Using two preferred retinal loci for different lighting conditions in patients with central scotomas.

PURPOSE Using a scanning laser ophthalmoscope, it was found that some patients with relative central scotomas reliably used two different preferred retinal loci (PRLs) at different stimulus illuminances. This article describes adaptations in a patient's PRL for fixation when dimming the stimulus increased the relative scotoma size. METHODS Twenty-eight patients with macular diseases had their dense and relative macular scotoma borders mapped with the scanning laser ophthalmoscope. The high-illuminance PRL (PRLhi) and low-illuminance PRL (PRLlo) were operationally defined as the PRLs that patients used to fixate a high or low illuminance stimulus, respectively. The PRLs' abilities to do visual tasks and their characteristics at the corresponding illuminances were assessed. RESULTS The PRL consistently shifted between the PRLhi and the PRLlo as the stimulus illuminance was changed. Brightness permitting, the visual system prefers to use the PRLhi with generally better performance in visual function such as fixation stability. There were no significant differences between the PRLhi and the PRLlo in pursuit and saccadic abilities, when assessed by subjective ratings. The illuminances that induced shifting ranged from 106 to 3437 trolands. The PRLhi was always located within an area of relative scotoma, usually at the fovea or just outside a dense scotoma. The PRLlo was located in relatively healthy retinal area, and usually below or to the left of the PRLhi in the visual field. CONCLUSIONS In the visual system, two well-defined PRLs can develop when visual function is adapting to maculopathy, with the use of each depending on the brightness of objects used in visual tasks. Rehabilitation and treatment strategies should consider the existence of multiple PRLs.