A comparison of tangent screen, goldmann, and humphrey perimetry in the detection and localization of occipital lesions

OBJECTIVE: To compare manual kinetic perimetry with tangent screen and Goldmann techniques and automated static perimetry with the Humphrey Field Analyzer in the detection and localization of occipital lobe lesions. DESIGN: Prospective consecutive comparative case series. PARTICIPANTS: Twelve patients with well-defined occipital lobe infarcts on magnetic resonance (MR) imaging were studied. MAIN OUTCOME MEASURES: The patients were tested by tangent screen, Goldmann, and Humphrey perimetry (central 30-2 threshold program). The three visual fields were compared and correlated with MR images. RESULTS: All three perimetric techniques detected the presence of postchiasmal lesions. However, localization of lesions differed with perimetric technique. Visual fields obtained from tangent screen and Goldmann perimetry were similar and corresponded well with the location of lesions on MR images in all 12 patients. Humphrey perimetry inaccurately localized the lesion to the proximal part of the postchiasmal pathway by revealing incongruous fields in two patients, failed to detect sparing of the posterior occipital cortex or occipital pole in four patients, and estimated a larger extent of damage in one patient when compared with MR images and manual perimetry. CONCLUSIONS: All three perimetric techniques are satisfactory screening tests to detect occipital lesions. However, tangent screen and Goldmann perimetry provide information about the location and extent of lesions that is more consistent with prevailing knowledge of the effects of the lesion in the postgeniculate visual pathway.     

Visual fields in neuro-ophthalmology

Visual field assessment is important in the evaluation of lesions involving the visual pathways and should be performed at baseline and periodically in the follow-up. Standard automated perimetry has been shown to be adequate in neuro-ophthalmic practise and is now the technique of choice for a majority of practitioners. Goldman kinetic visual fields are useful for patients with severe visual and neurologic deficits and patients with peripheral visual field defects. Visual fields are useful in monitoring progression or recurrence of disease and guide treatment for conditions such as idiopathic intracranial hypertension (IIH), optic neuropathy from multiple sclerosis, pituitary adenomas, and other sellar lesions. They are used as screening tools for toxic optic neuropathy from medications such as ethambutol and vigabatrin. Visual field defects can adversely affect activities of daily living such as personal hygiene, reading, and driving and should be taken into consideration when planning rehabilitation strategies. Visual field testing must be performed in all patients with lesions of the visual pathway.     

视觉刺激功能磁共振成像在枕叶病变患者中的初步应用

目的 观察枕叶病变患者患侧与健侧的功能磁共振成像（fMRI）特点，评价fMRI在视觉中枢功能性病变检查、枕叶肿瘤定位、手术入路选择以及切除范围方面的临床应用价值。设计 病例系列。研究对象 伴有同侧偏盲的视觉中枢功能性病变及单侧枕叶肿瘤患者各1例。方法 对上述2例患者应用自行设计的双眼棋盘格刺激（5Hz）行脑fMRI检查。所得数据应用SPM软件处理（P〈0．01），与Goldmann视野计检查结果相比较，验证视野损害与其大脑皮层投影改变的一致性。主要指标 统计参数图，脑激活图，激活脑区信号变化的时间曲线，与标准化T1像叠加的脑激活图。结果 在视觉刺激on时，枕叶视功能区激活；off时无信号；2例患者fMRI检查右侧视功能区激活明确，左侧视功能区无信号与视野检查双眼右半视野缺损相一致。结论 视觉刺激程序能够很好地引出视觉中枢fMRI；fMRI的检查结果与视野结果一致性较好；fMRI在视觉中枢功能性检查、枕叶肿瘤范围定位的确定方面有良好的临床应用前景。     

A comparison between Humphrey and frequency doubling perimetry for chiasmal visual field defects

PURPOSE: To evaluate and compare the diagnostic ability of frequency doubling technology perimetry (FDT) with standard automated perimetry (SAP) using Humphrey Field Analyser for the detection of visual field defects produced by chiasmal lesions. METHODS: Fifteen patients with documented chiasmal disease and previously diagnosed of bitemporal hemianopia with Humphrey perimetry were prospectively evaluated. All of them underwent a new SAP (SITA 24-2) followed by FDT tests (C-20 threshold). Diagnostic criteria for hemianopia were established according to the total deviation plot and the threshold values of FDT. A patient was diagnosed with hemianopia if one or both criteria were met. Based on these criteria, FDT sensitivity was calculated. Testing time and global indexes for both perimetric strategies were compared. RESULTS: The sensitivity of FDT was 75.0% (18 out of 24 eyes); the criterion based on threshold values was met more often (70.83%) than the criterion based on the total deviation plot (50.0%). Linear correlation was better for the external column than for the internal column of the visual field. Testing time with FDT was 122.16 seconds shorter than with SAP (p<0.001). The mean value for mean deviation (MD) was -13.62 dB (SD 6.88) for SAP and -8.83 dB (SD 5.94) for FDT (p<0.001). CONCLUSIONS: Compared with standard automatic perimetry, FDT has a low sensitivity for detecting temporal hemianopias and also has more difficulty in defining the vertical limits of the defects. Therefore, it does not appear to be an adequate method for the detection of chiasmal visual field defects.     

High-pass resolution perimetry in neuro-ophthalmology. Clinical impressions.

High-pass resolution perimetry is a new technique for visual field testing that determines extrafoveal resolution thresholds. The authors used this method in a neuro-ophthalmology clinic and compared it with other visual field tests. The main advantages of the technique were the short test time and the strong preference by patients for this technique over conventional automated perimetry. The sensitivity and specificity of the test seemed to be as good as or better than conventional perimetry. A minor disadvantage was its slightly less precise spatial definition of field defects. In this report, the authors present their experiences with this new perimetric technique.     

Macular sparing investigated by means of Haidinger brushes.

Haidinger brushes, an entoptic phenomenon perceived only through the most central macular retina, have been used in addition to kinetic and static perimetry with the Tubingen perimeter for determining macular sparing and splitting in hemianopic patients. Seven patients were examined: 2 with a bitemporal hemianopia resulting from traumatic damage to the optic chiasma, and 5 with a homonymous hemianopia resulting from extensive lesions of the optic radiations and/or the occipital cortex (including 2 cases of hemidecortication). On perimetric examination some exceptions could be observed in the correspondence of macular splitting and sparing respectively with pre- and postgeniculate lesions, but this was not the case when Haidinger brushes were used. Half of the figure was then perceived by the patients with lesions of the chiasma and the entire figure by all the patients with geniculostriate lesions. We consider that results obtained by this simple method are more reliable than those obtained by perimetry and that Haidinger brushes should be used for macular field examination in neuro-ophthalmic practice.     

Occipital lobe infarction after open heart surgery

The most common permanent neuro-ophthalmologic complication of cardiopulmonary bypass surgery is visual loss. Bilateral lower altitudinal visual field defects were documented in a patient who noted blurred vision following open heart surgery. A difference of opinion existed as to whether the field defects were due to retina-optic nerve or occipital lobe lesions. Two points are emphasized in this report: 1) the field defects were much easier to define on the tangent screen than on Goldman perimetry, and 2) occipital coronal high resolution CT scan confirmed bilateral upper bank calcarine cortex infarctions in this patient. Occipital coronal, thin-section, high-resolution computed tomographic scans are helpful in studying patients with occipital lobe visual field defects.     

Chiasmal syndromes

PURPOSE OF REVIEW: This review of the more recent literature and testing strategies in patients with chiasmal syndromes focuses on the clinical evaluation and management of these patients. Visual loss is often the initial manifestation of disorders involving the optic chiasm. Hemianopic defects and preferential involvement of the temporal visual field are the earliest and most common visual deficits. Progression of the lesion may cause compression of adjacent structures, including the optic nerves and cavernous sinuses, and may result in more profound visual loss, ocular motor deficits, and hypopituitarism. RECENT FINDINGS: Although a number of modalities have been used to assess visual function in patients with chiasmal disorders, perimetry remains the most effective means of detecting and following the visual deficit. SUMMARY: Most chiasmal syndromes can be categorized as intrinsic (thickening of the chiasm itself) or extrinsic (compression of the chiasm from an adjacent structure). Magnetic resonance imaging is the best mode of neuroimaging for most chiasmal lesions and may also provide clues to the etiology of an isolated chiasmal syndrome.     

Humphrey Matrix perimetry in optic nerve and chiasmal disorders: comparison with Humphrey SITA standard 24-2

PURPOSE: To compare the Humphrey Matrix 24-2 perimetry (Matrix; Carl Zeiss Meditec, Inc., Dublin, CA) with the standard automated perimetry Humphrey Visual Field Analyzer using SITA (Swedish Interactive Threshold Algorithm) program 24-2 (SAP; Carl Zeiss Meditec, Inc.) in neuro-ophthalmic disorders affecting the optic nerve and chiasm. METHODS: Matrix and SAP were performed on 93 patients with neuro-ophthalmic disorders affecting the optic nerve and optic chiasm. Three readers compared the total and pattern deviation probability plots and judged the similarity and the extent of the visual field defects. The sensitivity and specificity of both perimeters were calculated. RESULTS: Concordance was good in 61%, fair in 30%, and poor in 9% of the total deviation plots. For the pattern deviation, concordance was good in 52%, fair in 34%, and poor in 14%. The extent of field loss was equal in 50%, 23% more extensive with Matrix, and 27% more extensive with SAP for total deviation plots. For the pattern deviation, the extent was equal in 47%, 20% more extensive with Matrix and 33% more extensive with SAP. The sensitivity for detecting defects was 84% (SAP) and 77% (Matrix) for total deviation and 80% (SAP) and 79% (Matrix) for pattern deviation (no significant difference, P > 0.05). The specificity was 84% (SAP) and 86% (Matrix) for total deviation and 68% (SAP) and 74% (Matrix) for pattern deviation (no significant difference, P > 0.05). CONCLUSIONS: The new Humphrey Matrix 24-2 testing strategy provides a visual field testing method for optic nerve and chiasmal disorders that has fair to good concordance with the Humphrey SITA Standard 24-2 program. Both tests have similar sensitivity and specificity.     

The Role of Low Vision Rehabilitation in Neuro-ophthalmic Disease

Neuro-ophthalmic disease can cause a wide array of visual impairments. Management should include neuro-ophthalmic examination, patient education regarding visual prognosis, and evaluation of visual function. Often, low vision examination and rehabilitation are useful adjuncts to the neuro-ophthalmic evaluation. Components of a low vision examination pertaining to neuro-ophthalmology are discussed. Specific low vision management strategies are reviewed for patients with visual acuity loss, visual field loss, decreased contrast sensitivity, and ocular motor disturbances caused by neuro-ophthalmic disease.     

眼眶肿瘤和类肿瘤致视神经损害的自动视野分析

目的为明确眼眶肿瘤与所致视野损害之间的关系。方法应用自动视野计检查２２例眼眶肿瘤及肿瘤样病变患者。结果视野改变的形式多样，包括弓形暗点、下方视野缺损、中心暗点、颞侧观野缺损及弥漫性视野损害。手术切除肿瘤或皮质类固醇治疗后视野可全部或部分恢复。结论视野变化可反映视神经受损的严重程度，并为可逆性改变；眶深部肿瘤更易造成视神经病变，轴突性与血管性因素是这些损害的主要病理机制。     

Role of frequency doubling perimetry in detecting neuro-ophthalmic visual field defects

PURPOSE: To report the ability of frequency doubling perimetry to detect "neuro-ophthalmic" field defects, characterize them as hemianopic or quadrantanopic, and differentiate glaucomatous from "other" neuro-ophthalmic field defects. METHODS: Sixty eyes of 30 normal subjects, 50 eyes of 29 patients with glaucomatous defects, and 138 eyes of 103 patients with "typical" neuro-ophthalmic field defects underwent automated perimetry using the Swedish Interactive Threshold Algorithm and frequency doubling perimetry. The sensitivity and specificity for identification of a field defect (frequency doubling perimetry 20-5 and 20-1 screening tests), or to characterize hemianopia/quadrantanopia (full threshold test) were determined. Ability to discriminate glaucomatous defects was determined by comparing frequency doubling perimetry full threshold test in glaucoma to pooled results of normal and neuro-ophthalmic groups. RESULTS: On frequency doubling perimetry, a single point depressed to less than 1% probability had a sensitivity of 97.1% (20-5 test) and 95.7% (20-1 test) for detecting a neuro-ophthalmic visual field defect. The corresponding specificities were 95% using pooled results in normal subjects and patients with glaucoma and "other" neuro-ophthalmic field defects.In 20-5 screening a single abnormal point depressed to less than 2% probability level had a sensitivity of 98.6% (specificity 85%). Two abnormal points in the 20-1 screening depressed to less than 1% probability level had a specificity of 100% (sensitivity 84.8%).In frequency doubling perimetry full threshold, sensitivity and specificity for detection of hemianopia were 86.8% and 83.2%; for quadrantanopia they were 79.2% and 38.6%. The sensitivity and specificity for categorizing a defect as glaucomatous were 86% and 74.7%. CONCLUSIONS: Frequency doubling perimetry is a sensitive and specific test for detecting "neuro-ophthalmic" field defects. The presence of two abnormal points (20-1 screening program) "rules in" the presence of a field defect. A normal 20-5 program (absence of a single abnormal point) almost "rules out" a defect. Frequency doubling perimetry could not accurately categorize hemianopic, quadrantanopic, or glaucomatous defects.     

Therapeutic value of citicoline in the treatment of glaucoma (computerized and automated perimetric investigation)

The favourable neurotrophic effects obtained by means of the intramuscular administration of citicoline, one of the intermediate compounds of phospholipids, on the visual field of patients suffering from open-angle glaucoma are referred. The drug was administered at the dose of 1 gm for ten consecutive days. Visual field was examined by means of central computerized perimetry and automated perimetry. All patients had well controlled intraocular pressure through beta-blockers, but presented characteristic glaucomatous perimetric defects. It is suggested that citicoline might be administered as a useful complement to conventional hypotensive therapy, since it acts positively on the glaucomatous optic nerve damage.     

Efficiency of Rarebit perimetry in the evaluation of homonymous hemianopia in stroke patients

AIMS: To compare the efficiency of Rarebit perimetry and the Humphrey field analyser (HFA) in detecting the homonymous hemianopia in stroke patients with occipital lobe infarcts. METHODS: 40 patients who suffered from visual complaints caused by acute occipital lobe infarcts underwent visual field analysis on the same day, in random order-first with either Humphrey perimetry 30-2, SITA standard program (Zeiss Humphrey Systems) or Rarebit perimetry. A visual field was classified into four quadrants for right and left eyes: superior temporal, superior nasal, inferior temporal, and inferior nasal. The entire mean hit rate numbers (MHR) and mean deviation and pattern standard deviation (PSD) values were compared for each quadrant of each eye. RESULTS: The results of Rarebit MHR and HFA mean deviation values for each quadrant of the right and left eyes were highly correlated in all patients with homonymous hemianopia (Pearson's r correlation coefficients for superior temporal, superior nasal, inferior temporal and inferior nasal quadrants of right and left eyes were 0.827, 0.833, 0.843, 0851 and 0.746, 0821, 0882, 0.824, respectively (p<0.001 for all quadrants)). There was a strong correlation between Rarebit MHR and HFA PSD for each quadrant of both eyes. CONCLUSIONS: Rarebit perimetry is rapid, reliable, and easily performed in patients with homonymous hemianopia. It can be done using a simple software program and simple hardware and it readily detects severe visual loss in patients with occipital lobe lesions.     

New,sensitive window on abnormal spatial vision: rarebit probing

Clinical tests have a poor sensitivity to low to moderate degrees of neuro-visual damage, possibly because their test targets involve numerous receptive fields. A new test used briefly exposed microdots of high contrast. Multiple visual field areas were probed repeatedly, with ever-new microdot positions. Normal subjects responded to a median 96.0% of probes. Patients with different visual field defects missed larger numbers of probes within defects and the deeper the defects, the larger the number of misses. Patients with minor chiasmal lesions averaged 1.8 times larger defects in microdot perimetry than in high-pass resolution perimetry, indicating superior sensitivity to minor damage.     

Stellenwert einer perimetrischen Differenzialdiagnostik beim primären Offenwinkelglaukom

Functional deficits in glaucomatous optic neuropathy are, apart from other disturbances in the visual field, typically detected with achromatic perimetry as a well accepted gold standard. With the development of new perimetric devices and strategies (e.g. short wave perimetry, frequency doubling perimetry and flicker perimetry) individually different patterns of scotomas in the different perimetric devices could be recognized. The reasons for this could be a different sensitivity reaction of the ganglion cell subpopulations to an increased intraocular pressure as well as an influence of the underlying systemic diseases. To obtain a differentiated detection of the functional loss in the visual field in glaucoma, the use of different perimetric methods seems to be reasonable and helpful.     

Sarcoidosis of the anterior optic pathways. A diagnostic discussion

Two anatomo-clinical cases of neuro-ophthalmic sarcoidosis are reported where recognition of systemic involvement was delayed because unusual and quite isolate visual symptoms were present. The first patient had granulomas involving the intracranial optic nerve, presenting as optic nerve glioma. The second case presented as a chiasmal syndrome sharing unusual perimetric evolution. This binasal hemianopsia was probably the consequence of pre-chiasmal circulatory changes. Neuro-ophthalmic sarcoidosis should be included in the differential diagnosis of any involvement of the anterior visual pathways since these localizations are not as rare as was formerly thought. Improved awareness of this condition is a result of better neurodiagnostic studies by computed tomography which was not accurate enough a few years ago.     

Progressive visual field defects from experimental glaucoma: measurements with white and colored stimuli.

PURPOSE: Our purpose was to study the effects of using monochromatic test stimuli to measure the relative rate of progression of visual field defects caused by experimental glaucoma. METHODS: Visual field measurements were obtained by static perimetry from trained macaque monkeys with laser-induced, unilateral glaucoma. The visual field defects were assessed by perimetric (global) indices derived from comparisons of experimental visual fields to the expected normal fields of monkeys. Three types of perimetry stimuli were used, the conventional white Goldmann III and two monochromatic (460 and 620 nm) Goldmann V test stimuli. The relationships between field defects with white and monochromatic stimuli were investigated by linear regression of the Z-scores for the perimetric indices. RESULTS: The correlations between the mean deviation global indices for chromatic vs. white stimuli were high (r > 0.9) and linear throughout the period of progression of field defects. The slopes of the regression lines typically were greater than unity, indicating that statistical significance was higher for visual field defects measured with chromatic stimuli than with white light stimuli. The higher significance level for defects measured with chromatic stimuli was not explained by a difference in visual thresholds, because the thresholds with chromatic and white light were highly correlated across the full range of visual field defects, from initial-onset to end-state. This result also suggests that the early detection of glaucomatous visual defects with monochromatic stimuli does not reflect a selective loss of retinal ganglion cells. CONCLUSIONS: Although these experiments do not suggest an alternative neural mechanism for the clinical utility of perimetry with chromatic light for the early detection of glaucoma, it is very likely that the combinations of neural and/or analytical factors that explain the utility of perimetry with chromatic stimuli will also provide an explanation for the higher sensitivities in identifying early glaucoma reported for other prototype stimuli.     

Correlation between confocal tomography of the optic nerve (HRT) and the perimetric frequency doubling technology

PURPOSE AND METHODS: To correlate the five phases of optic nerve (ON) damage staging, as assessed by means of confocal tomography (HRT) with the five stages of visual field, assessed by conventional perimetry (standard automatic perimetry, SAP) and classified in five stages according to the "GLAUCOMA STAGING SYSTEM". The second step was to correlate the same optic nerve staging system with the results of the visual field tested with non-conventional perimetry using the frequency doubling technology (FDT) employing the Humphrey-Zeiss and Welch-Allyn perimeter. The five stages of FDT visual field data evolution were classified according to the new "FDT STAGING SYSTEM". MATERIAL: 58 visual fields of 58 consecutive selected patients with either ocular hypertension or glaucoma with an age-range between 15 and 65 years. METHOD: Visual field examination was performed with conventional (Octopus G2 threshold test) and non-conventional perimetry (FDT N30 threshold test), and the ON was assessed with confocal tomography (Heidelberg Retina Tomograph). RESULTS: In 40 % of the visual fields tested normal with conventional perimetry, non-conventional perimetry (FDT) detected glaucomatous visual field defects corresponding topographically with the optic nerve damage revealed by HRT. CONCLUSIONS: New non-conventional perimetric techniques such as FDT enable the very early detection of visual field defects topographically correlated to optic nerve damage.     

Functional magnetic resonance imaging of visual cortex in a patient with cerebrovascular insufficiency

We compare the findings of functional magnetic resonance imaging (MRI) of the visual cortex in a patient with moyamoya disease with other neuro-imaging techniques. Automated static perimetry demonstrated a slight depression of the left visual field in both eyes. MRI of the brain showed diffuse atrophy of the right cerebral hemisphere, sparing the occipital lobe. Single-photon emission computed tomography showed relatively preserved perfusion to the right occipital lobe. Functional MRI during visual stimulation, however, demonstrated an apparent lack of activation of the right primary visual cortex, which did not correlate with the known retinotopic map of the visual cortex. The patient seems to have had a lack of reserved ability to respond to visual stimuli with maximal autoregulatory vasodilatation in the visual cortex, even though apparent morphologic change and dense visual field defects had not been observed.