Multi-line Adaptive Perimetry (MAP): A New Procedure for Quantifying Visual Field Integrity for Rapid Assessment of Macular Diseases.

PurposeIn order to monitor visual defects associated with macular degeneration (MD), we present a new psychophysical assessment called multiline adaptive perimetry (MAP) that measures visual field integrity by simultaneously estimating regions associated with perceptual distortions (metamorphopsia) and visual sensitivity loss (scotoma).MethodsWe first ran simulations of MAP with a computerized model of a human observer to determine optimal test design characteristics. In experiment 1, predictions of the model were assessed by simulating metamorphopsia with an eye-tracking device with 20 healthy vision participants. In experiment 2, eight patients (16 eyes) with macular disease completed two MAP assessments separated by about 12 weeks, while a subset (10 eyes) also completed repeated Macular Integrity Assessment (MAIA) microperimetry and Amsler grid exams.ResultsResults revealed strong repeatability of MAP and high accuracy, sensitivity, and specificity (0.89, 0.81, and 0.90, respectively) in classifying patient eyes with severe visual impairment. We also found a significant relationship in terms of the spatial patterns of performance across visual field loci derived from MAP and MAIA microperimetry. However, there was a lack of correspondence between MAP and subjective Amsler grid reports in isolating perceptually distorted regions.ConclusionsThese results highlight the validity and efficacy of MAP in producing quantitative maps of visual field disturbances, including simultaneous mapping of metamorphopsia and sensitivity impairment.Translational relevanceFuture work will be needed to assess applicability of this examination for potential early detection of MD symptoms and/or portable assessment on a home device or computer

A Study on Ophthalmic Manifestations in Pituitary Gland Tumors

INTRODUCTION: Pituitary adenoma is a benign tumour that originates from the adenohypophyseal cells of the anterior lobe of pituitary gland. It accounts for 12% to 15% of all intracranial tumours. A spectrum of visual manifestations are seen with these tumours, ranging from the absence of any visual symptoms to severe visual field defects and loss of vision The clinical manifestations depend on the cell type of the tumour, hypo or hypersecretion of hormones, direction of local spread and compression of adjacent structures. Pituitary adenomas are of 2 types according to the size : microadenomas (≤10 mm) and macroadenomas (>10 mm). In comparison to men, women have a 2-fold increased risk of developing pituitary adenomas. Pituitary adenoma is a benign tumour, however, it has a tendency of recurrence. Clinical features of adenomas are either due to hypersecretion or hyposecretion of hormones or compression of pituitary adenoma to the surrounding structures. Pituitary gland is situated in the sella turcica, 10–13 mm below the optic chiasm. Therefore, when it increases in size, it can easily compress the optic nerve fibres at the chiasma. AIM OF THE STUDY: PRIMARY OBJECTIVES: 1. To study the various ophthalmic manifestations in cases of pituitary tumors. 2. To analyse the proportion of cases presenting with ophthalmic manifestations in cases diagnosed as pituitary adenoma on radiological imaging. SECONDARY OBJECTIVES: 1. To analyse the sensory visual disturbances like degree of visual loss, pattern of visual field defects and ocular motility defects, in diagnosed cases of pituitary adenomas. MATERIALS AND METHODS: Patients who are diagnosed with pituitary adenoma on radiological imaging, presenting in Squint and Neuro-ophthalmology services will be registered and evaluated during the study period. A detailed history of the patient, evaluation of visual acuity on a Snellen chart, extraocular movement and pupillary assessment, colour vision, visual field examination by 32 program on octopus field analyser octopus, slit lamp examination, and fundus examination will be done. INCLUSION CRITERIA: 1. Patients diagnosed as having pituitary tumour on radiological imaging 2. Age 25- 65 years. EXCLUSION CRITERIA: 1. Patients with other ocular pathologies affecting visual fields such as glaucoma, optic neuritis, retinitis pigmentosa. 2. Patients with pre-existing defective vision to due to other causes. 3. Patients with ocular media opacities. 4. Patients physically or mentally unfit for detailed ocular examination. SUMMARY: • Commonest Age group was more than 50 years (60%). Mean age 50.6 years. • Females were more commonly affected (72%). • Headache was the most common presenting complaint (80%). • Most of the Patients (62%) had visual acuity between 6/6 to 6/12. • Patients had Pituitary macroadenomas in 96% of cases compared to microadenomas. • Bitemporal hemianopia was the commonest visual field defect (57.9%). • 24% of the patients had no visual field defect. • 16% Patients had features of Optic Atrophy on Fundus examination. CONCLUSION: As the primary goal in the management of pituitary adenoma revolves around restoration of visual loss, a neuro-ophthalmic evaluation is essential for early detection, planning treatment and subsequent follow up. Although a bitemporal visual field defect is a pathognomonic ophthalmic finding in cases of pituitary adenomas, various other clinical features like headache, ophthalmoplegia, sensory visual disturbances, and other field defects were also noted in our study. Hence, a thorough clinical evaluation is warranted in pituitary adenomas

Strategies for improving early detection and diagnosis of neovascular age-related macular degeneration

Treatment of the neovascular form of age-related macular degeneration (AMD) has been revolutionized by the introduction of such agents as ranibizumab, bevacizumab, and aflibercept. As a result, the incidence of legal blindness occurring secondary to AMD has fallen dramatically in recent years in many countries. While these agents have undoubtedly been successful in reducing visual impairment and blindness, patients with neovascular AMD typically lose some vision over time, and often lose the ability to read, drive, or perform other important activities of daily living. Efforts are therefore under way to develop strategies that allow for earlier detection and treatment of this disease. In this review, we begin by providing an overview of the rationale for, and the benefits of, early detection and treatment of neovascular AMD. To achieve this, we begin by providing an overview of the pathophysiology and natural history of choroidal neovascularization, before reviewing the evidence from both clinical trials and "real-world" outcome studies. We continue by highlighting an area that is often overlooked: the importance of patient education and awareness for early AMD detection. We conclude the review by reviewing an array of both established and emerging technologies for early detection of choroidal neovascularization, ranging from Amsler chart testing, to hyperacuity testing, to advanced imaging techniques, such as optical coherence tomography

A case control study examining the feasibility of using eye tracking perimetry to differentiate patients with glaucoma from healthy controls

Abstract To explore the feasibility of using Saccadic Vector Optokinetic Perimetry (SVOP) to differentiate glaucomatous and healthy eyes. A prospective case–control study was performed using a convenience sample recruited from a single university glaucoma clinic and a group of healthy controls. SVOP and standard automated perimetry (SAP) was performed with testing order randomised. The reference standard was a diagnosis of glaucoma based a comprehensive ophthalmic examination and abnormality on standard automated perimetry (SAP). The index test was SVOP. 31 patients with glaucoma and 24 healthy subjects were included. Mean SAP mean deviation (MD) in those with glaucoma was − 8.7 ± 7.4 dB, with mean SAP and SVOP sensitivities of 23.3 ± 0.9 dB and 22.1 ± 4.3 dB respectively. Participants with glaucoma were significantly older. On average, SAP sensitivity was 1.2 ± 1.4 dB higher than SVOP (95% limits of agreement = − 1.6 to 4.0 dB). SVOP sensitivity had good ability to differentiate healthy and glaucomatous eyes with a 95% CI for area under the curve (AUC) of 0.84 to 0.96, similar to the performance of SAP sensitivity (95% CI 0.86 to 0.97, P = 0.60). For 80% specificity, SVOP had a 95% CI sensitivity of 75.7% to 94.8% compared to 77.8% to 96.0% for SAP. SVOP took considerably longer to perform (514 ± 54 s compared to 267 ± 76 s for SAP). Eye tracking perimetry may be useful for detection of glaucoma but further studies are needed to evaluate SVOP within its intended sphere of use, using an appropriate design and independent reference standard

Functional evaluation in inherited retinal disease.

Functional assessments are a fundamental part of the clinical evaluation of patients with inherited retinal diseases (IRDs). Their importance and impact have become increasingly notable, given the significant breadth and number of clinical trials and studies investigating multiple avenues of intervention across a wide range of IRDs, including gene, pharmacological and cellular therapies. Moreover, the fact that many clinical trials are reporting improvements in vision, rather than the previously anticipated structural stability/slowing of degeneration, makes functional evaluation of primary relevance. In this review, we will describe a range of methods employed to characterise retinal function and functional vision, beginning with tests variably included in the clinic, such as visual acuity, electrophysiological assessment and colour discrimination, and then discussing assessments often reserved for clinical trials/research studies such as photoaversion testing, full-field static perimetry and microperimetry, and vision-guided mobility testing; addressing perimetry in greatest detail, given it is commonly a primary outcome metric. We will focus on how these tests can help diagnose and monitor particular genotypes, also noting their limitations/challenges and exploring analytical methodologies for better exploiting functional measurements, as well as how they facilitate patient inclusion and stratification in clinical trials and serve as outcome measures

Optical coherence tomography measurement of retinal nerve fibre layer thickness and comparison with visual field analysis in patients with primary open angle glaucoma

INTRODUCTION: Glaucoma is among the leading causes of irreversible blindness in the developing world and a major health problem in the developed world. World Health Organisation statistics indicate that glaucoma accounts for blindness in 5.1 million persons, or 13.5% of global blindness. Primary open angle glaucoma is explicitly characterized as a “multifactorial optic neuropathy with a characteristic acquired loss of optic nerve fibres”, developing in the presence of open anterior chamber angles and manifesting characteristic visual field abnormalities in the absence of other known causes of the disease. AIMS AND OBJECTIVES: PURPOSE To quantitatively assess the retinal peripapillary nerve fibre layer using optical coherence tomography and compare with standard automated perimetry in eyes with primary open angle glaucoma. AIMS: • To quantitatively assess the retinal peripapillary nerve fibre layer in eyes with primary open glaucoma and evaluate its efficacy in diagnosing glaucoma • To correlate the retinal nerve fibre layer thickness with a diagnostic gold standard, in this case standard automated perimetry by Humphrey’s visual field analyser • To compare the efficacy of each of these investigations in diagnosing primary open angle glaucoma. • To investigate the agreement in glaucomatous damage detection between structural changes by OCT and functional alteration by automated perimetry. MATERIALS AND METHODS: A prospective study to quantitatively measure the peripapillary retinal nerve fibre layer using optical coherence tomography and compare it with standard automated perimetry using Humphrey visual field analyser in patients with primary open angle glaucoma was undertaken in the Department of Glaucoma Services, Aravind Eye Hospitals, Madurai. The study was conducted for a period of two years from1st July 2003 to 31st July 2005 during which time 76 eyes of 38 patients were studied and analysed. SUBJECTS - INCLUSION CRITERIA: Best corrected visual acuity of at least 6/12 or better Age < 60 years Patients diagnosed with Primary open angle glaucoma at the time of diagnosis or after investigation Open angles (angle grading >2 by Shaffer’s system) Patients cooperative for visual field analysis and OCT Refractive errors Myopia < -5D Hypermetropia < +3.5D Astigmatism < 2D EXCLUSION CRITERIA: Age > 60 years of age Closed angles by Gonioscopy Media opacities – cataractous lenticular changes, vitreous haemorrhage, corneal edema/ opacity - which preclude examination of the posterior segment Retinal pathology – advanced diabetic retinopathy, age related macular degeneration, retinitis pigmentosa, maculopathy. All secondary glaucomas All juvenile glaucomas All subjects had a complete ophthalmologic examination including thorough slit lamp examination, Gonioscopy, dilated direct and indirect ophthalmoscopy, intra ocular pressure measurement using Goldmann Applanation tonometry, central corneal thickness measurement and refraction. DISCUSSION AND CONCLUSION: This study was done to evaluate a relatively new diagnostic modality – the Optical coherence tomography in the diagnosis and management of Primary Open Angle Glaucoma (POAG). To achieve this we evaluated the association between functional findings as determined by perimetry, and structural findings as measured by OCT Peripapillary Nerve Fibre Layer (NFL) thickness. The assessment also included the correlation of OCT NFL measurements with ophthalmoscopically visible optic nerve head changes. The current study shows significant agreement of peripapillary NFL thinning measured by OCT and detection of glaucomatous optic nerve head changes by dilated slit lamp biomicroscopic fundus evaluation (p<0.000). High Area under Curve (AUC) (0.761) was found in the Receiver Operator Characteristic (ROC) for the peripapillary NFL thickness measurements in patients with primary open angle glaucoma with visible optic nerve head changes. In a significant number of eyes, i.e., 20.52 % (n=27) NFL thinning could be demonstrated by OCT even when visible optic nerve head changes could not diagnose the presence of POAG. This suggests that OCT could predict the onset of optic nerve head changes much before they become visible and may be used in the diagnosis of early glaucoma. OCT in the field of glaucoma may have a significant impact on its diagnosis and clinical management. In this way, the disease can be investigated a step closer to “where the action is,” at the level of the NFL, as opposed to determining if there are fewer axons among the hundreds of thousands making up the optic nerve in the 1.5 mm scleral canal. By direct investigation of the NFL with OCT, earlier diagnosis of glaucoma and earlier detection of glaucomatous progression should be possible, before conventional signs such as visual field loss, cupping of the optic nerve head, and NFL defects are evident, thus allowing earlier treatment and reducing the damage done by glaucoma

Structural and Functional Progression in the Early Manifest Glaucoma Trial.

PurposeTo elucidate the temporal relationship between detection of glaucomatous optic disc progression, as assessed by fundus photography, and visual field progression.DesignProspective, randomized, longitudinal trial.ParticipantsThree hundred six study eyes with manifest glaucoma with field loss and 192 fellow eyes without any field defect at the start of the trial, from a total of 249 subjects included in the Early Manifest Glaucoma Trial (EMGT), were assessed.MethodsEvaluation of visual field progression and optic disc progression during an 8-year follow-up period. Three graders independently assessed optic disc progression in optic disc photographs. Visual field progression was assessed using glaucoma change probability maps and the EMGT progression criterion.Main Outcome MeasuresTime to detection of visual field progression and optic disc progression.ResultsAmong study eyes with manifest glaucoma, progression was detected in the visual field first in 163 eyes (52%) and in the optic disc first in 39 eyes (12%); in 1 eye (0%), it was found simultaneously with both methods. Among fellow eyes with normal fields, progression was detected in the visual field first in 28 eyes (15%) and in the optic disc first in 34 eyes (18%); in 1 eye (1%), it occurred simultaneously.ConclusionsIn eyes with manifest glaucoma, progression in the visual field was detected first more than 4 times as often as progression in the optic disc. Among fellow eyes without visual field loss at baseline, progression was detected first as frequently in the optic disc as in the visual field

A new method to devise strategies for the visual field examination

Trattasi di un progetto di tesi che prevede la realizzazione, tramite MATLAB, di un modello generativo di pazienti virtuali sui quali è stato simulato l'esame perimetrico per l'acquizione del campo visivo. In questo modo, è stato possibile eliminare la soggettività tipica dell'esame perimetrico causata dalla risposta del paziente. I risultati ottenuti quindi hanno permesso di valutare le performance delle strategie (algoritmi) utilizzate con i valori reali