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Article

The Effect of Visual Acuity Corrections on the Determination of Unilateral Neglect When Conducting the Apple Cancellation Test

by
Jae-Hyeon Noh
,
Hyun Gug Cho
,
Byeong-Yeon Moon
,
Dong-Sik Yu
and
Sang-Yeob Kim
*
Departement of Optometry, College of Health Science, Kangwon National University, Samcheok-si 25949, Republic of Korea
*
Author to whom correspondence should be addressed.
Appl. Sci. 2023, 13(10), 5951; https://doi.org/10.3390/app13105951
Submission received: 5 April 2023 / Revised: 7 May 2023 / Accepted: 10 May 2023 / Published: 11 May 2023
Browse Figure
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Abstract

:
This study examined the effects of visual acuity corrections on the diagnosis of unilateral neglect (UN) in elderly subjects. Nineteen subjects between the ages of 61 and 86 participated in this study. For the assessment of UN, the frequency of subjects diagnosed as UN, the number of correct responses, and the time spent completing the test were examined under three conditions; naked eye state, with distance-correction glasses, and with near-correction glasses, in order to determine whether or not the subjects had UN using the apple cancellation sheet. The frequency of subjects diagnosed with UN decreased when wearing both distance- and near-correction glasses, and the number of correct responses showed a significant increase while wearing near-correction glasses (p < 0.05). In addition, the time spent completing the test was significantly reduced while wearing near-correction glasses (p < 0.05). For elderly subjects, near visual acuity correction can improve near visual perception, reading ability, and concentration, acting as a positive factor in the apple cancellation test, which is tested at near distance, and prevent the misdiagnosis of UV.

1. Introduction

USN (unilateral spatial neglect), a condition characterized by an impaired ability to perceive visual information in the space contralateral to the damaged hemisphere following brain damage, is commonly caused by stroke [1,2]. In particular, USN occurs in approximately 50% of patients who have suffered an acute stroke and is often manifested as left-sided neglect resulting from damage to the temporal and frontal lobes of the right hemisphere [3,4]. Right-sided neglect caused by damage to the left brain has also been reported [5]. UN (unilateral neglect), including USN, is classified as motor neglect or sensory neglect according to the type of deficit [6,7]. Due to a lack of awareness of space contralateral to the side of the brain that has been damaged, patients with UN experience difficulties in performing daily activities. They typically leave food on the opposite side of the damaged brain untouched during meals, frequently bump into objects, and have problems reading and writing [8,9]. In addition, sitting or standing balance can be difficult for UN patients and there is an increased risk of falls [10]. Therefore, UN treatment and rehabilitation are critical for a patient’s recovery to an independent daily life.
The occurrence of UN is a result of complex causes in the cerebrum, and the approaches to the treatment of UN include medication therapy, promotion of sustained arousal and attention, neck vibration, neck electrical stimulation, eye patching, and wearing prism glasses [10]. Of these, prism adaptation, a bottom-up approach classified by Barrett et al. [11], changes the external environment using prism refractive power towards the direction of the base, which is helpful for improving perception; this method is the most commonly examined therapeutic approach for UN, and the efficacy of wearing prism glasses has been previously demonstrated [12,13]. Research on a large number of assessment tools for the diagnosis of UN is currently underway [14]. Among the assessment tools, the pen-and-paper test is used most often because of its convenience. The types of tests include the line bisection test, copying and drawing test, and cancellation test [14,15]. In particular, when compared with other tools, the cancellation test is preferred for the diagnosis of UN [16]. Ota et al. [17] reported the development of a cancellation test, which was later modified by Bickertion et al. [18], which involved the replacement of the stimulus shape with an apple shape. The apple cancellation test can enhance patients’ interest in the test, leading to a more accurate determination of UN. This test has recently attracted significant attention for distinguishing between two different types of UN, EN (egocentric neglect: missing information in the space opposite the brain injury centered on the viewer) and AN (allocentric neglect: missing information in the space opposite the brain injury centered on the object) [19].
However, the apple cancellation test is a subjective test conducted in the form of a pen-and-paper test where the subject looks directly at the evaluation sheet. Nevertheless, no reference for conditions for the correction of visual acuity prior to the test has been specified. The use of the method for the correction of visual acuity (for distance or near visual acuity) may cause errors in test results due to the use of different corrective refractive powers for the correction types. Therefore, this study examined the effect of conditions for the correction of visual acuity on the diagnosis of UN syndrome caused by brain diseases such as stroke and provides guidelines for the correction of visual acuity that can be referenced for use in the performance of pen-and-paper tests. We hope that the information provided in the study will be helpful for professionals in the field.

2. Materials and Methods

2.1. Participants

A study that included 19 subject (11 males, 9 females) with an average age of 73.23 ± 7.06 years who had not worn distance vision glasses in the past year was conducted. Screening was performed for exclusion of subjects with brain diseases or serious eye diseases that might affect the experiment, while those who had been diagnosed with age-related cataracts but had not undergone surgery due to the mildness of their condition were included in the experiment. In addition, it was confirmed that the subjects had sufficient cognitive ability to perform the apple cancellation test on their own. The average refractive error of the subjects was Sphere + 0.69 ± 1.18, Cylinder − 0.75 ± 0.66 for the right eye, and Sphere + 0.48 ± 2.24, Cylinder − 0.68 ± 0.73 for the left eye, while their visual acuity was 0.39 ± 0.25 before correction and 0.09 ± 0.08 after correction, based on logMAR. The experiment was conducted after all subjects had been provided with an adequate explanation of the purpose and method.

2.2. Apple Cancellation Test

The apple cancellation test consists of 150 stimuli randomly scattered on an A4-sized sheet of paper, including 50 complete apples, 50 apples with a left-sided opening, and 50 apples with a right-sided opening (Figure 1a). The evaluation sheet is divided into ten squares that are invisible to patients, five horizontally and two vertically, in order to distinguish locations that may not be perceived by the patients due to the effects of UN (Figure 1b). For each square, 15 apples, including complete and left-sided and right-sided openings, are evenly distributed [18]. Using an apple cancellation test sheet, evaluation of a patient can be performed according to both UNs, such as EN and AN, at the same time. EN refers to ignoring the shape information of an object on the right or left side with reference to the subject’s body midline, while AN refers to ignoring the shape of an object’s left or right side regardless of its position towards the subject [19]. The assessment for EN was performed using the outcome numbers, which involved subtracting the number correctly answered with regard to apple shapes on the left side to the center point of the sheet from the number correctly answered with regard to apple shapes on the right side to the center point. A difference greater than 3 is regarded as left neglect, and a difference lower than −2 is regarded as right neglect. For AN, a difference between the number of incorrect answers on the right and left sides greater than 1 is regarded as left neglect, and a difference lower than −1 is regarded as right neglect. The test was limited to five minutes.

2.3. Experimental Procedures

In order to provide appropriate corrective glasses for the subjects, subjective refraction was performed using a manual phoropter (Phoropter 11625B, Reichert, Depew, NY, USA) and an LCD eye exam chart (LUCID’LC, Everview, Seoul, Republic of Korea). Based on the results of subjective refraction, glasses for correction of distance visual acuity were made, and glasses for correction of near visual acuity were also made according to the degree of presbyopia addition measured using the near-field cross-sight and cross-cylinder methods. For the UN test, an apple cancellation test sheet was placed on the table, and an evaluation of each subject was performed repeatedly before and after visual correction that included wearing glasses for correction of distance and near visual acuity. The order of testing was randomly assigned for each subject according to the state of visual acuity correction. All tests were performed under bright lighting conditions, and a 5 min rest period was allowed after each test condition. The frequency of subjects diagnosed as UN under each condition for correction of visual acuity, the number of correct responses regarding apple shapes, and the time spent completing the test were measured, and a comparison and analysis of the data was performed before and after correction of visual acuity.

2.4. Analysis of Measurement Results

SPSS (Ver. 26.0, SPSS Inc, Chicago, IL, USA) for Windows was used for data analysis and statistics. The apple cancellation test was performed before and after correction of visual acuity, including wearing glasses for correction of distance and near visual acuity. For the assessment of UN, an analysis of the frequency of subjects diagnosed as UN was performed. As described above, the number of correct responses in regard to apple shapes was counted, and an analysis of the differences in the numbers between the right and left sides and the time spent answering was performed using repeated-measures ANOVA according to the state of vision correction. Post hoc analysis was performed using the Bonferroni method, and p < 0.05 was considered statistically significant.

3. Results

3.1. Frequency Analysis of Subjects Diagnosed as UN According to Conditions for Correction of Visual Acuity

The frequency of subjects diagnosed as UN under three different conditions for the correction of visual acuity is shown in Table 1. Among the 19 subjects, the frequency of subjects diagnosed as right neglect, a type of EN, was 6 (31.57%) under the pre-correction condition, 2 (10.52%) wearing glasses for the correction of distance visual acuity, and 1 (5.26%) wearing glasses for the correction of near visual acuity, indicating that the frequency of UN decreased with the increasing accuracy of the vision correction. None of the subjects were diagnosed with left neglect, another type of EN, under the same conditions described above.

3.2. Changes in the Number of Correct Responses on the EN Test According to Conditions for Correction of Visual Acuity

The differences in the number of correct responses regarding apple shapes, resulting from performance of the EN test under three different conditions for the correction of visual acuity, are shown in Table 2. The number of correct responses for the complete apple shape located on the left side of the center of the test sheet was 17.57 ± 2.98, 18.00 ± 2.82, and 18.89 ± 1.55 under the conditions of pre-correction, wearing glasses for the correction of distance visual acuity, and wearing glasses for the correction of near visual acuity, respectively. The results of the post hoc analysis showed a significant increase between the pre-correction and near visual acuity correction conditions (F = 3.78, p = 0.04). Similarly, the number of correct responses for the complete apple shape located on the right side of the center of the test sheet was 16.63 ± 3.38, 18.05 ± 2.24, and 19.00 ± 1.52 under the same conditions for the correction of visual acuity described above, and the results of the post hoc analysis showed a significant difference between the pre-correction and near visual acuity correction conditions (F = 9.05, p = 0.00).

3.3. The Reading Time for Completion of the Apple Cancellation Test Sheet According to Conditions for Correction of Visual Acuity

The results for time spent completing the apple cancellation test under different conditions for the correction of visual acuity are shown in Table 3. The scores for time were 121.73 ± 47.08, 125.05 ± 46.10, and 103.78 ± 33.37 s under the conditions of pre-correction, wearing glasses for the correction of distance visual acuity, and wearing glasses for the correction of near visual acuity, respectively. The results of the post hoc analysis showed a significant decrease in time spent completing the test under the condition of wearing glasses for the correction of near visual acuity over the condition of wearing glasses for the correction of distance visual acuity (F = 5.44, p = 0.01).

4. Discussion

UN, a neurobehavioral disorder, can occur as a result of neurodegenerative diseases [2], tumors [20], trauma [21], and stroke [22], where the brain ignores or fails to perceive information about half of the visual field. The severity of the disorder is significant, as it can result in a complete lack of attention to all types of stimuli occurring on the affected side of the body, placing not only the individuals but also those around them at risk in daily life. Even patients with UN may not recognize problems with the ability to recognize objects, making diagnosis difficult [23], and highlighting the importance of accurate screening and diagnosis for patients who plan to return to daily life through rehabilitation and treatment. The usefulness of the apple cancellation test, a tool for the diagnosis of UN, has received recent attention; however, the authors of this study found that the criteria for the correction of visual acuity before the test are unclear. Therefore, in this study, the authors analyzed the effect of different conditions for the correction of visual acuity on the results of the apple cancellation test. The aim was to establish guidelines regarding the correction of visual acuity for professionals in this field to assist in the accurate interpretation of results. The frequency of subjects diagnosed with UN using the apple cancellation test under three different conditions for the correction of visual acuity is shown in Table 1. Regardless of the type of UN, a positive diagnosis was made in eight cases (42.11%) before visual correction, in four cases (21.1%) with correction using glasses for the correction of distance visual acuity, and in two cases (10.1%) with correction using glasses for the correction of near visual acuity. In other words, the frequency of positive diagnosis of UN shows a significant decrease when the correction of visual acuity is achieved by wearing glasses for the correction of distance or near visual acuity compared to no correction of visual acuity. In addition, we performed an analysis to determine whether there were differences in the number of correct responses in the apple cancellation test under three different conditions for the correction of visual acuity (Table 2). The mean number of completely formed apples correctly marked by the subjects, which were placed on the right and left sides of the test sheet, increased in the order: before correction of visual acuity, with glasses for the correction of distance visual acuity, and with glasses for the correction of near visual acuity. According to the results of the post hoc analysis, an increase in the number of correct responses was observed with the use of glasses for the correction of distance visual acuity compared with pre-correction, but without statistical significance, whereas the number of correct responses showed a significant increase when wearing glasses for the correction of near visual acuity compared to before visual correction (p < 0.05). In addition, the authors performed an analysis to determine whether there were differences in the time spent completing the apple cancellation test depending on the type of glasses used for the correction of visual acuity (Table 3). The time spent in determining the completely formed apples varied depending on the conditions for the correction of visual acuity, which was significantly shortened when wearing glasses for the correction of near visual acuity (p < 0.05).
Refractive error is a common condition that can easily cause the deterioration of visual acuity, as the eye is unable to focus an image onto the central fovea of the retina in an uncontrolled state with the ciliary muscle in a relaxed state. Although most of the subjects in this study had degenerative hyperopia refractive error (OD: mean Sphere + 0.69 ± 1.18, Cylinder − 0.75 ± 0.66, OS: mean Sphere + 0.48 ± 2.24, Cylinder − 0.68 ± 0.73 D), the degree of their refractive errors was not so severe, so they did not wear glasses for distance correction. Uncorrected farsightedness can lead to problems such as decreased comprehension ability [24], decreased reading ability [25], and poor visual perception and attention [26]. However, the use of an appropriate optical correction that can improve not only distance visual acuity but also near visual acuity can enhance reading speed [27]. Compared with no vision correction, the use of the glasses that were provided to the participants in this study for the correction of distance visual acuity resulted in an increase in the number of correct responses and a reduction in the time spent completing the apple cancellation test. Accordingly, the proportion of participants who were diagnosed with positive UN decreased; however, the effect was marginal when compared with the results for glasses for the correction of near visual acuity. Presbyopia, an age-related change in the eyes that usually occurs around the age of 45, is characterized by a decrease in the physiological function of the crystalline lens and ciliary muscles, leading to a decline in near vision; thus, it can cause inconveniences during the performance of close-range work in daily life [28]. In addition, continuous age increase is accompanied by the deterioration of visual acuity [29] and cognitive decline [30]. Therefore, the authors provided specific guidelines for visual correction conditions, with consideration for the age of the subjects, prior to performing various tests that require conducting examinations at a close range. In particular, considering that the apple cancellation test used in this study is performed at close range and that the average age of the study participants was 73 years old, appropriate visual correction should be achieved by wearing near-vision glasses that are prescribed with the addition of presbyopia. We believe that the clinical implications of our study are significant, as it is the first interdisciplinary study attempting to analyze the effect of visual correction conditions on various pen-and-paper tests performed in the physical therapy and occupational therapy fields.
In summary, the results of the apple cancellation test for the determination of UN varied depending on the conditions for the correction of visual acuity. Although wearing glasses for the correction of distance visual acuity alone resulted in a reduction in the overall frequency of subjects diagnosed with positive UN compared with the pre-correction and an increase in the number of correct responses with regard to apple shapes, specific guidelines for the correction of visual acuity required during the test should be provided. We were not able to confirm the two cases diagnosed with positive UN under the condition of wearing glasses for the correction of near visual acuity, shown in Table 1; the results of our research indicate that during the apple cancellation test by elderly subjects under inaccurate conditions for visual correction, there is a risk of misdiagnosis of UN, a serious brain disorder. The apple cancellation test is a pen-and-paper test performed approximately 30 cm to 40 cm away from the subject; the test is performed by the subject on an A4-sized sheet of paper. Therefore, wearing glasses for the correction of near visual acuity, made according to a prescription including the addition of presbyopia, should be emphasized in order to eliminate errors in the determination of UN in the elderly. The limitations of this study are as follows: First, it was not possible to conduct experiments with subjects who were confirmed as having UN syndrome that could be supported by medical evidence. Second, the criteria for the selection of experimental subjects were limited to elderly subjects who had no experience wearing glasses for the correction of distance visual acuity within the last year, making it difficult to obtain an adequate sample size. Conducting additional studies will be required in order to address these limitations.

5. Conclusions

As the elderly population increases, the incidence of stroke also increases. UN caused by stroke can cause life-threatening accidents as well as continual inconvenience in daily life; thus, it should not be regarded as a casual issue. Although treatment and rehabilitation for patients with UN are essential processes for an individual’s return to independent daily life, the establishment of articulated guidelines with regard to conditions for the correction of visual acuity prior to testing is required in order to conduct an accurate determination of UN. Therefore, it is emphasized that visual acuity correction status is an important factor that can have a great impact on reliability in standardized tests such as the apple cancellation test, and the importance of cooperation between optometrists and experts in unilateral neglect is also emphasized.

Author Contributions

Conceptualization, J.-H.N.; methodology, J.-H.N. and S.-Y.K.; validation, J.-H.N., H.G.C., D.-S.Y., B.-Y.M. and S.-Y.K.; investigation, J.-H.N. and S.-Y.K.; resources, J.-H.N., H.G.C., D.-S.Y., B.-Y.M. and S.-Y.K.; data curation, J.-H.N. and S.-Y.K.; writing—original draft preparation, J.-H.N.; writing—review and editing, J.-H.N., H.G.C., D.-S.Y., B.-Y.M. and S.-Y.K.; visualization, J.-H.N., H.G.C., D.-S.Y., B.-Y.M. and S.-Y.K.; supervision, S.-Y.K. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

This study was approved by the Kangwon National University Institutional Review Board (KWNUIRB 2023-03-008-001) and conducted in accordance with the tenets of the Declaration of Helsinki.

Informed Consent Statement

Informed consent was obtained from all participants involved in the study.

Data Availability Statement

The data presented in this study are available upon request from the corresponding author.

Conflicts of Interest

The authors declare no conflict of interest.

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Applsci 13 05951 g001 550
Figure 1. Apple cancellation sheet (a) and an overlaying grid dividing the apple cancellation sheet into areas with equal number of target apples and each type of distractor apples (b). [18].
Figure 1. Apple cancellation sheet (a) and an overlaying grid dividing the apple cancellation sheet into areas with equal number of target apples and each type of distractor apples (b). [18].
Applsci 13 05951 g001
Table
Table 1. The frequency of subject determination as UN according to conditions for correction of visual acuity.
Table 1. The frequency of subject determination as UN according to conditions for correction of visual acuity.
ClassificationEN 1
n (%)		AN 2
n (%)		n
Right
Neglect		Left
Neglect		Right
Neglect		Left
Neglect
UCVA 36 (31.57)-1 (5.26)1 (5.26)19
DCVA 42 (10.52)-1 (5.26)1 (5.26)
NCVA 51 (5.26)--1 (5.26)
1 Egocentric neglect (EN); 2 Allocentric neglect (AN); 3 Uncorrected visual acuity (UCVA); 4 Distance-corrected visual acuity (DCVA); 5 Near-corrected visual acuity (NCVA).
Table
Table 2. The number of correct responses with regard to apple shapes under three different conditions for correction of visual acuity during performance of the EN test.
Table 2. The number of correct responses with regard to apple shapes under three different conditions for correction of visual acuity during performance of the EN test.
AccuracyScoring (The Number)pFPost-HocN
UCVA 1DCVA 2NCVA 3
Egocentric
Left Side		17.57 ± 2.98 a18.00 ± 2.82 b18.89 ± 1.55 c0.043.78a < c19
Egocentric
Right Side		16.63 ± 3.38 a18.05 ± 2.24 b19.00 ± 1.52 c0.009.05a < c
Data are expressed as mean ± SD; p-value for repeated measure ANOVA; Analyzed using repeated-measures ANOVA; a, b, c: subgroups by Bonferroni post-hoc analysis; 1 Uncorrected visual acuity (UCVA); 2 Distance-corrected visual acuity (DCVA); 3 Near-corrected visual acuity (NCVA).
Table
Table 3. The time spent for completion the apple cancellation test sheet under three different conditions for correction of visual acuity.
Table 3. The time spent for completion the apple cancellation test sheet under three different conditions for correction of visual acuity.
Scoring Time (s)pFPost-HocN
UCVA 1DCVA 2NCVA 3
121.73 ± 47.08 a125.05 ± 46.10 b103.78 ± 33.37 c0.015.44b < c19
Data are expressed as mean ± SD; p-value for repeated measure ANOVA; Analyzed using repeated measures ANOVA; a, b, c: subgroup by Bonferroni post-hoc analysis; 1 Uncorrected visual acuity (UCVA); 2 Distance-corrected visual acuity (DCVA); 3 Near-corrected visual acuity (NCVA).
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Noh, J.-H.; Cho, H.G.; Moon, B.-Y.; Yu, D.-S.; Kim, S.-Y. The Effect of Visual Acuity Corrections on the Determination of Unilateral Neglect When Conducting the Apple Cancellation Test. Appl. Sci. 2023, 13, 5951. https://doi.org/10.3390/app13105951

AMA Style

Noh J-H, Cho HG, Moon B-Y, Yu D-S, Kim S-Y. The Effect of Visual Acuity Corrections on the Determination of Unilateral Neglect When Conducting the Apple Cancellation Test. Applied Sciences. 2023; 13(10):5951. https://doi.org/10.3390/app13105951

Chicago/Turabian Style

Noh, Jae-Hyeon, Hyun Gug Cho, Byeong-Yeon Moon, Dong-Sik Yu, and Sang-Yeob Kim. 2023. "The Effect of Visual Acuity Corrections on the Determination of Unilateral Neglect When Conducting the Apple Cancellation Test" Applied Sciences 13, no. 10: 5951. https://doi.org/10.3390/app13105951

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