Bringing Infant Vision Testing to the Modern Age in Hype with Iain Livingstone

When unique and interesting projects built with Hype come across our desk at Tumult, we like to reach out and learn more about the individuals and the stories behind the work. The project featured below pioneers a new medical examination technique.


We’re happy to introduce a project created by Iain Livingston, an ophthalmologist and researcher based in NHS Forth Valley, Scotland. Iain developed a more portable and accurate tool to test infant vision, improving upon techniques created in the 80s. In January of 2019, Iain published Testing Pediatric Acuity With an iPad: Validation of “Peekaboo Vision” in Malawi and the UK in Translational Vision Science & Technology covering his research, which was prototyped in Hype and is coming soon to the App Store.

Iain was kind enough to answer some questions about this project and his upcoming research in the area of infant vision:

Daniel: It would be great to know a bit more about how you created this test platform in Hype and how you translated the testing platform and research question into the prototype. Could you give me a brief explanation of the project and the goals behind it for a non-medical audience?

Iain: Infant vision tests have remained largely unchanged for over 30 years, comprising a set of large, expensive cards. I used Hype years ago to make a proof of concept test, where a child presses on a grating target and gets an animation and sound reward. It worked a charm, and I quickly noticed that children preferred a tablet-based test to the traditional cards, with the animated cartoon rewards increasing their interest and engagement. It was also ultra-portable and much faster. We formally evaluated this test with adult volunteers using a range of blurring lenses, and observed the paradigm was actually more reliable (better test-retest repeatability) than the reference standard. We then took the prototype to Malawi, where we do a course teaching ophthalmic clinical officers (non-medical) in Malawi to test vision in the very young. There, we recognised that a lower cost digital platform could be quite transformative, and undertook a clinical evaluation, echoing our findings from the adult cohort. We then formalised the build into an iPad app, Peekaboo Vision, which is an app that is CE marked as a medical device, and is the new clinical standard for infant vision testing in our Trust.

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Daniel: Can you share what the physical ‘cards’ look like that are typically used for this type of eye test? It’s incredible that Hype can make these tests easier and cheaper to administer at scale and improve health outcomes.

Iain:  This video captures the reference standard:

The traditional card-based tests  (Keeler Cards, Teller Cards, Cardiff Acuity Cards, and Lea Paddles) are great, but we see Peekaboo Vision offering several advantages. We have a paper in submission that suggests the digital version (that started as a Hype prototype build) is superior to card-based tests in terms of the physical properties of the digital displays, combined with the software, when it comes to testing vision. One type of cards that the iPad app replaces can be seen on this page. 

Daniel: Can you share a video walkthrough of the prototype, or images from the app in use? During the test, what types of observations are the testers making?

Iain: In this video, you will see that in the first part, I am looking over the top of the screen to see where the child is looking.

I know the target will be in one of the four corners, but I can’t see the screen, so I tap the relevant corner based on where she is looking, and if that is where the grating is, the target is presented, until the threshold is reached. So the “eyetracking” is very manual! When the child increases in confidence during the tests, she starts bashing the screen where the target is, which is to be encouraged, as she is driving the vision test herself. We have a PhD working on taking the automated eye tracking to the next level. Still in R&D phase.

Daniel: Do you have any other upcoming projects you’re planning to use Hype to build?

Iain: The one in the video was an executable written in Visual Basic by a colleague. I made an HTML5 version as it meant we just needed to share a URL instead of a file, and it became platform agnostic (phone/tablet/Mac/window). We use this with screen share to test vision via VC, which allows us to do acute tests in a patient’s home. You can see a demo of this technology at 1:43s in this video presented by Andrew Bastawrous:

This video is actually of a .exe version that was not made with hype. We found that was a pain to run on hospital computers (recognised as a virus and was a nightmare to get white-listed for bureaucratic reasons) and also couldn’t run on a mac or tablet, so I made a new version with Hype that is working a charm on all platforms and super easy for all to access, and now set to be used in a multi-site clinical evaluation. Premise is the same as demonstrated: supervised home vision test to check children’s vision remotely during COVID-19. They would usually come to hospital for such a test in the UK.

Daniel: What new techniques are you trying to do with the browser-based version of the app? I imagine getting it to run on any laptop would make the test even easier to distribute and administer (though you’d have less screen resolution and no touch screen interface).

Iain: This test is conducted via screen share during a video call, with credit card pinch/zoom matching used to calibrate sizing before the test proceeds. The big benefit for us as clinicians is that we can see that the test is being conducted properly, and we control the test screens, just like we would if the child was present in the clinic. We can easily see if they are peeking through fingertips or cheating by moving forward towards the screen.

Daniel: Thank you for chatting with us Iain! Closing thoughts?

Iain: My pleasure. I love working with Hype. I’m sure hype will be a continued part of the development pipeline as we try to make vision tests more accessible in a browser-based way!


You can follow Iain’s work at: https://www.researchgate.net/profile/Iain_Livingstone