Emphasizing the application potential of critical flicker fusion frequency in visual function assessment_Chinese Journal of Ocular Fundus Diseases

Authors：

 Wei Shihui ¹ , Xu Guangcan ^1,2

1. Senior Department of Ophthalmology, The Chinese PLA General Hospital, Beijing 100853, China;
2. School of Medicine, Nankai University, Tianjin 300071, China;

Corresponding author：

Wei Shihui, Email: weishihui706@hotmail.com

Keywords：

Critical flicker fusion frequency; Visual function assessment; Optic neuropathy; Visual impairment; Editorial

DOI：

10.3760/cma.j.cn511434-20240807-00301

Video：

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Critical flicker fusion frequency (CFF) is a dynamic visual function test that measures the minimum frequency at which a flicker source is perceived by the visual system as continuous light. The measurement method is convenient, the inspection time is short, and it can be effectively evaluated in the case of refractive interstitial opacity. Although CFF has many advantages, its application in the field of ophthalmology has not received sufficient attention. The pathway of CFF involves the pathway from the retina to the lateral geniculate body to the primary visual cortex, where the macrocellular pathway is sensitive to temporal resolution and responsible for transmitting rapidly changing information. Its measurements typically use red, green, or yellow light as a flashing light source to detect the functional integrity of the macular region. As a subjective test, the results of CFF can be affected by a variety of factors, such as drug use, fatigue, and luminous intensity. In order to improve the repeatability of the measurement, it is necessary to follow standardized measurement steps. CFF has important application value in the diagnosis of optic nerve diseases. It can assist in diagnosing the presence of optic neuropathy, evaluating the conduction function of the optic nerve, and monitoring the progression of the disease and the effect of treatment. As a convenient and efficient visual function evaluation tool, CFF has great potential in the diagnosis of optic nerve diseases and visual function monitoring. In view of its application prospects in the field of ophthalmology, this study calls for more attention and support from ophthalmologists, and carry out related basic and clinical research to further explore the application value of CFF in different disease conditions.

Citation： Wei Shihui, Xu Guangcan. Emphasizing the application potential of critical flicker fusion frequency in visual function assessment. Chinese Journal of Ocular Fundus Diseases, 2025, 41(6): 409-412. doi: 10.3760/cma.j.cn511434-20240807-00301 Copy

1.	Hecht S, Shlaer S, Verrijp CD. Intermittent stimulation by light : Ⅱ. the measurement of critical fusion frequency for the human eye[J]. J Gen Physiol, 1933, 17(2): 237-249. DOI: 10.1085/jgp.17.2.237.
2.	Xu G, Fu J, Qi H, et al. The theory of critical flicker fusion frequency and its application in cataracts[J]. Adv Ophthalmol Pract Res, 2023, 3(1): 29-32. DOI: 10.1016/j.aopr.2022.10.002.
3.	Xu G, Luo Y, Qi H, et al. Trichromatic critical flicker frequency as potential visual test in cataract and macula disease patients[J]. Graefe's Arch Clin Exp Ophthalmol, 2024, 262(7): 2171-2179. DOI: 10.1007/s00417-024-06398-w.
4.	Livingstone MS, Hubel DH. Psychophysical evidence for separate channels for the perception of form, color, movement, and depth[J]. J Neurosci, 1987, 7(11): 3416-3468. DOI: 10.1523/JNEUROSCI.07-11-03416.1987.
5.	Derrington AM, Lennie P. Spatial and temporal contrast sensitivities of neurones in lateral geniculate nucleus of macaque[J]. J Physiol, 1984, 357: 219-240. DOI: 10.1113/jphysiol.1984.sp015498.
6.	Brown A, Corner M, Crewther DP, et al. Human flicker fusion correlates with physiological measures of magnocellular neural efficiency[J/OL]. Front Hum Neurosci, 2018, 12: 176[2018-05-14]. https://pubmed.ncbi.nlm.nih.gov/29867406/. DOI: 10.3389/fnhum.2018.00176.
7.	Mathis T, Vignot S, Leal C, et al. Mechanisms of phosphenes in irradiated patients[J]. Oncotarget, 2017, 8(38): 64579-64590. DOI: 10.18632/oncotarget.18719.
8.	MacNab MW, Foltz EL, Sweitzer J. Evaluation of signal detection theory on the effects of psychotropic drugs on critical flicker-fusion frequency in normal subjects[J]. Psychopharmacology (Berl), 1985, 85(4): 431-435. DOI: 10.1007/BF00429659.
9.	Smith JM, Misiak H. Critical flicker frequency (CFF) and psychotropic drugs in normal human subjects-a review[J]. Psychopharmacologia, 1976, 47(2): 175-182. DOI: 10.1007/BF00735818.
10.	Duan T, Zhang N, Li K, et al. Study on the preferred application-oriented index for mental fatigue detection[J]. Int J Environ Res Public Health, 2018, 15(11): 2555. DOI: 10.3390/ijerph15112555.
11.	Tyler CW, Hamer RD. Analysis of visual modulation sensitivity. Ⅳ. validity of the ferry-porter law[J]. J Opt Soc Am A, 1990, 7(4): 743-758. DOI: 10.1364/josaa.7.000743.
12.	Mcfarland RA, Warren AB, Karis C. Alterations in critical flicker frequency as a function of age and light: dark ratio[J]. J Exp Psychol, 1958, 56(6): 529-538. DOI: 10.1037/h0049128.
13.	Eisen-Enosh A, Farah N, Burgansky-Eliash Z, et al. Evaluation of critical flicker-fusion frequency measurement methods for the investigation of visual temporal resolution[J/OL]. Sci Rep, 2017, 7(1): 15621[2017-11-15]. https://pubmed.ncbi.nlm.nih.gov/29142231/. DOI: 10.1038/s41598-017-15034-z.
14.	Sandry M. Critical flicker frequency in multiple sclerosis[J]. Percept Mot Skills, 1963, 16: 103-108. DOI: 10.2466/pms.1963.16.1.103.
15.	Mason RJ, Snelgar RS, Foster DH, et al. Abnormalities of chromatic and luminance critical flicker frequency in multiple sclerosis[J]. Invest Ophthalmol Vis Sci, 1982, 23(2): 246-252.
16.	Ayadi N, Dörr J, Motamedi S, et al. Temporal visual resolution and disease severity in MS[J/OL]. Neurol Neuroimmunol Neuroinflamm, 2018, 5(5): e492[2018-08-14]. https://pubmed.ncbi.nlm.nih.gov/30175166/. DOI: 10.1212/NXI.0000000000000492.
17.	付俊霞, 王永平, 陈碧玥, 等. 闪烁融合频率在鉴别视神经炎和非动脉炎性前部缺血性视神经病变中的价值[J]. 解放军医学院学报, 2022, 43(10): 1019-1024, 1030. DOI: 10.3969/j.issn.2095-5227.2022.10.004.Fu JX, Wang YP, Chen BY, et al. Preliminary exploration of critical flicker fusion frequency in differentiating optic neuritis from non-arteritic anterior ischemic optic neuropathy[J]. Academic Journal of Chinese PLA Medical School, 2022, 43(10): 1019-1024, 1030. DOI: 10.3969/j.issn.2095-5227.2022.10.004.
18.	Young MT, Braich PS, Haines SR. Critical flicker fusion frequency in demyelinating and ischemic optic neuropathies[J]. Int Ophthalmol, 2018, 38(3): 1069-1077. DOI: 10.1007/s10792-017-0561-z.
19.	Taguchi A, Kinoshita Y, Tokumo K, et al. Usefulness of critical flicker fusion frequency measurement and its laterality for evaluating compressive optic neuropathy due to pituitary neuroendocrine tumors[J]. Neurosurg Rev, 2022, 46(1): 4. DOI: 10.1007/s10143-022-01915-z.
20.	Fu J, Wang Y, Tan S, et al. The clinical application of critical flicker fusion frequency in demyelinating optic neuritis[J/OL]. Adv Ophthalmol Pract Res, 2021, 1(2): 100011[2021-11-17]. https://pubmed.ncbi.nlm.nih.gov/37846319/. DOI: 10.1016/j.aopr.2021.100011.
21.	Baumgarten TJ, Neugebauer J, Oeltzschner G, et al. Connecting occipital alpha band peak frequency, visual temporal resolution, and occipital GABA levels in healthy participants and hepatic encephalopathy patients[J]. Neuroimage Clin, 2018, 20: 347-356. DOI: 10.1016/j.nicl.2018.08.013.
22.	Oeltzschner G, Butz M, Baumgarten TJ, et al. Low visual cortex GABA levels in hepatic encephalopathy: links to blood ammonia, critical flicker frequency, and brain osmolytes[J]. Metab Brain Dis, 2015, 30(6): 1429-1438. DOI: 10.1007/s11011-015-9729-2.
23.	Woung LC, Wakakura M, Ishikawa. Critical flicker frequency in acute and recovered optic neuritis[J]. Jpn J Ophthalmol, 1993, 37(2): 122-129.
24.	Mimura O, Ishikawa H, Kezuka T, et al. Intravenous immunoglobulin treatment for steroid-resistant optic neuritis: a multicenter, double-blind, randomized, controlled phase Ⅲ study[J]. Jpn J Ophthalmol, 2021, 65(1): 122-132. DOI: 10.1007/s10384-020-00790-9.
25.	Sheng WY, Wu SQ, Su LY, et al. Ethambutol-induced optic neuropathy with rare bilateral asymmetry onset: a case report[J]. World J Clin Cases, 2022, 10(2): 663-670. DOI: 10.12998/wjcc.v10.i2.663.
26.	Shankar H, Pesudovs K. Critical flicker fusion test of potential vision[J]. J Cataract Refract Surg, 2007, 33(2): 232-239. DOI: 10.1016/j.jcrs.2006.10.042.
27.	Douthwaite WA, Vianya-Estopà M, Elliott DB. Predictions of postoperative visual outcome in subjects with cataract: a preoperative and postoperative study[J]. Br J Ophthalmol, 2007, 91(5): 638-643. DOI: 10.1136/bjo.2006.093401.
28.	Williamson SL, Cortina MS. Boston type 1 keratoprosthesis from patient selection through postoperative management: a review for the keratoprosthetic surgeon[J]. Clin Ophthalmol, 2016, 10: 437-443. DOI: 10.2147/OPTH.S83677.
29.	Lachenmayr BJ, Gleissner M. Flicker perimetry resists retinal image degradation[J]. Invest Ophthalmol Vis Sci, 1992, 33(13): 3539-3542.
30.	del Romo GB, Douthwaite WA, Elliott DB. Critical flicker frequency as a potential vision technique in the presence of cataracts[J]. Invest Ophthalmol Vis Sci, 2005, 46(3): 1107-1112. DOI: 10.1167/iovs.04-1138.
31.	Vianya-Estopà M, Douthwaite WA, Pesudovs K, et al. Development of a critical flicker/fusion frequency test for potential vision testing in media opacities[J]. Optom Vis Sci, 2004, 81(12): 905-910.
32.	Vianya-Estopà M, Douthwaite WA, Noble BA, et al. Capabilities of potential vision test measurements: clinical evaluation in the presence of cataract or macular disease[J]. J Cataract Refract Surg, 2006, 32(7): 1151-1160. DOI: 10.1016/j.jcrs.2006.01.111.
33.	Xu G, Qi H, He Q, et al. Predicting visual outcomes in keratoprosthesis surgery with critical flicker fusion frequency, B-scan, visual electrophysiology and endoscopy[J/OL]. Br J Ophthalmol, 2024, 2024: bjo-2024-325719[2024-08-17]. https://bjo.bmj.com/lookup/pmidlookup?view=long&pmid=39153832. DOI: 10.1136/bjo-2024-325719. [published online ahead of print].

1. Hecht S, Shlaer S, Verrijp CD. Intermittent stimulation by light : Ⅱ. the measurement of critical fusion frequency for the human eye[J]. J Gen Physiol, 1933, 17(2): 237-249. DOI: 10.1085/jgp.17.2.237.
2. Xu G, Fu J, Qi H, et al. The theory of critical flicker fusion frequency and its application in cataracts[J]. Adv Ophthalmol Pract Res, 2023, 3(1): 29-32. DOI: 10.1016/j.aopr.2022.10.002.
3. Xu G, Luo Y, Qi H, et al. Trichromatic critical flicker frequency as potential visual test in cataract and macula disease patients[J]. Graefe's Arch Clin Exp Ophthalmol, 2024, 262(7): 2171-2179. DOI: 10.1007/s00417-024-06398-w.
4. Livingstone MS, Hubel DH. Psychophysical evidence for separate channels for the perception of form, color, movement, and depth[J]. J Neurosci, 1987, 7(11): 3416-3468. DOI: 10.1523/JNEUROSCI.07-11-03416.1987.
5. Derrington AM, Lennie P. Spatial and temporal contrast sensitivities of neurones in lateral geniculate nucleus of macaque[J]. J Physiol, 1984, 357: 219-240. DOI: 10.1113/jphysiol.1984.sp015498.
6. Brown A, Corner M, Crewther DP, et al. Human flicker fusion correlates with physiological measures of magnocellular neural efficiency[J/OL]. Front Hum Neurosci, 2018, 12: 176[2018-05-14]. https://pubmed.ncbi.nlm.nih.gov/29867406/. DOI: 10.3389/fnhum.2018.00176.
7. Mathis T, Vignot S, Leal C, et al. Mechanisms of phosphenes in irradiated patients[J]. Oncotarget, 2017, 8(38): 64579-64590. DOI: 10.18632/oncotarget.18719.
8. MacNab MW, Foltz EL, Sweitzer J. Evaluation of signal detection theory on the effects of psychotropic drugs on critical flicker-fusion frequency in normal subjects[J]. Psychopharmacology (Berl), 1985, 85(4): 431-435. DOI: 10.1007/BF00429659.
9. Smith JM, Misiak H. Critical flicker frequency (CFF) and psychotropic drugs in normal human subjects-a review[J]. Psychopharmacologia, 1976, 47(2): 175-182. DOI: 10.1007/BF00735818.
10. Duan T, Zhang N, Li K, et al. Study on the preferred application-oriented index for mental fatigue detection[J]. Int J Environ Res Public Health, 2018, 15(11): 2555. DOI: 10.3390/ijerph15112555.
11. Tyler CW, Hamer RD. Analysis of visual modulation sensitivity. Ⅳ. validity of the ferry-porter law[J]. J Opt Soc Am A, 1990, 7(4): 743-758. DOI: 10.1364/josaa.7.000743.
12. Mcfarland RA, Warren AB, Karis C. Alterations in critical flicker frequency as a function of age and light: dark ratio[J]. J Exp Psychol, 1958, 56(6): 529-538. DOI: 10.1037/h0049128.
13. Eisen-Enosh A, Farah N, Burgansky-Eliash Z, et al. Evaluation of critical flicker-fusion frequency measurement methods for the investigation of visual temporal resolution[J/OL]. Sci Rep, 2017, 7(1): 15621[2017-11-15]. https://pubmed.ncbi.nlm.nih.gov/29142231/. DOI: 10.1038/s41598-017-15034-z.
14. Sandry M. Critical flicker frequency in multiple sclerosis[J]. Percept Mot Skills, 1963, 16: 103-108. DOI: 10.2466/pms.1963.16.1.103.
15. Mason RJ, Snelgar RS, Foster DH, et al. Abnormalities of chromatic and luminance critical flicker frequency in multiple sclerosis[J]. Invest Ophthalmol Vis Sci, 1982, 23(2): 246-252.
16. Ayadi N, Dörr J, Motamedi S, et al. Temporal visual resolution and disease severity in MS[J/OL]. Neurol Neuroimmunol Neuroinflamm, 2018, 5(5): e492[2018-08-14]. https://pubmed.ncbi.nlm.nih.gov/30175166/. DOI: 10.1212/NXI.0000000000000492.
17. 付俊霞, 王永平, 陈碧玥, 等. 闪烁融合频率在鉴别视神经炎和非动脉炎性前部缺血性视神经病变中的价值[J]. 解放军医学院学报, 2022, 43(10): 1019-1024, 1030. DOI: 10.3969/j.issn.2095-5227.2022.10.004.Fu JX, Wang YP, Chen BY, et al. Preliminary exploration of critical flicker fusion frequency in differentiating optic neuritis from non-arteritic anterior ischemic optic neuropathy[J]. Academic Journal of Chinese PLA Medical School, 2022, 43(10): 1019-1024, 1030. DOI: 10.3969/j.issn.2095-5227.2022.10.004.
18. Young MT, Braich PS, Haines SR. Critical flicker fusion frequency in demyelinating and ischemic optic neuropathies[J]. Int Ophthalmol, 2018, 38(3): 1069-1077. DOI: 10.1007/s10792-017-0561-z.
19. Taguchi A, Kinoshita Y, Tokumo K, et al. Usefulness of critical flicker fusion frequency measurement and its laterality for evaluating compressive optic neuropathy due to pituitary neuroendocrine tumors[J]. Neurosurg Rev, 2022, 46(1): 4. DOI: 10.1007/s10143-022-01915-z.
20. Fu J, Wang Y, Tan S, et al. The clinical application of critical flicker fusion frequency in demyelinating optic neuritis[J/OL]. Adv Ophthalmol Pract Res, 2021, 1(2): 100011[2021-11-17]. https://pubmed.ncbi.nlm.nih.gov/37846319/. DOI: 10.1016/j.aopr.2021.100011.
21. Baumgarten TJ, Neugebauer J, Oeltzschner G, et al. Connecting occipital alpha band peak frequency, visual temporal resolution, and occipital GABA levels in healthy participants and hepatic encephalopathy patients[J]. Neuroimage Clin, 2018, 20: 347-356. DOI: 10.1016/j.nicl.2018.08.013.
22. Oeltzschner G, Butz M, Baumgarten TJ, et al. Low visual cortex GABA levels in hepatic encephalopathy: links to blood ammonia, critical flicker frequency, and brain osmolytes[J]. Metab Brain Dis, 2015, 30(6): 1429-1438. DOI: 10.1007/s11011-015-9729-2.
23. Woung LC, Wakakura M, Ishikawa. Critical flicker frequency in acute and recovered optic neuritis[J]. Jpn J Ophthalmol, 1993, 37(2): 122-129.
24. Mimura O, Ishikawa H, Kezuka T, et al. Intravenous immunoglobulin treatment for steroid-resistant optic neuritis: a multicenter, double-blind, randomized, controlled phase Ⅲ study[J]. Jpn J Ophthalmol, 2021, 65(1): 122-132. DOI: 10.1007/s10384-020-00790-9.
25. Sheng WY, Wu SQ, Su LY, et al. Ethambutol-induced optic neuropathy with rare bilateral asymmetry onset: a case report[J]. World J Clin Cases, 2022, 10(2): 663-670. DOI: 10.12998/wjcc.v10.i2.663.
26. Shankar H, Pesudovs K. Critical flicker fusion test of potential vision[J]. J Cataract Refract Surg, 2007, 33(2): 232-239. DOI: 10.1016/j.jcrs.2006.10.042.
27. Douthwaite WA, Vianya-Estopà M, Elliott DB. Predictions of postoperative visual outcome in subjects with cataract: a preoperative and postoperative study[J]. Br J Ophthalmol, 2007, 91(5): 638-643. DOI: 10.1136/bjo.2006.093401.
28. Williamson SL, Cortina MS. Boston type 1 keratoprosthesis from patient selection through postoperative management: a review for the keratoprosthetic surgeon[J]. Clin Ophthalmol, 2016, 10: 437-443. DOI: 10.2147/OPTH.S83677.
29. Lachenmayr BJ, Gleissner M. Flicker perimetry resists retinal image degradation[J]. Invest Ophthalmol Vis Sci, 1992, 33(13): 3539-3542.
30. del Romo GB, Douthwaite WA, Elliott DB. Critical flicker frequency as a potential vision technique in the presence of cataracts[J]. Invest Ophthalmol Vis Sci, 2005, 46(3): 1107-1112. DOI: 10.1167/iovs.04-1138.
31. Vianya-Estopà M, Douthwaite WA, Pesudovs K, et al. Development of a critical flicker/fusion frequency test for potential vision testing in media opacities[J]. Optom Vis Sci, 2004, 81(12): 905-910.
32. Vianya-Estopà M, Douthwaite WA, Noble BA, et al. Capabilities of potential vision test measurements: clinical evaluation in the presence of cataract or macular disease[J]. J Cataract Refract Surg, 2006, 32(7): 1151-1160. DOI: 10.1016/j.jcrs.2006.01.111.
33. Xu G, Qi H, He Q, et al. Predicting visual outcomes in keratoprosthesis surgery with critical flicker fusion frequency, B-scan, visual electrophysiology and endoscopy[J/OL]. Br J Ophthalmol, 2024, 2024: bjo-2024-325719[2024-08-17]. https://bjo.bmj.com/lookup/pmidlookup?view=long&pmid=39153832. DOI: 10.1136/bjo-2024-325719. [published online ahead of print].

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