192 Vol. 37, No.

2 / February 2020 / Journal of the Optical Society of America A Research Article

Relating wavefront error to visual acuity in pre-

and post-LASIK eyes: a comparison of methods
Edward Dehoog,1, * Robert Van Dine,2 Lindsay Fitzgerald-Dehoog,1,2 AND
Jim Schwiegerling3
1
Optical Engineering & Analysis LLC, 1030 Loma Ave #102, Long Beach, California 90804, USA
2
California State University Long Beach, Dept. of Mathematics and Statistics, 1250 Bellflower Blvd., Long Beach, California 90840, USA
3
University of Arizona, College of Optical Sciences, 1630 East University Blvd., Tucson, Arizona 85721, USA
*Corresponding author: oea.dehoog@gmail.com

Received 30 July 2019; revised 28 November 2019; accepted 2 December 2019; posted 3 December 2019 (Doc. ID 372984);
published 8 January 2020

Contrast threshold and visual Strehl ratio methods are used to predict visual acuity from wavefront error for a
sample population of pre- and post-LASIK patients. Relative error (in logMAR) between predicted and measured
visual acuity values are computed for each method and compared using paired t-tests. Differences in aberration
data between pre- and post-LASIK eyes are then evaluated. The visual acuity prediction using visual Strehl proved
to be more accurate for pre-LASIK patients than contrast threshold. However, both methods are comparable for
post-LASIK patients. © 2020 Optical Society of America
https://doi.org/10.1364/JOSAA.37.000192

1. INTRODUCTION In this paper, we compare VA predictions with the contrast

Visual acuity (VA) is a clinical metric for determining how well a
patient can resolve a target of a specific spatial/angular frequency
at various distances. The most common methods used to assess
acuity are letter targets such as a Snellen or Early Treatment
Diabetic Retinopathy Study (ETDRS) charts. Letter target
metrics are particularly important, as they take into account
the entire visual process: (1) how the optics images the target
on the retina, (2) how the retina samples and detects the target,
and (3) how the brain processes the target. Furthermore, it is a
routine clinical measure of visual performance that all practi-
tioners are familiar with. When designing ophthalmic optics for
vision correction, it is important to understand the implications
of the design on VA. In general, optical design focuses on the
correction of aberrations that are measured by one or more
objective image quality metrics such as the Strehl ratio (SR),
wavefront error (WFE), the optical transfer function (OTF), the
modulation transfer function (MTF), the point spread function
(PSF), or focal spot size. These metrics are good indicators of
image quality of traditional optical systems but do not account
for the remaining portions of the human visual system in the
detection process. However, these metrics are directly related
to VA, since they relate the quality of the image formed on the
retinal surface. For this reason, it is important to understand
the impact of conventional optical image quality metrics on
patient VA and how they are related to visual performance. In
this manner, clinically relevant performance metrics can be used
in developing ophthalmic optical systems [1–3].
threshold (CT) method and the visual Strehl (VS) ratio method
in a population of pre- and postoperative refractive surgery
patients. In this manner, we seek to determine which technique
is better suited for analyzing these types of patients, who are
known to have elevated levels of spherical aberration following
surgery [4]. We are interested in which method results in less
prediction error and also how the estimates are influenced by
the presence of different aberration types. Additionally, we seek
to understand the relationship between VA predictions and the
presence of different aberration types, the actual VA measure-
ment in the log of the minimum angular resolution (logMAR),
and the root mean square (RMS) of the Zernike polynomials.
2. METHODS
A. Mathematics of VA Prediction
VA is typically measured using eye charts. The ETDRS chart
was developed to provide a standardized and statistically sound
means of assessing VA [1,5]. These charts measure acuity in
units of logMAR and incorporate a logarithmic reduction in
letter size on each line and constant number of letters on each
line. The logMAR score L is given by the following relationship:
L = 0.02(55 − Nl ), (1)
where Nl is the total number of letters read on the chart. For
20/20 vision, L = 0 and Nl is 55 out of 70 total letters on the

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 Research Article Vol. 37, No. 2 / February 2020 / Journal of the Optical Society of America A 193

logMAR chart [1]. For 20/10 vision, L = −0.3 and all 70 let-
ters are identifiable by the patient. LogMAR can be related to
Snellen acuity by the following relation:
 
1
L = Log10 , (2)
S
where L is VA in logMAR and S is the Snellen fraction. For
example, for S = 20/40, L is 0.3. The VA score in logMAR is
calculated by the clinician from the number of letters correctly
identified by the patient [1]. The minimum resolvable angular
frequency for a given value of L is given by
30
v0 = = 30S, (3)
10 L Fig. 1. Diffraction-limited MTF, CSF, and CTH are plotted as
where v0 is the angular frequency in cycles/degree [5]. a function of spatial frequency in cycles/degree. The intersection of
Relating VA to objective measurements of image quality such the MTF and CTH (∼ 54 cycles/deg) is labeled. This intersection is
as MTF, WFE, PSF, and many others has been a topic of interest important for approximating VA.
in the vision science community [2,6–8]. This idea is of utmost
importance in relating objective measurements of optical image
quality taken in a laboratory setting to subjective measurements SR, and VA in logMAR. An SR between 0.1 and 0.6 L can be
taken with the patient in the clinic. In two studies presented determined by [2]
by Lang in 1993, the through-focus MTF measurements per-
formed on a multifocal intraocular lens (IOL) in a wet cell are L = 0.02(12 − 20S R). (6)
related to the VA measured when a similar IOL is implanted
in the patient [6,7]. Lang related Snellen VA to the measured When the SR is above 0.6, we assume the patient has better
contrast sensitivity function (CSF) by finding the frequency v0 , than 0 logMAR or 20/20 vision. A similar study performed by
Cheng et al. in 2010 shows similar results [7].
MTFDL (vo ) In a short technical note, Iskander in 2006 described the
CTH(vo ) = , (4)
CSF(vo ) calculation of the VS based on the visual OTF [7]. The VS based
where CTH(ν) is the retinal contrast threshold (CT) function on the OTF is calculated by weighting the OTF by the CSF
and MTFDL (ν) is the diffraction-limited MTF [6,7]. This of the eye. Mathematically, this is expressed in the following
intersection frequency νo is then converted to an acuity value form [8]:
using Eq. (3). Greivenkamp et al. in 1995 used a similar tech- R∞
CSF(v)OTF(v)dv
nique to predict VA in the presence of refractive error [9]. In VSOTF = R ∞−∞ , (7)
this case, they found the intersection frequency νo using the −∞ CSF(v)OTFDL (v)dv
equation
where OTF(v) is the OTF of the eye and CSF(v) is the CSF of
MTFRef (νo ) − CTH(vo ) = 0, (5) the eye. The subscript DL denotes the diffraction-limited case.
where MTFRef is the aberrated MTF in the presence of various Iskander also gives alternative formulas that make use of MTF
levels of refractive error. More recently, this method was used for data instead of OTF [8]. This can be advantageous, considering
a pseudophakic population by Weeber et al. in 2010, yielding MTF data are real-valued. The relation for using MTF instead
calculations within 0.05 logMAR of clinical measurements of OTF is
[7]. The average CTH(ν) based on the general population is R∞
CSF(v)Re{OTF(v)}dv
plotted in Fig. 1 [1]. In this paper, we will refer to the process of VSOTF A = R−∞ ∞
calculating VA by finding the intersection frequency the (CT) −∞ CSF(v)OTFDL (v)dv
method. R∞
Alternative means for predicting VA have been explored. CSF(v)MTF(v)cos(PTF(v))dv
= −∞
R∞ , (8)
−∞ CSF(v)MTFDL (v)dv
In a study by Marsack et al. in 2004, a series of image quality
metrics based on measured aberrations data were determined
for a specific population [2]. These image quality metrics were where the phase transfer function (PTF) is related to the OTF
then correlated to the measured VA of each patient to determine by [3]
which objective image metrics correlated most strongly with
the measured VA of the patient. In this study, the WFE, volume OTF(v) = MTF(v)exp(jPTF(v)). (9)
under the OTF, and full width at half-maximum of the PSF cor-
related poorly with VA. The strongest image quality metrics for In the diffraction-limited case, the PTF is strictly zero, so
correlating VA and aberration data were the VS ratio calculated the OTF and MTF are equivalent. In this paper, we will refer
from the visual PSF and/or visual OTF. A study by Marsack et al. to the process of calculating VA by calculating the VS ratio
in 2004 determined the following relationship between the VS, from the OTF and the VS method.
 194 Vol. 37, No. 2 / February 2020 / Journal of the Optical Society of America A Research Article

B. Collection of Patient Data

WFE and VA data from a sample population of 155 eyes from 84
patients with visual acuities ranging from −0.3 to 1 were used
in this study. The subjects were pre- and postoperative myopic
LASIK patients who had been deemed eligible for surgery and
consequently had healthy eyes, excluding their refractive error.
The same pre- and post-LASIK procedure was applied to all
patients. All procedures were conducted using the same excimer
laser and wavefront sensor. WFE and subjective refraction for
these subjects were obtained preoperatively and at 7, 30, 90,
180, and 360 days postoperatively. Wavefront aberration data
for the population of patients in terms of Zernike coefficients
are provided in Fig. 2. Pupil size was controlled by dilation for
both measurements. Subjective refraction was measured using
a Snellen chart test. WFE and pupil size were measured using
a custom-built Shack–Hartmann sensor, the details of which
are described in a proceeding by Schaub [10]. The tenets of the
Declaration of Helsinki were followed and Institutional Review
Board approval and informed consent were obtained for this
study.

C. Processing of Patient Data

VA was calculated using both the VS and the CT methods
described above. An analytical model of the CSF given by [1]
CSF(v) = 2.6(0.0192 + 0.114v)exp(−(0.114v)1.1 ), (10)
where ν is the angular frequency in cycles/degree was used in
the calculation. This analytical model is plotted in Fig. 1. For
a diffraction-limited optical system with a circular pupil, the
MTF can be expressed using the following relation:
2
MTF(v) = (ϕ − cosϕsinϕ), (11)
π
where ϕ is expressed by Fig. 2. WFE data for the patient population in terms of Zernike
coefficients.
λv
 
ϕ = cos−1 . (12)
2NA
In this relation, NA is the numerical aperture of the optical is set to the pupil size measured by the wavefront sensor for each
system, λ is the wavelength, and ν is the spatial frequency. This patient. The MTF was calculated by ray tracing, and VA was
mathematical framework gives us the ability to take metrics such subsequently calculated by finding the frequency at which the
as WFE and predict the VA for a patient with a specific WFE CTH and MTF intersected in the tangential and sagittal direc-
using the VS ratio calculation given by Eqs. (6) and (8) or the CT tions. Finally, the VS ratio was calculated and VA was predicted
method used by both Lang and Piers [6,7,11]. In the presence of from the logMAR and VS relationship presented in Eq. (6).
nonrotationally symmetric aberrations, the MTF is different in The detailed procedure for calculating VA from patient error
the tangential and sagittal orientation. The implication of the data is as follows:
MTF being different in the tangential and sagittal orientations
is that there will be two distinct frequencies where the CTH and 1. Enter patient WFE data (Zernike terms) into the FRED eye
MTF intersect. Tangential and sagittal spatial frequency values model.
are used to find VA scores by Eq. (3). Both tangential and sagittal 2. Calculate patient MTF data.
VA scores are used in this study. 3. Find CT frequencies ν0 by solving Eq. (5) for tangential and
A simplistic eye model was created in the FRED optical sagittal patient MTF. This will yield two VA values: one for
design software (Photon Engineering, Tucson, AZ). The eye tangential orientation and another for sagittal orientation,
model consists of an ideal paraxial lens with a 17 mm focal
length and an aberrated phase surface. The aberrated phase MTFRef (νo ) − CTH(vo ) = 0.
surface is used to account for the WFE measurements from each
patient. The aberration terms of the phase surface are expressed 4. Convert CT frequencies ν0 to VA score using Eqs. (2)
in terms of Zernike polynomials. The pupil size of the model eye and (3),
 Research Article Vol. 37, No. 2 / February 2020 / Journal of the Optical Society of America A 195

υ0
 
L = log10 0 . Table 1. Measured logMAR VA Statistics for the
3 Population of Interest Prior to LASIK (0), and at Time
Periods of 7, 30, 90, 180, and 360 Days Following the
5. Calculate the VS ratio using Eq. (7), Refractive Procedure
R∞
CSF(v)OTF(v)dv Days Since 0 7 30 90 180 360
VSOTF = R ∞−∞ . Procedure
−∞ CSF(v)OTFDL (v)dv
Mean 0.0065 0.0947 0.0596 0.0371 0.0629 0.0744
6. Using the VS from the previous step, the VA can be calcu- Standard 0.09636 0.1526 0.1773 0.1363 0.1780 0.1646
lated using deviation
Max 0.4 0.7 1 0.5 0.8 0.7
L = 0.02(12 − 20V S OT F ). Min −0.22 −0.2 −0.3 −0.3 −0.22 −0.3
Number of eyes 152 155 144 126 102 128

D. Statistical Analyses
VA predictions were calculated from the patient eye model
using the CT method and the VS ratio method. Relative error
in logMAR between the predicted and measured VA values
were computed for each method, and exploratory data analyses
were first employed to search for major trends and themes in
the data. Individual and mean response profile plots were fit
for each method across the length of the study. Additionally,
paired t-tests were used to compare differences in the defocus,
astigmatism, coma, spherical, and Zernike RMS aberration
measurements between the pre- and post-LASIK eyes. It should
be noted that for this analysis, astigmatism and coma values refer
to the RMS values of astigmatism terms, Z(2,-2) and Z(2,2) and
coma terms, Z(3,-1) and Z(3,1). Paired t-tests were also used
to compare differences in the relative error estimates between
the VS and CT methods. Finally, linear regression models were
fit on the VA estimate errors for both the VS and CT methods
to model the relationship between the estimate errors and the
actual VA in logMAR, the four optical aberrations, defocus,
astigmatism, coma, spherical, and the RMS of the Zernike poly-
nomials (RMS WFE). Computation of RMS WFE is reported
for 2nd–6th order Zernike terms, 0th and 1st order; piston and
tilt are removed.
3. RESULTS
Summary statistics for VA are presented in Table 1. The data
in the table show that the mean VA score is on average an order
of magnitude lower in the pre-LASIK measurements than in
the post-LASIK measurements. Standard deviation of the mea-
surements is significantly larger in the post-LASIK results as
compared to the pre-LASIK results.
The mean response profile plot in Fig. 3 displays the relative
estimate errors among the two methods for the pre-LASIK and
post-LASIK at 7, 30, 90, 180, and 360 days after surgery and
reveals differences in the estimate errors among the pre- and
post-LASIK results. In the pre-LASIK patients, the mean errors
of the CT values for tangential and sagittal orientations are
virtually identical, but they are much larger than the VS ratio
error. Additionally, in the post-LASIK patients, there does not
appear to be much difference between the estimate errors, both
within each day and between each day. This suggests an intuitive
result: patients’ eyes are significantly altered by LASIK surgery,
but after surgery, their eyes do not change much, if at all.
Paired t-tests were performed on the error estimates to
determine whether the differences among the methods were
Table 2. Paired T-Test Results for VS Error versus CT
Errors for Pre-LASIK Eyes
Degrees of
Test Comparison Freedom Test Statistic P Value
CT tangential versus 151 29.6011 <2.2e − 16
VS error
CT sagittal versus 151 28.6157 <2.2e − 16
VS error
CT tangential versus 151 1.3651 0.1742
CT sagittal error
statistically significant in the pre-LASIK eyes. Table 2 contains
the results of the tests and indicates that the error estimate for the
VS method is significantly smaller that the error estimates for
the CT method in both the tangential and sagittal orientation
(P < 2e − 16) for both comparisons). There is not a statistically
significant difference in the error estimates between the tangen-
tial and sagittal orientation of the CT method (P > 0.05).
To understand the nature of the change in estimate errors
pre- and post-LASIK, paired t-tests were also carried out on
each of the four aberrations and the Zernike RMS. The mean of
post-LASIK measurements for each patient’s eye is compared to
the pre-LASIK measurement. Results are presented in Table 3.
All aberrations except coma are significantly different in the
post-LASIK eyes. Defocus, astigmatism, and Zernike RMS
aberrations decreased, while the spherical aberration signifi-
cantly increased in the post-LASIK eyes. This result is consistent
with Yoon et al., who reported that spherical aberration was
increased in post-LASIK eyes relative to pre-LASIK eyes [4].
Finally, the relationship between the aberration types and VA
estimation was explored using regression models. Linear regres-
sion models were fit for each of the three estimation methods,
regressing the estimate errors on the four optical aberrations,
total RMS WFE, and logMAR. Additionally, separate models
were fit for pre- and post-LASIK eyes, as the prior analyses
revealed clear structural differences in the eyes after LASIK
surgery. Final models were determined by selecting variables
whose coefficients were statistically significant at the α = 0.05
level. The appropriateness of the linear models for these data was
assessed separately for the pre- and post-LASIK data sets using
the GVLMA package in R, version 3.1.2, as well as assessing the
 196 Vol. 37, No. 2 / February 2020 / Journal of the Optical Society of America A Research Article

Fig. 3. Plot of mean estimate errors plotted preoperatively and at 7, 30, 90, 180, and 360 days post-surgery. The estimate error values denoted
VStrehl correspond to the VS method, whereas error values denoted LMtan, and LMsag values correspond to the CT method for tangential and sagit-
tal values.

Table 3. Paired T-Test Results for Comparison of Table 4. Linear Model Results for VS Error in
Aberration Data Pre- and Post-LASIK Patients Pre-/Post-LASIK Eyes
Pre-LASIK Post-LASIK Standard P
Aberration Mean Mean T P Value Parameter Estimate Error T Value R
Defocus 0.00397 0.000521 −20.7 <0.0001 Pre-LASIK intercept 0.0389 0.007 5.93 <0.0001 0.35
Astigmatism 0.000861 0.000588 −3.29 0.0012 astigmatism 14.2 5.65 2.52 0.0127
Coma 0.000284 0.000341 1.54 0.1258 spherical −43.9 21.4 −2.05 0.0420
Spherical 0.0000732 0.000347 11.33 <0.0001 logMAR 0.408 0.0521 7.84 <0.0001
RMS WFE 0.00858 0.00253 −22.54 <0.0001 Post- intercept 0.194 0.00744 25.0 <0.0001 0.92
LASIK
RMS WFE −18.6 2.90 −6.40 <0.0001
logMAR 0.904 0.0221 40.9 0.0019
leverage values, standardized residuals, and Cook’s D values for
each model.
Table 4 contains the pre- and post-LASIK models for VS
error. For this analysis, it should be noted that the intercept Table 5. Linear Model Results for CT Tangential Error,
terms represent the expected mean VS in the absence of any CT Method
aberrations. In the pre-LASIK model, both astigmatism and
Standard
spherical aberration were found to be significant predictors
Parameter Estimate Error T P Value R
of estimate error. The coefficients of the pre-LASIK model
indicate that increased astigmatism is associated with larger Pre-LASIK intercept 0.668 0.106 6.31 <0.0001 0.33
estimate errors, while increased spherical aberration is associated RMS WFE 98.6 11.4 8.68 <0.0001
with smaller estimate errors. The value for logMAR is found Post-LASIK intercept 0.0832 0.0268 3.23 0.0015 0.28
to be highly significant in predicting VS error (P < 0.0001). RMS WFE 32.2 10.0 3.20 0.0017
logMAR 0.398 0.0765 5.20 <0.0001
In the model for post-LASIK eyes, we see that astigmatism
and spherical aberration are no longer significant predictors of
error, but RMS WFE is now highly significant (P < 0.0001). respectively). RMS WFE is the only significant predictor of
logMAR remains a significant predictor of estimate error in the the size of CT tangential estimate error in the pre-LASIK eyes
post-LASIK eyes (P < 0.05), and in fact, its effect size is more (P < 0.0001). While RMS WFE is a still a significant predictor
than double what it was in the pre-LASIK model. The R square of estimate error in the post-LASIK eyes (P < 0.05), the size
values for these models (0.35 and 0.92, respectively) indicate of the effect is greatly reduced relative to the effect estimate in
that that the linear model for the post-LASIK eyes explains the the pre-LASIK eye model (98.6 versus 32.2). Additionally, VA
VS estimate error better than the pre-LASIK linear model. in logMAR was found to be a highly significant predictor of
Table 5 contains the final models for CT tangential error. estimate error in the post-LASIK eyes (P < 0.0001).
These models explain the estimate errors for pre- and post- Table 6 contains the final models for CT sagittal error. In the
LASIK eyes about equally well (R square = 0.33 and 0.28, pre-LASIK model, the spherical aberration, RMS WFE, and
 Research Article Vol. 37, No. 2 / February 2020 / Journal of the Optical Society of America A
Table 6. Linear Model Results for CT Sagittal Error,
CT Method
Standard
Parameter Estimate Error T P Value R B. Post-LASIK Results
Pre-LASIK intercept 0.869 0.110 7.91 <0.0001 0.33
spherical −619.2 167.2 −3.70 0.0003
RMS WFE 73.5 11.7 6.31 <0.0001
logMAR 1.08 0.433 2.50 0.0135
Post-LASIK intercept 0.164 0.0101 16.2 <0.0001 0.31
logMAR 0.519 0.0626 8.30 <0.0001
VA in logMAR are significant predictors of estimate error, with
the Zernike RMS being highly significant (P < 0.0001). While
logMAR remains a significant predictor in the post-LASIK
model, its effect is reduced by almost half. This is consistent with
the observation that the CT tangential error was significantly
less for the post-LASIK eyes than it was for the pre-LASIK eyes.
It is also interesting that none of the aberrations are significant
predictors in the post-LASIK model. Both of these models
perform about equally well at explaining estimate error, with R
square values of 0.33 and 0.31, respectively.
The fit of each of the six final models was assessed for adher-
ence to the assumptions of a linear model. It was found that the
linear model was moderately appropriate for the pre-LASIK
sample, with the CT models exhibiting less residual error com-
pared to the VS model. Compared to the pre-LASIK sample, the
post-LASIK data showed a much better fit to a linear model. In
the post-LASIK sample, the VS model was found to exhibit less
residual error than did the CT models.
4. CONCLUSION
A. Pre-LASIK Results
It was shown that the estimate errors differed significantly
between the VS and CT methods for pre-LASIK patients and
did not differ significantly between the two CT methods. The
final linear models for the estimate errors showed that 33%–
35% of the variance in the estimate errors were explained by
each of the models (R square = 0.35 for the VS model, 0.33
for both CT models). When we consider the fit of the linear
models to the data, the linear model for the VS estimate error
was somewhat weak and exhibited larger residuals compared
to the CT models. However, this model is of some utility, since
35% of the variance in the estimate error can be explained by
astigmatism, spherical aberration, and logMAR values in this
model. The linear models for the CT estimate errors in both
directions showed a much better fit to the data, and both models
still explained 33% of the variance in estimate error. The CT
tangential error was shown to be significantly influenced by the
Zernike RMS values alone, which means that the RMS WFE
values explain about 33% of the variance in the CT tangential
estimate error. The CT sagittal error was shown to be signifi-
cantly influenced not only by the RMS WFE values, but also by
the spherical aberration value and the logMAR values for the
patients. We can see that overall, a patient’s VA in logMAR, their
197
RMS WFE, and spherical aberration values are the significant
predictors of estimate error in the pre-LASIK patients.
It was observed that overall estimate errors were about the same
across all methods and all days for the post-LASIK patients. It
is significant, then, that 92% of the variance in the VS estimate
error is explained by the model (R square = 0.92), while the
models for CT tangential and CT sagittal in the post-LASIK
patients do not describe the variance in the error estimates nearly
as well (R square = 0.31 and 0.28, respectively). Additionally,
the linear model for the VS estimate error was shown to be a
good fit to the data, in that many of the major assumptions
of the linear model were met with these data and there were
very few influential observations. This indicates that the linear
model based on a patient’s VA in logMAR and the RMS of
their Zernike terms is an excellent and reliable predictor of the
VS estimate error in post-LASIK patients. In each of the three
post-LASIK models, it was found that patients’ VA in logMAR
was a significant predictor of estimate error. In addition, the
RMS WFE was also found to be a significant predictor in two of
the three post-LASIK models. None of the aberration types were
found to be significant predictors of estimate error for any of the
three post-LASIK models.
C. Study Results
Methods for calculating VA are becoming increasingly impor-
tant, as they provide a way to translate optical metrics of image
quality to the clinical metrics that most patients and practi-
tioners are familiar with. It has been shown that the methods
of calculating VA from the CT and VS ratio values provide
good methods for predicting VA for optical metrics that cor-
relate highly with clinical results [2,7,9,12–14]. Based on our
study, we see that these metrics work fairly well, but the VS ratio
clearly outperforms the CT method in terms of error. The VS
performed best for virgin corneas but did show some reduced
accuracy for the post-operative LASIK conditions. This suggests
that the aberrations induced by the refractive procedure, LASIK,
are not fully accounted for. However, under all conditions, the
VS metric provided better performance than the MTF-based
calculations, and this metric should be preferred over these pre-
vious techniques. These results are consistent with the findings
that RMS WFE is not well correlated with VA [2,7,9,12–14].
The VS method performing the best is consistent with results
provided by Marsack, in which VS showed the highest corre-
lation with predicting VA in patients [2]. The use of VS as an
excellent predictor of VA has been well documented and is con-
sistent with the results of our study, in which the VA prediction
using the VS showed significantly less error [7,12–14]. The CT
method is a valid method, provided the aberration levels are
smaller, which has been demonstrated by Cheng and Weber
[7,13,14].
Acknowledgment. This research was made possible by
the Whitaker Foundation.
 198 Vol. 37, No. 2 / February 2020 / Journal of the Optical Society of America A
Disclosures. The authors have no financial interests in the
research presented in this paper.
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