Ординатура / Офтальмология / Английские материалы / Atlas of Glaucoma, Second Edition_Choplin, Lundy_2007

102 Atlas of glaucoma

Figure 8.10 Nasal steps.

Nasal steps are very common in glaucoma, representing an asymmetry in threshold across the horizontal midline at the nasal periphery of the measured field. They are the first defects in about half the glaucoma patients. This patient shows a dense superior nasal step.

Figure 8.11 Early glaucomatous damage in the inferior hemifield. This is another example of early glaucomatous damage in the inferior hemifield. An inferior nasal step combined with inferior paracentral defects indicates damage to the superior arcuate nerve fibers.

Psychophysical and electrophysiological testing in glaucoma 103

Figure 8.12 An inferior arcuate scotoma. This example of early glaucoma damage shows an inferior arcuate scotoma which does not reach the nasal periphery.

Figure 8.13 A broad inferior arcuate scotoma.

This patient has had openangle glaucoma for many years. He has extensive damage in the fellow eye and has lost fixation. This is an example of a broader inferior arcuate scotoma (compared to Figure 8.12) which connects to the blind spot.

104 Atlas of glaucoma

Figure 8.14 A complete loss of a bundle of axons.

Extension of the optic cup to the rim of the disc will result in loss of nerve fibers corresponding to that portion of rim. This patient with low-tension glaucoma developed extension of the cup to the inferior pole of the disc and this superior nerve-fiber bundle defect. This represents loss of a complete bundle of axons, is very deep, and breaks through to the nasal periphery. This could possibly represent an ischemic infarction of a portion of the optic nerve.

Figure 8.15 A ‘double arcuate’ scotoma. This is an example of a ‘double arcuate’ scotoma, which results from extension of the cup to both poles of the disc. Note that the inferior loss is worse than the superior.

Psychophysical and electrophysiological testing in glaucoma 105

Figure 8.16 Complete nervefiber bundle defects. Complete nerve-fiber bundle defects are not common as the initial defects in glaucoma patients. This pair of visual fields from the right and left eyes of this 51- year-old African-American woman were the patient’s first visual fields. Initial pressures were in the upper 20s. Note the asymmetry, with the left eye worse than the right.

106 Atlas of glaucoma

Figure 8.17 Superior altitudinal defect. Complete loss of the inferior pole of the nerve will give rise to a superior altitudinal defect, illustrated here. Although commonly seen following ischemic optic neuropathy, this defect gradually enlarged over time in this patient with low-tension glaucoma (see Figure 8.26).

Figure 8.18 Isolated temporal defects. Isolated temporal defects occur about 3% of the time as initial glaucoma defects. This patient shows temporal defects above and below the horizontal midline. Note that the statistical software gives more significance to the inferior disturbances, indicating that some depressions in the superior field of older people is not unusual.

Psychophysical and electrophysiological testing in glaucoma 107

Figure 8.19 Far-advanced glaucomatous optic neuropathy. Progressive loss of nerve fibers results in greater visual field loss, usually affecting the macular fibers and the nasal retina last, leaving central and temporal islands as the end-stage before complete visual loss. This is an example of a patient with far-advanced glaucomatous optic neuropathy, with small islands remaining centrally, temporally and in the superior arcuate area.

Figure 8.20 High intraocular pressure.

Very high intraocular pressure can lead to extensive loss which may become symptomatic. This visual field showing extensive damage was obtained upon initial presentation of a young male with intraocular pressure in the 50s. He noted visual loss and went for an eye examination. His visual acuity was reduced to 20/70. The fellow eye had minimal loss with pressures in the 30s and 20/20 vision. He was found to have abnormal anterior chamber angles, indicating a juvenile-onset type of glaucoma. Following filtering surgery, his visual acuity returned to 20/25 and some of the visual field loss returned.

108 Atlas of glaucoma

Figure 8.21 The progression of visual field defects. Visual fields may show progression over time in a variety of ways. If initially normal, they may go on to diffuse loss or the development of isolated depressions. This series of fields over a 7-year period was obtained in an African-American man with ocular hypertension which was under treatment. It shows a gradual but steady decrease in retinal sensitivity affecting the field uniformly (the last field is the same as Figure 8.6). A review of optic nerve photographs (particularly comparing the earliest to the latest) shows a concentric enlargement of the cup over time with the neuroretinal rim still intact.

Psychophysical and electrophysiological testing in glaucoma 109

Figure 8.22 The development of new defects.

Fields initially with defects may show the development of new defects. This series of fields in a patient with open-angle glaucoma shows completion of an inferior nerve-fiber bundle defect as well as the development of new defects in the superior field. Part of the diffuse change in the latter fields is due to the development of cataract.

110 Atlas of glaucoma

Figure 8.23 Widening and deepening of single nerve-fiber bundle defects. Visual fields may progress by widening and deepening of single nervefiber bundle defects. This series of visual fields is from the patient in Figure 8.14. Initially the field was normal and then she developed disturbances in the superior arcuate area. These coalesced and extended over time to involve the entire bundle of axons and a good portion of the superior field.