Ординатура / Офтальмология / Английские материалы / Shields Textbook of Glaucoma, 6th edition_Allingham, Damji, Freedman_2010

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Shields > SECTION I - The Basic Aspects of Glaucoma >

5 - Assessment of Visual Fields

Authors: Allingham, R. Rand

Title: Shields Textbook of Glaucoma, 6th Edition

Copyright © 2011 Lippincott Williams & Wilkins

1 - Cellular and Molecular Biology of Aqueous Humor Dynamics Page 162 of 225

> Table of Contents > SECTION I - The Basic Aspects of Glaucoma > 5 - Assessment of Visual Fields 5

Assessment of Visual Fields

Advances in the technology of visual field testing have changed our clinical perception of normal and abnormal fields of vision. For example, the two-dimensional presentation of concentric lines around the point of fixation has given way to three-dimensional displays in symbols and numerical values. However, the normal field of vision and the changes created by glaucoma are just the same as they were 100 years ago when Bjerrum discovered the arcuate scotoma using the back of his consulting room door as a background for his field testing. This chapter therefore first considers the normal field of vision and how it is altered by glaucomatous damage, and then reviews the instruments and techniques by which these parameters can be measured.

NORMAL VISUAL FIELD

A helpful way to begin the study of visual fields and the methods by which they are measured is to consider Traquair's classic analogy of “an island of vision surrounded by a sea of blindness” (Fig. 5. 1). This three-dimensional concept can be reduced to quantitative values by plotting lines (isopters) at various levels around the island, or by measuring the height (sensitivity) at different points in the island of vision.

Figure 5.1 The normal visual field (right eye) is depicted as the Traquair “ island of vision surrounded by a sea of blindness,” with projections showing the p eripheral limits (A) and the profile (B). Fixation (f) corresponds to the foveola of the retina, and the blind spot (bs) to the optic nerve head. The approximate dimensions of the absolute peripheral boundary of the visual field and the location of the blind spot are shown (A).

Boundaries

The shoreline of the island corresponds to the peripheral limits of the visual field, which normally measure, with maximum target stimulation, approximately 60 degrees above and nasal, 70 to 75 degrees below, and 100 to 110 degrees temporal to fixation (1). The typical configuration of the normal visual

field, therefore, is a horizontal oval, often with a shallow inferonasal depression (Fig. 5.1). The shape is usually of greater diagnostic significance than the absolute size of the visual field is, because the latter is influenced by many physiologic and testing variables.

Contour

The peaks and valleys on the island correspond to areas of increased or decreased vision within the peripheral limits of the visual field. These contours can be mapped by recording the weakest light stimulus that can be seen at specific locations in the field of vision or by using test objects with reduced stimulus value to plot smaller isopters within the absolute boundaries. The area of maximum visual sensitivity in the normal field during photopic condition is at the point of fixation, corresponding to the foveola of the retina, and appears as a smoothly rising peak surrounded by a high plateau (2). The visual sensitivity

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then tapers down more gradually until it again falls abruptly at the peripheral limits. Blind Spot

Nerve fibers, collecting visual information from the retina, come together approximately 10 to 15 degrees nasally from the fovea. This region corresponds to the optic nerve head, and because there are no photoreceptors in this area, it creates a deep depression within the boundaries of the normal visual field, which is called the blind spot. Because the image formed on the retina is upside down and backward, the blind spot is located temporal to fixation. The blind spot has two portions: (a) an absolute scotoma and (b) a relative scotoma (3). The absolute scotoma corresponds to the actual optic nerve head and is seen as a vertical oval. Because the nerve head has no photoreceptors, this portion of the blind spot is independent of the test object stimulus value.

The relative scotoma surrounds the absolute portion and corresponds to peripapillary retina, which has reduced visual sensitivity, especially inferiorly and superiorly. In a study correlating the blind spot size to the area of the optic disc and peripapillary atrophy, the absolute scotoma included the peripapillary scleral ring and the peripapillary zone beta (see definitions in Chapter 4), whereas zone alpha was attributed to the relative scotoma (4).

VISUAL FIELD LOSS IN GLAUCOMA Peripheral Loss

Defects along the peripheral boundaries of the visual field (i.e., peripheral nasal steps, vertical steps, and temporal sector defects) are most often found in association with scotomas in the more central arcuate area, although in some patients with early glaucomatous visual field loss, peripheral defects may be the only detectable abnormality (5, 6, 7 and 8). With automated static perimetry (discussed later), it has become common practice to measure only the central 24 to 30 degrees of the visual field, because of the increased time requirement with this technique. The question arises, therefore, as to how much information is being missed by ignoring the more peripheral portions of the field. In the presence of paracentral scotomas, peripheral measurements appear to add no significant information regarding the progression of visual field damage (9). In the initial diagnosis, however, a peripheral field defect, usually a nasal step, may be the only abnormality detected by automated perimetry in 3% to 11% of patients, depending on the testing method (10, 11, 12 and 13). To be clinically useful, the time required to obtain this information must not add excessively to the overall testing time; further study is needed to determine whether this can be achieved with newer programs for automated perimetry.

Localized Nerve Fiber Layer Defects

In glaucoma, structural damage to ganglion cells and their axons causes partial or complete functional loss in the area of damaged cells. The glaucomatous process typically causes initial damage to one or more axon bundles, creating a localized visual field defect. Focal defects, due to loss or impairment of retinal nerve fiber bundles, constitute the most definitive early evidence of visual field loss from glaucoma. The nature of the nerve fiber bundle defects relates to the retinal topography of these fibers, as discussed in Chapter 4.

Arcuate Defects

Bjerrum (pronounced bee YER um) described an arcuate visual defect, which he showed is strongly suggestive of glaucoma. This arcuate scotoma starts from the blind spot and arches above or below fixation, or both, to the horizontal median raphe, corresponding to the arcuate retinal nerve fibers (Figs. 5.2A and 5.3). The nasal extreme of the arcuate area along the median raphe may come within 1 degree of fixation and extends nasally for 10 to 20 degrees (14). Early visual loss in glaucoma commonly occurs in this arcuate area, especially in the superior half, which correlates with the predilection of the inferior and superior temporal poles of the optic nerve head for early glaucomatous damage (14, 15). As field defects develop within the arcuate area, they most often appear first as one or more localized defects, or paracentral scotomas (Fig. 5.2B). The typical pattern of progression of glaucomatous visual field defects is for a shallow paracentral depression to become denser and larger (16), eventually forming a central absolute defect, surrounded by a relative scotoma (17, 18). The relative scotoma represents fluctuation that can be seen at the border of the physiologic blind spot and glaucomatous defects, but is significantly larger and more sloping in the latter (19). Occasionally, the early arcuate defect may connect with the blind spot and taper to a point in a slightly curved course, which has been referred to as a Seidel scotoma (Fig. 5.2C). As the isolated defects enlarge and coalesce, they form an arching scotoma that eventually fills the entire arcuate area from the blind spot to the median raphe, which is called an arcuate or Bjerrum scotoma (Fig. 5.2D). With further progression, a double arcuate (or ring) scotoma develops (Fig. 5.2E). The rate of visual field loss correlates with the size of the scotoma, in that, the larger the scotoma, the more rapidly it is likely to enlarge (20).

Although the arcuate defect is probably the most reliable early form of glaucomatous field loss, it is not pathognomonic, and the following additional causes must be considered, especially when the field and disc changes do not seem to correlate: chorioretinal lesions, optic nerve head lesions, anterior optic nerve lesions, and posterior lesions of the visual pathway (21, 22 and 23) (Table 5.1). At times the arcuate defect involves the papillomacular nerve fiber bundle (Fig. 5.4).

Nasal Steps

The loss of retinal nerve fibers rarely proceeds at the same rate in the upper and lower portions of an eye. Consequently, a steplike defect is frequently created where the nerve fibers meet along the median raphe (Fig. 5.5). Because the superior field is involved somewhat more frequently than the inferior portion is in the early stages of glaucoma, the nasal step more often results from a greater defect above the horizontal midline, which is referred to as a superior nasal step. However, inferior nasal

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steps are not uncommon. Nasal steps are also distinguished by their central or peripheral location (5). A central nasal step is created at the side of an unequal double arcuate scotoma closest to fixation. Unequal contraction on the peripheral side of the defect, due to loss of corresponding bundles of peripheral arcuate nerve fibers, produces a defect that has been called the peripheral nasal step of Ronne. Nasal step often begins as an isolated scotoma in the nasal periphery (6). The shape of the peripheral nasal step with kinetic testing differs according to its distance from fixation and is not necessarily found in all isopters (18, 24). Nasal step appears to be a common defect in acute and early chronic angle-closure glaucoma (25, 26).