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

(118).

The ERG evoked by a flash of light (flash ERG) is affected more by outer retinal elements and is not typically abnormal in glaucoma. Acute IOP elevation in cats, however, caused a reduction in both pattern and flash ERG, proportional to the reduction in perfusion pressure and regardless of the absolute IOP, suggesting a vascular mechanism to which the ganglion cells are less likely to recover (119). Patients with glaucoma in one study had reduced ERG amplitudes in response to a flickering stimulus (flicker ERG) (106). One study suggested that the flash and pattern ERG changes in glaucoma cannot be attributed simply to optic atrophy, suggesting additional outer retinal damage in glaucoma (120). Multifocal ERG (mfERG) (Fig. 6.1) permits simultaneous recording of multiple spatially localized ERG (121, 122). It consists of the same components as a standard ERG (123). Preliminary studies suggest that it does not appear to correlate well with glaucomatous damage and may be able to detect abnormalities before automated achromatic visual fields can (124, 125, 126, 127, 128 and 129).

Visual-Evoked Potentials

VEPs may also be abnormal in patients with chronic or acute glaucoma, although this is more variable than the PERG response (15, 99, 102, 103, 117, 130, 131, 132 and 133). However, larger diameter axons of the magnocellular pathway, which may be preferentially damaged in glaucoma (134), correlate with fast, transiently responding retinal ganglion cells, and a reduced response to high-frequency flicker VEP (greater than 13 Hz) has been shown to correlate with the degree of glaucomatous damage (135, 136, 137 and 138). Blue-on-yellow VEP may be useful in glaucoma research and may be an objective electrophysiologic test for monitoring patients with glaucoma (139, 140).

mfVEPs (Fig. 6.2) can be recorded simultaneously from many regions of the visual field and appear to provide objective measures of glaucomatous damage (94, 141, 142, 143, 144 and 145). The amplitude and waveform of the mfVEP responses vary across individual patients and within the visual field of an individual. Methods for analyzing the responses and for displaying the results of mfVEP compare the monocular responses from the two eyes of an individual and produce a map of the defects in the form of a probability plot, similar to the one used to display visual field defects measured with standard automated perimetry. It is hypothesized that both the signal in the mfVEP and the sensitivity of the Humphrey visual field perimeter are linearly related to ganglion cell loss (94).

New approaches will allow a direct comparison of the efficacy of the mfVEP and standard automated perimetry in detecting glaucomatous damage. For example, one study evaluated the reliability of VEPs, obtained with chromatic and achromatic patterns in healthy persons and patients

P.124

with suspected glaucoma without subjective visual field defects, and found that patients with suspected glaucoma had greater impairment of VEPs to blue-black checkerboards (146). The mfVEP may develop a significant role in the clinical management of glaucoma (145), although it is unlikely to replace static automated achromatic perimetry in the near future (142).

Figure 6.1 The multifocal elec-troretinogram (mfERG) display. A, top: The mfERG display with circles drawn to indicate radii of 5 degrees (thick, solid, dark gray), 15 degrees (thinner solid), and 25 degrees (dashed light gray). A, middle: A schematic of the eye illustrates where the image of the display falls. A, bottom: The three-dimensional mfERG density plot of the responses (E) from a normal subject. B: The mfERG display at one moment in time. C: The stimulation sequence of two sectors in. D: The single continuous ERG record generated by the display. E: The 103 mfERG responses (first-order kernel) extracted by correlating the stimulus sequence (C) with the continuous ERG record (D). (From Hood DC, Odel JG, Chen CS, et al. The multifocal electroretinogram. J Neuroophthalmol. 2003;23:225.) Steady-state VEP may be able to detect glaucomatous loss earlier than automatic achromatic perimetry can (63).

AFFERENT PUPILLARY DEFECT

A relative afferent pupillary defect offers yet another measure of visual pathway disturbance in glaucoma (147). It has been shown to be proportional to the amount of visual field loss and may precede

detectable field loss by static automated perimetry (148, 149 and 150). When pupillary status, such as marked miosis, prevents determination of relative afferent pupillary defect, brightness comparison testing has been shown to correctly predict the presence of a relative afferent pupillary defect in 92% of patients with glaucoma (151). Pupillary evaluation by using pupillometry and testing relative sensitivity between stimuli present in superior and inferior visual fields was able to correctly identify visual field defects in 70% of patients with glaucoma (152).

KEY POINTS

Some patients with glaucoma may have abnormal responses to brightness and contrast sensitivity (especially temporal) and color vision (especially blue sensitivity), although these findings are insufficiently consistent to have clinical value at this time.

Objective measures of visual function, including ERG and VEP, may also be abnormal in glaucoma patients and may one day provide useful clinical tools.

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Figure 6.2 A: The mfVEP display with 60 scaled sectors. B: The averaged mfVEP responses from the right and left eyes of 30 control subjects for 60 sectors. The circles on the right have radii of 2.6 degrees (inside), 9.8 degrees (middle), and 22.2 degrees (outside). C: The mfVEP display divided into 16 groups. Each group includes four sectors, except for the (center four groups, which include three sectors. D: The averaged mfVEP responses from the 30 control subjects summed by the 16 groups shown in panel C. E: The responses from panel B summed and averaged separately for the upper and lower field and summed and averaged for the entire field. The calibration bars in panels B, D, and E indicate 200 nV and 100 ms. (Reprinted from Hood DC, Greenstein VC. Multifocal VEP and ganglion cell damage: applications and limitations for the study of glaucoma. Prog Retin Eye Res. 2003;22:201-251, with permission.)

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