Preferred retinal loci and macular scotoma

characteristics in patients with age-related

macular degeneration
Ronald A. Schuchard, PhD
ABSTRACT RSUM
Many patients with macular scotomas due to age-related macular degeneration do not
perceive black spots in the visual field where the scotomas are located. Rather, they
describe objects as vanishing, jumping out of nowhere or having blurry parts, or
a combination of features. In addition, when the macular scotoma affects the fovea, the
visual system uses 1 or more preferred retinal loci (PRLs) as a pseudofovea to
perform visual tasks. Visual function testing with the scanning laser ophthalmoscope
has provided a wealth of information regarding how patients perceive the visual world
and how the oculomotor system directs eye movements. This article describes
2 specific functions of the oculomotor system, fixation stability and refixation
precision, with data collected from normally sighted people and patients with visual
field loss. The implications of the characteristics of PRLs and macular scotomas for
clinical testing are discussed.
Plusieurs patients qui ont des scotomes attribuables une dgnrescence maculaire
lie lge ne peroivent pas de points noirs du champ visuel l o se situent les
scotomes. Ils dcrivent des objets qui disparaissent , venus de nulle part ou
partiellement flous ou ayant un mlange de ces caractristiques. De plus, lorsque
les scotomes maculaires affectent la fova, lappareil visuel utilise une ou plusieurs
zones de rtine prfrentielles comme pseudofova pour accomplir des tches
visuelles. Lexamen de la fonction visuelle avec lophtalmoscope laser balayage a
donn une abondance de renseignements sur la perception quont les patients du
monde visuel et sur la faon dont le systme oculomoteur dirige les mouvements de
lil. Cet article dcrit 2 fonctions particulires du systme oculomoteur, la stabilit
de la fixation et la prcision de la refixation, avec des donnes recueillies chez des
personnes qui ont une vue normale et des patients qui ont subi une perte du champ
visuel. Il traite aussi des implications des caractristiques des zones de rtine
prfrentielles et des scotomes maculaires pour les tests cliniques.

he visual system with a central scotoma from agerelated macular degeneration (AMD) chooses
(often without the conscious knowledge of the
patient) a preferred eccentric retinal area because the
fovea can no longer perform visual tasks; that is, in an
eye with a central scotoma affecting all of the fovea, 1

or more eccentric preferred retinal loci (PRLs) naturally and reliably develop to perform the foveal visual
tasks such as recognizing objects and directing eye
movements while reading or tracking objects.116 This
choosing by the visual system of an eccentric pseudofovea for visual-performance functions has been

From the Department of Veterans Affairs, Rehabilitation Research &

Development, Center of Excellence for Aging with Vision Loss, Atlanta, Ga.

GA 30033-4004, USA; fax (404) 728-4837; rschuch@emory.edu

Correspondence to: Dr. Ronald A. Schuchard, Atlanta VA Rehabilitation

Research & Development Center (151R), 1670 Clairmont Rd., Decatur,

Preferred retinal lociSchuchard

This article has been peer-reviewed.

Can J Ophthalmol 2005;40:30312

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Preferred retinal lociSchuchard

Fig. 1Characteristics of preferred retinal loci (PRLs) and scotomas in the right eye (left image) and left eye (right image) of a
patient with exudative age-related macular degeneration (AMD).The green solid line describes the border of the dense scotoma
(DS), the yellow letters describe the area of the relative scotoma (RS), the red circle describes the border of the PRL, and the blue
F indicates the best estimate of the location of the nonfunctioning fovea.

noted primarily by the use of the scanning laser ophthalmoscope (SLO). The SLO also allows accurate
characterization of the central visual field by macular
perimetry with direct retinal observation of fixation
and perimetry targets.17,18 For example, fixation performance has 2 operational definitions: refixation
precision is defined as the retinal area that a patient
uses during repeated fixation (refixation); fixation stability is defined as the retinal area that a patient uses
while maintaining fixation. Refixation precision and
fixation stability show variability, of course, and the
distribution of retinal positions used during fixation
performance is operationally defined as the retinal
locus for fixation.
The concept of using a retinal locus for visual tasks
such as fixation is accepted in vision rehabilitation
but seldom used with normally sighted patients. The
term PRL has typically been reserved for patients
whose visual system has chosen a preferred eccentric
retinal area for visual tasks because of a central
scotoma. However, the visual system of patients with
paracentral scotomas or even normal sight does
choose to use the fovea over other retinal areas; thus,
the fovea can be referred to as their PRL.
RETINAL

CONSIDERATIONS

For patients with a functioning fovea, visual tasks

are performed by aiming the eye such that the image
of the visual target of regard is placed within the
foveal area. For patients with a central scotoma from
AMD involving all of the fovea, visual tasks are performed by aiming the eye such that the image of the
visual target of regard is placed within a PRL.
Unfortunately, there is no conclusive way of deter-

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mining where the eccentric PRL is located except by

monitoring the location of visual-stimuli images on
the retina. Fig. 1 shows how visual stimuli can be
directly monitored with an SLO to determine scotoma
and PRL characteristics. Generally, in the low-vision
population with central scotomas, there is no consistent retinal location relative to the scotoma for the
PRLs. In a study of 825 patients, 84.4% of low-vision
eyes (1130 of 1339) demonstrated an established
PRL (foveal or eccentric) for fixation, which varied
from 1.0 to 9.0 in diameter.14 Only 4.4% of the
patients did not demonstrate a PRL in either eye.
There was a dense scotoma within 2.5 of all of the
eccentric PRLs, surprisingly, and it completely surrounded 17.4% of the PRLs (ring scotoma).
In an eye with a functioning fovea, fixation is the
act of directing the eye toward the visual target of
regard, causing the image of the target to be within
the fovea. The anatomic fovea is a retinal area about
5 (1500 mm) in diameter in which the central
1.21.7 diameter of photoreceptors (referred to as
the anatomic foveola or clinical fovea) is composed
entirely of cones.19,20 The traditional view is that
within the centre of the fovea, where the cone density
is highest, is a small and spatially invariant retinal area
referred to as the optimal locus.21 The optimal locus
has been hypothesized to direct the location of a fixation stimulus when fixation is initiated and to direct
drifts and microsaccades to maintain fixation.
In an eye with a central scotoma affecting all of the
fovea, eccentric fixation is the act of directing the eye
toward the visual target of regard, causing the image
of the target to be placed in 1 or more preferred
eccentric retinal areas. Eccentric fixation refers to fixation performance in which the oculomotor system is

Preferred retinal lociSchuchard

oriented to the eccentric retinal area, and the patient

has the sensation of looking directly at the visual
target during fixation. Eccentric viewing, on the
other hand, refers to viewing performance in which
the oculomotor system is not oriented to the target
and the patient has the sensation of looking above,
below or to either side of the target to see it. A shift
of the oculomotor reference from the fovea to a preferred eccentric retinal area is possible in patients
with bilateral macular disease.7,8 However, even
though the saccades of patients with central scotomas
can consistently direct images to the PRL, they sometimes have the latency and dynamic characteristics of
nonfoveal saccades.8 But the latency can be shortened
with practice, eventually tending asymptotically to
the normal saccadic duration.22 Eccentric viewing or
fixation naturally and reliably occurs when the foveal
areas in both eyes are no longer functional, such as
when both eyes have central scotomas.16,22
POSITION

OF GAZE CONSIDERATIONS

The primary position of gaze is defined as the position of the eye when a patient is looking at a visual
target that is straight ahead. From this primary position all ocular movements are initiated. More specifically, the primary position of the eye is the position
against which all torsional, rotational and translational movements are measured. The position of the
eye at the primary position of gaze is not necessarily
identical to an anatomically straightforward position
of the eye (as in an AMD patient with a central
scotoma). A secondary position of gaze is defined as
any position of the eye represented by a vertical, horizontal or oblique (a combination of vertical and horizontal) deviation from the primary position of gaze.
It is expected that patients with functioning foveal
areas (e.g., patients with paracentral scotomas or
normal sight) will use the foveal area as their PRL for
visual tasks when visual targets are in either the
primary position of gaze or secondary positions of
gaze. In addition, it is expected that patients with
nonfunctioning foveal areas (owing to central scotomas) will use a preferred eccentric retinal area as the
PRL for fixation when targets are in either the
primary position of gaze or secondary positions of
gaze. However, patients with central scotomas use 1
or more PRLs for visual tasks when visual targets are
in the secondary positions of gaze and almost always
use a primary PRL for visual tasks when the targets
are in the primary position of gaze;8 that is, patients

are more likely to use a secondary PRL when fixating on a target in a secondary position of gaze. The
use of multiple PRLs has also been observed for different visual tasks13 and lighting conditions.15
Patients are often completely unaware of when or
how they use multiple PRLs.
PRL

CHARACTERISTICS

The ability to make efficient and effective eye

movements with a PRL is often considered the most
difficult and yet the most valuable component of
visual tasks such as scanning and reading. The more
basic eye movements made by the visual system are
fixation, pursuit and saccadic movements. These
tasks are thought to possibly represent measurable
parameters of the PRL quality for visual performance;
that is, to optimally function as a retinal locus for
visual performance, the PRL needs to keep a visual
image in a discrete and stable retinal area (fixation
stability), to track moving objects through space
(pursuit) and to move rapidly to objects of interest
appreciated in the visual field away from the PRL
(saccadic movements). These and other characteristics of the PRL are thought to be important in activities of daily living for patients with AMD.
Refixation precision

Subjects were asked to fixate for 30 s on a target

randomly placed in 1 of 25 positions determined by
a 5 5 grid within the 17 12 SLO field of view.
The centre of the grid was at the primary position of
gaze, and the remaining grid locations provided 24
secondary positions of gaze. Table 1 presents the characteristics of the PRL for fixation described by a
bivariate analysis that provides an elliptical fit of the
30-s retinal positions during fixation (unpublished
data, 2003). The characteristics of the ellipsis are orientation of the major axis ( 90 from the positive
horizontal axis), eccentricity (the ratio of the major to
minor axes when a value of 1 indicates a circular
shape), major axis length (in minutes of arc) and area
(in minutes of arc squared).
An analysis of variance in the characteristics of the
PRL for fixation found by refixation precision was
first performed for 3 normally sighted subjects who
had extensive experience fixating. Effects with p <
0.05 are reported as significant in this and all further
analyses of variance. The orientation of the major
axes of the PRLs was not affected by the positions of

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Table 1Characteristics of ellipses representing preferred retinal loci for fixation found by refixation
precision and studied by bivariate analysis
Primary position of gaze

Secondary positions of gaze

Major axis

Subject*

Stimulus

Angle
(degrees)

EN-1

1 cross
12 disc
1 disc
1 cross
12 disc
1 disc
1 cross
12 disc
1 disc
1 cross
1 cross
1 cross
1 cross
1 cross
1 cross
1 cross
1 cross

14.1
23.6
46.0
13.6
3.0
20.6
15.2
75.5
65.5
42.8
38.6
78.3
10.8
47.9
63.5
2.2
124.6

EN-2

EN-3

IN-1
IN-2
IN-3
IN-4
PS-1
PS-2
CS-1
CS-2

Length
(min of
arc)
26.5
30.5
31.9
28.8
28.8
27.9
21.1
34.7
33.0
59.8
57.9
76.9
56.1
81.9
48.4
212.9
390.0

Major axis
Area (min
Angle
of arc

Eccentricity squared) (degrees)

0.78
0.61
0.56
0.55
0.60
0.78
0.97
0.46
0.83
0.77
0.88
0.44
0.89
0.60
0.48
0.55
0.28

434
443
452
392
389
476
337
436
608
2 172
2 317
2 050
2 205
3 163
890
19 759
33 735

43.8
63.9
86.6
24.0
1.1
71.4
42.8
61.1
11.4
14.2
37.7
16.9
81.2
53.7
23.0
13.9
64.4

Length
(min of
arc)
42.2
44.2
58.1
82.1
44.4
47.8
43.2
54.8
30.6
100.5
199.2
150.5
88.5
87.2
172.3
549.2
555.0

Area (min
of arc
Eccentricity squared)
0.79
0.78
0.66
0.40
0.72
0.65
0.45
0.69
0.68
0.56
0.44
0.73
0.61
0.61
0.50
0.36
0.64

1 105
1 190
4 042
2 056
1 120
1 176
661
1 631
3 007
4 443
13 769
13 028
3 741
3 660
11 667
84 770
155 790

*Subjects were experienced (E) or inexperienced (I) in fixation and had normal (N) sight or had scotomas (S), either paracentral (P) with a
functioning fovea or central (C). Subject PS-2 had a ring scotoma surrounding the fovea. All scotomas were due to age-related macular
degeneration.

Plus or minus 90 from the positive horizontal axis.

A value of 1 indicates a perfect circle.

gaze (primary or secondary), the different fixation

stimuli or the different subjects. The eccentricity of
the PRLs also was not affected by the positions of
gaze (primary or secondary), the different fixation
stimuli or the different subjects. However, the eccentricity values in Table 1 clearly indicate that the PRL
for fixation is not a circle (eccentricity = 1) except in
a few cases (e.g., subject EN-3 with 1 cross at the
primary position of gaze). The major axis length and
the area of the PRLs were not affected by different
fixation targets or different subjects. Therefore, the
orientation and shape of the PRLs for fixation change
in apparently random and nonsystematic ways. However, the major axis length and area were significantly
larger for secondary positions of gaze than for
primary positions of gaze with all 3 fixation targets
and all 3 subjects (the interaction terms were not significant).
To extend the finding that the major axis length
and area of the PRL is affected by the fixation-target

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position of gaze, additional studies were done with 4

normally sighted subjects who were inexperienced in
fixation. These results and those for the experienced
subjects with the 1 cross were combined for analysis.
In all subjects, the major axis length and area of the
PRLs were significantly larger with the primary position of gaze than with the secondary positions of
gaze. However, all the inexperienced subjects had
larger fixation areas than the experienced subjects.
The same effect of experience on fixation performance has been reported for fixation stability.23
Patients with central visual field loss not affecting
the fovea (e.g., patients with ring scotomas) would be
expected to have fixation performance similar to that
of normally sighted subjects. The results for 2
patients with paracentral scotomas shown in Table 1
are typical of these types of field loss: the PRLs for fixation found with primary and secondary positions of
gaze were similar to those of the normally sighted
subjects. However, such patients sometimes place the

Preferred retinal lociSchuchard

fixation target in an eccentric PRL for fixation. For

example, patient PS-2 twice placed the fixation target
in an eccentric retinal location outside the ring
scotoma when the target was at a secondary position
of gaze (these 2 eccentric fixation positions were not
included in the bivariate analysis). The patients are
often completely unaware of the change in the retinal
fixation position. The last 2 patients listed in Table 1
had central scotomas affecting the fovea. The increase
in size of the PRL for fixation is typical of this type of
field loss. Patient CS-1 used 2 eccentric retinal areas
to place the fixation target; patient CS-2 used only 1
PRL. Patients with central scotomas affecting the
fovea are also often completely unaware of using different retinal positions for PRLs. It is not known why
patients place fixation targets in locations less often
used for fixation.
Fixation stability

The retinal loci for fixation found by fixation stability in 8 of the secondary positions of gaze (at the
corners and the horizontal/vertical axes of the 17
12 SLO field) were found along with 8 primaryposition trials. An analysis of variance (repeatedmeasures design) was performed on the characteristics of the PRLs for fixation (again significance is
reported for p < 0.05). Like refixation precision, the
orientation of the major axis and the eccentricity of
the PRLs were not affected by the position of gaze
(primary or secondary). Unlike refixation precision,
however, major axis length was significantly affected
by position of gaze. Previous studies of fixation stability in normally sighted subjects had shown PRL
and foveal areas for fixation of 31.6 to 373
squared.2125 The PRL areas found with SLO were
337 to 443 squared for small fixation targets with
experienced patients. The main difference between
the previously reported and the SLO values is the 3:1
ratio between the 95% and 63% equal-frequency
PRLs, that is, the difference in the retinal areas in
which one would expect to find 95% versus 63% of
the retinal positions of fixation.
To further investigate the concept of a larger retinal
locus for fixation, the 400 samples (25 samples
during 8 primary-position trials and 8 secondarypositions trials) for each patient performing fixation
stability in the SLO were analyzed to find the radius
from the centroid for each sample. The normalized
cumulative frequency indicated that 95% of the time
the patients kept the fixation stimulus within a retinal

area of 68 in diameter. In addition, the patients did

not place the target in a small retinal area of 10.5
most of the time and very seldom placed the fixation
stimulus outside the small retinal area (a Gaussian
distribution). Rather, patients placed the target in a
larger retinal area most of the time (a roughly flat distribution of 40 or 50) and outside this larger area
very seldom.
Comparison of results

The PRL sizes during a fixation-stability trial, at

both primary and secondary positions of gaze, were
very similar to the PRL sizes for the 24 repeated fixations at the primary position of gaze during refixation-precision trials. Patients appear to use a larger
retinal area for fixation when asked to fixate on a
target that is away from the primary position of gaze.
However, when they have fixated on a target at a secondary position of gaze, they appear to be able to
maintain the image of the fixation target in a retinal
locus for fixation that is the same as when they are
asked to fixate and maintain fixation on a target at
the primary position of gaze. Interestingly, even
though the patients used a larger retinal area for secondary-position fixation, the diameters of the major
axes of the PRLs were almost always 1 or less. It may
not be a coincidence that the retinal positions for fixation are typically within an area of about 1.2 to 1.7
for most normally sighted patients. The central
1.21.7 area of the fovea, the foveola, is a retinal
area with roughly equal resolution capability.
Binocular PRLs

In previous investigations of PRLs each monocular

PRL was studied separately, but individuals typically
perform activities of daily living with both eyes open.
Therefore, previous investigators have forced subjects
to perform visual tasks monocularly without fully
understanding the consequences for the monocular
PRL characteristics. In a recent study of binocular
PRLs,26 67% of the patients saw stimuli with only 1
eye (monocular perception) while performing simple
free-viewing binocular fixation and perception tasks.
No single visual factor (acuity, contrast, threshold
sensitivity, fixation stability, saccadic ability, pursuit
ability or scotoma characteristics) had a statistically
significant effect on perception of the stimulus,
monocular or binocular. However, if the subjects had
a large difference in monocular visual function (e.g., a

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Fig. 2In a patient with AMD and monocular perception, the binocular PRLs are not in the same direction or at relatively the same
distance from the nonfunctioning fovea in the right eye (left image) and the left eye (right image).

logMAR [logarithm of the minimum angle of resolution] difference greater than 0.66, or more than
6 lines of letters on the ETDRS [Early Treatment
Diabetic Retinopathy Study] chart), the dominant
PRL was the PRL with better visual-function capability. But, in the large group of subjects (82%) who
did not have these large differences in visual-function
capability between the 2 eyes, the only way of
knowing which PRL was dominant was by a binocular perception test that directly evaluated which PRL
was dominant. The only other factor that seems to
contribute to monocular perception is noncorrespondence of binocular PRLs. Fig. 2 shows an example of
binocular PRLs that are in different directions and at
different distances from the nonfunctioning foveas.
Compare the PRLs in Fig. 2 with those in Fig. 1,
where the binocular PRLs are in the same direction
and at relatively the same distance from the nonfunctioning foveas.
The finding that 2 out of 3 patients with central
scotomas see visual stimuli at fixation with only 1 eye
does not mean that the patients are seeing the entire
visual world with only 1 eye. Patients reported seeing
the world with both eyes, although not always appreciating that when looking at a target in the central
visual field (e.g., a number, letter or word) they were
seeing the target with only 1 eye. Previous studies of
PRL abilities in eye movements might be considered
to have been testing similar types of tasks: typically
the subject was asked to fixate, saccade to a small
target or follow a small target. It is possible that the
eye that actually is used by the visual system in binocular tasks is a dominant eye that is better at eye-

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movement tasks; that is, the fellow eye is actually following the lead of the dominant eye. Therefore,
determining the dominant PRL can be critical in
guiding the prescription of monocular-visionenhancing equipment, testing monocular visual function and other monocular issues.
IMPLICATIONS

OF

PRL AND
AMD

SCOTOMA

CHARACTERISTICS IN

The idea of 1 or more PRLs instead of a single

retinal point being used for visual tasks is an important concept for clinical vision testing and visual
tasks. Many clinical tests or treatments presume that
the eye movement system is operating by referencing
a retinal point or at least a single retinal area. A few
examples are presented to demonstrate the implications of PRLs and scotomas for clinical testing and
visual tasks.
Reading

The ability of the eye to make movements so that

the visual-target image is placed or kept in the PRL
has been shown to be correlated to reading rate and
reading errors.2733 Previous reports on reading rate
had shown that the existence of a central scotoma was
a much greater predictor of reading impairments than
was reduced acuity.31,32 However, the ability of the
PRL to direct eye movements, both saccadic ability
(measured by the number of saccades and the saccade
characteristics) and fixation stability (measured by
the retinal area of fixation), had a much higher correlation with reading speed and correct reading rate

Preferred retinal lociSchuchard

than did either acuity or scotoma existence.

Furthermore, subjects with macular diseases who
were undergoing vision rehabilitation clustered into 2
groups, 1 showing significant improvement and the
other showing no improvement in reading with
vision-rehabilitation training.33,34 That research also
showed a strong association between saccade scores
and reading rate or reading errors. Patients with
AMD who present with low reading rates (fewer than
10 words/min and more than 2 errors with a short
passage) and poor saccadic ability are less likely to
show improvement in reading with vision rehabilitation.
Visual search

Unlike reading, the ability of the eye to make

movements so that the visual-target image is placed
or kept in the PRL has been shown to not be highly
correlated to visual search efficiency or accuracy.
Saccades of patients with central scotomas were
found to consistently direct fixation targets to the
PRL even though the saccades sometimes had the
latency and dynamic characteristics of saccades not
directed by the fovea.12,22 The patients with AMD
also had, on average, more saccades of shorter length
than normally sighted patients. However, the latency
of the first saccade and the number of saccades to
move the search-target image into the PRL were not
correlated to the search time (together or separately).12 Rather, the time after the search-target
image was moved into the PRL was the greatest contributor to the total visual search time; that is,
patients with macular scotomas deliberated longer
about the identity of the search target. Therefore, any
patient with a macular scotoma, regardless of the
retinal location of the PRL, will have impaired visual
search ability beyond the inability to see targets
located inside the scotoma.
Perimetry testing

The size and location of the PRL have obvious

implications for perimetric testing of patients with
AMD. For example, perimetric results can be translated in position, and if this translation is not recognized the location of the macular scotoma will be
inaccurately positioned in the visual field relative to
the fovea. If the patient has a very large PRL for fixation or multiple PRLs, the perimetry results reported
at 1 point of the visual field (e.g., the grid point in a

Humphrey 10-2 test) could be the average of flashes

actually presented at multiple retinal locations. The
instability inherent in eccentric PRLs for fixation also
makes accurate mapping of the scotoma boundaries
very difficult.
Pericentral fixation targets are used when the
purpose of the testing is to measure visual function in
the central macular retinal area (foveal area). These
targets are intended to guide fixation by stimulating
the perifovea (the outer limit of the macular area)
while providing no visual stimulation of the inner
macular area, including the foveal area. When subjects are instructed to fixate in the centre of the
target, clinicians often assume that patients with
central scotomas place the centre of the pericentral
fixation target within the PRL for fixation. They also
often assume that, when instructed to look directly
at the centre of the target, patients place the target
centre in the foveal area, even though the fovea is no
longer functioning owing to the central scotoma.
However, most patients with central scotomas appear
to orient images of targets to the PRL, and verbal
instructions do not change the location of the pericentral fixation target.7,8 Therefore, one cannot
assume that using pericentral fixation targets in clinical tests (e.g., a big X in the tangent screen or Amsler
grid), with or without verbal instructions, provides
testing with the fovea directed at the centre of the test
area.
Patient awareness of macular scotomas

The presence of scotomas in the macula hinders the

performance of many daily activities, such as reading,
but most patients with AMD are unaware of even
large defects in their central visual field. A valuable
application of the information gained from PRL
testing and macular perimetry is to educate the
patient about the presence of the scotomas, especially
when they occur relative to fixation. Macular perimetry methods can be used to demonstrate to the
patient what a scotoma is and what compensatory eye
movements can be used to move the scotoma out of
the way. These compensatory techniques are especially important for the nearly 1 out of 5 low-vision
patients who have fairly good visual function (as good
as 20/40) but ring scotomas surrounding the PRL
(Fig. 3). The patient who has gained an awareness of
the scotomas effects on visual tasks is more likely to
make accurate compensatory eye movements to
search for, find and identify pertinent visual informa-

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Fig. 3A ring scotoma, a scotomatous area completely surrounding the PRL, is a typical stage of the progression of vision loss in
geographic atrophy.This patient has AMD due to geographic atrophy in the right eye (left image) and the left eye (right image).

Fig. 4PRL shift in the left eye of a patient with AMD. The
patient consistently used 2 PRLs in the same retinal locations
and at approximately the same light levels during 1 year of
monitoring: the primary PRL (red circle) with typical bright
indoor light (about 100 cd/m2 or more) and the secondary
PRL (purple circle) with less light (e.g., when watching television).TS indicates the scotoma that exists at the threshold of
the secondary PRL.

tion. The ability to be aware of the scotomas effects

on visual tasks is even more challenging when the
patient is using multiple PRLs (Fig. 4), often without
conscious knowledge of changing retinal positions for
different lighting conditions or visual tasks.
Calibration of eye-position instruments

The calibration of eye trackers for vision testing is

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another example of when the concept of retinal locus

for fixation is important. Calibrating eye trackers
(e.g., the pupil eye tracker in the Humphrey Visual
Field Analyzer) is done by having patients fixate on
targets at known spatial locations. The recordings
from the trackers are transformed to real-world
dimensions by the relationships between these
recordings and the known spatial locations of the fixation targets. The underlying assumption is that
patients place the fixation targets in exactly the same
retinal position each time they are instructed to look
at the target; that is, one must assume that the PRL
has no shift in retinal position when the fixation
target is placed in different spatial locations, even
though multiple PRLs occur. To make matters worse,
the SLO results show that patients use a larger retinal
locus for fixation when looking at fixation targets in
secondary positions of gaze (see Table 1). To develop
the transformation algorithm for calibration, one
must have patients look at fixation targets in many
secondary positions of gaze.
Eccentric-viewing training

The orientation of the oculocentric system (fovea

or eccentric PRL) affects eccentric-viewing training.
Many vision rehabilitation practitioners believe that
patients with central scotomas benefit greatly from
such training.35,36 A goal of this training is to enable
the patient to use a specific eccentric area of the retina
as if it were a fovea. To the extent that the PRL can
play this role, this goal is reasonable. Results of fixation performance and visual-search performance,12 as

Preferred retinal lociSchuchard

measured with an SLO, indicate that patients with

central scotomas are able, and indeed likely, to use a
PRL. The PRL appears to be developed by a patient
simply through experience of a central scotoma,
without formal training. However, it is certainly possible that eccentric-viewing training could facilitate
this behaviour, making fixation more stable and accurate or influencing the patient to use a more optimal
eccentric retinal area for eccentric viewing. It is not
known whether patients with central scotomas can be
trained to develop a new, more optimal, PRL as the
reference for the oculocentric system. Further results
are needed to determine what factors (e.g., resolution,
field of view, proximity to the nonfunctioning fovea
and binocular conditions) the visual system uses
when naturally choosing a retinal area as the PRL.
CONCLUSION

Although there have been reports concerning some

aspects of the PRL, the characteristics of the PRL are
still not well known and understood. For example,
more results need to be collected to determine
whether single or multiple PRLs are influenced by
retinal abnormalities. Also, what is known from previous work needs to be reevaluated, since it was never
determined that the PRLs that were studied were actually used by the visual system in binocular (natural)
viewing tasks. However, the characteristics that are
known about the PRL have been shown to be important in their relationship to activities of daily living for
patients with AMD. Therefore, clinicians may want to
consider assessing the PRLs and scotomas of their
patients as part of a complete evaluation.
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Key words: age factor, macular degeneration, ocular fixation,
scotoma