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N. K. Sahoo et al.
28.8 Conclusion
In conclusion, OCT and OCTA provide detailed
structural evaluation in a wide range of retinal
pathologies. Their use, as part of multimodal
imaging strategies, can support the diagnosis and
treatment-response evaluation of many retinal
conditions. In many cases, the noninvasive nature
of OCT and OCTA is signicantly advantageous
over dye-based angiography.
Funding Hyderabad Eye Research Foundation,
Hyderabad, India.
Disclosure GC: Speaker for Zeiss, Topcon
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Microperimetry
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29
KaraR.Grimes andJayChhablani
29.1 Introduction
Microperimetry, or fundus-tracked perimetry, is
a visual eld test to assess central retinal function. Current uses of microperimetry have been
built on early developments of non-automated
fundus- tracked perimetry. These devices have
subsequently improved with the innovation of
scanning laser ophthalmoscopy. Microperimetry
allows for the measurement of xation stability
and topographic characterization of visual function, enabling a correlation between retinal
structure and visual function. Using microperimetry, the sensitivity threshold of any point of the
retina can be matched with its clinical appearance in real- time. This method can therefore provide insights into disease progression and
severity, particularly in conditions that affect the
retina. This chapter comprehensively reviews the
history, technology, techniques, and clinical
application of microperimetry.
K. R. Grimes (*)
New York Medical College, New York, USA
J. Chhablani
Department of Ophthalmology, University
of Pittsburgh, Pittsburgh, PA, USA
29.2 Brief History
ofMicroperimetry
The introduction of perimetry to the eld of ophthalmology is credited to Albrecht von Graefe in
the mid-nineteenth century, building on the revolutionary work of the founder of the ophthalmoscope, Hermann von Helmholtz [1]. In 1856,
these early ophthalmologists used various xation points during fundus examinations to create
a visual eld plot [2]. Nearly a century following
these experiments, clinicians began publishing
documentation of retinal sensitivity while examining the fundus. Early devices permitting static
fundus-tracked perimetry were reported in the
late 1970s [3]. Subsequent key developments in
microperimetry were made following the invention of the scanning laser ophthalmoscope (SLO)
by Webb, Hughes, and Pomerantzeff in 1980 [4].
The originally designed SLO used a laser to illuminate a small area of the retina, employing a
novel principle in which light was collected from
one retinal point at a time [5]. This method facilitates repeated inspection of the retina and allows
the exact locus of each point to be viewed directly
by the clinician to measure acuity and investigate
macular disease [5].
The SLO 101 (Rodenstock Instrument GmbH,
Ottobrunn-Riemerling, Germany) was the rst
commercially available device supporting
fundus- tracked perimetry. In the following years,
Microperimeter 1 (MP-1, NIDEK, Gamagori,
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
T. Das, P. Satgunam (eds.), Ophthalmic Diagnostics, https://doi.org/10.1007/978-981-97-0138-4_29
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Japan) was more often used for fundus-tracked
perimetry. The MP-1 had real-time automated
full-threshold perimetry software, allowing fundus perimetry in a larger, color-visualized eld.
Although MP-1 was more reliable than SLO for
xation analysis, limitations of poor infrared
image quality and artifacts disrupting the test grid
on fundus imaging spurred further developments
on this instrument [6]. These technical limitations were addressed by the Macular Integrity
Assessment System (CenterVue, Padova, Italy),
which provided higher quality images and a
dynamic range of 36 dB compared to earlier
instruments. The Microperimeter 3 (Mp-3,
NIDEK) and Compass (CenterVue) were later
adaptations of previous devices that allowed for
mesopic (1.27 cd/m2) and photopic (10 cd/m2)
testing using liquid crystal display (LCD) and
light-emitting diode (LED) projectors, respectively. Additionally, various research groups have
developed custom-built devices for microperimetry to answer specic research questions [7].
MP-3, the Spectral Optical Coherence
Tomography (OCT) SLO (OPKO Health, Inc.,
Miami, FL, USA), the COMPASS, and the
Macular Integrity Assessment System (MAIA).
29.3.1 Analysis ofRetinal Sensitivity
The principal feature of microperimetry is the ability to present stimuli on a liquid crystal display
background at specic locations in the retina,
which allows for continuous visualization
(Fig.29.1a and b) of the retina [8]. Retinal sensitiv-
ity is measured as the minimal light intensity perceived by the patient when the retina is stimulated
by spots of light in specic areas. Each examination can differ with variable numbers of stimuli and
different elds of vision. In microperimetry, the
stimuli luminance is measured in apostilbs (asb),
which is an absolute unit of luminance equal to
0.3183cd/m2. The maximum intensity emitted by
the fundus-tracking perimeter is then used to create
the relative decibel (dB) scale (Fig.29.1c).
29.3 Technology
29.3.2 Decibel Scale, Weber’s Law,
The development of commercially available
microperimeters over the past 50years has been
largely based on standard automated perimetry
and has led to the widespread use of fundustracked perimetry. Yet, some factors of fundustracking are unique to microperimetry and vary
depending on the instrument. Currently, devices
used for microperimetry include the MP-1 and
abc
Fig. 29.1 Standard output given by the MAIA microperimeter for a healthy subject. (a) Point threshold values
overlaid onto a fundus image. (b) Heatmap output using a
radial interpolation with point threshold values. (c)
Weber’s law, Fechner’s law, and the decibel scale
are used to determine stimulus brightness in
microperimetry [7]. Weber’s law describes the
relationship between the smallest change in the
intensity of the light stimulus (∆I) and the initial
stimulus intensity (I). Based on the assumptions
Histogram of point threshold values and a mean sensitivity value for all points. (Reprinted with permission from
Josan etal. [8] Copyright 2021, Association for Research
in Vision and Ophthalmology)
Fechner’s Law

constant
I
I
∆
∆
∆
I
I
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Table 29.1 Commercially available microperimetry devices
Device
MP-1 2004; Nidek 1.27cd/m2128cd/m20–20dB Goldmann I,
OCT-SLO 2006; Optos 10cd/m2125cd/m20–20dB Goldmann III 4mm 29.7° 8Hz
MAIA 2015;
MP-3 2015; Nidek
COMPASS 2016;
Year;
manufacturer
CenterVue
co.,
CenterVue
Background
luminance
1.27cd/m21000 asb 0–36dB Goldmann III 2.5mm 36° 25Hz
31.4 asb 10,000 asb 0–34dB Goldmann
31.4 asb 10,000 asb 0–25dB Goldmann III 3mm 60° 25Hz
Maximum
stimulus
luminance
Threshold
range Stimuli Size
II, III, IV eV
I-V
Minimum
pupil size
4mm 22.5° 25Hz
4mm 40° 430Hz
Visual
eld
Tracking
frequency
389
of Weber’s law, Fechner’s law describes the proportional relationship between subjective sensation (∆S) and the logarithm of stimulus intensity.
In this equation, the maximal luminance of an
instrument (I
luminance (∆I=I
) is proportional to the differential
max
threshold
−I
Background
) [7].
Weber’s Law
K
=
()
Fechner’s Law
S
()
=
in dB x10 log
max
Data are interpreted according to Weber’s and
Fechner’s laws to determine the stimulus brightness in decibels (dB). Zero dB is dened as the
brightest stimulus that can be produced. Each
1dB increment corresponds to an attenuation of
the luminance in the stimulus by a factor of 1.26,
while 3dB corresponds to a two-fold attenuation
of luminance, and 10 dB corresponds to a tenfold attenuation as described by Pfau etal. (2021)
[7]. In the most widely used commercially available instruments, the stimuli can be presented
over a dynamic range of 0–20dB with a scotopic
background luminance of <0.03cd/m2, mesopic
background luminance of 1.27cd/m2, or photopic
background luminance of 10cd/m2. The decibel
scale is not standardized because maximal luminance can vary between instruments (Table29.1).
Additionally, some microperimeters, such as the
MAIA, color-code the decibel scale for interpretation, with “green” representing normal, “red”
representing abnormal, and “black” representing
a scotoma (Fig.29.1c).
Various stimulus patterns are used to test the
central visual eld. The fundus image is viewed
and tracked using an infrared fundus camera or
an infrared SLO throughout perimetric testing.
Concurrently, data from the visual eld is mapped
directly to the fundus image (Fig. 29.1a). The
minimal retinal sensitivity over a certain area is
then measured by projecting the light stimuli
over a specied spot several times at different
intensities. Stimuli vary in luminous intensity
and size, with the Goldman size III (0.43° and
4.0 mm2 area) being the most used size
(Table 29.1). The Goldman size IV stimulus
(1.72 and 64 mm2 area) is larger and is more
often tested in people with low vision or in scotopic conditions in healthy eyes.
29.4 Technique
Microperimetry measures the sensitivity of the
macula and allows examiners to perceive changes
as a diagnostic tool. Although this process is
automatic, the technician can have a substantial
impact on the outcome of the examination. The
following section will discuss common practices
to obtain the best results using microperimetry.
29.4.1 Adaptation oftheRetina
andPupil Dilation
Before beginning microperimetry, it is essential to allow the retina to adapt to the changing
light conditions. For mesopic (or twilight) testing, 10minutes of adaptation is sufcient after

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K. R. Grimes and J. Chhablani
exposure to a bright stimulus, such as fundus
imaging [9]. Contrastingly, adaptation to
mesopic lighting is not required following
exposure to ambient lighting [10]. Studies have
shown that mesopic microperimetry performance does not improve with increasing adaptation time beyond 20min [10]. Microperimetry
in scotopic (or dim-light) conditions requires
at least 20min of dark adaptation, particularly
for patients with retinal diseases [11].
Additional time (30–40minutes) is suggested
for older adults and/or those with Bruch’s
membrane damage [12].
The minimum pupil size needed for adequate
testing varies depending on the machine used.
Dilation requirements vary from ~2.5 mm to
~6mm, depending on the instrument (Table29.1)
[13]. The state of the eye must remain consistent
across examinations, irrespective of whether the
eye is dilated or undilated. No further preparation
of the eye is required.
29.4.2 Evaluation, Instruction,
andDuration ofTesting
During the evaluation, each eye is tested independently by covering one eye rst, then the
other. A customized stimulus grid may be
designed to evaluate a specic number of points
located at varying degrees from xation. The
patient must actively collaborate with the provider during the examination by pressing a button each time a light stimulus is perceived in
various positions on a screen. Some devices provide auditory feedback if the patient’s eyes
move out of alignment. Regardless of this feedback, the technician should continue to optimize
alignment throughout the examination. This
also applies to adjusting the plane of focus.
Although many devices will auto-focus, autoalign, and have automatic grid placement, manual input is necessary to ensure the optimal
focus and alignment are achieved at the most
accurate sensitivity.
The total duration of evaluation (for both eyes)
is approximately 25minutes. If consecutive tests
are being performed, a few minutes of rest
between the tests may be benecial to the patient
to minimize the effect of fatigue. Additionally,
the accuracy of microperimetry can be improved
if the patient receives adequate instruction and
practice.
29.4.3 Fixation Testing
Microperimetry devices use xation testing to
measure the ability of the eye to xate on the
preferred retinal locus (PRL). In patients who
lose central xation automatically, the next preferred spot is known as the PRL.The provider
can instruct the patients to nd the PRL quickly
(e.g., using ashcards) once the scotoma location, position, and size relative to the PRL have
been identied. Providers can then estimate
xation stability at the PRL, which can direct
intervention to improve functional vision.
Using xation testing, the precision of eye xation on a target can be evaluated, and xation
can be measured at a location up to 25 times per
second [14]. During testing, landmarks in the
retina are tracked and then plotted as xation
points over an image of the fundus, revealing
the portion of the retina used to see the stimulus
(Fig.29.2) [15].
29.4.4 Photopic, Scotopic,
andMesopic Conditions
The relative contributions of rods and cones to
vision vary across changing light intensities, with
most vision being mediated by the cone (photopic) system and the rod (scotopic) system contributing to the low-light vision. However, rods
comprise nearly 95% of retinal photoreceptors
and cones comprise less than 5%. The properties
of rods and cones are isolated in microperimetry
by the selection of background luminance.
Conventional microperimetry is typically performed under mesopic or twilight conditions in a
dim but not completely dark room. The rod versus cone function can be evaluated under photopic, scotopic, or mesopic conditions by selecting
the background luminance.

56
y (degrees)
a
c
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7.5
5.0
2.5
0.0
–2.5
12 15
x (degrees)
18 21
6
5
4
3
2
distance [°]
1
1234
Fixation Graph
time [minutes]
b
Fig. 29.2 Fixation in a healthy subject. (a) Custom 181-
point grid pattern with 0.5° spacing. (b) Three consecutive
examinations for an example participant: left, middle, and
right with xation on the target, xation off the target, and
repeat xation on the target, respectively. (c) Time-series
29.4.5 Follow-Up
Follow-up testing can be performed on the same
area of the retina using the same parameters as
previous tests. By re-measuring the same anatomical locations, changes in sensitivity and xation
xation graph detailing eye position throughout testing.
(Reprinted with permission from Josan et al. [15]
Copyright 2023, Association for Research in Vision and
Ophthalmology)
allow researchers to evaluate disease progression
and/or assessment of treatment outcomes. It is
important to remember that comparing xation
stability between machines is unreliable due to
inherent differences in stimulus/background contrasts and tracking frequency (Table29.1).

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29.5 Clinical Application
andInterpretation
Microperimetry is the technique of choice to
assess residual visual function. It has been used
to study macular degenerative diseases, including
age-related macular degeneration, diabetic macular edema, hereditary retinal dystrophies, and
macular dystrophies. This tool is also benecial
for the visual rehabilitation of people with low
vision, as its software can be used to train eccentric xation and stimulate a new preferred point
of view [16]. Additionally, microperimetry can
quantitatively examine the retina and allow early
surgical treatment of macular diseases, such as
retinal detachment and epiretinal membrane. In
this section, we provide an overview of the clinical application of microperimetry in completed
clinical studies and trials.
29.5.1 Age-Related Macular
Degeneration
Age-related macular degeneration (AMD) is
caused by damage to the macula. Globally, it is
the leading cause of blindness in adults over 50
[17]. This disease is categorized into neovascular
(wet) and non-neovascular (dry) AMD, with the
former referring to the late stage of the disease.
The current rst-line treatment for neovascular
AMD (nAMD) is anti-vascular endothelial
growth factor (anti-VEGF) injections. Although
OCT has been used to locate uid in the macula
and direct treatment, [18] this technique does not
provide information about the retinal function.
Microperimetry is a diagnostic technique that can
be used to evaluate the function of the retina in
people with AMD.
29.5.1.1 Neovascular Age-Related
Macular Degeneration
This progressive retinal degenerative disease is
characterized by neovascularization of the choroid [19]. The progression of the disease is slow
and may not be associated with a loss of vision
[20]. Available evidence suggests that an important predictor for visual outcomes in nAMD fol-
lowing treatment with anti-VEGF is the interval
between symptom onset and the initiation of
treatment [21]. By identifying early changes in
the retina, such as uid in the intraretinal and/or
subretinal space, treatments can be initiated earlier, improving the patient’s long-term visual outcomes. Microperimetry studies have evaluated
improvements in retinal sensitivity and changes
in scotoma size following anti-VEGF treatment
[22].
An early loss in macular function can be
detected by microperimetry before the development of signicant visual impairment and
has been reported as a predictor of the progression of AMD to the advanced neovascular stage
[23]. Other studies have used microperimetry
to detect changes in retinal sensitivity in
asymptomatic AMD and have measured a statistically signicant improvement in retinal
sensitivity within treatment-naïve cohorts [20,
22]. These ndings, and those reported in anti-
VEGF studies, may be subjective because there
is a learning curve with microperimetry in
which retinal sensitivity can improve with
repeat testing [24].
Larger studies, such as the Laser Intervention
in Early Stages of AMD (LEAD) study, used
microperimetry to detect the onset of nAMD
[25]. Although microperimetry was the best
method to detect nAMD in this study, further
ndings revealed no signicant difference
between microperimetry and best corrected
visual acuity in detecting the onset of nAMD due
to low sensitivity ranges (between 11% and
35%) [25]. Other studies found that scotopic
sensitivity is a better functional indicator for
evaluating early and intermediate AMD progression than mesopic sensitivity [26]. Although scotopic microperimetry takes longer and requires
prior dark adaptation, this method is more sensitive in detecting and differentiating changes in
rod and cone cells [26]. Conversely, mesopic
microperimetry was better than scotopic perimetry in predicting AMD progression through
morphological changes [27]. Both scotopic and
mesopic testing were more sensitive to changes
during early AMD than intermediate or advanced
AMD [27].

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Larger longitudinal studies are needed to continue tracking the progression of AMD using
microperimetry. Although it is a useful tool in
evaluating changes in the early stages of AMD,
the ability to detect such changes using microperimetry can be improved by using patient-tailored
perimetry patterns that allow for an increased
density of test points [7, 12].
29.5.1.2 Non-Neovascular Age-
Related Macular
Degeneration
andGeographic Atrophy
Microperimetry has frequently been used as an
alternative to best corrected visual acuity (BCVA)
to measure the foci of geographic atrophy (GA)
(Fig. 29.3). These foci often present as fovealsparing scotomas in non- neovascular AMD [12].
Multiple studies have used this technique to
determine the number of scotomatous loci and
the mean sensitivity of the macula as an alternative to BCVA [28]. One of the rst known studies
assessing macular function using microperimetry
examined the eye following lutein supplementation in patients with non-neovascular AMD [29].
Microperimetry measurements demonstrated a
tendency toward improvement in macular function although the effect did not reach statistical
signicance [29]. Other assessments of retinal
sensitivity using microperimetry are subthreshold laser treatment for GA secondary to AMD,
[30] retinal sensitivity at different stages of AMD
[31], and following administration of medications such as elamipretide [32].
29.5.2 Diabetic Retinopathy
andDiabetic Macular Edema
raphy, contrast sensitivity, low- luminance visual
acuity, and microperimetry [34]. Eyes with DR or
diabetic macular edema (DME) can have normal
visual acuity despite reduced retinal sensitivity,
suggesting that changes in sensitivity may precede reductions in visual acuity (Fig.29.4) [35].
Functional testing of macular sensitivity using
microperimetry can assess disease severity and
response to therapy by quantifying functional
loss due to extrafoveal macular edema or ischemic diabetic maculopathy. Studies using microperimetry have demonstrated that patients with
DR have signicant loss of retinal sensitivity as
compared to healthy individuals (p<0.001); the
decrease in sensitivity is more apparent with
increasing severity of DR. [36] The decline in
retinal sensitivity has been correlated with the
decreased thickness of the nerve ber layer, [37]
the photoreceptor layer measured by OCT, [37]
and the severity of neuropathy [38]. However,
other studies have found only a weak association
between the structural and functional decits in
early-stage DR, suggesting that other mechanisms, in addition to retinal thinning, may underlie the functional defects [39].
Most microperimetry studies for DR and diabetic maculopathy are done with pre-established
patterns that study 20° of central vision. Other
studies created a customized grid that was superimposed with OCT-A. Although this method
offers point-to-point structural and functional
correlations for a detailed evaluation, the ndings
have been inconsistent; this may be due to differences in the test populations and the instruments
used [40]. Microperimetry can also detect
decreased retinal sensitivity in patients without
macular edema, without DR, and in
pre-diabetics.
The long-term effects of diabetes mellitus can
lead to diabetic retinopathy (DR), causing damage to the retina and, potentially, blindness [33].
Diabetes is associated with asymptomatic vascular damage that can progress before clinical signs
appear. Proposed tests to detect early functional
and structural abnormalities in DR include optical
coherence tomography (OCT) and OCTangiography (OCT-A), multifocal electroretinog-
29.5.3 Stargardt’s Disease
Stargardt’s disease type 1 (STGD1) is the most
common cause of juvenile macular dystrophy
caused by biallelic mutations in the ABCA4 gene.
An early diagnosis may be established using
multimodal imaging, but patients can be easily
misdiagnosed and subjected to multiple tests and

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b
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Manual registration
MP-3 color fundus
K. R. Grimes and J. Chhablani
SLO
Fovea center
MP grid alignment
MP grid positions
Manual keypoints
Fig. 29.3 Aligning microperimetry with scanning laser
ophthalmoscopy (SLO) image to measure retinal sensitivity
in in dry AMD. (a) User-selected key points in the color fundus photograph (CFP) and at the same anatomic location in
the SLO (red crosses) to align CFP with SLO. (b) Fovea cen-
therapies. Typical disease progression spares the
peri-capillary and foveal regions and presents
with bilateral central vision loss with variable
degrees of macular atrophy. As such, BCVA is
ter position and scaling of the grid were manually set such
that microperimetry measurement locations matched with
CFP (left). Final locations are presented on SLO to the user
for validation (right). (Reprinted with permission from Reiter
etal. [31] Copyright 2023, Springer Nature)
insufcient in quantifying the functional loss
over time. The visual function outcomes
generated by microperimetry have been used in
Stargardt’s disease treatment trials, specically to
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