems and devices provide ease of operation, patient comfort and efficiency. The methods, systems and devices are suitable for providing a wide range of information required to identify the cause of vision loss, which will affect treatment decisions. The system has several subsystems that together provide improved accuracy and can be manufactured at a significantly lower cost than systems that perform only some of the functions of the subsystems or provide better accuracy and efficiency. The devices and systems can easily interface with modern computer technology to augment databases used for decision making or transmit information to external databases for decision making for treatment decisions.

[0008] The disclosed technology provides devices and methods that are much more advanced than typical wall-mounted test charts or computer screens, which especially highlight problems related to presbyopia. Errors and variability are a direct result of these artifacts and cannot be overcome by software or algorithms alone, many of which have been proposed to address specific stimuli or optotypes, algorithms for stimulus presentation, or test factors such as patient fatigue, patient-used criteria, or cognitive impairment. See, for example, U.S. Patent No. 10,758,120 to Lesmes. The disclosed innovations improve many of these problems by combining one or more of the following features:

[0009] The present invention provides 1) an assessment of fixation location using video-rate and near-infrared retinal imaging that is invisible to the patient. The portion of the retina used for fixation and performing visual function testing is located. Because the human eye moves frequently, without retinal imaging at or faster than video rate, the location of the visual stimulus relative to the state of the retina cannot be known. Wall charts and computer screens cannot establish this correlation. Thus, it is not known whether the portion of the retina being considered for treatment is actually in a position that is the basis for the measured performance. Video-rate retinal imaging determines this location. Furthermore, without retinal imaging that is relatively fast relative to eye movement, it is not possible to determine whether the eye is wobbly and whether the visual target is blurred across the retina or whether the eye is in a position long enough to allow for detection or recognition of the visual target. As used herein, video rate includes an image capture or display rate of at least 10 frames per second.

[0010] The widespread use of near-infrared light as an illumination source to provide retinal images to visualize retinal landmarks and structures, instead of other wavelengths or color images, is discussed extensively in Elsner, A.E. et al., Infrared Imaging of Sub-retinal Structures in the Human Ocular Fundus, Vision Res, Vol. 36, No. 1 (1996), pp. 191-205 (Elsner et al., 1996). Several implementations have been demonstrated by inventor A.E. Elsner. See, for example: Elsner, AE, Burns, SA, Hughes, GW, and Webb, RH (1992). Reflectometry with a scanning laser ophthalmoscope. Applied optics, 31(19), 3697-3710. (Elsner et al., 1992) and Elsner, AE et al., Multiply scattered light tomography: Vertical cavity surface emitting laser array used for imaging subretinal structure, Lasers and Light in Ophthalmology, 1998 (Elsner et al., 1998a).

[0011] While each embodiment has its own unique features, high quality images of the retina obtained by many methods are suitable for combination with the projection of visual stimuli onto the retina, for example scanning with a light spot and synchronously detecting the light returning from the retina one spot at a time, providing information about the state of the retina in eye diseases: Hartnett, ME and Elsner, AE, Characteristics of Exudative Age-related Macular Degeneration Determined In Vivo with Confocal and Indirect Infrared Imaging, Ophthalmology, Vol. 103, No. 1 (January 1996), pp. 58-71 (Hartnett et al., 1996a); and Hartnett, ME et al., Deep Retinal Vascular Anomalous Complexes in Advanced Age-related Macular Degeneration, Ophthalmology, Vol. 103, No. 12 (December 1996), pp. 2042-2053 (Hartnett et al., 1996b). The location of visual fixation and visual stimuli on a patient's retina has been well visualized by inventor AE Elsner and co-workers: Remky, A., Elsner, AE, Morandi, AJ, Beausencourt, E., and Trempe, CL (2001).Blue-on-yellow perimetry with a scanning laser ophthalmoscope: small alterations in the central macula with aging vision,18(7)、1425~1436;(Remkyらによる、2001);.Remky, A. and Elsner, AE(2005). ophthalmology,89(4) 464~469(Remky, 2005); I, C., Suzuki, H., Nehemiah, MB, Soriano, DS, and Kara-Jose, N. (2007).Avaliacao. of macular perimetry in patients with age-related macular degeneration due to laser tracking ophthalmoscope-Evaluation of macular perimetry in patients with age-related macular degeneration using the scanning laser ophthalmoscope.Brazilian archives of ophthalmology,70(5),844~850(Moraesらによる、2007).

[0012] Similar methods have been used by the present inventors to image the retina using near-infrared illumination consisting of scanned light strips and detection synchronized with either one- or two-dimensional arrays: see, for example, U.S. Patent Nos. 7,331,669, 7,831,106, 8,237,835, and 8,488,895. The near-infrared image of the retina is combined with a visual display such that the locus of fixation and the location of stimuli on the retina are unambiguously recorded using near-infrared or long-wavelength visible illumination as shown by Elsner, AE, Petrig, BL, Papay, JA, Kollbaum, EJ, Clark, CA, and Muller, MS (2013) as described herein. Fixation stability and scotoma mapping for patients with low vision. Optometry and vision science: official publication of the American Academy of Optometry, 90(2), 164-173 (Elsner et al., 2013) and Elsner, AE, Papay, JA, Johnston, KD, Sawides, L., de Castro, A., King, BJ, Jones, DW, Clark, CA, Gast, TJ, and Burns, SA (Elsner et al., 2020), Cones in aging and harsh environments: the neural economy hypothesis. Ophthalmic & physiological optics: The Journal of the British College of Ophthalmic Opticians (Optometrists), 40(2), 88-116 (Elsner et al., 2020).

[0013] The present invention provides 2) assessment of gaze stability using the same video-rate near-infrared retinal imaging: the patient's eye movements are analyzed by registering retinal images acquired over time.

[0014] The present invention 3) identifies optical errors in a patient's eye, including but not limited to spherical and cylindrical, as well as other optical errors, including those due to pathological or aging conditions found in the cornea, lens, or pupil, collected by wavefront sensor measurements of light returning from the retina. These errors arise from wavefront aberrations that cause complex blurring on the retina, making it difficult to determine whether a loss of vision is due to retinal disease or anterior segment problems such as cataracts or poor tear film. It has long been known that aging increases these optical errors that blur visual stimuli on a patient's retina, and the blurring cannot be easily improved by simply adding spherical or cylindrical corrections such as those found in eyeglasses. See, for example, How Age-Related Changes in Monochromatic Wave Aberrations of the Human Eye Can Be Measured, as reported by McLellan, JS, Marcos, S., and Burns, SA (2001); Investigative ophthalmology & visual science, 42(6), 1390-1395. Accordingly, the present disclosure provides one or more embodiments including methods and / or apparatus that emphasize improved characterization of the factors underlying the visual performance or function of an aging eye, which reduces costs and improves accuracy of analyzing ocular conditions.

[0015] The invention 4) provides objective correction with adaptive optics during measurement of the visual function of the main optical errors of the patient's eye, not limited to sphere and cylinder, using the wavefront measurements described above in item 3 above. The invention also provides an estimate of the accuracy of the measurements leading to the correction and the predicted success of the correction. This allows the visual function test to be performed using a directional light beam precisely focused on the retina, thereby providing a more complete result than can be achieved with just standard sphere and cylinder correction or habitual refraction, which often produces significant errors when the retina is bulging as a result of exudative eye disease. This feature is essentially an autorefractor that does not include only sphere and cylinder, and when used in combination with other features not found in autorefractors, provides even greater accuracy.

[0016] The optical correction required to provide correction of higher order aberrations, and therefore improve measurements of visual function that depend on high contrast at high spatial resolution, was not possible prior to the use of wavefront corrected imaging of the fundus by the authors Burns, SA, Marcos, S., Elsner, AE, and Bara, S. (2002). Contrast improvement of confocal retinal imaging by use of phase-correcting plates. Optics letters, 27(6), 400-402. It was first shown by Timberlake and colleagues Timberlake, GT, Mainster, MA, Peli, E., Augliere, RA, Essock, EA, and Arend, LE (1986) that previous equipment provided fundus images and visual stimuli but lacked sufficient spatial resolution to test visual acuity. Reading with a macular scotoma.I.Retinal location of scotoma and fixation area.Investigative ophthalmology&visual science,27(7), 1137~1147.

[0017] In the above known conventional methods for refractive correction beyond sphere and cylinder mentioned and cited above, a wavefront measuring device is used in combination with a retinal image. In an embodiment to reduce the cost and complexity of the components, the information in the image can be used to quantify the optical quality of the eye. This has been done to determine the refractive error of the spherical components. Peripheral Refraction Across The Posterior Pole Using Structured Illumination.ARVO Annual Meeting,Investigative Ophthalmology&Visual Science 52(14),2717~2717,2011(Clark et al., 2011);Elsner AE,Muller MS,Petrig BL,Papay JA,Christopher CA,Jovan A,Haggerty BP.Toward Low Cost Imaging:A Laser Scanning Digital Camera.Bio-Optics:Design and Application(BODA)2011 paper:BWA1 (Elsner et al., 2011).

[0018] Additionally, information in the fundus image provides autofocus for the retinal camera. This technique is known as sensorless adaptive optics (AO), described in Burns, SA, Elsner, AE, Sapoznik, KA, Warner, RL, and Gast, TJ (2019). Adaptive optics imaging of the human retina Progress in retinal and eye research, 68, 1-30 (Burns et al., 2019). In some cases, the retinal image acts as a sensor. By injecting a spatial pattern, such as black and white stripes, into the illumination, the contrast of the fundus image is improved, as described in Clark's reference above. Thus, there is in effect a sensor, i.e., a retinal image and a computation. Projection of a pattern onto the retina has been achieved with both point and line scanning, but not with the use of wide-field images or computation of wavefront error based on a specific portion of the retinal image with a known spatial relationship to the fixation point. The area on the retina that is corrected by the adaptive optics system may or may not be located at the fovea or fixation point, i.e. the visual stimulus is viewed eccentrically or the peripheral field is examined. The quality of this calculation is a measure of the optical quality of the eye, which can be used to measure and evaluate potential visual performance. Based on the calculation of the fundus image after correction by the adaptive optics system, this optical quality is quantified by repeated measurements, even in the presence of eye movements. The feedback loop then consists of the fundus image, the calculation from the image, and the adaptive optics system. See, for example, Clark, 2010; Clark, 2011; Elsner, 2011.

[0019] It is well known that taking into account factors of the visual stimulus, including the distance from the fovea, retinal eccentricity and contrast, together with certain algorithms, the sensitivity of visual function tests can be improved (Hahn, G. A., Messias, A., Mackeben, M., Dietz, K., Horwath, K., Hyvarinen, L., Leinonen, M., and Trauzettel-Klosinski, S. (2009). Parafoveal letter recognition at reduced contrast in normal aging and in patients with risk factors for AMD. Graefe's archive for clinical and experimental ophthalmology-Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie, 247(1), 43-51.The distance of a visual stimulus from the fovea is quantified by retinal imaging. Measurement of the contrast of a visual stimulus projected through the optical system of the eye onto the retina is improved by the use of wavefront measurements. To reduce cost and complexity, calculations from retinal images, with or without structured illumination, can also be used to provide information on the contrast of visual stimuli on the retina. Another way to reduce cost and complexity is to use a visual display as illumination for the wavefront sensor. The currently limited sensitivity of current sensors precludes simultaneous measurement of the contrast of visual stimuli on the retina during visual function measurements. NIR illumination is preferred for this purpose because visible wavelength illumination would have to be very bright and would interfere with visual function tasks. However, in one or more of the disclosed embodiments, a visual display is used as an illumination source to estimate wavefront errors using visual stimuli with wavelengths in the visible range and contrast measurements by either a wavefront sensor or retinal imaging methods. In one or more embodiments, light with wavelengths shorter than near infrared (NIR) is used. In another embodiment, temporal modulation of illumination for the wavefront sensor or retinal image can also be used to provide a frequency-based detection scheme to improve the signal-to-noise ratio.In other embodiments, more sophisticated schemes of frequency-based homodyne and heterodyne detection are used to improve the signal-to-noise ratio.

[0020] Other than recent Augmented Reality (AR) and Virtual Reality (VR) devices, previous products that offered refractive correction beyond sphere and cylinder have thus far found limited markets due to the inability to apply the wavefront information and correction to regular eyeglass or contact lenses that do not tightly position the eye's pupil relative to the corrective device. Expensive devices such as headsets or laboratory devices for AR or VR can have positioning mechanisms, and intraocular lenses can utilize this (high order refractive) information by positioning them relative to the pupil.

[0021] The present invention 5) projects a visual target onto the retina through a fixed size pupil of the instrument, reducing the large individual variations in a patient's natural pupil size when compared to an ideal pupil size or based on the amount of light reaching the retina through the pupil.

[0022] Different pupil sizes not only result in more or less light reaching the retina, but also in different numerical apertures at the entrance pupil of the eye, and different depths of focus, which result in different optical throughputs. This method of projecting visual targets is a known technique and is used in a wide variety of applications, and is used in many versions of devices that provide fundus imaging, providing both a retinal image and a projection of a visual stimulus, including both devices that incorporate the visual stimulus as part of the illumination that scans the point. For additional information, see the following references: Timberlake, GT, Mainster, MA, Peli, E., Augliere, RA, Essock, EA, and Arend, LE (1986). Reading with a macular scotoma. I. Retinal location of scotoma and fixation area. Investigative ophthalmology & visual science, 27(7), 1137-1147, or line scanning by Elsner et al. (2020), and point scanning by Rossi, EA, Weiser, P, Tarrant, J., and Roorda, A (2007) et al., including correction of high-order optical aberrations. Visual performance in emmetropia and low myopia after correction of high-order aberrations. Journal of vision, 7(8), 14 (Rossi et al., 2007) notes that the retinal image and visual stimuli are provided by separate illumination channels when scanning a point to generate a retinal image, as in Remky et al., 2001; Remky et al., 2005; and Moraes et al., 2007, or when scanning a line to generate a retinal image (Elsner et al., 2013). Some embodiments are described in U.S. Patent Nos. 7,331,669, 7,831,106, 8,237,835, and 8,488,895.

[0023] The present invention 6) provides for the analysis of retinal images by confocal and multiple scattered light, or adjusts the time or position difference between illumination and detection (temporal or spatial detection offset), i.e., imaging modes. Different imaging modes use confocal or multiple scattered light imaging, and a combination of information from different imaging modes, as described in U.S. Pat. Nos. 7,331,669, 7,831,106, 8,237,835, and 8,488,895, to clarify the state of the retina at that location and to detail the exact lesion at the fixation point used by the patient in the visual test. Further examples of detection offsets include, but are not limited to, the ratio at each location in the image of the intensity difference in each image to the total at each location, the ratio at each location in the image of the intensity of the confocal image intensity to the image with a larger offset, and similar calculations that aggregate areas larger than a particular location or pixel. Infrared imaging with scanning laser ophthalmoscopes (SLO), multiple scattered light tomography, laser scanning digital cameras, and digital light ophthalmoscopes have been used to implement reflectometry techniques to rapidly and non-invasively view the eye. Initially performed with scanning laser devices, infrared and near-infrared imaging of the subretinal structures of the fundus could reveal subretinal deposits, optic nerve head, retinal and choroidal vessels, fluid collections, hyperpigmentation, atrophy, and breaks in Bruch's membrane. Infrared light is less absorbed and can be scattered over longer distances than visible light. With flood illumination, these features are not observed with the same clarity and are fewer in number. The relatively low absorption has the advantage that minimal light can be used as an illumination source. However, the reflected and scattered light must be separated in some fashion to allow the user to utilize the light used to highlight the features of interest.

[0024] Methods for detecting and localizing such features are described in the prior art of the inventors and colleagues: Elsner et al., 1996; 1998a; Elsner, AE et al., Foveal Cone Photopigment Distribution: Small Alterations Associated with Macular Pigment Distribution, Investigative Ophthalmology & Visual Science, Vol. 39, No. 12 (November 1998), pp. 2394-2404; Hartnett et al., 1996a; Hartnett et al., 1996b; Remky et al., 2005; and Elsner et al., 2020. Specifically, if the acquired retinal image is only the macula centered on the fovea, the only features present in a normal eye with near-infrared illumination are the retinal and choroidal vessels, as well as potential surface reflections from the fovea, etc. In monochromatic images, any difference in image intensity from these features beyond the noise inherent in any electronic signal is interpreted as a pathology. If the optic disc is also in the image, either because the field of view is wide enough or because the eye is positioned relative to the instrument to incorporate this feature, the intensity changes of the retina also define the location and state of such structures. Hartnett et al., 1996a; Elsner et al., 1996; and Miura, M et al., Grading of Infrared Confocal Scanning Laser Tomography and Video Displays of Digitized Color Slides in Exudative Age-Related Macular Degeneration, Retina, Vol. 22, No. 3 (2002), pp. 300-308, show that such monochrome images using infrared illumination are superior to methods using color photography in detecting certain features.

[0025] The present invention further provides 7) a novel system for measuring potential vision, including a combination of all components 1-6 above, using unique statistical analysis. The present disclosure provides a metric using a measure of central tendency, such as the mean, plus a metric of variability, such as the variance, to report the significance of confounding reasons for vision loss. For example, reports from wavefront error show how vision measurements are limited in cataracts. The unique statistical analysis combines information from the various sources above to place boundaries on predicted performance. For example, there are boundaries such as confidence limits derived from central tendency (predicted value) and variability including optical error, fixation data, and other data to determine the potential vision that a particular eye can achieve with retinal therapy. Using the aberrations measured and determined to be correctable, upper and lower limits of potential vision can be achieved with measures such as the logarithm of the minimum visual angle (LogMAR), which is widely used to characterize vision. Sample methods include, but are not limited to, a paradigm that includes a target that is a tumbling E and four possible directions that the E may point, but allows the patient to respond in only one way (four-alternative forced choice). Statistical analyses include determining whether optical, neural, and other factors are independent or whether they must be modeled as interacting.

[0026] The key tenet of the model involves the collection of data to determine whether the variables are independent and the overall variance is the sum of the variances of the individual factors. Conversely, the model may require a function beyond the simple addition of the variances of two or more variables that must be used to calculate the predicted visual function performance after the optical factors are corrected. Furthermore, each variable may have a function more complex than a Gaussian distribution, and the variances may be distributed in a manner that is not symmetric around the mean and does not scale linearly with respect to the mean. The combined variances are used to calculate the upper and lower confidence limits. These confidence limits, i.e., the boundaries used to interpret the visual function test scores, are wider or narrower depending on the function that combines the variances of the component factors. The upper limit corresponds to the value that the visual function measurement must exceed for the retinal treatment to be considered successful or to be counted as an improvement in long-term measurements. The lower limit corresponds to the value that the visual function must exceed or be considered not to have deteriorated at follow-up. These values ​​may relate to current metrics such as lines of vision gained or lost that lack significant evaluation of optical effects, gaze stability, or other factors.

[0027] The above-mentioned aspects of the invention and the manner in which they are obtained will become more apparent, and the invention itself will be better understood, by reference to the following description of embodiments of the invention taken in conjunction with the accompanying drawings, in which: [Brief description of the drawings]

[0028] [Figure 1] FIG. 1 is a schematic diagram of an eyeball showing selected tissues having a pupil onto which light from a visual display is projected. [Diagram 2] FIG. 2 is a schematic diagram of an optical imaging system used to measure visual function, including a wavefront measurement subsystem that corrects for ocular aberrations. [Diagram 3] FIG. 3 is a schematic diagram of an optical imaging system used to measure visual function, without including a wavefront measurement subsystem. [Figure 4]FIG. 4 is a schematic diagram of an optical imaging system used to measure visual function that includes a wavefront measurement subsystem that uses a visible wavelength display as an illumination source. [Diagram 5] FIG. 5 is a schematic diagram of an exemplary embodiment of a device for determining visual function when using the Hartmann-Shack method of optical aberration measurement. [Figure 6A] FIG. 6A shows a sample graphical representation of low and high order aberrations (LOA) from near infrared (NIR) wavelength measurements showing the effects of aging and refractive error. [Figure 6B] FIG. 6B shows a sample graphical representation of low and high order aberrations (LOA) from near infrared (NIR) wavelength measurements showing the effects of aging and refractive error. [Figure 6C] FIG. 6C shows a sample graphical representation of low and high order aberrations (LOA) from near infrared (NIR) wavelength measurements showing the effects of aging and refractive error. [Figure 6D] FIG. 6D shows a sample graphical representation of low and high order aberrations (LOA) from near infrared (NIR) wavelength measurements showing the effects of aging and refractive error. [Figure 7A] FIG. 7A illustrates one way of recording wavefront aberration and shows the differences between younger and older patients. [Figure 7B] FIG. 7B illustrates one way of recording wavefront aberration and shows the differences between younger and older patients. [Figure 8A] FIG. 8A illustrates another method of recording wavefront aberration, showing the difference between young and older patients in plots of wavefront aberration at the pupil plane. [Figure 8B] FIG. 8B illustrates another method of recording wavefront aberration, showing the difference between younger and older patients in plots of wavefront aberration at the pupil plane. [Figure 9A] FIG. 9A shows the predicted degradation contrast of the letter E due to wavefront aberration, comparing a farsighted young eye with a myopic elderly eye. [Figure 9B]FIG. 9B shows the predicted degradation contrast of the letter E due to wavefront aberration, comparing a farsighted young eye with a myopic elderly eye. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0029] The embodiments of the present invention described below are not intended to be exhaustive or to limit the present invention to the precise forms disclosed in the following detailed description. Rather, the embodiments are chosen and described so that others skilled in the art can appreciate and understand the principles and practices of the present invention.

[0030] 1 shows a schematic diagram of an eye 10 showing the pupil 16 onto which light from a light source providing a visual stimulus, such as a visual display, the retinal surface 12 as a target plane of focus for the projection of the visual stimulus and imaging of the retina and subretinal structures, the cornea 26, the lens 24, and selected tissues including other anterior ocular structures. As used herein, a "visual display" is used to describe a device that transmits visible or non-visible light images that are directed at and received by a patient's eye. Once received by the eye, the patient is tasked with determining one or more aspects of visual function, including but not limited to visual acuity.

[0031] Depending on the state of the various tissues of the eye, strong unwanted reflections and the location of potential unwanted light scattering aberrations, pathological or age-related aberrations and lack of transparency adversely affect the retinal image appearing in the anterior segment 22 of the eye 10. Unwanted reflections adversely affect the retinal image, the location of potential unwanted light scattering aberrations, and lack of transparency due to pathological or age-related conditions. The anterior segment 22 is generally located at or near the pupil 16, the crystalline lens 24, and the cornea 26. Retinal diseases, including but not limited to diabetic macular edema and exudative age-related macular degeneration, can cause one or more portions of the retina to bulge, bringing the focal plane closer to the pupil plane and creating errors in habitual refraction. This results in visual stimuli that were previously in focus on the retina now becoming blurred. Such lack of retinal focus can vary in degree depending on the location of the retina. This effect of defocus can be optically corrected as long as the retina is also intact. A distinction must be made between optical and neurological effects so that the underlying visual function can be accurately identified.

[0032] To distinguish optical from neurological effects, the devices and systems described herein for measuring potential visual function are particularly suited to guide management of retinal disease in clinical trials and to evaluate treatments for retinal disease. The described devices and systems identify key factors that affect the retina 14 (see FIG. 1), affect the measurement of visual function, and affect the potential vision gained with treatment. The devices and systems include non-contact systems and do not require eye drops to dilate the pupil of the eye.

[0033] Referring to FIG. 1, substantially all of the predetermined amount of light from the visual stimulus is projected through the pupil of the eye 16 along an illumination path 18. The focal plane 12 of the visual stimulus is the retina 14, specifically the layer within the retina where visual acuity is greatest. One of the main locations of interest for testing retinal function is the fovea 11, which provides the best visual acuity and color vision in normal eyes and is an important tissue in administrative decisions and clinical trial outcomes. To reach the retina, light must be focused by the cornea 26 and the lens 24, either of which may have lost transparency or deteriorated optics due to aging, disease, trauma, or adverse events related to treatment.

[0034] There are several conditions that can adversely affect the illumination path 18, such as a reduction in the amount of light reaching the retina due to a contraction of the pupil, which occurs naturally with aging. Pupil size can also decrease as a result of other conditions, such as drugs or neurological conditions that cause the pupil to constrict. Additionally, pupil sizes greater than about 3 mm can adversely affect the focus of both the illumination path 18 and the detection path 20 due to the varying focus across the pupil plane.

[0035] Furthermore, light may not pass completely through the cornea 26, the lens 24, or any portion of the anterior segment 22, depending on the condition of those portions. For example, the anterior segment may contain numerous locations or regions containing tissue changes and aberrations that may alter normal ocular function, and may result in undesirable light scattering or other aberrations and lack of transparency due to pathological conditions or aging. Both the amount of light that reaches the retina and the precision of the focus affect the measurement of visual function.

[0036] The presence of a small light-restricting pupil may result in inaccurate rendering of information about the retina. The cornea 26, lens 24, or other locations of the anterior segment 22 may have reduced transmission or may be unable to focus light onto the retina 14. The structure of the retina 14 may be altered by disease or trauma, causing the retina to bulge and shorten the distance between the bulged structures, moving too close to the cornea 26 to achieve optimal focus at one or more locations. All of these factors may also degrade the quality of the images of the retina 14 captured along the detection path 20 as light must exit through them on its way to the imaging device. Images of the retina 14 under different conditions indicate the condition of the retina 14, the locus of the fixation point, and the stability of the fixation by comparing retinal landmarks with the location of visual stimuli projected through the pupil 16. The retinal images determine the relative location of the visual stimulus to the fovea 11 or other locations on the retina 14.

[0037] FIG. 2 illustrates one embodiment of an optical imaging visual display system 40 according to the present invention. A near infrared (NIR) imager 60 directs light to the eye 10 so that the light is directed and focused on the retina to provide an accurate image. Those skilled in the art will recognize that a variety of different configurations can perform this function. In different embodiments, the NIR imager is a point or line scanning system, such as Elsner et al., 1992; the Heidelberg Spectralis (Heidelberg Engineering, Heidelberg, Germany); U.S. Pat. Nos. 7,331,669, 7,831,106, or 8,237,835; and the Eidon Camera (iCare, Vantaa, Finland). In a preferred embodiment, the NIR illumination is sufficiently dim so as not to interfere with the interpretations used in visual function measurements. U.S. Patent Nos. 7,331,669, 7,831,106, and 8,237,835 are each incorporated herein by reference in their entirety.

[0038] Light returning from the retina to the NIR imager 60 is focused on the retina with sufficient precision to generate an image of the retina 14, providing a clearly focused, excellent image for comparison with the location of the projected target on the visible wavelength display 70. The illumination and detection characteristics of the NIR imager 60 provide both confocal and multiple scattered light imaging, as described in Elsner et al., 2020 or in U.S. Pat. Nos. 7,331,669, 7,831,106, 8,237,835, and 8,488,895. The processor 100 includes one or more processors, including, but not limited to, computers, microcomputers, and electronic control devices. In different embodiments, the processor 100 includes a memory for storing received data or includes a transmitter for transmitting data. In other embodiments, the memory or transmitter is located external to the processor 100. The processor 100 also controls the imager 60 via data acquisition and control lines 101 such that the characteristics of the NIR imager 60 allow imaging of both the light transmitted through the eye and the characteristics of the sensor for the NIR imager 60. The parameters of the image or image data are selectable by an operator, including but not limited to the intensity, gain, imaging mode, polarization characteristics, wavelength, width of illumination on the retina, or field of view of the transmitted light waves. The operator adjusts the functions of the imager 60 via control lines 102 through an input device, such as a user interface 104, coupled to the processor 100 via control lines 102. The selected parameters are stored or recorded in the processor 100, its internal memory, or a connected memory, and are used in making a determination of visual function. As used herein, user interface means one or more devices that allow an operator or patient to interact with or control system 40 using display of visual images of current or stored images, visualization of stored data, results or normative values, voice or audio commands, touch screen commands, user selectable buttons, or other functionality used to select, display, or control test examination procedures or results based on current or stored information.

[0039] The visible wavelength display 70, also controlled by the processor 100 via control lines 106, transmits a light output that is directed towards the retina 14 in a manner that directs a predetermined amount and type of light through the pupil 16 and into the eye 10. Connected between the processor 100 and the visible wavelength display 70 is a visible display controller 72 that adjusts the output of the visible wavelength display. In other embodiments, the visible display controller 72 is not included and the processor 100 is configured to adjust the function of the visible display controller 72. The directional light is directed using a Maxwell field, also known as Kohler illumination, in one or more embodiments, and is thus directed in a manner such that the illumination on the retina 14 is identifiable, consistently repeatable, and constant from one eye to the next, either for a single patient or multiple patients. Display 70, in one embodiment, comprises a one-dimensional or two-dimensional display, including but not limited to a digital light projector, a liquid crystal display screen, liquid crystal on silicon, a cathodoluminescent display, an electroluminescent display, a photoluminescent display, a plasma display panel, an incandescent display, a light emitting diode, combinations thereof, or any similar optical display that projects a visual stimulus. In different embodiments, the visual stimulus is one or more predefined images stored in a memory located internal or external to processor 100.

[0040] Processor 100 sends commands to project visual stimuli generated or stored in memory over control lines 106 which control the displayed image of display 70, including, but not limited to, one or more patterns of visual stimuli, the intensity of the patterns, the timing of the images displayed, the motion of the images, the position of the display on the retina, and the color of the images. The output of additional visible or NIR illumination for wavefront measurement system 75, also controlled by processor 100 over control lines 107, is combined with the output of light from visible wavelength display 70 by beam shaper and combiner 130.

[0041] Processor 100 controls parameters of this light source, i.e. visible wavelength display 75, including but not limited to image, pattern, intensity, timing, movement, location on the retina, and color. The combined light output of visible wavelength display 70 and the illumination of wavefront measurement system 75 is directed to adaptive optics section 90, which includes one or more adjustable optical elements. Adjustments of adaptive optics 90 are controllable by adaptive optics controller 95 via control line 105, so that the focus of the illumination on retina 14 is improved beyond that achieved by correcting sphere and cylinder alone. Adaptive optics controller 95 is controlled by processor 100 via control line 103. This combined light output is directed to the eye from beam combiner 120 and combined with light from NIR imager 60 in beam combiner 110. Light from all three sources of illumination, the NIR imager 60, the visible wavelength display 70, and the wavefront measurement system 75, are all directed through the pupil of the eye and focused onto the retina, with the visible wavelength display 70 and the wavefront measurement system illumination being focused by an adaptive optics section 90. The NIR imager 60 is focused by internal components via control from a processor 100, which communicates with both the NIR imager 60 and the wavefront measurement system 80. Light returning from the retina 14 passes through the pupil 16 of the eye 10. The amount of light projected through the pupil is calculated from the wavefront measurement data, the NIR image intensity, or other features of the image data or measurements from the patient's retina. Additionally, properties of the light returning from the eye and analyzed by the processor include, but are not limited to, fluorescence, coherence, or polarization, either at each location or collectively over a larger area.

[0042] No. 7,416,305 to Williams et al. is distinguished from the present invention in that Williams requires that the image of the retina must be a high resolution image that is improved by the adaptive optics to provide a higher contrast image than the image received from the retina without the adaptive optics. However, in the present disclosure, the image of the retina does not need to be a high resolution image, and the received image does not need to be improved by the adaptive optics. According to Williams et al., the adaptive optics functions as an adaptive optics device that is tuned to provide a high resolution, high contrast image of the retina using calculated wave aberrations. In contrast, the adaptive optics 90 of the present disclosure operates to improve the quality of the visual stimulus on the retina and not alter the retinal imager NIR imager 60.

[0043] Patients with retinal damage to the fovea often use a fixation point location that is peripheral to the fovea, demonstrating the need to use the fixation point location and the objective optics correction for visual function tests obtained according to the fixation point location. Furthermore, when testing peripheral vision, the visual stimulus is far from the fovea. In patients with retinal damage, the fixation location is often far from the fovea, which is generally the location where the normal eye would fixate during the performance of visual function tests. The optical error corresponding to this location is unlikely to have been recorded in previous ophthalmic or refractive tests. These off-axis optical errors are difficult to measure by subjective refraction. However, the prior art has demonstrated that improved focus through the use of adaptive optics improves the performance of visual function tests both in the case of using the fovea to fixate the visual stimulus, i.e., on-axis viewing, and in the case of eccentric viewing, i.e., off-axis viewing. Rossi et al., 2007 and Lewis, P., Baskaran, K., Rosen, R., Lundstrom, L., Unsbo, P., and Gustafsson, J. (2014). Objectively determined refraction improves peripheral vision. Optometry and vision science: official publication of the American Academy of Optometry, 91(7), 740-746, respectively. In particular, Lewis et al. teach the importance of using objectively determined refraction for visual function at peripheral locations. However, wavefront aberrations at these eccentric locations cannot be measured with narrow-field retinal imaging instruments unless the instrument is aimed at a specific location and held in a precise position during optical measurements. This positioning and precise optical measurements are difficult due to eye movements by the patient unless wider-field, video-rate retinal imaging is used. The requirement for measurement over a wide range of potential positions and accurate positioning is one of the differences from Williams' U.S. Pat. No. 7,416,305, which describes a single retinal imaging device with high resolution and has only one wavefront measurement system.This system does not allow for detailed wavefront measurements over a large enough retinal area with accurate positioning to support use in eccentric viewing. At the high-resolution limit, diffraction-limited imaging is possible in the human retina, but the field of view is limited to about 2 degrees at best in eyes with normal optics. Previous methods described by Burns et al. 2019 and colleagues, and Williams, do not have high-resolution images across eccentric fixation locations or retinal imaging systems with a wide enough field of view to use adaptive optics for testing peripheral visual stimuli.

[0044] Therefore, the present disclosure does not rely on a single feature resulting from imaging of the eye. Instead, a combination of perceived features, including but not limited to retinal imaging features with a wide field of view, is used to determine the location and stability of the fixation point combined with wavefront measurements. High-resolution images that are compensated for wave aberrations, such as those of Williams, do not provide the type of information used in the present disclosure. For example, in Williams, the size of the retinal image that can achieve optical compensation must be limited to an isoplanar patch whose area is too small to localize the fixation point if the patient has fixational sway or uses eccentric vision, as described above. Small retinal areas also provide incomplete information about retinal landmarks or retinal status. Thus, the method of Williams cannot be used because the field of view of the high-resolution images produced by Williams is too small.

[0045] In addition, the use of high resolution retinal images precludes the use of multiply scattered light to generate the retinal image because high spatial frequency information in the image is found primarily in the light that passes through the confocal aperture rather than being rejected. Furthermore, in the present invention, the improvement of visual stimulation on the retina is incorporated into a statistical framework, i.e., a statistical model, for determining potential performance in visual function tests and limitations imposed by optical or other factors, whereas Williams' invention is directed to implementation for use in refractive surgery or for manufacturing contact lenses that improve real-world vision beyond defocus and astigmatism. Finally, Williams specifies that the technique of wavefront measurement is limited to a point source of illumination and specifically uses the method of a Hartmann-Shack sensor. In contrast, the present method is not limited to the Hartmann-Shack method as described in 1994 by Liang and colleagues: Liang J, Grimm B, Goelz S, Bille JF. Objective measurement of wave aberrations of the human eye with the use of a Hartmann-Shack wave-front sensor. J Opt Soc Am(A)1994;11:1949-57. Other examples of techniques include laser ray tracing, spatially resolved refractometry, compared to the Hartmann-Shack technique.Moreno-Barriuso E, Marcos S, Navarro R, Burns SA. Comparing laser ray tracing, the spatially resolved refractometer, and the Hartmann-Shack sensor to measure the ocular wave aberration. Optom Vis Sci. 2001 Mar;78(3):152-6. doi:10.1097 / 00006324-200103000-00007. PMID:11327676, and pyramidal wavefront sensing methods are described, for example, in Singh NK, Jaskulski M, Ramasubramanian V, Meyer D, Reed O, Rickert ME, Bradley A, Kollbaum PS, Validation of a Clinical Aberrometer Using Pyramidal Wavefront Sensing. Optom Vis Sci. 2019 Oct;96(10):733-744. doi:10.1097 / OPX.0000000000001435. PMID:31592956.

[0046] The present invention uses a point source to illuminate the wavefront sensor in one embodiment, while in other embodiments, a visible wavelength display 70 or a retinal image is used to calculate the required wavefront compensation. In other embodiments, other methods are used, such as a Hartmann-Shack sensor or a pyramidal wavefront sensing method to correct the focus of the visual display on the retina. The present invention also reports data from the wavefront correction for use in statistical models to identify and clarify causes of visual performance degradation that are used to calculate predicted performance.

[0047] The NIR light returning from the eye 10 passes through a beam combiner 110 and is returned to the NIR imager 60 where an image of the retina 14 is formed. The fundus image, including the retinal image, is sent to the processor 100 via data acquisition and control line 101 for storage and analysis. Since the coordinate location of the projection of the visible wavelength stimulus on the retina is known, the NIR image provides a means of registering the location of the visible wavelength stimulus on the retina to known retinal landmarks. These include, but are not limited to, retinal blood vessels, optic disc, peripapillary atrophy, foveal light reflex, atrophy, hemorrhage, neovascular membrane, epiretinal membrane as well as gliosis, pigmentary changes, and polarization changes. This provides fixation locus, also known as eccentric visual field, and variability in fixation locus, also known as fixation sway. The retinal image further provides information regarding the condition of the retina at the location on the retina where the visible wavelength display is focused. Fixation information and retinal state information regarding the location of the visual stimulus on the retina is displayed as a graphic overlay and / or stored numerically by the computer as a numerical database using the processor 100 and user interface 104.

[0048] Light returning from the eye 10 that is not intended to be directed to the NIR imager 60 is directed away from the beam combiner 110 to the beam combiner 120. Light in the wavelength range from the visible or NIR illumination of the wavefront measurement system 75 is directed to a visible or NIR wavefront measurement system 80 which provides data to the processor 100 via data collection and control lines 108 to quantify the optical aberrations of the light returning from the retina 14 measured at the pupil plane 22. In other embodiments, data of images of different illumination wavelengths other than NIR or long wavelength visible illumination are directed to the processor. The wavefront measurement system 80 also communicates hardware and / or software related data to the processor 100 via data collection and control lines 108 to enable precise control of the wavefront measurement system 80 by the processor 100, including but not limited to timing, gain, number of samples included in each measurement, and location of samples included in each measurement, whether controlled by measurements under the command of the processor or by post-processing following acquisition of the data sent to the processor. This wavefront measurement data is optimized by processor 100 to provide sufficiently accurate information for focusing visual stimuli onto the retina while simultaneously not introducing enough visible illumination that it is dim or interferes with the measurement of visual function.

[0049] A control loop for the adaptive optics system 90 is formed by the wavefront measurement system 80, the processor 100, the adaptive optics controller 95, and the adaptive optics system 90, based on a measurement of the focus of the illumination of the wavefront measurement system 75 on the retina 14. The wavefront aberrations are calculated and those that can be corrected by the adaptive optics system are identified as correctable, recorded, and stored as data in a database. Additionally, those that cannot be corrected or are impractical to correct and leave optical errors are also identified as uncorrectable, recorded, and stored as data.

[0050] Certain types of aberrations, namely very high order aberrations, cannot be easily corrected and are not necessary to provide acceptable vision correction. The present disclosure provides a cost-effective solution, i.e., eliminates large visual errors and quantifies the residual errors that often cannot be corrected at all or at an acceptable price. As a result, the present disclosure does not aim for the best focus ever, which would not or cannot be obtained in the real world with glasses, is difficult to provide with contact lenses, or even with intraocular lens implants (IOLs). Thus, the present disclosure, in one or more embodiments, uses mirrors and optical designs to provide correction of low order aberrations and some high order wavefront errors. In some embodiments, adaptive optics is utilized, which tilts the imaging rays and moves them enough to return them to where they should be directed. The excessive cost of fine tuning many mirrors makes the correction of very high order aberrations impractical, some of which change rapidly over time with the tear film.

[0051] The response mechanism 150 reports the patient's judgments regarding the visible wavelength stimuli, including but not limited to whether the target was seen, the direction the letter was pointing, and the color, and provides input to the processor. In one embodiment, the response mechanism 150 is operated by the patient. In another embodiment, the response mechanism is a user interface 104 for an operator to input the patient's response.

[0052] The determination as to whether the target is correctly seen is then used to control the next visible wavelength stimulus by the processor 100 for the measurement of visual function, which in one or more embodiments is based on the patient's response or a predetermined sequence. A database 200 in communication with the processor 100 stores the current response, past responses, and any data related to the determination of visual function. The processor 100 further processes the retinal image from the NIR imager 60 received over the control line 101 to determine the condition of the retina 14 at the location of the target. The retinal condition includes results from confocal imaging and multiply scattered light imaging, which indicate changes in signal amplitude indicative of irregular retinal or subretinal absorption due to blood or pigment defects, and calculations indicative of protuberance or thickening of subretinal structures, or movement of blood cells or other particles through blood vessels. The database 200 includes results from the system including retinal images, location of the target on the retina, fixation stability, results from processing of the retinal image or artificial intelligence from the retinal image data, retinal condition, retinal condition at the location of the target, results from measured visual function including both central tendency and variability, wavefront error before correction, and correctable versus uncorrectable wavefront error.

[0053] The database also includes other relevant clinical and demographic data, including, but not limited to, color fundus photography, scanning laser ophthalmoscopy, vascular maps from scanning laser ophthalmoscopy, retinal status from other instruments such as optical coherence tomography, optical coherence tomography angiography, or any of these used in conjunction with adaptive optics, wavefront aberration or optical measurements from other instruments, age, sex, diagnosis, treatment history, and results from other measurements of visual function.

[0054] The model 210 is in communication with the processor 100 and uses the data stored in the database 200 to provide statistical estimates of the central tendency and variability of visual function, thereby quantifying the range of potential vision that may be achieved. The central tendency is a single value that attempts to describe a data set by identifying a central location within that data set. This includes factors unrelated to optical factors such as small pupils, poor optics in the cornea or tear film, cataractous lenses, imprecise focal planes due to poor refraction, and other factors, some of which may be mitigated during measurements with the disclosed system to more accurately determine the condition of the retina and the potential for improvement with treatment. In one embodiment, the metric of central tendency is the mean and the metric of variance is the variance, providing statistical limits on the significance of confounding reasons for vision loss in the form of upper and lower confidence limits that can be set according to a certain probability, for example the probability of falling outside the confidence limits by a 95% confidence limit. Furthermore, reports from the wavefront error show how vision measurements are limited in cataracts.

[0055] The proprietary statistical analysis combines information from the various sources described above to place boundaries on predicted performance. For example, boundaries are determined from confidence limits derived from central tendency (prediction) and variability, including optical error, fixation data, and other data, to address the visual acuity that a particular eye could potentially achieve with retinal treatment. Aberrations that are measured and found to be correctable are used to determine upper and lower limits of potentially achievable visual acuity. For example, for LogMAR measurements based on visual acuity measurements, one method includes tumbling E and four alternative forced choice. The statistical analysis includes determining whether optical, neurological, and other factors are independent or whether they must be modeled as interacting. The key tenet of the model involves the aggregation of data to determine whether the variables are independent and the overall variance is equal to the sum of the variances of the individual factors. The system quantifies this condition, including whether a prediction of visual acuity with successful retinal treatment or the elimination of extraneous factors such as lens opacity can be achieved.

[0056] Conversely, in different embodiments, the model requires a function that goes beyond the simple addition of the variances of two or more variables that must be used to calculate the predicted visual function performance after optical factors are corrected. Furthermore, each variable may have a function that is more complex than a Gaussian distribution, and the variances may be distributed in a manner that is not symmetric around the mean value and not linearly scaled with respect to the mean value. The combined variances are used to calculate the upper and lower confidence limits. These confidence limits, i.e., the boundaries used to interpret the visual function test scores, are wider or narrower depending on the function that combines the values ​​and variances of the component factors. The upper limit, by definition, corresponds to the value that the visual function measurement must exceed in order for the retinal treatment to be considered successful or to be counted as an improvement in long-term measurements. The lower limit, by definition, corresponds to the value that the visual function must exceed or to be considered not to have deteriorated in follow-up. The lower limit is also the value that the visual function must exceed in order for the treatment to be considered effective if the goal is to maintain vision over time. These values ​​may relate to current metrics such as lines of vision gained or lost that lack a significant assessment of optical effects, gaze stability, or other factors.

[0057] The invention has the following features: 1) provides an assessment of fixation location using video-rate and near-infrared retinal imaging that is invisible to the patient; 2) provides an assessment of gaze stability using the same video-rate near-infrared retinal imaging; 3) identifies optical errors of the patient's eye, including those due to pathological or aging conditions found in the cornea, lens, or pupil, not limited to sphere and cylinder, collected by wavefront sensor measurements of light returning from the retina; 4) provides objective correction during measurement of visual function of the primary optical errors of the patient's eye, not limited to sphere and cylinder, using the wavefront measurements described above in item 3 above with adaptive optics; and 5) projects a visual target onto the retina through the fixed size pupil of the instrument to reduce the large variability due to individual differences in pupil size. 6) Provides analysis of retinal images by confocal and multiple scattered light, different imaging modes as described in U.S. Patent No. 7,331,669, U.S. Patent No. 7,831,106, U.S. Patent No. 8,237,835, and U.S. Patent No. 8,488,895, to clarify the condition of the retina at its location and detail the exact lesion at the fixation point used by the patient in the visual test; 7) Provides a novel system for measuring vision potential including a combination of all the above components 1-6 using a unique statistical analysis.

[0058] FIG. 3 illustrates another embodiment of an optical imaging visual display system 50 according to the present invention. A near infrared (NIR) imager 60, i.e., an imaging device, directs light to the eye 10 so that the light is directed and focused on the retina to provide an accurate image. Those skilled in the art will recognize that a variety of different configurations can perform this function. In different embodiments, the NIR imager is a point scanning system or a line scanning system, as described in Elsner et al., 1992; and the Heidelberg Spectralis (Heidelberg Engineering, Heidelberg, Germany); and U.S. Pat. Nos. 7,331,669, 7,831,106, or 8,237,835; and the Eidon Camera (iCare, Vantaa, Finland). The imaging device 60 illuminates the retina by scanning the illumination across the retina or by projecting a series of illumination areas onto the retina, and light from the retina is detected synchronously. In one embodiment, the imaging device 60 has a wide field of view, i.e., a viewing angle of about 8 degrees to 60 degrees, to allow for the determination of eccentric fixation and retinal landmarks. Light returning from the retina to the NIR imager 60 is focused on the retina with sufficient precision to generate an image of the retina 14, providing a clearly focused, excellent image for comparison with the location of the projected target on the visible wavelength display 70. The illumination and detection characteristics of the NIR imager 60 provide both confocal and multiple scattered light imaging, as described in Elsner et al., 2020. The images or data used to compute the images are directed to a processor 100, which may consist of one or more processors, including computers, microcomputers, and electronic control devices. In different embodiments, the processor 100 includes a memory for storing received data or includes a transmitter for transmitting data. In other embodiments, the memory or transmitter is located external to the processor 100. The processor 100 also controls the imager 60 via data acquisition and control lines 101 such that the characteristics of the NIR imager 60 enable imaging of both the light passing through the eye and the characteristics of the sensor for the NIR imager 60.The characteristics may be selected by an operator, including, but not limited to, intensity, gain, imaging mode, polarization characteristics, wavelength, width of illumination on the retina, or field of view of transmitted light waves. The operator adjusts the functions of the imager 60 via control lines 102 through an input device, such as a user interface 104, coupled to the processor 100 via control lines 102. The selected parameters are stored or recorded in the processor 100 and used in making a determination of visual function.

[0059] The visible wavelength display 70, also controlled by the processor 100 via control lines 106, has a light output that is directed towards the retina 14 in a manner that directs a known amount and type of light through the pupil 16 into the eye 10. The directional light is directed using Maxwell's field of view, also known as Kohler illumination, in one or more embodiments, such that the illumination on the retina 14 is identifiable, consistently repeatable, and constant from one eye to the next, either for a single patient or for multiple patients. The display 70, in one embodiment, includes a one-dimensional or two-dimensional display, including but not limited to a digital light projector, a liquid crystal display screen, liquid crystal on silicon, a cathodoluminescent display, an electroluminescent display, a photoluminescent display, a plasma display panel, an incandescent display, a light emitting diode, combinations thereof, or any similar optical display that projects a visual stimulus. In different embodiments, the visual stimulus is one or more predefined images stored in a memory located internal or external to the processor 100. As used herein, a one-dimensional display transmits a single line that is scanned across the retina.

[0060] The processor 100 sends commands to project visual stimuli generated or stored in memory over control lines 106 that control the displayed image of the display 70, including but not limited to the pattern of visual stimuli, the intensity of the pattern, the timing of the image displayed, the motion of the image, the position of the display on the retina, and the color of the image. The output of the visible wavelength display 70 sends light through a beam shaping and combiner component 135 to an adaptive optics section 90 that corrects wavefront errors with one or more adjustable optical elements. The adaptive optics section 90 is controlled by an adaptive optics controller 95 over control lines 105. The adaptive optics controller 95 is controlled by the processor 100 over control lines 103.

[0061] Adjustments to the adaptive optics 90 are controllable by an adaptive optics controller 95 via control lines 105, resulting in improved focus of illumination on the retina 14 over that achieved by correcting for sphere and cylinder alone. This combined light output is directed to the eye from a mirror, beam splitter, or filter 125 and combined with light from the NIR imager 60 at a beam combiner 110. Light from both the NIR imager 60 and the visible wavelength display 70 is directed through the pupil of the eye and focused, along with the visible wavelength display 70, onto the retina by the adaptive optics section 90. The NIR imager 60 is focused by internal components via control from a processor 100 in communication with the NIR imager 60. Light returning from the retina 14 passes through the pupil 16 of the eye 10.

[0062] The NIR light returning from the eye 10 passes through a beam combiner 110 and is returned to the NIR imager 60 where an image of the retina 14 is formed. The fundus image, including the retinal image, is sent to the processor 100 via data acquisition and control line 101 for storage and analysis. Since the coordinate location of the projection of the visible wavelength stimulus on the retina is known, as described above, the NIR image provides a means of registering the location of the visible wavelength stimulus on the retina to known retinal landmarks. This provides the fixation point locus, also known as the eccentric visual field, and the variability of the fixation point locus, also known as fixation sway. The retinal image further provides information regarding the state of the retina at the location on the retina where the visible wavelength display is focused. Fixation information and retinal state information regarding the location of the visual stimulus on the retina can be displayed as a graphic overlay, stored numerically in a computer, or both, using the processor 100 and user interface 104.

[0063] Light returning from the eye 10 that is not intended to be directed to the NIR imager 60 is directed away from the beam combiner 110 to a mirror, beam splitter, or filter 125. The NIR imager 60 also provides data to the processor 100 via data collection and control lines 101 to quantify the optical aberrations of the light returning from the retina 14. This is known as sensorless adaptive optics, since the NIR imager 60 includes illumination and sensors, but there are no additional illumination sources and sensors (Burns et al., 2019). In one embodiment, the location of the target on the retina is used to limit the optical correction data to a sample of that location using the processor 100, which is more accurate than averaging over a portion of the retina including outside the area where the visual stimulus is projected, for example, because these may vary in retinal height. The present invention is not limited to the narrow field of view of the retina, an inherent limitation of Williams et al., and therefore the area of ​​the retina sampled can be optimized to provide an accurate focus at a specific location on the retina.

[0064] In the present invention, retinal pathological features can be identified, which is important because such pathological features may change the preferred focal plane on the retina 14 during visual function testing at one retinal location compared to another retinal location. In another embodiment, the wavefront error is pre-calculated, either from another device or from a measurement of the visual acuity that a particular eye can potentially achieve, and the location of the target on the retina determined by the NIR imager is used by the processor 100 to specify the correction of the wavefront error, which is then transmitted to the adaptive optics controller 95 via control line 103. In one embodiment, the signal enhancement for the wavefront error calculation is generated by using structured illumination, as described in Clark et al., 2010, 2011; Elsner et al., 2011. This is achieved whether the NIR imager is a point-scanning system or a line-scanning system, as described in Elsner et al., 1992; the Heidelberg Spectralis (Heidelberg Engineering, Heidelberg, Germany); U.S. Pat. Nos. 7,331,669, 7,831,106, or 8,237,835; and the Eidon Camera (iCare, Vantaa, Finland). The latter allows low-cost and rapid switching of the illumination line on and off, which provides a square wave grating that facilitates Fourier and other analyses of light transmission through the eye to sample from regions of interest on the retina. The amount of light returned from the retina of the NIR imager 60 depends on the pupil diameter due to the negligible effect of fundus pigmentation, thereby reporting the patient's pupil diameter in the absence of a wavefront measurement system, as described in Elsner et al., 2013, in Figures 2, 4, and 5.

[0065] The control loop of the adaptive optics system 90 is formed by the NIR imager 60 or data in database 200, processor 100, controller 95 of the adaptive optics system, and adaptive optics system 90, based on measurements of the focus from the NIR imager 60 on the retina 14. Wavefront aberrations are calculated and those that can be corrected by the adaptive optics system are reported, as well as those that cannot be corrected or are impractical to correct and result in residual optical system errors. In one embodiment, the illumination of the NIR imager 60 is modulated in time, and then a frequency-based detection scheme in the detection mechanism of the NIR imager 60 is used to achieve an improved signal-to-noise ratio. Alternatives include simple flickering of the illumination, as well as more complex schemes of homodyne and heterodyne detection by the NIR imager 60 based on frequency. In one embodiment, the NIR illumination for the wavefront measurement alternates in time with a pattern of NIR illumination used to generate a more optimal retinal image for determining the retinal location of visual targets, fixation sway, or retinal status. In a preferred embodiment, the NIR illumination is dim enough not to interfere with judgments made by the patient used in visual function measurements. In a preferred embodiment, data from the focus and wavefront error calculations are reported in a manner that describes the low and high order aberrations due to wavefront error, as well as the estimated error of retinal focus. The response mechanism 150 reports judgments made by the patient regarding the visible wavelength stimuli as perceived by the patient, including but not limited to whether the target was seen, the direction the letter is pointing, and what the color is, and provides input to the processor. In one embodiment, the response mechanism is operated by the patient. In another embodiment, the response mechanism is a user interface 104 for an operator to input the patient's response.

[0066] The determination as to whether the target is seen correctly, i.e., correctly identified, is then used by the processor 100 to control the next visible wavelength stimulus for the measurement of visual function. A database 200 in communication with the processor 100 stores the current response, past responses, and any data related to the determination of visual function. The processor 100 further processes the retinal image from the NIR imager 60 received over control line 101 to determine the condition of the retina 14 at the location of the target. The retinal condition includes results from confocal imaging and / or multiply scattered light imaging, which indicate changes in signal amplitude indicative of irregular retinal or subretinal absorption due to blood or pigment defects, and calculations indicating protuberance or thickening of subretinal structures, or movement of blood cells or other particles through blood vessels. The database 200 stores the retinal image, the target on the retina, and the corresponding data. Results from the system include target location, fixation stability, results from retinal image or artificial intelligence processing from retinal image data, retinal condition, retinal condition at the target location, results from measured visual function including both central tendency and variability, wavefront error before correction, and correctable vs. uncorrectable wavefront error.

[0067] Database 200 also includes other relevant clinical and demographic data, including, but not limited to, retinal status from other instruments such as color fundus photography, scanning laser ophthalmoscopy, optical coherence tomography, optical coherence tomography angiography, or any of these used in conjunction with adaptive optics, wavefront aberrations or optical measurements from other instruments, age, sex, diagnosis, treatment history, and results from other measurements of visual function, which can be used to improve the calculation of the wavefront error.

[0068] The model 210 is in communication with the processor 100 and uses the data stored in the database to provide statistical estimates of the central tendency and variability of visual function, whereby the range of potential vision that may be achieved is quantified as described above. The central tendency is a single value that attempts to describe a data set by identifying a central location within that data set. This also includes factors unrelated to optical factors such as small pupils, poor optics in the cornea or tear film, cataractous lenses, imprecise focal planes due to poor refraction, and other factors, some of which may be mitigated during measurements by the disclosed system to more accurately determine the condition of the retina and the potential for improvement with treatment. Upper and lower bounds of performance for visual tasks are calculated and used in a similar manner to the embodiment of FIG. 2.

[0069] Figure 4 shows another embodiment of an optical imaging visual display system 40 according to the present invention. The NIR imager 60 having several embodiments as described above directs light to the eye 10 so that the light is directed and focused on the retina to provide an accurate image. The functionality is similar to that of Figures 2 and 3, except for certain modifications as described.

[0070] Light returning from the retina to the NIR imager 60 is focused on the retina with sufficient precision to generate an image of the retina 14, providing a clearly focused, excellent image for comparison with the location of the projected target on the visible wavelength display 70. As described in Elsner et al., 2020 and other descriptions of FIG. 2, the illumination and detection characteristics of the NIR imager 60 provide both confocal and multiple scattered light imaging. The images or data used to calculate the image are directed to a processor 100, which may be one or more processors including computers, microcomputers, and electronic control devices. In different embodiments, the processor 100 includes a memory for storing received data or includes a transmitter for transmitting data. In other embodiments, the memory or transmitter is located external to the processor 100. The processor 100 also controls the imager 60 via data acquisition and control lines 101 such that the characteristics of the NIR imager 60 allow imaging of both the light passing through the eye and the characteristics of the sensor for the NIR imager 60. The characteristics may be selected by an operator, including, but not limited to, intensity, gain, imaging mode, polarization characteristics, wavelength, width of illumination on the retina, or field of view of transmitted light waves. The operator adjusts the functions of the imager 60 via control lines 102 through an input device, such as a user interface 104, coupled to the processor 100 via control lines 102. The selected parameters are stored or recorded in the processor 100 and used in making a determination of visual function.

[0071] The visible wavelength display 70, also controlled by the processor 100 via control lines 106, has a light output that is directed towards the retina 14 in a manner that directs a known amount and type of light through the pupil 16 into the eye 10. The directional light is directed using Maxwell's field of view, also known as Kohler illumination, in one or more embodiments, such that the illumination on the retina 14 is identifiable, consistently repeatable, and constant from one eye to the next, either for a single patient or for multiple patients. The display 70, in one embodiment, includes a one-dimensional or two-dimensional display, including but not limited to a digital light projector, a liquid crystal display screen, liquid crystal on silicon, a cathodoluminescent display, an electroluminescent display, a photoluminescent display, a plasma display panel, an incandescent display, a light emitting diode, combinations thereof, or any similar optical display that projects a visual stimulus. In different embodiments, the visual stimulus is one or more predefined images stored in a memory located internal or external to the processor 100.

[0072] The processor 100 sends commands to project visual stimuli generated or stored in memory over control lines 106 that control the displayed image on the display 70, including, but not limited to, the pattern of the visual stimulus, the intensity of the pattern, the timing of the image displayed, the motion of the image, the position of the display on the retina, and the color of the image.

[0073] The light output of the visible wavelength display 70 is directed by a beam shaper and combiner 135 to an adaptive optics section 90, which includes one or more adjustable optical elements. Adjustments of the adaptive optics 90 are controllable by an adaptive optics controller 95 via control line 105, so that the focus of the illumination on the retina 14 is improved beyond that achieved by correcting for sphere and cylinder alone. The adaptive optics controller 95 is controlled by a processor 100 via control line 103. This light output is directed from a beam combiner 120 to the eye where it is combined with light from the NIR imager 60 at a beam combiner 110. Light from both the NIR imager 60 and visible wavelength display 70 sources is directed through the pupil of the eye and focused by the adaptive optics section 90, along with the visible wavelength display 70, onto the retina 14. The NIR imager 60 is focused by internal components via control from the processor 100, which communicates with both the NIR imager 60 and the wavefront measurement system 80. Light returning from the retina 14 passes through the pupil 16 of the eye 10 .

[0074] The NIR light returning from the eye 10 passes through a beam combiner 110 and is returned to the NIR imager 60 where an image of the retina 14 is formed. The fundus image, including the retinal image, is sent to the processor 100 via data acquisition and control line 101 for storage and analysis. Since the coordinate location of the projection of the visible wavelength stimulus on the retina is known, the NIR image provides a means of registering the location of the visible wavelength stimulus on the retina to known retinal landmarks. These include, but are not limited to, retinal blood vessels, optic disc, peripapillary atrophy, foveal light reflex, atrophy, hemorrhage, neovascular membrane, epiretinal membrane as well as gliosis, pigmentary changes, and polarization changes. This provides fixation locus, also known as eccentric visual field, and variability in fixation locus, also known as fixation sway. The retinal image further provides information regarding the condition of the retina at the location on the retina where the visible wavelength display is focused. Fixation information and retinal status information regarding the location of the visual stimulus on the retina are displayed as a graphic overlay and / or stored numerically in a computer using the processor 100 and user interface 104. Light returning from the eye 10 that is not intended to be directed to the NIR imager 60 is directed away from the beam combiner 110 to a beam combiner 120. Light in the wavelength range from the visible wavelength display 70 is directed via data acquisition and control lines 108 to a visible or NIR wavefront measurement system 80 which provides data to the processor 100 to quantify the optical aberrations of the light returning from the retina 14 measured at the pupil plane 22. Wavefront measurement system 80 also communicates hardware and / or software related data to processor 100 via data acquisition and control lines 108 to enable precise control of wavefront measurement system 80 by processor 100, including, but not limited to, timing, gain, number of samples included in each measurement, and position of the samples included in each measurement, whether controlled by measurements under the command of the processor or by post-processing following acquisition of data sent to the processor.

[0075] A control loop for the adaptive optics system 90 is formed by the wavefront measurement system 80, the processor 100, the adaptive optics controller 95, and the adaptive optics system 90 based on the measurement of the focus of the illumination from the visible wavelength display 70 on the retina 14. The wavefront aberrations are calculated and those that can be corrected by the adaptive optics system are reported, as well as those that cannot be corrected or are impractical to correct and result in residual optical system errors. In one embodiment, the illumination from the visible wavelength display 70 is modulated in time and then a frequency-based detection scheme in the detection mechanism of the visible or NIR wavefront measurement system 80 is used to achieve an improved signal-to-noise ratio. Alternatives include a simple flicker of the illumination as well as more complex schemes of homodyne and heterodyne detection by the visible or NIR wavefront measurement system 80 based on frequency. In one embodiment, the illumination for the wavefront measurement is alternated in time with the pattern used to test the visual function. In a preferred embodiment, the NIR illumination of the NIR imager 60 is dim enough not to interfere with the judgments used in the visual function measurement. Similarly, in a preferred embodiment, the NIR illumination of the NIR imager 60 does not overlap with the wavelength range of the visible wavelength display 70 so as not to interfere with either the wavefront measurements or the visual function measurements. In a preferred embodiment, data from the focus and wavefront error calculations are reported in a manner that describes the low and high order aberrations due to the wavefront error, as well as the estimated error in retinal focus.

[0076] The response mechanism 150 reports the patient's judgments regarding the visible wavelength stimuli, including but not limited to whether the target was seen, the direction the letter was pointing, and the color, and provides input to the processor. In one embodiment, the response mechanism 150 is operated by the patient. In another embodiment, the response mechanism is a user interface 104 for an operator to input the patient's response.

[0077] The determination as to whether the target is seen correctly is then used to control the next visible wavelength stimulus by the processor 100 for the measurement of visual function. This next visible wavelength stimulus can be based on the patient's response or a predefined sequence of visual targets. A database 200 in communication with the processor 100 stores the current response, past responses, and any data related to the determination of visual function. The processor 100 further processes the retinal image from the NIR imager 60 received over control line 101 to determine the condition of the retina 14 at the location of the target. The retinal condition includes results from confocal imaging and multiply scattered light imaging, showing changes in signal amplitude indicative of irregular retinal or subretinal absorption due to blood or pigment defects, and calculations indicative of protuberance or thickening of subretinal structures, or movement of blood cells or other particles through blood vessels. The database 200 includes results from the system including retinal images, location of the target on the retina, fixation stability, results from processing of the retinal image or artificial intelligence from the retinal image data, retinal condition, retinal condition at the location of the target, results from measured visual function including both central tendency and variability, wavefront error before correction, and correctable versus uncorrectable wavefront error.

[0078] The database also includes other relevant clinical and demographic data, including, but not limited to, retinal status from other instruments such as color fundus photography, scanning laser ophthalmoscopy, optical coherence tomography, optical coherence tomography angiography, or any of these used with adaptive optics, wavefront aberration or optical measurements from other instruments, age, sex, diagnosis, treatment history, and results from other measurements of visual function. The model 210 is in communication with the processor 100 and uses the data stored in the database to provide statistical estimates of central tendency and variability of visual function, such that the range of potential vision that may be achieved is quantified, as described above. Central tendency is a single value that attempts to describe a data set by identifying a central location within that data set. This includes factors unrelated to optical factors such as small pupils, poor optics in the cornea or tear film, cataractous lenses, inaccurate focal planes due to poor refraction, and other factors, some of which may be mitigated during measurements by the disclosed system to more accurately determine the condition of the retina and the potential for improvement with treatment. In one embodiment, the metric of central tendency is the mean and the variance is the variance, providing statistical limits of the significance of confounding reasons for visual impairment in the form of upper and lower confidence limits that can be set according to a certain probability, for example, the probability of falling out of the confidence limit by a 95% confidence limit.Furthermore, the report from the wavefront error shows how the visual measurement is limited in cataracts.The upper and lower limits of the performance of the visual task are calculated and used similarly to the embodiment of FIG.

[0079] 5 illustrates another embodiment of an optical imaging and visual display system 40 for determining visual function using wavefront measurements with a Hartmann-Shack sensor while performing measurements of optical aberrations. The NIR or visible wavelength imager 64 is shown as a digital light projector (DLP) with a digital mirror device (DMD) and an illumination source that is a vertical cavity surface emitting laser (VCSEL) as seen in Muller MS, Elsner AE. Confocal Retinal Imaging Using a Digital Light Projector with a Near Infrared VCSEL Source. Proc SPIE Int Soc Opt Eng. Feb 2018; 10546:105460G. doi:10.1117 / 12.2290286. PMID:29899586; PMCID:PMC5995569. A visible wavelength display 74, which in this embodiment uses a separate DLP for illumination and pattern generation, is directed to the adaptive optics system 90 by an additional focusing lens 250 under the control of a visible or NIR wavefront measurement system 82 for correcting wavefront aberrations to achieve precise focusing on the retina 14. Illumination from the NIR or visible wavelength imager 64 is combined with illumination from the visible wavelength display 74 using a series of lenses 250 and a beam combiner 120. The well-known Hartmann-Shack technique is implemented by using a visible or NIR wavefront measurement system 82 to evaluate the intensity and position of an array of points focused in the pupil plane created by sampling light returning from the retina passing through a lenslet array, as described in Burns et al., 2019.

[0080] 6A, 6B, 6C, and 6D are sample graphical representations of low-order aberrations (LOA) and high-order aberrations (HOA) from NIR wavelength measurements showing the effects of aging and refractive errors. This also demonstrates that pyramidal wavefront sensing methods can be used in the present invention. That is, the method of measuring wavefront aberrations is not limited to the Hartmann-Shack method. FIG. 6A, top left, shows results from a 30-year-old patient's eye, which is emmetropic but has some astigmatism, but is still predicted to have minimal low-order aberrations (280). FIG. 6B, top right, shows results from a 30-year-old patient's eye, which is emmetropic and has some astigmatism, but is predicted to have minimal high-order aberrations because the lens is predicted to have little change with age (281). FIG. 6C, bottom left, shows results from a 71-year-old patient's eye, which is predicted to have significant low-order aberrations because it is myopic (282). Figure 6D, bottom right, shows results from an eye of a 71 year old patient, who is myopic and predicted to have aging changes in the lens and tear film and therefore is predicted to have larger higher order aberrations (283). The plot on the left shows astigmatism (vertical), defocus, astigmatism (total), tilt (horizontal), tilt (vertical), and piston. The plot on the right shows quadrafoil (vertical), astigmatism (vertical), spherical aberration, astigmatism (total), trefoil (total), coma (horizontal), coma (vertical), and trefoil (vertical).

[0081] 7A and 7B show another way of reporting wavefront aberrations, showing the difference between a young patient (FIG. 7A) and an older patient (FIG. 7B) in the calculated deviation from the spot focused on the retina by the eye, known as the point spread function. The younger eye on top has a more compact distribution of light on the retina, indicating better focus. The older eye on the bottom has a less compact distribution, with a more complicated function than simple defocus would produce. Again, this demonstrates that the pyramidal wavefront sensing method of the present invention, i.e. the method of measuring wavefront aberrations, is not limited to the Hartmann-Shack method.

[0082] Figures 8A and 8B show another way of reporting wavefront aberration, illustrating the difference between a younger patient (Figure 8A) and an older patient (Figure 8B) in a plot of wavefront aberration at the pupil plane. The younger patient on the top, Figure 8A, has a fairly consistent wavefront across the pupil, while the older, more myopic patient on the bottom, Figure 8B, has a noticeable difference between the central and peripheral regions of the pupil.

[0083] 9A and 9B are representations of predicted degradation contrast of the letter E due to wavefront aberrations, comparing an emmetropic young eye (FIG. 9A) with an older eye with myopic and increased high order wavefront aberrations (FIG. 9B). The letter E is predicted to be poorly focused on the retina of the older patient, predicting a decline in visual function even if the retina is healthy. Again, this demonstrates that in one or more embodiments, a pyramidal wavefront sensing method is used, i.e., the method of measuring wavefront aberrations is not limited to the Hartmann-Shack method.

[0084] Although exemplary embodiments incorporating the principles of the present invention have been disclosed herein, the present invention is not limited to the disclosed embodiments. Instead, this application is intended to cover any variations, uses, or adaptations of the present invention using its ordinary principles. Moreover, this application is intended to cover such departures from the present disclosure as come within known or customary practice in the art to which the present invention pertains and which fall within the scope of the appended claims.

Claims

1. 1. A system for measuring visual function of an eye having a pupil while quantifying or minimizing factors that adversely affect vision but are unrelated to a retinal condition, comprising: (a) a visual display having an optical design that projects light through the pupil of the eye onto the retina and transmits a majority of the light through the pupil to eliminate individual differences in the amount of light that reaches the retina while accurately transmitting visual stimuli containing high spatial frequencies or low contrast; (b) a processor configured to receive a fundus image, the fundus image including one or more retinal views including details based on one or more conditions of a retinal structure, a subretinal structure, or a fixation point locus; and (c) the processor is configured to compare the visual stimuli from the visual display with the one or more retinal images to provide the locus of the retinal target, known as a locus of fixation, and in other fields known as an eccentric visual zone; (d) the processor is configured to receive wavefront measurements assessing a visual function being tested based on a deviation at a pupil plane of the eye of a wavefront of the light reaching the retina at a location of the visual stimulus; (e) the processor determining a wavefront error resulting from the optical system of the eye from the wavefront measurements; (f) a control mechanism for controlling one or more adaptive optics components to correct the wavefront error of the visual display and achieve improved focusing of the visual stimulus on the retina; (g) the processor adjusting the focus of the visual stimulus on the retina based on the wavefront measurements and assessing corrected and uncorrectable wavefront aberrations; (h) a response mechanism that records a decision regarding the visual stimulus; (i) the control mechanism controls one or more parameters of the visual stimulus of a visible wavelength display; (j) the processor calculating the parameters to be used in the visual display or final output according to the results of b, c, d, e, g, h, and i; (k) the measures of visual function include the expected visual acuity if successful retinal treatment or elimination of extraneous factors such as lens opacity is achieved; and (l) the processor providing metrics of visual function including measures of central tendency and variability and identifying an upper limit that must be exceeded to conclude that the retinal condition is improving, and including a lower limit that the metrics of visual function must exceed to conclude that the retinal condition is not deteriorating. system.

2. 10. The system of claim 1, wherein the light of the visual display is projected through a pupil having a diameter of about 3 mm, providing a sufficient numerical aperture to transmit high spatial frequency stimuli.

3. The system of claim 1 , wherein the retinal image is collected using an imaging device that illuminates the retina by scanning illumination across the retina or by projecting a series of illumination areas onto the retina and synchronously detects light from the retina.

4. The system of claim 1 , wherein the imaging device provides confocal imaging, or alternatively multiple scattered light imaging, with the illumination beams and detection readout being spatially or temporally displaced.

5. The system of claim 1 , wherein the processor analyzes the image with detection offsets for two or more directions of illumination within an image or over time.

6. The system of claim 1 , wherein the processor analyzes images at different illumination wavelengths, including NIR or visible illumination.

7. 2. The system of claim 1, wherein the processor analyzes properties other than intensity of the light returning from the eye in the retinal image, such as fluorescence, coherence, polarization, or changes over time in at least a video-rate image sequence, either at each location or collectively over a larger area.

8. The system of claim 1 , wherein the measurement device for measuring the wavefront is a Shack-Hartmann sensor system.

9. The system of claim 1 , wherein the measurement device for measuring the wavefront uses visible or NIR illumination.

10. 2. The system of claim 1, wherein the wavefront measurement device is devised to have sufficient resolution to allow specification of vision-affecting aberrations not limited to only spherical and cylindrical, but to be of lower cost or resolution than that required to control adaptive optics required to produce diffraction-limited imaging.

11. 10. The system of claim 1, wherein the wavefront measurement system is temporally modulated to reduce the light required for the measurement of wavefront aberrations, including but not limited to modulating illumination synchronous with the sensor to improve signal to noise ratio.

12. The system of claim 1 , wherein the wavefront measurement system has an illumination source separate from the visual display.

13. The system of claim 1 , wherein the wavefront measurement device reports the wavefront aberration for a pupil of about 3 mm.

14. 10. The system of claim 1, wherein the wavefront measurement device reports the wavefront aberration for a pupil of about 3 mm and reports the amount of correction for spherical aberration, cylindrical aberration, and other low order aberrations.

15. 10. The system of claim 1, wherein the wavefront measurement device reports the wavefront aberration for a pupil of about 3 mm and reports the amount of correction by the adaptive optics system for spherical aberration, cylindrical aberration, other low order aberrations, and higher order aberrations.

16. 10. The system of claim 1, wherein the wavefront measurement device reports the wavefront aberration for a pupil of about 3 mm and reports the amount of correction by the adaptive optics system for spherical, cylindrical, other low-order, and higher-order aberrations in conjunction with clinical or other data regarding the health of the anterior segment of the eye, such as the tear film and the lens.

17. 2. The system of claim 1, wherein a wavefront measurement device reports the wavefront aberration for a pupil of approximately 3 mm, and the processor quantifies the amount of spherical, cylindrical, other low-order, and higher-order aberrations corrected by the adaptive optics system in conjunction with clinical or other data regarding the health of the anterior segment, such as the tear film and the lens, to refine the central tendency and variability of the measured visual function.

18. The system of claim 1 , wherein the focusing on the retina from the visual display is improved by adaptive optics, and the improvement is quantified by the measurements of a wavefront measurement system.

19. The system of claim 1 , wherein the focus on the retina from the visual display is improved by adaptive optics, and control parameters of the adaptive optics are specified by auxiliary measurements.

20. 10. The system of claim 1, wherein the imaging device has a wide field of view with a viewing angle of 8 degrees to 60 degrees to enable determination of eccentric fixation and retinal landmarks.

21. The system of claim 1 , wherein the imaging device has an extended field of view with a viewing angle of less than 8 degrees.

22. The system of claim 1 , wherein the measure of visual function comprises a database or model of the effect of the uncorrectable wavefront aberrations on the visual function.

23. The system of claim 1 , wherein illumination of the wavefront measurement system is performed by the visual display.

24. 2. The system of claim 1, however, including a database or model of the effect on visual function measure central tendency and variability when none of the input measurements are measured in a simultaneous manner, within the same device, or alternative or auxiliary measurements are input and constrained to a set of detection offsets for two or more directions of illumination, b, c, d, e, g, or h, within a retinal image or over time.

25. 1. A method for measuring visual function while quantifying or minimizing factors that adversely affect vision but are unrelated to retinal status, comprising: (a) projecting light through a pupil of an eye onto the retina and transmitting a majority of the light through the pupil to accurately transmit visual stimuli containing high spatial frequency or low contrast while eliminating individual differences; (b) receiving a fundus image including details based on one or more of a retinal structure, a subretinal structure, or a fixation point locus; (c) comparing the visual stimuli received from a visual display with the fundus image to provide the locus of the retinal target, known as a fixation point locus and in other fields as an eccentric viewing zone; (d) measuring wavefront aberrations to assess deviations at the pupil plane of the eye of a wavefront for the light reaching the retina at the location of the visual stimulus; (e) determining a focal point of the retina of the optical system of the eye from wavefront measurements; and (f) correcting wavefront errors of the visual display to achieve better focusing of the visual stimulus at the retina; and (g) reporting the corrected and uncorrectable wavefront aberrations to the operator and using this information to interpret visual function measurements; (h) recording a patient's judgment of the visual stimuli; and (i) controlling one or more parameters of the visual stimuli based on the patient's response or a predetermined sequence; and (j) calculating the parameters to be used in the visual display or final output according to the results of b, c, d, g, h, and i and a model of the visual function being measured, including prior data, all working together to identify the visual function that a given eye can potentially achieve, the measurements being optimized to quantify factors that adversely affect vision that are independent of retinal condition, and to generate central tendency and variability metrics describing the retinal condition and potential condition; Including, The visual function metrics include a predictive value for visual acuity if successful retinal treatment is achieved or if removal of extraneous factors such as lens opacity is realized, the visual function metrics include a measure of central tendency and variability and identify an upper limit that must be exceeded to conclude that the retinal condition is improving, and the visual function metrics include a lower limit that must be exceeded to conclude that the retinal condition is not worsening. method.

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