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THE RELIABILITY OF LIGHT PROJECTION TEST IN PREOPERATIVE

ASSESSMENT OF CATARACT PATIENTS. JOBIOMED VOL. 16 (1&2) JOBIOMED
JOURNAL OF BIOMEDICAL SCIENCES IN AFRICA

Article · September 2019

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 JOBIOMED JOURNAL OF BIOMEDICAL SCIENCES IN AFRICA JOBIOMED VOL. 16 (1&2)

THE RELIABILITY OF LIGHT PROJECTION TEST IN

PREOPERATIVE ASSESSMENT OF CATARACT PATIENTS.
Ekweremadu E. N1, Okoloagu N.N.M1, Eze B.U.N2
1 2
Department of Ophthalmology, Department of Surgery, College of Medicine, Enugu State University of Science and Technology
Enugu, South East Nigeria. Corresponding Author: Dr. Ezekiel Ekweremadu. Department of Ophthalmology, College of
Medicine, Enugu State University of Science and Technology Enugu, South East Nigeria.
Email: ezekiel.ekweremadu@esut.edu.ng
Submitted: 10 June, 2019 Accepted: 30 July, 2019 Published: 25th September, 2019

ABSTRACT.
The objective was to assess the reliability of light projection test as a potential vision test in patients with significant cataract
impairing visualization of the posterior segment. This was a prospective, cross-sectional hospital-based study. Subjects were
recruited as consecutive consenting adults with operable cataract and requesting cataract surgery for improved visual
performance. Light projection test was done as a dark-room procedure. All subjects had uneventful small-incision cataract
surgery. Data collected was analyzed with Baye's theorem for measure of sensitivity and specificity. One hundred and twenty-
three eyes of one hundred and sixteen eligible consenting adult patients were analyzed in this study. Seventy-two patients
(68.6%) were men and 33 patients (31.4%) were women. This represented a male to female ratio of 2.2:1. The mean age of the
patients was 61.5+7.7 years with a range of 40 to 86 years. Females had a slightly higher mean age (62.4) when compared to men
[60.8]. Perception of light (PL) was the modal entry visual acuity followed by hand movement (HM) and between them
accounted for 56% of all eyes. One hundred and twenty eyes or 97.6% gave a grade 1 response to light projection, 2 eyes gave a
grade 2 response and 1 eye gave a grade 3 response. No grade 4 response to projection of light was seen. A total of 91 eyes or
74.8% achieved good visual outcome while 32 eyes representing 25.2% obtained a borderline visual outcome. No patient had
poor visual outcome. The calculated sensitivity and specificity of light projection test were 6.3% and 98.9% respectively in
patients with moderate visual impairment and 9.7% and 96.2% in patients with severe visual impairment to blindness. Light
projection test may be used to delineate patients with likely posterior segment lesion that can negatively impact the outcome of
cataract surgery even in the presence of dense cataract. However, it is not recommended as a stand-alone test in predicting the
visual outcome following an uneventful cataract surgery. These observations warrant follow-up studies with larger sample
frame.

KEY WORDS: Cataract, Light ProjectionTest, Preoperative and Postoperative vision.

INTRODUCTION that the burden of cataract blindness and visual impairment

Cataract is the commonest cause of reversible blindness will increase especially in regions undergoing these changes
globally. It is as a result of opacification of the crystalline lens. in their population dynamics notably Sub-Saharan Africa.
The prevalence of cataract doubles every ten years from forty
There is no proven drug or dietary modification that can alter
years of age and by ninetieth birthday, visually significant
cataract is universal1. Hence, increasing age is a major risk or reverse cataract formation. Recourse to surgical
factor. Genetic factors have also been implicated as a intervention is hence both necessary and inevitable. Couching
predisposing factor for human cataractogenesis2. Latest
was probably the earliest form of surgical intervention17.
statistics from WHO showed that 39.8 million people are blind
globally and untreated cataract is responsible for about 18 Serious ocular complication following this procedure was
million of these.3,4 This represents 45.2% of global blindness. common and eventual loss of vision was not infrequent.
In Nigeria, cataract is a public health problem5,6. The national
Unfortunately, this ancient practice has endured in under-
blindness and visual impairment survey done between 2005
and 2007 showed that cataract was the leading cause of developed parts of the globe. The Nigerian national blindness
blindness, accounting for 43.0 % of 1.13 million blind survey revealed that couching accounted for 46.3% of cataract
Nigerians over the age of 40 years with a prevalence of 1.8%5 .
surgeries in the sample population5. Despite this, modern
This finding has been amply corroborated by several
population- and hospital-based studies6-16. The increasing cataract surgery has evolved to become the most cost effective
world population and improvement in life expectancy implies
Ekweremadu E. N et al JobiomedAfric Vol.16 NO 1&2
20
surgical procedure performed worldwide and is responsible [ORS] and critical flicker frequency [CFF] have been added to
the growing body of tests with the promise of improved
for more than one half of all ophthalmic operations in most
performance37-38.
countries including Nigeria18-20. The benefits of cataract
This study will be assessing the usefulness of the time-
extraction in terms of visual rehabilitation and quality of life

are real and immediate and surgeons are willing to carry out honored light projection test as a potential vision test in

the surgery at increasingly lower levels of visual impairment21- patients with significant cataract impairing visualization of the
26
. This is largely due to advances in surgical techniques and
posterior segment. The findings in this study could help define
constantly improving technological environment27.
For the avoidance of needless cataract extractions and to the appropriateness of the test in resource-challenged centers
prognosticate surgical outcome, it is expedient a pre-operative
who rely on it for pre-operative evaluation of cataract patients.
potential vision of the eye is determined. This is because
intact retinal and neural elements are absolute prerequisites for
PATIENTS AND METHOD
visual improvement after an uneventful cataract surgery28.
Moreover, the degree of a patient's visual impairment might This is a prospective, cross-sectional hospital-based study.
not be fully accounted for by the presence of lens opacity. The study was done at Evangelical Church of West Africa
Needless litigations against the surgeon can be mitigated by ECWA] Sabon-Gari Kano, Kano state, Nigeria located in
this important component of preoperative assessment. north-western part of the country. Subjects were recruited as
consecutive consenting adults with operable cataract and
Distance visual acuity is a form of visual function that can
easily be determined because of its ease of quantification and it requesting cataract surgery for improved visual performance.
is the basis of most Potential vision tests (PVT) in clinical They were enrolled between August and September 2011. The
practice. No PVT can boast of 100% in both sensitivity and inclusion criteria for participation in the study were patients
specificity and that partly explains why there is a profusion of
who were 40 years and above, eyes with clear cornea normal
PVTs today. Before 1993, Agency for Health Care Policy and
anterior segment findings on slit-lamp examination and eyes
Research, the United States body that regulates clinical best
practice, did not recommend PVT as prerequisite test before with normal pupillary reactions. Exclusion criteria were eyes
cataract surgery because the PVTs at the time could not show with complicated cataract, eyes with sluggish pupillary
overall advantage over the clinical judgment of the responses or relative afferent pupillary defect [RAPD], eyes
ophthalmologist29.Despite this, psychophysical,
with no perception of light [NPL], patients who were less than
electrophysiological and anatomic tests are available and the
40 years, eyes that had intra- or postoperative complication[s]
newer instruments have tried to address the issues raised by
the U.S body. They are all committed to the pursuit of better and patients who are unable to understand or respond to the
visual acuity prognostication in cataract patients. Pinhole testing parameters. Also excluded were those that refused to
[PH], potential acuity meter [PAM] and light projection have give consent. The materials used for the study were KeelerR
been the conventional psychophysical potential vision tests.
pen torch of 6volts rating, Illuminated Snellen's optotype
Light projection is one of the earliest tests of potential vision30.
visual acuity chart and 1.0millimeter pinhole. The tenets of the
The patient's responses to a fine beam of light presented to the
four visual field quadrants with respect to its accurate Helsinki Declaration regarding the conduct of research
localization is perceived to reflect the integrity of retinal involving human Subjects were adhered to4. All the subjects
elements. However, scattering of light within the eyes that met the inclusion criteria were subjected to complete
especially in the presence of media opacity can easily give rise
ocular examination comprising distance visual acuity with
to false positive results. Maddox rod test is another
Snellen's optotype visual acuity chart, slit- lamp evaluation,
psychophysical test which preferentially evaluates macular
function 3 1 . Two-point discrimination, PAM, laser applanation tonometry and dilated fundoscopy. When the
interferometer [LI] and blue field entoptic phenomenon are presenting visual acuity was hand movement or better,
other modalities used in potential vision assessment32-36. More refraction was done to exclude those with significant
recently, retinal acuity metre [RAM], optimal reading speed
Ekweremadu E. N et al JobiomedAfric Vol.16 NO 1&2
21
refractive error. Subjects who were refracted to 6/24 optotype subject to light projection were entered in light projection
or better were offered spectacle correction and surgery was response form. Ocular biometry for calculation of intraocular
deferred. The cut-off visual acuity for surgical intervention lens (IOL) power was done for all patients. For uniformity of
was thus 6/36 or worse [up to perception of light]. Post-
surgical procedure, only patients that had small incision
refraction visual acuity was taken as the entry visual acuity
cataract surgery (SICS) were analyzed for the study while
[best-corrected visual acuity]. The visual acuities were
those that underwent other forms of cataract surgery (extra-
recorded in fractions and then converted to their decimal
equivalent to make statistical analysis possible. Light capsular cataract extraction and phacoemulsification) were

projection test was done as a dark-room procedure on the excluded. The surgeries were done by 2 consultant ophthalmic
index eye with a bright pen torch [6 volts] assessing the four surgeons and a diplomate in ophthalmology. The decision to
retinal quadrants while occluding the contra lateral eye. the proceed with surgery was based on the general clinical
response to light projection was graded as follows:
assessment independent of the test outcome. Data collected
· Grade 1 response—patient could localize the
was analyzed with Baye's theorem for measure of sensitivity
light direction in the four quadrants.
and specificity40. Data were presented with tables, charts and
· Grade 2 response—patient could localize the
prose.
light in three quadrants.
· Grade 3 response—the light could only be RESULTS
One hundred and thirty-three eyes of 116 consecutive patients
localized in two quadrants were enrolled. One hundred and twenty-six eyes of one
· Grade 4—patient perceives light but could only hundred and 11 patients underwent small-incision cataract
surgery with intra-ocular lens insertion as calculated from
localize it in one quadrant or none b i o m e t r y. F o u r e y e s o f 3 p a t i e n t s w e r e o ff e r e d
phacoemulsification while three eyes of two patients had extra
It took on the average 2 minutes to perform the test including capsular cataract extraction. One eye had intra-operative
vitreous loss and 2 eyes developed postoperative corneal
the time spent on explaining the protocol though a few patients
edema and they were equally excluded from the study. Thus,
may require longer time. Only subjects that gave consistent 123 eyes of 125 patients were finally analyzed for this study.
The demographic characteristics of the participants is
responses were included in the study. The responses from each presented in the table below:

TABLE 1: Demographic characteristics of the study participants.

Male Female %
Age (years)

Mean 60.8 62.2

Range 42-78 40-86
40-49 9 2 11%
50-59 25 10 33%
60-69 24 11 33%
70-Above 14 10 23%

No. eyes 83 40
Eye involvement
Right eye 44 20 52%
Left eye 39 20 48%

Ekweremadu E. N et al JobiomedAfric Vol.16 NO 1&2

22
Seventy-two patients (68.6%) were men and 83 (31.4%) were
NO. OF EYES
women. This represented a male to female ratio of 2.2:1. The
Light projection grade
mean age of the patients was 61.5+7.7 years with a range of 40 Grade 1/ 120
to 86 years. Females had a slightly higher mean age (62.4) VA > 6/60 20
when compared to men (60.8). VA <6/60 100
The pre-operative visual acuity also varied where 99 eyes
Grade 2/ 2
(80.5%) had a visual acuity of less than 6/60 (5/60 to VA > 6/60 -
perception of light) while only 24 (19.5%) had preoperative VA <6/60 2
visual acuity of 6/60 or better (6/36 to 6/60). Details of pre- Grade 3/ 1
VA > 6/60 -
operative visual acuity results in percentages are illustrated in
VA <6/6 1
the pie chart below: Grade 4/ -
Figure 1: Pie chart showing the pre-operative visual acuity
distribution of subjects (in percentages). Average hospital stay was 3 days with a range of 2-6 days. The
study subjects that stayed longer than 3 days were those that
had bilateral cataract surgery (36 patients) which was usually
done 2 days after the first-eye surgery. The tables below show
the postoperative visual acuity outcome and the
corresponding preoperative responses to light projection (the
decimal equivalent of the visual acuity is enclosed in
bracket):.

Projection of light grade 1 2 3 4

Postoperative VA (No. of eyes)

HM= Hand movement 6/6 (1.00) 1 - - -
PL= Perception of light
6/9 (0.69) 18 - - -
From the above representation, perception of light [PL] was
6/12 (0.50) 46 - - -
the modal entry visual acuity followed by hand movement
[HM] and between them accounted for 56% of all eyes. 6/18 (0.33) 25 1 - -
120 eyes or 97.6% gave a grade 1 response to light projection, 6/24 (0.25) 14 - 1 -
2 eyes gave a grade 2 response and 1 eye gave a grade 3 6/36(0.17) 13 - - -
response. This restricted analysis of light projection responses
6/60 (0.10) 3 1 - -
to grade-1-responding eyes. No grade 4 response was
observed. Table 3: Light projection response grade and postoperative
visual outcome in subjects.\
A further analysis of the responses of patients with severe
Table 2: Light projection response grade and preoperative visual impairment (VA<6/60) denoting dense cataract and
their responses to both tests yielded the tables below:
visual acuity
Table 4: Postoperative visual outcome of eyes with severe
visual impairment and the corresponding light projection
responses

Ekweremadu E. N et al JobiomedAfric Vol.16 NO 1&2

23
 The calculated sensitivity of light projection test in
Light projection response 1 2 3 4 detecting subjects with posterior segment lesion capable of
hindering the patient from having a good surgical outcome
was 6.3% while specificity of the test was 98.9% as taken
Visual acuity from table 3. When the eyes with severe visual impairment
6/6 - - - - were analyzed, light projection test had a sensitivity of 9.7%
in excluding a possibility of a good visual outcome and a
6/9 11 - - - specificity of 96.2% (table 5). The tables below summarised
the findings discussed above:
6/12 36 - - - Table 5: Overall Sensitivity and specificity of light
projection test.
6/18 24 1 - -

6/24 13 - 1 - Grade 1 LPT

6/36 12 - - -
Sensitivity
6/60 3 1 - -

The modal visual acuity outcome was 6/12 (0.5) which was +1 line 6.3%
observed in 46 eyes. Ninety-one eyes or 74.8% achieved good
visual outcome while 32 eyes representing 25.2% obtained a
borderline visual outcome. No patient had poor visual outcome.
The pie chart below (fig. 2) shows the distribution of visual
Specificity
outcomes:
+1 98.9%
LEGEND:
LPT = Light projection test

Table 6: Sensitivity and Specificity of light projection

test in eyes with severe visual impairment

Grade 1 LPT

Figure 2: Pie chart representing the Visual acuity outcomes in Sensitivity

participants (WHO classification). The bar chart below
illustrates the observed visual outcome differences.
+ 1line 9.7%%

Specificity

+ 1line 96.2%
LEGEND: LPT= Light projection test value.

Figure 3: Bar chart showing visual acuity outcomes in patients

with grade 1 response to light projection tests.
Ekweremadu E. N et al JobiomedAfric Vol.16 NO 1&2
24
DISCUSSION be further explored. The low sensitivity of light projection test
An appraisal of the demographic characteristics of the study suggests that a grade 1 response should not form the only basis
participants showed a male preponderance which has been of a decision to operate but any grade less than 1 strongly
suggests that the patient should be counseled on a likely
attributed to some socio-cultural and economic factors
undesirable outcome. Hence, light projection test should
prevailing in the study environment. The female gender and always be combined with a more sensitive testing algorithm if
poor cataract surgical uptake has been reported in previous available.
studies1,5,18. The study also showed that old age was a risk One patient considered as a glaucoma suspect with pre-
factor for cataract as the mean age was 61.5 years which is in operative visual acuity of 6/36 did not improve after surgery.
The Patient gave grade 1 response. It is possible that the
keeping with the findings in previous stdies5-19. Most of the
presence of mild to moderate optic nerve disease in the
subjects (80.5%) had severe visual impairment and light
patients is not readily reflected with this testing protocol. The
perception was the modal entry visual acuity (32%). Many usefulness of the test in the presence of other co-morbid ocular
reasons have been adduced for this late presentation in our conditions requires further query. The limitations of the study
environment 7 - 1 4 . Several studies have shown that included the fact that all the patients were offered manual
ophthalmologists suffer some degree of incapacitation when small incision cataract surgery but the relative short
postoperative duration could have affected the observed visual
assessing potential vision in the presence of dense cataract33-35.
outcome46-48. A pinhole was used to minimize this effect. The
This creates the need for potential vision test(s) well suited to visual acuity with pinhole may not be the same post-
our peculiar resource –challenged practice. refraction. Moreover, a larger sample size could have
A review of the clinical relevance of established potential permitted for a more detailed and definitive study of
vision tests showed that scanning laser ophthalmometer associations between type of cataract and light projection test.
The effect of patient's age could not be controlled in the study
(SLO) has a sensitivity and specificity of 96.4% and 100%
and may be a confounding variable. Being an unmasked
respectively and potential acuity meter (PAM) can achieve a
study, the prior knowledge of the entry visual acuity could bias
sensitivity of 67.0% and specificity of 100%43. The present the investigator in interpreting the subject's test response.
study performed poorly with regards to sensitivity but
compared favorably with specificity with a value of 96.2%.
CONCLUSION
However, projection of light was not adversely affected in
The 'humble' Light projection test has shown itself to a
eyes with dense cataract (visual acuity less than 3/60) unlike
the other studies. Vryghem et al44 found a sensitivity of 92.7% useful adjunct in preoperative evaluation of cataract patients
and specificity of 75.0% within 1 line of visual acuity in their with dense cataract. This is especially relevant in the event
study of 396 patients using a test protocol developed by him of a grade 2 response or worse because such subjects may
(macular function chart). However, he acknowledged that
not fully benefit from the surgery. This is pertinent in our
presence of dense cataract undermined the usefulness of the
practice where most of our patients present with dense
test. Shankar et al45used critical fusion frequency (CFF) to
cataract and other alternatives for posterior segment
assess his cohort of preoperative cataract patients. It had a
sensitivity and specificity of 88% and 90% respectively. This evaluation are either absent or too expensive to be routinely
compares well with the present study albeit a lower specificity employed. A large-scale study will help to illuminate any
but a much higher sensitivity than the present study. It was also association between cataract type and ocular co-morbidity
stated that presence of dense cataract had minimal effect on
on patients' responses to the test.
the test outcome.
The testing parameter used in the present study is both
inexpensive and simple to perform, even in busy clinic CONFLICT OF INTEREST.
settings. Adequate explanation is all that is needed to obtain
appropriate responses from the patient. This is even easier The authors hereby declare that there was no conflict of
when the patient has relatively good vision in the contralateral
interest regarding this study. No grant was received to carry
eye and comparison of what was seen can be made between
the two eyes. Location of the cataract namely cortical, nuclear, out the study.
posterior sub-capsular or mixed could be an important
variable in this test. The nature of this association will need to

Ekweremadu E. N et al JobiomedAfric Vol.16 NO 1&2

25
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