About

Andrew Toole is a Clinical Professor of Optometry at The Ohio State University College of Optometry. He attended three years of undergraduate education at Ohio State before earning his Doctor of Optometry degree from the same institution in 1997. Following graduation, he completed an Advanced Practice Fellowship in Binocular Vision and Pediatrics and obtained a Master of Science in Physiological Optics in 2000. He initially joined the faculty at Ohio State, serving as the Associate Chief of the Binocular Vision and Pediatrics Services and becoming the Chief of the Aniseikonia Service. He later returned to graduate school, earning a PhD in Vision Science in 2008. Since rejoining the faculty in 2008, he has been appointed as an Associate Professor of Clinical Optometry and serves as the Chief of the Aniseikonia and Environmental Vision Service. His clinical expertise includes treating rare conditions such as aniseikonia, and he routinely sees patients from around the country and internationally. He is actively involved in teaching, mentoring students, residents, and fellows, and has contributed to the academic community through lectures and research. His research interests focus on pediatric and binocular vision disorders, including convergence insufficiency, amblyopia, and eye movement studies, with participation in large-scale clinical trials that have influenced standard care practices. He also engages in neuroimaging research using fMRI to explore the neurological basis of convergence eye movements and has recently begun evaluating the role of vision in sports performance. Additionally, Toole has served in leadership roles at the college and national levels, including chairing faculty committees and performing accreditation site visits, utilizing his clinical, research, and educational expertise to contribute to the advancement of optometric education and practice.

Research topics

• Artificial Intelligence
• Medicine
• Computer Science
• Psychology
• Ophthalmology
• Neuroscience
• Computer vision
• Cognitive psychology
• Audiology
• Psychiatry
• Anatomy
• Physical medicine and rehabilitation
• Internal medicine
• Radiology
• Optics
• Optometry
• Mathematics

Selected publications

• Ohio Contrast Cards are reliable and robust to blur under cycloplegia in visually normal children

  Optometry and Vision Science · 2025-09-23 · 1 citations

  articleOpen access

  SIGNIFICANCE: Few clinical tests of visual performance can be performed equally well regardless of whether the patient has been dilated with a cycloplegic agent. This report shows that the Ohio Contrast Card test (OCC) is reliable across repeated measurements and robust to blur under cycloplegia. PURPOSE: The OCC measures clinical contrast sensitivity, including of patients who cannot read and report the letters on an eye chart. The OCC presents a 0.15 cycle per degree (20/4000, 2.3 logMAR) square-wave grating of variable contrast. We examined the test/retest reliability of the OCC, whether it can be used equally successfully to measure contrast sensitivity before versus after dilation with a cycloplegic agent, and whether it is sensitive to blur from uncorrected refractive error and cycloplegia. Participants were a group of visually normal pediatric optometric patients. METHODS: Two examiners used the OCC to measure the eyes of 38 children who were seen for full eye examinations. Two tests were performed before cycloplegic agents were administered while participants wore their habitual refractive corrections. The examiners were randomly assigned to the two tests. After the eye examination (post-cycloplegia), the measurements were repeated, with and without correction. Statistical analyses examined test/retest reliability before and after cycloplegia and the impact of blur due to cycloplegia and uncorrected refractive error. RESULTS: The first two (pre-cycloplegic) tests indicated high reliability. The contrast sensitivity values from the second test were within ±0.15 log 10 units of the first in 97.4% of cases (mean difference = 0.012 log 10 units). Similar results were obtained when the first test was compared with the post-cycloplegic tests, with or without correction. Limits of agreement were the same (±0.220) when the first test was compared with each repeat test. Under cycloplegia, participants' contrast sensitivity was not associated with the absolute amount of blur for the OCC grating. Thus, the OCC results did not depend systematically on the refractive state of the eye in this pediatric population. CONCLUSIONS: The OCC is a reliable test that can be used on pediatric patients irrespective of whether the patient is under cycloplegia. Its resistance to blur is due to the very low-spatial-frequency square-wave target.

  PublisherOA PDFDOI

• Long‐term test and retest reliability of clinical vergence testing

  Ophthalmic and Physiological Optics · 2025-10-06

  articleOpen access

  PURPOSE: To establish long-term reliability measures for vergence testing in a control population of adolescents. METHODS: Healthy participants between 12 and 17.5 years with normal binocular vision were recruited from 10 clinical sites. Cover test, near point of convergence (NPC), positive and negative fusional vergences, vergence facility (12∆ base-out/3∆ base-in) and vergence jumps (using the Oculomotor Assessment Tool) were performed at the initial visit and repeated at 90 days. The mean and standard deviation were calculated for the overall group for NPC, vergence facility and vergence jumps and by prism dioptre step value for PFV and NFV (1Δ or 2Δ if below 20∆ or 5Δ above 20∆). Agreement was assessed using Bland-Altman plots and 95% limits of agreement (LOA). RESULTS: Ninety-three participants (mean age 14.3 ± 1.7 years, 52% female) were enrolled and 91 (98%) completed the initial and 90-day outcome evaluation. The mean differences were significantly greater than zero for vergence facility (p < 0.05) and the first and second 30 s of vergence jumps (p < 0.01). The 95% LOA were narrow for NPC (±2.5) and negative fusional vergence (±5.9), suggesting good repeatability. LOA were larger for positive fusional vergence (±17.8), vergence facility (±9.8) and vergence jumps (±16.2). Analysis of the positive fusional vergence data indicates that the different step sizes (1∆ or 2∆ vs. 5∆) in the horizontal prism bar contribute to considerably larger variability in these measures. CONCLUSIONS: In participants with normal binocular vision and no concussion history, good reliability yielded comparable results 90 days apart for all vergence measures. The results provide values that can be used to interpret the effect of intervention for vergence disorders in clinical practice and research studies. An important outcome of this study is the understanding that 5∆ steps on the typical horizontal prism bar contribute to high variability in positive fusional vergence measures when findings are ≥20∆.

  PublisherOA PDFDOI

• Ball-Flight Viewing Duration and Estimates of Passing Height in Baseball

  Vision · 2025-01-25

  articleOpen access

  Predictions of the vertical location of a pitched ball (termed the passing height) when the ball arrives at an observer may be based on internal models of ball trajectory and situational cues, kinematic cues from the pitcher's motion, and visual ball-flight cues. The informational content of ball-flight cues for judgments of vertical passing height when the ball's launch angle is small and when situational and kinematic cues are limited is unknown. The purpose of this study was to determine whether passing heights can be judged adequately from ball-flight cues and whether judgments of passing height improve as viewing time increases under the aforementioned conditions. Twenty subjects stood 40 feet (12.19 m) from a pneumatic pitching machine that propelled tennis balls toward them at three speeds (from 53 mph (85 kph) to 77 mph (124 kph)). The ball's launch angle was constant. The subject's vision was blocked at 100 ms or 250 ms after pitch release. Subjects indicated the height at which they expected the ball to arrive. In the absence of explicit situational cues or kinematic cues and in the presence of a small and constant launch angle, the longer viewing time of ball-flight cues improved passing height estimates but did not result in accurate responses for the slower speeds.

  PublisherOA PDFDOI

• Detection of significant vision conditions in children using <scp>QuickSee</scp> wavefront autorefractor

  Ophthalmic and Physiological Optics · 2024 · 6 citations

  • Artificial Intelligence
  • Medicine
  • Ophthalmology

  PURPOSE: This study evaluated the ability of QuickSee to detect children at risk for significant vision conditions (significant refractive error [RE], amblyopia and strabismus). METHODS: Non-cycloplegic refraction (using QuickSee without and with +2 dioptre (D) fogging lenses) and unaided binocular near visual acuity (VA) were measured in 4- to 12-year-old children. Eye examination findings (VA, cover testing and cycloplegic retinoscopy) were used to determine the presence of vision conditions. QuickSee performance was summarised by area under the receiver operating characteristic curve (AUC), sensitivity and specificity for various levels of RE. QuickSee referral criteria for each vision condition were chosen to maximise sensitivity at a specificity of approximately 85%-90%. Sensitivity and specificity to detect vision conditions were calculated using multiple criteria. Logistic regression was used to evaluate the benefit of adding near VA (6/12 or worse) for detecting hyperopia. A paired t-test compared QuickSee without and with fogging lenses. RESULTS: The mean age was 8.2 (±2.5) years (n = 174). RE ranged up to 9.25 D myopia, 8 D hyperopia, 5.25 D astigmatism and 3.5 D anisometropia. The testability of the QuickSee was 94.3%. AUC was ≥0.92 (excellent) for each level of RE. For the detection of any RE, sensitivity and specificity were 84.2% and 87.3%, respectively, using modified Orinda criteria and 94.5% and 78.2%, respectively, using the American Academy for Pediatric Ophthalmology and Strabismus (AAPOS) guidelines. For the detection of any significant vision condition, the sensitivity and specificity of QuickSee were 81.1% and 87.9%, respectively, using modified Orinda criteria and 93% and 78.6%, respectively, using AAPOS criteria. There was no significant benefit of adding near VA to QuickSee for the detection of hyperopia ≥+2.00 (p = 0.34). There was no significant difference between QuickSee measurements of hyperopic refractive error with and without fogging lenses (difference = -0.09 D; p = 0.51). CONCLUSIONS: QuickSee had high discriminatory power for detecting children with hyperopia, myopia, astigmatism, anisometropia, any significant refractive error or any significant vision condition.

  PublisherOA PDFDOI

• Neural consequences of symptomatic convergence insufficiency: A small sample study

  Ophthalmic and Physiological Optics · 2024 · 3 citations

  • Medicine
  • Psychology
  • Anatomy

  INTRODUCTION: Convergence insufficiency (CI) is an oculomotor abnormality characterised by exophoria and inadequate convergence when focusing on nearby objects. CI has been shown to cause symptoms when reading. However, the downstream consequences on brain structure have yet to be investigated. Here, we investigated the neural consequences of symptomatic CI, focusing on the left arcuate fasciculus, a bundle of white matter fibres which supports reading ability and has been associated with reading deficits. METHODS: We compared the arcuate fasciculus microstructure of participants with symptomatic CI versus normal binocular vision (NBV). Six CI participants and seven NBV controls were included in the analysis. All participants were scanned with 3 T magnetic resonance imaging (MRI), and anatomical and diffusion-weighted images were acquired. Diffusion-weighted images were processed with TRACULA to identify the arcuate fasciculus in each participant and compute volume and radial diffusivity (RD). RESULTS: Compared with NBV controls, those with symptomatic CI had significantly smaller arcuate fasciculi bilaterally (left: t = -3.21, p = 0.008; right: t = -3.29, p = 0.007), and lower RD in the left (t = -2.66, p = 0.02), but not the right (t = -0.81, p = 0.44, false discovery rate (FDR)-corrected p > 0.05) arcuate fasciculus. Those with higher levels of reading symptoms had smaller arcuate fasciculi (r = -0.74, p = 0.004) with lower RD (r = -0.61, p = 0.03). CONCLUSIONS: These findings suggest that symptomatic CI may lead to microstructural changes in the arcuate fasciculus. Since it is highly unlikely that abnormalities in the arcuate fasciculus are the cause of the neuromuscular deficits in the eyes, we argue that these changes may be a potential neuroplastic consequence of disruptions in sustained reading.

  PublisherOA PDFDOI

• Effects of vision therapy on near exodeviation in children with convergence insufficiency treated during the convergence insufficiency treatment trials

  Ophthalmic and Physiological Optics · 2024-04-15 · 1 citations

  articleOpen access

  PURPOSE: To report the change in the magnitude of near exodeviation in children with symptomatic convergence insufficiency successfully treated with office-based vergence/accommodative therapy in the Convergence Insufficiency Treatment Trial-Attention and Reading Trial. METHODS: A total of 131 children 9-14 years of age with symptomatic convergence insufficiency classified as successfully treated with office-based vergence/accommodative therapy at the 16-week outcome visit were included. Masked examiners measured the near ocular deviation by the prism and alternate cover test at baseline, primary outcome and 1-year post-treatment. The mean change in near deviation was calculated from baseline to primary outcome, from primary outcome to 1-year post-treatment and from baseline to 1-year post-treatment. RESULTS: Of the 131 participants successfully treated with vergence/accommodative therapy, 120 completed the 1-year post-treatment visit. A significant change in near exodeviation was observed at baseline to primary outcome (2.6Δ less exo, p < 0.001, moderate effect size d = 0.61) and at baseline to 1-year post-treatment (2.0Δ less exo; p < 0.001, small effect size d = 0.45). The change from primary outcome to 1-year post-treatment (0.6Δ more exo; p = 0.06, small effect size d = 0.11) was not significant. Forty per cent (48/120) of participants had a decrease in near exodeviation >3.5∆ (expected test/retest variability) between baseline and the primary outcome examination. Of the 120 participants, one (1.0%) was esophoric at the primary outcome and was subsequently exophoric at 1-year post-treatment. Four participants (3.3%) who were orthophoric or exophoric at the primary outcome were esophoric (all ≤3∆) at the 1-year post-treatment visit. CONCLUSION: On average, the near exodeviation was smaller in size immediately after the discontinuation of vergence/accommodative therapy (2.6∆, moderate effect size) and 1 year post vergence/accommodative therapy (2.0∆, small effect size) in children with convergence insufficiency who were successfully treated; 40% had a clinically meaningful decrease in exophoria. The development of near esophoria was rare.

  PublisherOA PDFDOI

• Impact of accommodative insufficiency and accommodative/vergence therapy on ciliary muscle thickness in the eye

  Ophthalmic and Physiological Optics · 2023-05-15 · 6 citations

  articleOpen access

  PURPOSE: Recent evidence suggests that the ciliary muscle apical fibres are most responsive to accommodative load; however, the structure of the ciliary muscle in individuals with accommodative insufficiency is unknown. This study examined ciliary muscle structure in individuals with accommodative insufficiency (AI). We also determined the response of the ciliary muscle to accommodative/vergence therapy and increasing accommodative demands to investigate the muscle's responsiveness to workload. METHODS: Subjects with AI were enrolled and matched by age and refractive error with subjects enrolled in another ciliary muscle study as controls. Anterior segment optical coherence tomography was used to measure the ciliary muscle thickness (CMT) at rest (0D), maximum thickness (CMTMAX) and over the area from 0.75 mm (CMT0.75) to 3 mm (CMT3) posterior to the scleral spur of the right eye. For those with AI, the ciliary muscle was also measured at increasing levels of accommodative demand (2D, 4D and 6D), both before and after accommodative/vergence therapy. RESULTS: Sixteen subjects with AI (mean age = 17.4 years, SD = 8.0) were matched with 48 controls (mean age = 17.8 years, SD = 8.2). On average, the controls had 52-72 μm thicker ciliary muscles in the apical region at 0D than those with AI (p = 0.03 for both CMTMAX and CMT 0.75). Differences in thickness between the groups in other regions of the muscle were not statistically significant. After 8 weeks of accommodative/vergence therapy, the CMT increased by an average of 22-42 μm (p ≤ 0.04 for all), while AA increased by 7D (p < 0.001). CONCLUSIONS: This study demonstrated significantly thinner apical ciliary muscle thickness in those with AI and that the ciliary muscle can thicken in response to increased workload. This may explain the mechanism for improvement in signs and symptoms with accommodative/vergence therapy.

  PublisherOA PDFDOI

• Aniseikonia

  2022-12-01

  book-chapter1st authorCorresponding
  PublisherDOI

• Functional magnetic resonance imaging activation for different vergence eye movement subtypes

  Ophthalmic and Physiological Optics · 2022 · 12 citations

  • Computer Science
  • Psychology
  • Neuroscience

  INTRODUCTION: Maddox suggested that there were four convergence subtypes, each driven by a different stimulus. The purpose of this study was to assess the neural correlates for accommodative convergence, proximal convergence (convergence stimulus provided), disparity convergence and voluntary convergence (no specific convergence stimulus provided) using functional magnetic resonance imaging (fMRI). METHODS: Ten subjects (mean age = 24.4 years) with normal binocular vision participated. The blood oxygenation level-dependent (BOLD) signals of the brain from fMRI scans were measured when subjects made vergence eye movements while: (1) alternately viewing letters monocularly where one eye viewed through a -2.00 D lens, (2) alternately viewing Difference of Gaussian targets monocularly at distance and near, (3) viewing random dot stereograms with increasing disparity and (4) voluntarily converging the eyes with binocular viewing. RESULTS: The accommodative convergence paradigm resulted in activation on the right side in the right fusiform cortex and the right middle occipital cortex. The proximal convergence stimulus mainly activated areas in the right occipital lobe. The disparity stimulus activated areas in the left occipital cortex and the left frontal cortex. Finally, the voluntary convergence paradigm resulted in activation primarily in the occipital lobe and mostly bilaterally. CONCLUSION: The accommodative, proximal, disparity and voluntary convergence paradigms resulted in activation in unique areas in the brain with functional MRI. Activation was found in more areas in the proximal and voluntary conditions compared with the accommodative and disparity conditions.

  PublisherOA PDFDOI

• Review: Head and Eye Movements and Gaze Tracking in Baseball Batting

  Optometry and Vision Science · 2021 · 16 citations

  1st authorCorresponding
  • Artificial Intelligence
  • Computer Science
  • Psychology

  SIGNIFICANCE: After a 30-year gap, several studies on head and eye movements and gaze tracking in baseball batting have been performed in the last decade. These baseball studies may lead to training protocols for batting. Here we review these studies and compare the tracking behaviors with those in other sports.Baseball batters are often instructed to "keep your eye on the ball." Until recently, the evidence regarding whether batters follow this instruction and if there are benefits to following this instruction was limited. Baseball batting studies demonstrate that batters tend to move the head more than the eyes in the direction of the ball at least until a saccade occurs. Foveal gaze tracking is often maintained on the ball through the early portion of the pitch, so it can be said that baseball batters do keep the eyes on the ball. While batters place gaze at or near the point of bat-ball contact, the way this is accomplished varies. In some studies, foveal gaze tracking continues late in the pitch trajectory, whereas in other studies, anticipatory saccades occur. The relative advantages of these discrepant gaze strategies on perceptual processing and motor planning speed and accuracy are discussed, and other variables that may influence anticipatory saccades including the predictability of the pitch and the level of batter expertise are described. Further studies involving larger groups with different levels of expertise under game conditions are required to determine which gaze tracking strategies are most beneficial for baseball batting.

  PublisherDOI

Frequent coauthors

• Marjean Taylor Kulp

  SUNY College of Optometry

  41 shared

• Nick Fogt

  22 shared

• G. Lynn Mitchell

  SUNY College of Optometry

  19 shared

• Emmanuel Owusu

  Lovely Professional University

  8 shared

• Loraine T. Sinnott

  SUNY College of Optometry

  8 shared

• Tamara Oechslin

  8 shared

• Susan A. Cotter

  Marshall B. Ketchum University

  6 shared

• Mitchell Scheiman

  6 shared

Labs

• Karla Zadnik LabPI

Awards & honors

• Inaugural Chair for the Faculty Awards Committee
• Performed a residency site visit for the Accreditation Counc…