After the excitement of the holiday season wears off, at least there's one gift that keeps giving: football playoffs!

For Dr. Andrew Lee, chair of Ophthalmology at the Houston Methodist Blanton Eye Institute, interest in the game isn't just personal. He and his Blanton Eye Institute colleagues have partnered with the National Football League (NFL) to develop a training program for referees that uses neuro-ophthalmic principles to strengthen on-field accuracy and performance.

"The concepts of ocular motility play a large role in professional sports officiating, whether participants realize it or not," Dr. Lee says. "Referees perform in real-time, high-stress conditions, with significant financial and social implications for a multi-billion-dollar sporting industry. Our goal is to give them a vocabulary to discuss their challenges as well as science-based tips that will make their jobs a little easier to perform."

Launched in the 2021-2022 season, the program recently entered its second year.

"We've been very pleased with what this partnership has been able to achieve in just a short time," says Walt Anderson, the NFL's senior vice president of Officiating, Training and Development. "Armed with a better understanding of how vision works, our game officials report feeling like they're in a much better position both physically, from a visual processing standpoint, and metaphorically, from a confidence standpoint, to be able to make the kind of instant judgements they have to make on the field."

The development of the curriculum and its first-year results were recently presented at the 2022 annual American Academy of Ophthalmology conference and will be the subject of an upcoming journal article.

Dr. Lee sat down with Leading Medicine to discuss what the training entails, which neuro-ophthalmic principles are most relevant to NFL officiating and what the plans are for measuring and building on the program's success.

Q: Why do you think the NFL was interested in a program like this? Why now?

In the past decade or so, the officiating of NFL games has changed significantly. There are sophisticated video replay programs, but they slow down the game and change the momentum. Also, you lose the human element when you rely on technology too much. The officials are very important; there's a lot of symbolism, history, routine, respect. Nobody wants to change that. But since these technologies do exist, it's important to ensure the officials are as precise and accurate as they can be. We're there to educate them on the science of vision. When you learn the scientific reason behind why certain things improve or degrade your vision during critical moments, it helps you remember what to do and what not to do. They actually already know a lot of this stuff; we're just providing them with the correct vocabulary to discuss it and formalize it.

Q: What neuro-ophthalmic principles do you focus on? What part of vision can officials actually control?

First of all, there's the visual field, which is your side vision. Your visual field will get bigger if you move away from something and smaller if you get closer. Although being closer may improve your resolution and acuity, it also means you could miss important things going on to your side. You have to balance visual acuity — how close you need to be to something — against the visual field. For example, when a snap is made from the center to the quarterback to start the play, it's really important for the game official to be right on top of that play to see the action around the ball since that interaction is the first point of contact and it's where a lot of infractions can occur. But once the play begins and there's been no false start or other penalty, referees have to drop back at least five steps so they can see the whole field.

Another principle is called dynamic visual acuity. When you move, your vision degrades. Whether you're moving your head or you're running, movement makes it harder to keep your eye on a target. If you have a clear line of sight and full visual field, you don't need to run, even when the play unfolds over some distance. It turns out, when it comes to accuracy of calls, it's better if you just stay where you are and follow the action with your head.

Q: Very interesting! What other principles are involved?

The last thing that we've been working with them on is eye movement. Referees constantly must make decisions about where to focus. They watch something, decide if it's legal or not, then move their eyes to the next likely point of contact or potential penalty. That fast movement — to get your center vision to a new target — is called a saccade. When you follow a moving target along with your eyes, that's called pursuit. Pursuit is a smooth movement.

Referees have to saccade in a certain sequence. They have to prioritize where they need to look. If a receiver is catching the ball on the sideline, they have to look at the feet first and make sure they're in bounds, then saccade to the arms to determine if the ball was caught. When a play starts, the official has to look at the football when it's snapped to the quarterback, then saccade to the running back if the quarterback hands it off. If it's a fake handoff, the official has to saccade back to the quarterback because he's now looking to throw. However, if the running back gets the ball and runs with it, that's pursuit. There are different saccadic prioritization and pursuit strategies, depending on whether it's a run or pass.

Q: How is the training provided?

There are camps every year for NFL employees, players, officials, trainers, managers, etc. We go to the camp and train the people who train the referees. We present a lecture on the basics of neuro-ophthalmology, and then we run through lots and lots of video. They're very visually oriented people. We show them where the breakdowns occur in both good and bad calls.

For the good, we show how the referee was in the right place or had the right saccadic prioritization. For the bad, we point out if the line of sight was obstructed or if adequate visual field wasn't maintained. Or if the official was running when he didn't really need to be running. Or if the official was looking at the wrong place when the critical play happened.

We're helping them understand why their eyes need to move in a certain way and providing them with a science-based vocabulary they can put in their training manual, so that everyone's speaking the same language.

Q: What's next for the program?

This year we were asked to present our work at the American Academy of Ophthalmology. We've also written about the program, describing the rationale and development of the curriculum, and submitted it to a journal for publication. That means there are solid academic metrics accompanying our work.

We plan to follow along with the referees that have been trained in this method to see if they're making more accurate calls. Assuming the NFL finds value in it, the next phase would be to show that it actually improves performance and accuracy in the field.

We already have some data. We asked participants to self-rate their confidence in using terms like saccade, pursuit, dynamic visual acuity, field of vision, etc. We know from these surveys that they enjoyed it and learning occurred. They do feel more confident. The next stage is finding out if that learning translated into improved performance.