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

Figure 5.19 Goldmann manual perimeter. A: Patient's side, showing headres (H), fixation target (F), and projection device for test objects (P). B: Operator's side, showing telescope for fixation monitoring (T) and visual field chart (C) for locating and recording position of test objects.

Suprathreshold static perimetry can be performed by turning the disc-shaped test object from the black to the white side or by using a self-illuminating target with an on-off switch. Specific locations at which the patient fails to see the target are then evaluated further with kinetic techniques.

The tangent screen has the advantages of low cost and simplicity of operation. However, reproducibility of the fields, which is essential in managing patients with glaucoma, is limited by variations in background lighting and stimulus value of the targets, and by difficulty in monitoring fixation. Furthermore, it does not include the peripheral field, where early glaucomatous defects may appear. Arc and Bowl Perimeters

With these instruments, both the central and peripheral fields of vision can be examined. The screen of the perimeter may be a curved ribbon of metal (arc perimeter) or bowl shaped. The latter is preferable for glaucoma examinations, and the prototype is the Goldmann perimeter (Fig. 5.19) (327). Other similar instruments have been compared with the Goldmann unit,

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with variable results (328). The bowl of the Goldmann perimeter has a radius of 300 mm and extends 95% to each side of fixation. The target is projected onto the bowl, and the stimulus value of the test object can be varied by changing the size or the intensity. Arbitrary designations for each value variable are usually printed on the visual field chart, with O-V for size, and 1-4 for intensity. An isopter,

therefore, might be designated as “I2e,” which indi cates a test object size of 0.25 mm2 and an intensity of 10 millilamberts. The examiner can monitor the patient's fixation through a telescope in the center of the bowl. The Goldmann perimeter can be used for both kinetic and static visual field testing. The

Tübingen perimeter has been designed exclusively fo r the measurement of static threshold (profile) fields and consists of a bowl-type screen and stationary test objects with variable light intensity (329, 330).

Figure 5.20 In-depth technique with Goldmann-type perimeter in which the visual field has been plotted with five targets. The size and stimulus of the corresponding isopters are shown in the table in the lower right of the figure. This demonstrates a normal visual field.

Specific Techniques for Manual Perimetry

In the context of glaucoma detection and management, manual kinetic visual field testing has two basic aspects: (a) screening techniques to detect the presence of glaucomatous field loss, and (b) in-depth techniques to more accurately determine the extent of the damage and to follow the fields for evidence of progressive change.

Screening Techniques

Armaly developed a method of visual field screening for glaucoma that was modified by Drance and associates and is commonly referred to as selective perimetry, or the Armaly-Drance technique (331, 332, 333 and 334). The basic concept is to test those areas in the visual field that have the highest probability of showing glaucomatous defects. The technique uses Goldmann-type perimeter with suprathreshold static perimetry to test for central field defects and both suprathreshold static and kinetic perimetry to examine the peripheral field, with emphasis on the nasal and temporal periphery. This technique revealed a high sensitivity and specificity, which made it suitable for clinical and survey screening (332, 334). An additional modification is to use the V4e isopter nasally to rule out crowding of the peripheral nasal isopters (45).

Another technique for use with Goldmann-type perimeters uses three suprathreshold targets in three concentric zones from fixation in accordance with the normal physiologic sensitivity gradient (335). Other investigators have developed protocols to significantly reduce the number of test points without sacrificing sensitivity or specificity by concentrating the testing in those portions of the field where a defect is most likely to be found (336, 337).

In-Depth Techniques

1 - Cellular and Molecular Biology of Aqueous Humor Dynamics Page 197 of 225

When a glaucomatous field defect is suspected by use of a screening technique, the physician has two choices. The patient can be asked to return another day for a repeated screening field or an in-depth study. In many cases, however, it is more practical to proceed with the in-depth test at the time the defect is detected. The principle of in-depth field testing is to map out the size and shape of all scotomas and complete isopters by using the central threshold target and two or more additional targets of greater stimulus value (Fig. 5.20). However, automated static perimetry has certainly more value in studying areas of known loss for the depth and shape of the scotoma and for subtle evidence of progressive damage in serial fields.

KEY POINTS

The normal visual field may be depicted as a three-dimensional contour, representing areas of relative retinal sensitivity and characterized by a peak at the point of fixation, an absolute depression corresponding to the optic nerve head (blind spot), and a sloping of the remaining areas to the boundaries of the field.

Early glaucomatous damage may produce a generalized depression of this contour, which can be demonstrated with several psychophysical tests.

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The more specific visual field changes of glaucoma, however, are localized defects that correspond to loss of retinal nerve fiber bundles, and include paracentral and arcuate scotomas above and below fixation and steplike defects along the nasal midline (nasal step).

Instruments used to measure the field of vision (perimeters) may have static or kinetic targets, which can be controlled automatically or manually. The targets are presented against a background that is bowl shaped or flat (tangent screen), with the former units providing more reliable measurements.

Comparative studies indicate that automated static perimeters, particularly those using new enhanced testing algorithms, are more sensitive than manual perimeters are at detecting and following glaucomatous visual field loss.

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