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FIELD & FUNDUS

DR. REZAUL MURSHED
M.B.B.S(DMC)D.O(D.U)
AHMAD MEDICAL CENTER
DHAKA BANGLADESH
Fax: 00-88-02-8117364
E-mail:
amc@bol-online.com
HISTORY
  • 450 BC: HIPPOCRATES describe HEMIANOPIA
  • 150 BC: Ptolemy estimating the outer limits of the Visual field
  • 1668: EDME MARIOTTE discover blind spot.
  • 1856: Clinically campimetry first started by Graefe.
  • 1851-1920: Prof.J.P.Bejerrum of Copenhagen devised Tangent screen. He drew his first screen on the back of his door. He also first described Arcuate scotoma, Bjerrum/Tangent screen was popular in USA for 100 years.
  • 1869: Forster and Aubert developed an arc perimeter. It was very popular and became known as Forster perimeter.
  • 1945: First Cupola perimetry was designed by Professor. Hans Goldman, Bern.
  • First Automated Static perimetry also came out from Switzerland, Bern.
  • First Automated Octopus 201 in late 1970 room size costing excess of US $ 100000 for unknown technology. And high cost kept perimetry in "IVORY TOWER".
  • 1982: First Humphrey field analyzer was displayed at "AAO"
  • 1983: Production unit delivery began. Because of small size & low cost the machine became very popular
  • Key Issue

    Understanding the Principles

    HUMPHREY IS GOLD STANDARD

  • To learn about perimetry is to understand the basic characteristics of the visual field.
  • With this knowledge the data and the results from all perimeters can be interpreted.
  • GOOD THINGS ARE CHEAP BUT CHEAP THINGS ARE NOT GOOD

    STATIC vs KINETIC

    STATIC

    1. Quantitative
    2. VFD detected earlier than kinetic, with 20% nerve damage
    3. Area is fixed but Stimulus varies in intensity
    4. Three dimensional
    5. Computerized
    6. Threshold type
    7. Less Error
    8. Quality & Expensive
    9. Good both for Glaucoma & Neurological

    KINETIC

    1. Qualitative YES/NO
    2. VFD when 40% nerve damage
    3. Fixed stimulus seen from seeing to non seeing, area is not fixed.
    4. Two dimensional
    5. Not Computerized
    6. Non Threshold
    7. Man behind Perimeter
    8. Not used so much
    9. Good for Neurological
    WHAT IS PERIMETRY

    Is the measurement of the differential light Sensitivity of the retina at a defined number of Locations.

    HOW TO INTERPRET THE HUMPHREY FIELD FOR GLAUCOMA & NEUROLOGICAL CASES

    WHEN WILL YOU SEND A PATIENT FOR FIELD?

  • ELEVATED IOP
  • SUSPECTED OPTIC NERVE
  • ASYMMETRIC CUP:DISC > 0 .3
  • IOP DIFFERS 3mmHg FROM OTHER EYE
  • UNEXPLAINED LOW VISUAL ACUITY
  • UNEXPLAINED HEADACHE
  • GLAUCOMA IN OTHER EYE
  • PREVIOUS RETINAL DETACHMENT
  • H/O OCULAR TRAUMA
  • SUSPECTED OR ESTABLISHED GLAUCOMA

    1. OPTIC NERVE HEAD CHANGE OR NERVE FIBER LAYER DEFECT
    2. VISUAL FIELD DEFECT
    3. RAISED INTRAOCULAR PRESSURE


    WHEN ONE OF THE THREE IS SEEN THEN GLAUCOMA IS SUSPECTED.
    WHEN ANY OF THE TWO ARE SEEN THEN GLAUCOMA IS ESTABLISHED.

    GLAUCOMA SUSPECT BY THE EUROPEAN GLAUCOMA SOCIETY
  • NTRAOCULAR PRESSURE <21 mmHg
  • NO VISUAL FIELD CHANGE
  • SUSPECTED OPTIC NERVE WAS DEFINED AS RIM AREA THINNING <2 CLOCK HOURS,EXCAVATION OF THE OPTIC NERVE HEAD THAT WAS NOT UNDERMINED BUT SEEMED PUNCHED OUT.
  • OCULAR HYPER TENSION

  • Peak IOP >21mmHg, on a diurnal day curve.
  • No Visual field defect
  • No optic nerve head change or Nerve fiber layer defect (NFLD).
  • AAO Vol. 109,Number 3,March 2002

    NORMAL GROUP

  • INTRA OCULAR PRESSURE <21 mmHg
  • NO VISUAL FIELD CHANGE
  • NO OPTIC NERVE HEAD OR RETINAL NERVE FIBER LAYER CHANGES SUGGESTIVE OF GLAUCOMA
  • NO INTRA- OCULAR DISEASE OR INTRA OCULAR SURGERY
  • NO H/O HYPERTENSION, DIABETES.
  • NO FAMILY HISTROY OF GLAUCOMA.
  • AAO VOLUME 109,NUMBER 3,MARCH 2002


    The Eye Care America Glaucoma Project

    Is your patient or their family at Risk for Glaucoma? Score below to see.

    1.Family History (Chose one) No F/H
    0
    Parent & Child has glaucoma
    2
    Siblings
    4
    Parents & Siblings
    4
    2.Race(Chose one) Caucasian
    0
    Hispanic
    1
    Black
    3
    3.Age(Chose one) <40
    0
    39-49
    1
    49-59
    2
    59+
    4

    To Score: Add one score in each of the above categories. If you have a total score 4 or higher, you have a high risk for having Glaucoma.

    GREATER RISK OF GLAUCOMA

    • OLDER THAN 45 YEARS
    • A FAMILY HISTROY OF GLAUCOMA
    • HIGH INTRAOCULAR PRESSURE
    • DIABETES
    • MYOPIA
    • USED STEROIDS FOR LONG TIME
    • HAD A PREVIOUS EYE INJURY

    Risk Factors

    Now CCT

    • Family History
    • Older Age
    • Race

    THRESHOLD

    THRESHOLD IS THE CRUCIAL CONCEPT IN PERIMETRY

    Threshold is the dimmest stimulus seen by the a subject,50% of the time. Measured in decibels(dB) in automated perimetry. Higher the dB minimum is the light, lower the dB (0dB) brightest is the light.


    0dB=Brightest light
    40dB=Dimmest light



    The Threshold of Sensitivity

    The threshold is the crucial concept in perimetry. The threshold is the dimmest Light seen by a subject, 50% of the time.

    • The threshold is not a distinct borderline. It is a transition region from seeing to not seeing like the transition from daylight to darkness.

    NORMAL THRESHOLD VALUES

    First four paracentral points are 3 º from vertical & horizontal lines,12.7 º from the fixation point & next all stimulus points are 6 degree apart.

    Maximum threshold is at the fovea say,35dB dimmest light, with each degree to periphery threshold decreases by .03 dB.



    STRATEGY/METHOD/TECHNIQUE HUMPHREY HAS MANY OPTIONS

    FULL THRESHOLD
    1983
    Normal 12-20 Min
    FASTPAC
    1991
    Normal 10-15 Min
    SITA
    1997


    SITA STANDARD= FULL THRESHOLD Normal 5-8 Min
    SITA FAST= FASTPAC Normal 3-5 Min

    • Printout
    • Single field analysis
    • Over view

    STRATEGIES ARE

    FULL THRESHOLD
    1983
    20-30 Min
    FASTPAC
    1991
    14-20 Min
    SITA
    1997


    Swedish Interactive
    Threshold Algorithm 5-8 Min

    SITA

    • SWEDISH INTERACTIVE THRESHOLD ALGORITHM
    • From MALMO UNIVERSITY OF SWEDEN 1997
    • Developed by Anders Heijl & Boel Bengtsson and group over 10yrs period.
    • New test Algorithm (a set of rules or procedures that must be followed in solving a particular problem)
    • Beginning of test estimates based on normative data.
    • Testing based on a model of "estimates" of normal and glaucomatous fields.
    • SITA knows when to quit, it computes when to stop at each test location. SITA compares with a Senior Professor. Spends more time when unsure of the result and spends less time when with consistent result.
    • SITA is time saving but results are equivalent to FULL THRESHOLD(SS) or FASTPAC(SF). Calculations are done after the test, so there is less fatigue for the patient.
    • There are two types of SITA STANDATD(SS) or SITA FAST(SF) like, TOP (Tendency oriented perimetry of OCTOPUS)


    SITA STANDARD 24-2

    • IS
    • SIMPLE
    • SHORT
    • SUPER
    • SOUND
    • SOLID
    • SCIENTIFIC
    • SINGLE FIELD ANALYSIS
    • SMART
    • SENIOR PROFESSOR
    • BOTH FOR GLAUCOMA & NEUROLOGY
    • USED ALL MOST ALL OVER THE WORLD

    SO USING FASTER STRATEGIES

    • SHORT TEST PROCEDURES :-

    Reduce the fatigue effect caused by both

    1. Retinal fatigue
    2. Physical fatigue

    Therefore a quicker test can be more reliable and accurate compare to testing with longer elaborate test strategies.


    Types of Glaucomatous field loss

    • First field loss was described by Albrecht von Graefe in 1856
    • A decade later, he demonstrated preservation of the temporal and central regions in advanced glaucoma.
    • Later,Bjerrum(1889) & Ronne(1909) demonstrated the presence of arcuate field defects, and nasal steps.
    • The very large study by Aulhorn and Harms in 1967 demonstrated the importance of paracentral defects as an early sign of glaucoma.

    Aulhorn's & Harms' classification of glaucomatous field loss

    • Isolated paracentral scotomas
    • Bjerrum's scotoma
    • Bjerrum's scotoma breaking through to the periphery
    • Central or temporal island
    • Blindness

    THE KEY PATTERN DEVIATION PLOT CHART




    Scotomas are seen in the Suspected & Expected zones

    LOOK ONLY LOWER RIGHT DEVIATION PLOT CHART




    SINGLE FIELD ANALYSIS

     

    SINGLE FIELD ANALYSIS




    1. Name,ID ,DOB,R/L, pupil size& age. Next is SIX IN ONE
    2. Upper left Parameters, Stimulus size, back ground 31.5 dB, Catch trial Pupil dia, V.A. Near Correction, Date, Time, Age
    3. Upper right GRAY SCALE
    4. Upper left next to Gray scale is NUMERIC DATA, this is the raw data printed in numbers that express the patient's response in dB.
    5. A. This segment is expressed numerically and probability Plots (5B) of abnormality demonstrates how the patient's responses deviated from known normal patients of their age. Middle left (5A) aged matched Numeric data. lower left aged matched probability plot (5B)
    6. A.PATTERN DEVIATION : This is the KEY PLOT. The pattern deviation fine tune and enhance the total deviation data. It corrects total deviation from any media opacity (cataract), miotic pupil. It also displayed as both a numeric (6A) difference and with probability analysis Plots(6B).Any real localized defect is seen in this plot. Middle right Numeric data & Lower right( 6B ) probability Plot chart (Actual picture of the patient)

    EVALUTING OF A SINGLE FIEL

      1. General information
    2. Reliability indices
    3 &4. Raw data and gray scale
    5. A & B Total deviation
    6. A & B Pattern deviation
    7. Global Indices (MD & PSD)
    8. Glaucoma Hemifield test (GHT)
    9. Gaze Tracking



     

    If you can correlate the disc with Pattern Deviation Probability Plot THAT'S ALL.

    HERE CUP V>H Thin sup NRR gives inf. arcuate Scotoms which later joins the inf nasal step. Here superior nasal step is also seen. An established case of early POAG. She had strong F/H & raised IOP.


    KEY POINTS

    • Combined evaluation of Optic disc & Visual field
    • The defect should be reproducible, in particular peripheral defects in the first visual field should be confirmed before accepted.
    • The shape of the field defect should correspond to retinal nerve fiber anatomy.
    • The defect should correspond to changes at the optic disc.
    • Diffuse loss is more likely to be due to cataract or more miotic therapy in glaucoma.


    PATTERN DEVIATION PLOT CHART

    IF YOU CAN ONLY READ THE PATTERN DEVIATION PROBABILITY PLOT CHART 6B THATS ALL.
    OF COURSE IT MUST CORRELATES WITH THE DISC



    Time : If it exceeds its normal then it's likely to be a Path. VF SS 5-8 Min SF 3-5 Min

    UPPER LEFT

    Fixation Monitor/Gaze Blind Spot: On the upper left side of the printout. Patient's eye is monitored by fixing the eye towards a yellow light. At the beginning of the test after fixation 5% of the supra threshold a type of stimulus is given on the B.S. to find out central fixation. This is called HEIJL-KRAKOW method. Here fixation target is central. If there is any macular pathology instead of central fixation we choose small diamond or large diamond just below the central fixation. (See Slide 31).

    FL is a tricky thing. It should be within 20%,but it will be a reliable VF with high FL, but low FP & FN.

    FP TRIGGER HAPPY it should be below 10%.It means that the pt. pressed the switch without seeing the light.

    FN First a low intensity light is seen. At the same point a brighter stimulation (more than 9dB) is given to see if Pt. is alert or not. Its normal value is 15%but in Path. Condition it goes up above normal level.

    INSIDE HUMPHREY PERIMETER

    A lesion in the retina is twenty times magnified in the bowl Optic nerve is 1.5mmx20=30mm which seen in reduced form.

    RELIABILITY PARAMETERS

    UPPER LEFT SIDE
    Normal
    FIXATION LOSS
    20%
    FALSE POITIVE
    10%
    FALSE NEGATIVE
    15%

    FOVEAL THRESH HOLD

    20 yrs. 35 dB
    30 yrs. 34 dB
    70 yrs. 30 dB
    FT decrease 1 dB per 10 yrs.

    If FT measures above 30 dB V.A. will be above 6/12
    0 dB=Brightest light in moon Lit night 40 dB= dimmest light

    Octopus Decibels HUMPHREY
    40
    50
    30
    40
    0
    10

    FP=It is better to omit than to commit

     

    UPPER RIGHT GRAY SCALE

    This is a "HOLISTIC" overview on the displays the patient's responses in various shades of grey instead of printing numeric data. It is of little clinical value. In octopus it is colored. From gray scale it is hard to pick out THE WHEAT from Chaff.


    SEARCHING FOR A
    NEEDLE IN HAY
    STACK



    A GLANCE GUESS FROM GRAY SCALE

     

     
    Typical clover leaf pattern FN 42% (Unreliable field). Think of other peripheral Constricted field.
    Young lady of 30yrs. V.A.6/6, F.L 29%, FP 25% & FN 59%. GHT O.N.L .A case of MALINGERING. Both Fundus ARE NAD.
     

    This 56 yrs. middle aged lady whose rt. eye vision is 6/9 FT 32 dB. Only a small nasal NRR persists which represents a small central vision with a small temporal island of vision remains, all other parameters are excellent.

     

    ONLY GROSS DEFECT

    This young lady of 23 is an established case of RP. Her both discs are pale with jet black spots in the peripheral retina, parents were cousins, sister and brother, H/O night blindness,V.A.6/6 with very good FT 37 dB, D/D 1.R.P 2.lens rim defect 3.Retinoschisis 4.Pan retinal photo coag 5Peripheral retinal degeneration 6C.R.O ..7.Aphakic glass.

    GRAY SCALE


    Early Nasal Stap


    Deformed Disc


    Paracentral Scotoma


    Typical Sup Arcuate Scotoma From B.S to Join Sup Nasal Step

     

    TYPES OF SCOTOMAS

     



    CREENING TEST





    A screening test of the same RP case. Two zones with central and peripheral ref. were 34dB.Out of 120 points pt. sees only 59 points R/E & 40 points in L/E.It's a suprathreshold type of test. A threshold test should be performed when a pt. cannot see 10 points out of 120 points or at any area 2 or 3 adjacent points of non seen points are detected.


    SCREENING PROGRAMS HFA II

    TEST PROG
    AREA & POINTS
    APPLICATION
    CENTRAL 76
    30 °
    GLAUCOMA
    76 Points
    Neurological
    Full Field 120
    60 º
    General
    120 Points
    Glaucoma
    Neurological

    SCREENING FOR GLAUCOMA MAJOR POINTS

    • No single good screening tool for Glaucoma exist.
    • Tonometry suffers from a poor balance between sensitivity and specificity.
    • Optic nerve head examination requires skilled observers and does not have a defined end point.
    • Perimetry is expensive, and has a learning curve.

    NAME DOB ID



    V.A 6/6 B/E

    IOP Normal

    C;D

    Rt. .4

    Lt. .6

    Plan

    Repeat VF

    By mistake her DOB was given 1969, instead of 1959.Gray scale shows slight Deep GHT GRS. But when her exact DOB is given 1959,GHT is WNL. So, always give Correct DOB as well as last corrected distance vision.

    BUT THIS IS A HIGHLY SUSPECTED FIELD.

     

    PUPIL SIZE 3 TO 7 mm


    One EYED

    established

    POAG ON

    Anti Glaucoma Drug

    First field done 2.1 2 nd VF 3.9 mm pupil


    All fields should be done with normal reacting pupil within 3-7 mm in size. Dilated pupil gives less false result than the small pupil. So, please check pupil size before seeing a Visual field (VF) Humprey's latest version 12.3 will give you the pupil size on the screen before starting the field.


    PUPIL SIZE

    • AREA OF CIRCLE = x r2
    • 2mm Pupil Area=3.14 x 1 mm2=1 mm2
    • 8mm Pupil Area=3.14 x 4 mm2=16 mm2
    • SO,IF YOU SHIFT PUPIL FROM 2mm TO 8mm, YOU WILL GET AN INCREASE OF 16 FOLD AREA OF THE PUPIL SIZE
    • SO,WIDE VARIATION OF THE PUPIL SIZE WILL GIVE YOU A FALSE VISUAL FIELD DEFECT, SO PUPIL SIZE SHOULD BE BETWEEN 3 mm TO 7 mm AND IT SHOULD REACT TO LIGHT ON PUPIL .

     

    GHT & PROBABILITY

     

    <5% = Significant

    <0.5% = More Sig.

    IN THE LOWER
    MIDDLE

    GHT- This test assumes that glaucoma does not cause a generalized Global depression of the field of vision. It takes advantage of the asymmetric field loss pattern generally seen in glaucoma. The test analyses defects in the superior hemi field and makes comparison with mirror image locations in the inferior hemi field.

    1. GHT may be OUT SIDE NORMAL LIMIT (ONL)
    2. BORDER LINE (BL)
    3. GENERAL REDUCTION OF SENSITIVITY (GRS)
    4. ABNORMALLY HIGH SENSITIVITY
    5. WITH IN NORMAL LIMIT (w.N.L)

     

    GHT

    The GHT has been evaluated by both Peter Åsman and Heijl(1992) and by Katz(1996). IT WILL GIVE YOU FIVE RESULTS.

    1. Abnormally high sensitivity. The general height of the field is beyond the 99.5% limit for normal.
    2. Out side normal limits (ONL) - The asymmetry is beyond the 99% limit for normal in any of sector pairs. If seen twice in two consecutive fields early glaucomatous defect criteria by "Anderson".
    3. Borderline (BL) - The asymmetry is beyond the 97% limit for normal in sector pairs. It's not a pathological field.
    4. General reduction in sensitivity (GRS) - The general height is below the 0.5% limit for normal. Seen in Cataract, High Myopia, Media opacity, Dilated pupil.
    5. Within normal limits (WNL) - When none of the above four criteria are seen.

     

    GAZE TRACKER

    By seeing this tracing at lower end of the field you can judge whether the fixation is OK or not.

    SEEN JUST BELOW THE GRAY SCALE

    GLOBAL INDICES MD (Mean deviation) Or mean defect- The mean deviation is the average difference between the patient's overall sensitivity and that of age matched controls. High MD seen in case of Normal:

    1. Cataract
    2. Miosis
    3. Ref.error
    4. Fatigue

    Then PSD will be normal.

    AT THE BOTTOM OF THE FIELD

    PSD: Is an index of unevenness in amount of field calculated from Pattern deviation Plot chart. (Normal up to 2.5)


    INTERPRETATION CRITERIA INTERPRETATION CRITERIA

    • THE REASON FOR DOING FIELD.
    • CORRECT DATA AND RELIABLE FIELD.
    • PUPIL SIZE n PATIENT'S PERFORMANCE
    • READ CHART WITH OTHER FINDINGS
    • DIAGNOSE THE CASE, IF IN DOUBT REPEAT THE SAME TEST BUT NOT THE SAME DAY
    • INTERPRETATION OF A FIELD IS NOT A CHILD'S PLAY

     

    AN EARLY FIELD DEFECT ACCORDING TO "ANDERSON "

    Cluster of 3 or more adjacent points in an expected, suspected location (Typical for glaucoma) of central 24 degree field. ON AT LEAST TWO CONSECUTIVE FIELDS
    OR
    Glaucoma Hemi field test (GHT) Outside normal for at least two consecutive Fields
    OR

    Cycling can't be learned in a day




    LEARNING CURVE

    First field is not always a reliable field (of course not all the time). She is a young school teacher. First VF done after seeing her IOP R30 &17 L. healthy NRR .6 & .5 are the cup : disc ratio R/L respectively. Since 5 th June '00 she was on anti- Glaucoma drug. We stopped her drops after Seeing the 2 nd field .On the 3 rd field on 29 th Oct '01 her VF is within Normal limit & IOP too. It's a long term fluctuation.


    FOLLOW UP



    PATIENT IS WITH BETA BLOCKER DROP SCINCE SEPTEMBER 2001


    First field is not always reliable


    Field done out side BANGLADESH



    This young girl of 10yrs.has been dig. in Marfan Sy with NTG.It can not occur before 45yrs.Diag. Out side BD.In Dhaka It has been dig. Marfan Without Glaucoma her first field is not reliable. Second field done at Dhaka is OK GHT ONL is due to high myopic cylinder. Doing field is like a Baby sitter. Glaucoma may be associated with sublaxation of the lens. Here her IOP is normal Her both NRR are healthy.

    I LOVE MY COUNTRY


    BEFORE SENDING THE PATIENT

    1. GIVE LAST CORRECTED DISTANCE VISION
    2. DETAIL OF OPTIC NERVE EXAMINATION IF POSSIBLE WITH DIAGRAM
    3. INTRA OCULAR PRESSURE (IOP) FLEXIBILITY IS THE ENEMY OF STANDARDIZATION

    A LABORIOUS THRESHOLD TEST HIGH RESOLUTION PATTERN MAY FERRET OUT EARLY SIGNS OF GLAUCOMA.BUT IT MAY ALSO GENERATE ARTIFACTS, IF THE PATIENT'S ENDURANCE IS STRESSED BEYOND 20 MINUTES PER EYE "LEADERSHIP IS LIKE SWIMMING CANNOT BE LEARNED IN A "DAY" OFTEN TO GET A RELIABLE FIELD YOU HAVE TO DO ONE FIELD EACH MONTH FOR THREE CONSECUTIVE MONTHS OF COURSE NOT ALL THE TIME.

    PLEASE TELL YOUR PATIENT THAT IT IS A TIME CONSUMING TEST.TELL HIM OR HER TO TRY TO COME IN THE MORNING. IT'S A PSYCOPHYSICAL TEST.TELL THEM NOT TO BE IN HURRY.HE OR SHE MAY MISS THE BUS, WITH AN UNRELIABLE FIELD.

    It will be like a game, very easy to do !!


    COMMON PROBLEMS WITH PERIMETRY

    • LEARNING / FATIGUE EFFECTS
    • PUPIL SIZE
    • REFRACTIVE ERROR
    • ARTIFACTS
    • PATIENT COOPERATION

     

    REPORT

     

    PHYSIOLOGICAL FUNDUS


    She is a young lady of 27yrs. old. Her IOP are normal. But big C;D .65 B/E, her Doctor put her anti Glaucoma drop. But her fundus NRR is healthy & ISNT rule is ok. Her two consecutive fields are normal as well her B/Y field are O.K It's a normal PHYSIOLOGICAL DISC

     


    BACK

    GROUND IS YELLOW & THE V IS THE BLUE STIMULUS
    SIZE


     
    1. HIGH INTER-INDIVIDUAL VARIABILITY
    2. LENS ABSORPTION
    3. PATIENT FATIGUE
    4. LONG ADAPTION TIME
    5. UNPLEASANT
    6. ONLY PATIENT UNDER 40YEARS !?
    DRAW
    BACKS B/Y
     

    This young man of 34yrs a typist came for red eyes. V.A. 6/6 B/E and IOP !7 mmhg. Both Funds showed ISNT rule are OK.Fields are normal too. It's nothing but a normal physiological cup.still than he should be on follow up.

    ALWAYS CORRELATES WITH THE FUNDUS

    GLAUCOMA

     

    NORMAL TENSION GLAUCOMA

    A CONDITION IN WHICH GLAUCOMATOUS CUPPING OF OPTIC NERVE HEAD, LOSS OF NERVE FIBER LAYER AND VISUAL FIELD LOSS OCCURS AT AN IOP BELOW <21mmHg MEASURED AT DIFFERENT TIMES, WITH OPEN AND NORMAL APPEARING ANGLE .

    VARIENTS OF NTG

    • NON-PROGRESSIVE FORM
    • PROGRESSIVE FORM

    OPTIC NERVE HEAD CHANGES IN NTG

    • Large cupping disproportionate to field loss
    • Sloping edges
    • Thinning of NRR especially inferiorly & Inf.temp
    • Hourglass pattern of lamina cribrosa
    • High incidence of acquired pit of the Optic head
    • Greater frequency & extent of Peripaillary atrophy
    • Higher incidence of splinter hemorrhage of OND
    • More localized nerve fiber layer defect

    VISUAL FIELD DEFECT

    • Localized, deep, steep defects
    • Close to fixation

    OTHER ASSOCIATES OF NTG

    • NTG usually seen in elderly F>M 6:1
    • More common in ASIANS
    • F/H ,Myopia, Systemic hypotension, hypertension, Postural hypotension, Nocturnal hypotension, Cardiovascular disease, Migraine, Raynaud's , Acute blood loss, Hypovolemia following severe vomiting & diarrhea

    Differential Diagnosis of NTG

    • POAG with a wide diurnal fluctuations
    • Pigmentary glaucoma
    • Intermittent IOP elevation as in, glaucomatocyclitic crisis and intermittent angle closure
    • Previous episode of IOP elevation: Steroid induced Glaucoma
    • Non-Glaucomatous optic nerve disease like ischemic optic neuropathy, Congenital optic disc pit, compressive lesions of optic nerve etc.

     

    DIAGNOSIS of NTG

    OCULAR EVALUTION ;

    Apart from routine ocular & FUNDUS examination.
    LOOK FOR

    1. Central corneal thickness(520 µM) , thin cornea may give false low IOP reading, POAG might appear as NTG
    2. Record of a diurnal curve
    3. Perimetry
    4. HRT
    5. Record of ocular blood flow

    MEDICAL EVALUTION

    1. Cardiovascular examination including 24 hrs. BP monitoring to rule out nocturnal hypotension, Carotid artery Doppler imaging to assess blood flow, capillary filling time on exposure to cold.
    2. Complete blood picture, ESR, Blood profile, Lipid profile to ruled out Hypercholesterolemia
    3. MRI to ruled out Diffuse cerebral ischemia

    MANAGEMENT OF NTG

    Goal of treatment is to preserve the visual FUNCTION

    Non-Progressive form does not require any treatment, as it rarely progresses. Monitoring & follow up is required every 6-12 months.

    Progressive form needs treatment. Target should be to reduce 30% IOP from the initial, may delay the progression.

    NTG

    • A GARDEN VARIETY OF POAG (30% out of 66%)
    • MOST LIKELY GENETIC (OPTINEUON GENE)
    • A BENIGN VARIETY OF POAG
    • BUT DIFFICULT TO TREAT IOP TO BE REDUCED BY 30%
    • BLINDNESS IS UNUSUAL IN NTG
    • F>M 6:1
    • PATIENTS ARE HYPOTENSIVE
    • LOCALIZED VFD & FIXATION THREATENING
    • Age must be above 45years & F/H
    • IT IS EASY TO MAKE IOP 4OmmHG TO 20mmHG BUT TOUGH TO BRING IOP 16mmHG TO 14 mmHG

    TREATMENT

    • Avoid beta blockers; non selective Beta-blockers may decrease the perfusion pressure. But selective blockers like Betaxolol may increase OBF but at the same time it has less IOP lowering.
    • Brimonidine (Alphagan)
    • Calcium channel blocker of systemic use Nifedipine is benificial
    • Prostaglandin
    • ALT
    • Surgery

    PROGRESSION OF NTG

    • Deepening of existing field defect
    • Expansion of existing field defect
    • Appearance of new defect
    • Threat to fixation

     

    PLAN OF TREATING LTG

    1. VERY DIFFICULT TO TREAT AS WELL AS TO DIAGNOSE
    2. FIRSTLY, TO REDUCE THE IOP BY 30%. HER IOP WAS 15 WE REDUCED HER IOP TO 15X.7=10.5MmmHg WITH AZOPT
    3. IF HER IOP BECOMES BELOW 10 THERE IS NO NEED OF DOING Visual Field
    4. THINK BEFORE USING BETA BLOCKER DROPS IN NTG
    5. PHASING TO BE DONE
    6. If medical treatment fails then ALT has to be tried, if it also fails go for Surgery
    7. 24 Hrs. MONITORING OF B.P. IF DIAS DIPS DOWN AT NIGHT BELOW 60 mmHG AND PT IS HYPERTENTSIVE AND IF HE/SHE IS ON BETA BLOCKER TYPE OF DRUGS THEN THAT SHOULD BE CHANGED.CONSULT WITH CARDIOLOGIST IOP/BP
    8. Neuro protector Vit E. Aspirin, aerobic exercise, anti oxidant can be used to improve perfusion. TRY TO CORRECT HYPOTENSION.
    9. What to do when there is High BP with Glaucoma? TOUGH QUESTION.?
    10. Three U.S. President died of hypertension. Theodore Roosevelt, Woodrow Wilson and Franklin Roosevelt, all died from Complication from FLUCTUATION OF HYPERTENSION
    Latanoprost 0.005% (XALATAN) PHARMACIA
    Travoprost 0.004% (TRAVATAN) ALCON
    Bimatoprost 0.03% (LUMIGAN) ALLERGAN
    Unoprostone 0.15% (RESCULA) NOVARTIS

    ANY FLUCTUATION IS BAD


    HIGHER RISK OF PROGRESSION NTG

    • IOP near the upper limit of normal
    • Wider diurnal variation
    • Deep localized notch of the disc
    • New optic disc hemorrhage
    • Systemic hypotension
    • Young age
    • Black race
    • Myopia
    • Vasopasam
    • No history of hemodynamic crisis (Hemodynamic episode is associated with non-progressive form)

     


    This young lady of 38 yrs. came to us about 3 yrs back. An established case of LTG with hypotension, and diag. a case of early presbyopic. on routine Fundus exam.
     
    Asymmetric C;D disc but ratio are same 0.65.Rt.disc & NRR ok Lt. disc shows Sup. temp. notching which corresponds with the three consecutive field. D/D retinal hemorrhage. (Ruled out)

     

    COMMON IN NTG



    NTG PATIENT'S VF AND FUNDUS


    Both the overviews show NTG R>L .Both Discs have V>H and Sup & Inf Notching are seen.

    AN ESTABLISHED CASE OF NTG.HER IOP IS NOW 10mmHg B/E

     

    LAST PT'S 24 MONITORING OF BP

    24 hrs. Monitoring of a LTG pt. done with mild hypertension. She is on Atenolol 50mg in the morning Amlodipine 5mg at bed time. After she has been diagnosed as NTG on Jan 02 and on Azopt thrice daily. During Night her diastole drops below 60.She has been advised to consult her cardiologist about her low diastole tendency at late Night.



    COLOR DOPPLER SONOGRAPHY


    HEALTHY............ .......GLAUCOMA PATIENT
    Color doppler, sonography, is used on Glaucoma patients to determine the blood velocity in several vessels leading to the eye. This enables a calculation of resistance index, a parameter for downstream resistance to flow that is of particular Importance in glaucoma. Here an ophthalmic artery of a healthy individual and the same test on Glaucoma pt. with reduced perfusion is shown.

     

    OVER VIEW

     

    This middle aged man complains of frequent Change of his reading glass. IOP normal. B/E. V.A 6/6 B/E. With +78 deep cupping has been noticed. B/E.ISNT rule is not ok. Rt. sup NRR is thinner than nasal NRR. In Rt. Fundus both Sup & inf. NFLD are seen which well correlates with the VFD Sup & inf arcuate SCOTOMAS. So, the second Rt. field is reliable and taken as base line VF and an early case of NTG.

    Lt. Fundus shows inf. temp. NFLD as well as inf. notching, which well correlates with VF's Supra Nasal arcuate SCOTOMA joins the upper nasal step. Lt. temp. pallor of the disc well correlates with the Upper Nasal step.

    SO BOTH THE SECOND FIELDS ARE RELIABLE & TAKEN AS A BASE LINE FIELD AND WELL CORRELATES WITH THE FUNDUS, A CASE OF EARLY NTG.

     

     

    WHY 21 CONSIDERED "NORMAL"

    THE IOP IS DISTRIBUTED IN THE NORMAL POPULATION IN A GAUSSIAN OR "BELL-SHAPED" MANNER



    DUANE'S CD-ROM 2003 EDITION

    TARGET PRESSURE RANGES; Goal for lowering IOP

    Intraocular Pressure
    Damage Pressure (mmHg)
    Decrease Desired (%)
    Absolute level desired (mmHg)
    Above 35
    About 50%
    18-25
    25-35
    About 40-50%
    13-18
    21-25
    About 40%
    14-16
    17-20
    About 40%-30%
    12-15
    13-16
    About 20%
    10-12
    10-12
    About 10%-20%
    8-9

    A target pressure will not damage the optic nerve any further.



    TARGET IOP

        TARGET
    IOP, Slight disc damage 17-18mmHg
    IOP, moderate disc damage 15 mmHg
    IOP, Serious disc damage 12 mmHg

    Slight damaged mean a change in the optic nerve ± small VFD

    Dr. Rick Wilson


    Establishing Initial Target IOP (CIGTS Study)

    Target IOP = (1 - Reference IOP + Visual Field Score ) x Reference IOP 100

    Example


    MODE OF ACTION

    .
    IOP Decrease
    Decreases Aqueous Production
    Increases Uveoscleral Outflow
    Increases Trabecular Outflow
    Brimonidine
    20%-30%
    .
    ß-Blockers
    20%-30%
    .
    .
    Pilocarpine
    10%-20%
    .
    .
    Dorzolamide
    15%-20%
    .
    .
    Prostaglandin
    25%-30%
    .
    .

     

    DISEASE CAPSULE ; POAG

    1. EPIDEMIOLOGY

    • Major Risk Factors
    • Advanced age
    • Black race
    • Positive F/H
    • Elevated intraocular pressure

    2. MINOR RISK FACTORS

    • Diabetes mellitus
    • Myopia

    3. SYMPTOMS

    • Early; none
    • Late; loss of peripheral vision
    • Very late; loss of central vision

    4.SIGNS

    • Cornea.............................Normal
    • Anterior Chamber............ Normal
    • Iris................................... Normal


    Angle & Trabecular Meshwork
    Normal
    Lens
    Normal
    Intra ocular pressure
    Elevated
    OPTIC NERVE
    Cupped

    TREATMENT

    • Topical medication
    • Laser trabeculoplasty
    • Trabeculectomy

     

    TILTED DISC/HIGH MYOPIA

    Disc size is due to PPA. When it is seen more likely to be Cong. A tip From SPAETH. Pale disc is due to Pseudophakic. Thin NRR does not Match with the VF.
    LT. Disc is tilted and VFD are not typical For early POAG. IOP B/E Normal She Was wearing -11 now Pseudophakic 6/6 vision with small cyl. correction.


    TILTED DISC 1

  • This 52 year-old woman was referred by his optician because of abnormal visual fields. Her intraocular pressure in both eyes were normal at 17mmHg. Fundoscopy revealed the above appearance in both eyes (the above picture is from the right eye). a. What does the picture show?
  • b. What type of visual field defect may be present?
  • c. What other ocular findings would you expect to find in this condition?
  • TILTED DISC 2


    TILTED DISC 3




    TILTED DISC 4

    RETINAL VESSELS EMERGE FROM THE DISC TISSUE SUP.TEMP. RATHER THAN NASALLY (SITUS INVERSUS)


    NOW ANSWER OF THE TD-1

    • This 52 year-old woman was referred by his optician because of abnormal visual fields. Her intraocular pressure in both eyes were normal at 17mmHg. Fundoscopy revealed the above appearance in both eyes (the above picture is from the right eye). a. What does the picture show?
    • Tilted disc with inferior juxtapapillary crescent. It is a congenital condition and is always bilateral. It results from the oblique insertion of the optic nerves into the globe. It may be associated with optic nerve hypoplasia.
    • b. What type of visual field defect may be present?
    • Supero-temporal field loss is typically seen. This defect is the result of decreased nerve fibres inferonasally. The defects can cause bitemporal hemianopia but does not respect the vertical midline. It is important to recognize this and does not put the patient through unnecessary investigation for pituitary tumour.
    • c. What other ocular findings would you expect to find in this condition? Other ocular findings include:
    • myopia with astigmatism
    • slightly decreased visual acuity even with full refractive correction


     

    CT Scan of Tilted Disc


    Tilted disc with retinal ectasia


    TILTED DISC HAS

    1. TILTED DISC SYNDROME OCCURS TO 1%-2% OF THE WHOLE POPULATION
    2. THE LONG AXIS OF THE OVAL DISC IS OBLIQUELY DIRECTED,UPPER & TEMPORAL REGIONS OF THE DISC ARE ANTERIOR TO THE INFERONASAL AREA.
    3. THE RETINAL VESSELS EMERGE FROM THE DISC IN THE SUP.TEMP AREA, RATHER THAN NASALLY(SITUS INVERSUS)
    4. HYPOPIGMENTATION INEFRONASALLY TO DISC
    5. IN CONTRAST WITH THE GLAUCOMATOUS DISC,TEMPORAL DISC USUALLY IS NOT EXCAVATED BUT IS EVEVATED SUPERIORLY
    6. AN OBLIQUE DIRECTION OF RETINAL VESSEL
    7. A CRESCENT ON THE SIDE OF THE DISC DEPRESSION
    8. HIGH MYOPIA OR MODERATE OBLIQUE MYOPIC ASTIGMATISM PRESENT
    9. OBLIQE INSERTION OF THE OPTIC NERVE IN THE GLOBE
    10. IN TITLES DISC RETINAL ECTASIA WILL BE FOUND IN CT SCAN


    ISNT NOT OK BUT NORMAL VF

    This 11yrs. old girl has C:D .65 B/E. Cong. anomaly of the retinal vessels seen. Both fields & fundus are normal. Butterfly dystrophy been seen in the OS. Both Fields & Fundus are ok according to Dr.Jeff Henderer Of WILLS Hosp USA. She should be in close observation to avoid Juvenile POAG. Now her IOP are normal

    CASE REF. BY DR.SABBIR ISLAMIA
    NO NFLD & HEALTHY NRR
    NOT STICKING TO ISNT RULE


    THUMB NAIL OF FUNDUS



    CONGENITAL ANOMALIES OF DISC

    • OPTIC DISC COLOBOMA
    • MORNING GLORY SYNDROME
    • OPTIC NERVE HYPOPLASIA
    • TILTED DISC
    • OPTIC DISC DRUSEN
    • OPTIC DISC PIT


    HORIZONTAL C:D 0.4, CUP OCCUPIES 4/10 WIDTH OF DISC



    Measuring Disc Diameter

    1. Normal optic nerve's head size is 1.5mm in diameter.
    2. But the disc diameter vary from 0.96mm to 2.91mm
    3. As a result, physiological cup can be as small as 0.1:1 or as large as 0.8:1.
    4. Clinical estimation of optic nerve can be done by WELSCH ALEEN OR
    5. Slit lamp with +78D or +90D

    By WELSCH ALEEN Ophthalmoscope

    The smallest white round spot of the Welsch Aleen ophthalmoscope casts a light of 1.5mm in diameter on the retina. This retinal spot size remains constant in phakic eyes with refractive errors between -5.00 & +4 dioptres. When this size coincides with the disc, then the disc diameter will be 1.5 mm. In eyes with large physiological cups due to large discs the area illuminated is less than the area occupied by the cup.



    BY SLIT LAMP

    • Vertical Slit beam to create rectangle of light
    • Beam 1/4 to 1/3 of size of disc diameter wide
    • Adjust length of beam to match vertical "height" of the disc
    • Example

    BAYER is the lead author and he is the first publication of the scale

     

    Conversion Chart

    Manufacturer
    .
    LENS
    .
    .
    60D
    78D
    90D
    VOLK
    0.88
    1.11
    1.33
    NIKON
    1.03
    .
    1.63

    Lim, et al. J Glaucoma 1996; 5:241

    Measuring Disc Diameter

    • Read length of light column from the continuous scale on the slit lamp
    • Multiply this length by a conversion factor
      -L ens specific
    - Manufacturer specific

    Example;
    1.6mm(Vertical length)x1.11(Volk 78)=1.78mm, will be the disc diameter.




    SIMPLE DRAWING



    NORMAL & GLAUCOMATOUS OA

    PAPER WHITE
    NORMAL

     

    ASYMMETRIC DISC



    Optic Nerve head change in Glaucoma

    • Large cup-disc-ratio
    • Progressive Optic Nerve head Cupping
    • CUP V>H
    • Asymmetric optic nerve head Cupping
    • Disc Hemorrhage
    • Baring of circumlinear vessels overpass vessels
    • Bayonetting of vessels




    NOTCHING


    NFLD


    BEANPOT


    Circumlinear

    No RIM at all
    Disc hemorrhage
    ONH GLAUCOMA

    Beanpot

    Vertical elogation with PPA

    Baring of Circumlinear Vessel


     

     

    Dr.Jeff Henderer

    Murshed.  Good case.  I'm here at the Academy meeting in Orlando.  Greetings from Disney World!  I think this guy looks normal.  The nerve OD looks a bit odd with the superior rim thickness, but I'm thinking that's a normal variant.  I don't see the NFL defect. I'm not bothered by the vasculature in this monoscopic view.  The PPA I never pay much attention to, but if it gets larger (the beta zone) then that can be glaucoma.  I'd watch him.  Great video by the way!  I'm seriously impressed!  Good to hear from you and I hope you are well too.  Take care!

    Jeff

    Baring of Circumlinear Vessel

    This vessel was originally at the rim but is now hanging out in space. A sign of GLAUCOMA and indication of Progressive cupping.



    OPTIC NERVE HEAD CUPPING IS A UNIFYING FEATURE OF ALL GLAUCUMAS

    DISC EXAMINATION BY AN EXPERIENCED GLAUCOMA SPECIALIST WAS ACCEPTED AS GOLD STANDARD.


    Evaluation of OPTIC NERVE HEAD & NFLD

    QUALITATIVE

    QUANTITATIVE

    1. Contour of NRR
    2. Disc hemorrhage
    3. Parapapillary atrophy
    4. Bared CCL Vessels
    5. Appearance of RNFL
    1. Optic disc V>H
    2. Cup H>V
    3. Rim / disc ratio
    4. RNFL Height

     

    OLD IS GOLD


     

    NORMAL EYE
    C;D VARY FROM O .0 TO 0.9

     

    NRR

    • NRR COLOR IS FROM PINK RED TO ORANGE
    • RIM PALLOR>CUPPING=NEURO DISEASE
    • RIM PALLOR &CUPPING=GLAUCOMA
    • IF ANY ONE CAN DIAGNOSE THE NRR/NFLD IS THE KEY TO DIAGNOSE OF THE CASE

    NORMAL NERVE-NRR SHAPE

    • DISC IS VERTICALLY OVAL V>H
    • CUP IS OVAL HORIZONTALLY H>V
    • THE ISNT RULE
    • THICKEST RIM INFERIORLY>SUPERIORLY>NASALLY> TEMPORALLY (THINNEST) ISNT
    • CRITICAL TO EXAMINE IN EARLY GLAUCOMA

     

    Theories of Glaucoma damage not yet

    Established Two broad categories:

    • MECHANICAL (PRESSURE)
    • VASCULAR MECHANISIMS

    Asymmetric DISC

    Tissue between The cup & disc is NRR made of nerve & capillaries So, looks red to orange

     

    DIFFUSE & LOCALIZED FIELD DAMAGE

    • Diffuse visual damage is highly co-related with IOP(HTG) with Concentric ONH excavation.
    • Focal or local visual damage is weakly related to IOP.
    • Patients
    • With normal pressure (NTG) tend to have localized nerve fiber defects with ONH notching.


    PATHOGENITIC CONCEPT



    IOP and Glaucoma

    Normal "IOP" is debatable value between 18-24 More 60%> population have IOP below 21 mmHg

    IOP curves of the Normal- and Glaucoma Population



    WHY CENTRAL 30/24 DEGREE

    • The central 30 ° field represents 66% of the ganglion cells and 83% of the visual cortex
    • Nearly all pathology are within this area of 30 °
    • If in doubt, it is recommended to repeat the central field rather than test the periphery
    • More than 99% of the static perimetry examination for diagnostic purposes are done in the central 30 ° area both for Glaucomatous & as well as Neurological cases.


    WHY 24 ° -2

    If we keep 30 ° nasal field & the rest peripheral points are discarded(22) taking 76 points in 30-2 instead of taking 24-2 where 54 points are taken which makes the patient less fatigue and test is reliable too, by discarding the peripheral points of no significant change in the field seen. So, now all the leading clinics are using 24-2.Left picture is from the "BUDENZ" atlas which also Says this.

     

    THE VISUAL FIELD


    The visual field is the extent of the area which one fixating eye can see.
     

    Periphery is five times the central 30 ° area. A static perimetry examination would take almost one hour to do the whole field. For the periphery, Goldman Kinetic perimetry is more accurate and faster. Kinetic type of perimetry can also be done in the HUMPHREY.


    Manual Goldmann Perimetry

    The original Goldmann perimeter remains a valuable instrument.

    IN 1945 FIRST CUPOLA PERIMETRY WAS DESIGNED BY PROFESSOR HANS GOLDMAN BERN, SWITZERLAND.

    FRUCTUATIONS

    Compare short and long term fructuation with the movements of the waves and tides.

    The sensitivity of the eye varies from moment to moment & from day to day, as do alertness of the patient & the critera the Pt.uses in answering.

     

     

     

    SUSPECTED

    EARLY NASAL STEP

    This young man of 38yrs. Came for presbyopic Correction. IOP & V.A are normal. Rt. Disc is very much suspected. In his Rt. field the most suspected & expected zone of the supra nasal quadrant shows 1 .cluster of sctomas. 2 .GHT=BL, If 1 & 2 are again seen in the 2 nd field it will be a case of early LTG.I took this FV reliable in spite of high FL 40% as because of low FP & FN. Tracking gaze shows fatigue in the later part of the VF.
     


    Early inf. NASAL step is seen here, if it is repeatable in the next VF it will be a case of early POAG.
    GLAUCOMATOUS DEFECT

    1. Paracentral scotoma(BA) 77%
    2. Nasal step 30 ° 14%
    3. Nasal Step in periphery 7%
    4. Temporal Wedge 3% According to Drance & Armaly

    In early stage with fundus photo, diagnosis of GLAUCOMA is very difficult to comment


    STEROID

    Field is well correlated with the DISC
    Children of Glaucomatous pt. should use steroid with caution

     

    Risk factors for Steroid Induced GLAUCOMA

    • PATIENT WITH POAG
    • FIRST DEGREE RELATIVES OF POAG PATIENTS
    • HIGH MYOPIA
    • DIABETES MELLITUS
    • CONNECTIVE TISSUE DISORDERS
    • EYES WITH TRAUMATIC ANGLE RECESSION
    • FELLOW EYES OF ANGLE RECESSION GLAUCOMA
    • PIGMENT DISPERSION SYNDROME
    • ENDOGENOUS HYPERCORTISOLISM

    MECHANISM FOR IOP ELEVATION

    CORTICOSTEROIDS CAUSE ELEVATION OF IOP BY DECREASING THE FACILITY OF AQUEOUS OUTFLOW.
    According to BECKER & ARMALY 5%-6% of normal population responder to steroid given over a 4-6 weeks period.

    MOST POTENT

    S
    T
    E
    R
    O
    I
    D

    LESS POTENT
    • BETAMETHASONE
    • FLUOROMETHOLONE
    • DEXAMETHASONE
    • LOTEPREDNOL
    • PREDNISOLONE
    • MEDRYSONE
    • RIMOXOLONE

    COMPARE

    Rt, picture shows very thin Sup & Inf NRR which corresponds the Sup& Inf. acurate scotomas in the PSD plot chart.An established case of POAG. Middle aged woman of 55yrs.

     

    CORRELATION WITH OPTIC DISC

    • Always correlate changes in visual field with the optic disc.
    • When correlation is lacking, other causes of visual loss should be considered, such as OPTIC NEUROPATHY,DEMYELINATING OR NEUROLOGICAL DISEASE, PITUITARY TUMOUR
    • In the next cases look for the following situations;
    • Disc seems less cupped than it is expected for the degree of field loss.
    • Pallor of the disc is more impressive than the cupping.
    • The progression of the visual field loss seems excessive.
    • Non classical for Glaucoma, respecting the vertical midline.


    PALE DISC

    This young man of 31yrs.Came for unexplained low V.A Does not improve With P.H above 6/12 H/O severe headache & vomiting too.C.T Scan normal. C'D, B/E 0.5 DISC PALE CENTRAL Scotomas Seeing both the fields In PSD plot chart, Both rim & Disc are Pale without cupping =Neuro case. Think of Nutritional optic.

    Neuropathy,Methanol ON,or Dominany optic Neuropathy. A NEURO Case. See for Color Vision, Vit B 12 & Folate Levels?



     
    Slight asymmetry of the disc. Pallor disc is R>L. Pallor disc is not Seen in glaucoma Unless late stage. V.A 6/6 B/E & IOP normal Lady of 25yrs.She has A right incongruous Hemianopia, think of NEUROLOGICAL case. Tough case SCAN can give the result. M/O One child, she had H/O severe PPH think of Stroke, or severe haem, May cause occipital Ischemia?

     

    Neuro 1

    This young man of 32yrs Total color blind R/E 6/9 with -1,-2.5 180.L/E C.F 5 feet. Disc and IOP are Normal. FT R/E 32, L/E 0dB.Diagnosis To be confirmed by CT/MRI. BITEMP HEMIANOPIA Lesion situated at the Chiasma, by Interrupting the Crossing nasal fiber, Bring about a loss in The temporal portion Of the field of each eye.
    Lesion depends on the growth of the tumour may be Congruous or Incongruous.

    Neuro 2

     

    "Pie in the Floor" this Young is middle aged Very andrestless (Motor Impersistence) H/O mild Hemi paresis on the left Side for 6 months. MRI On 03.03.01 "Late Sub Acute Infarcts at rt. frontal & Parietal regions. Field done on 13.03.01 Shows Left homonymous Quadrantanopia (Pie in Floor )due to lesion in the superior fibers of the rt.optic radiation signs of Rt.Parietal lobe function.


    Neuro 3

    This young Doctor had H/O Convulsion.V.A,6/24 B/E does not improve with P.H.& also does not correspond with the FT 36 dB,35dB.He has also

    Neuro 4

     


    This 50yrs. old man known as DM &BP. H/O had Lt. sided Hemiparesis. Lt. upper Incongruous quadran tic hemianopia"Pie in the sky"Should be Confirmed by MRI or MRA.

    1. Finger agnosia
    2. Rt./Lt. Confusion
    3. Agraphia
    4. Does not respond to command
    5. Dyscalculia
    "COMPLETE RT.INF.HOMO NYMOUS QUADRANTANO PIA "PIE IN THE FLOOR"
    OPTIC RAD.TEMP.L.LESION FIELD DEFECT "PIE IN THE SKY" PARIETAL LOBE FIELD DEFECT "PIE ON THE FLOOR"
       


    Neuro 5

    A known diabetic noticed sudden loss of Upper lt.field. Her vision is 6/6 L/E when She looks downward. R/E V.A.6/6. Sup or inf ALTITUDINAL VFD results from damage to the upper or lower pole Of the disc.

    ALTITUDINAL FD



    ALTITUDINAL FIELD DEFECT


    24-2 SF B/E

     

    POOR FOVEAL THRESHOLD

    WHEN POOR FOVEAL THRESHOLD MACULAR 10-2 IS MANDATORY


    UPPER TEMPORAL BRANCH VEIN OCCLUSSION



    ALTITUDINAL FIELD DEFECTS MAY BE UNILATERAL OR BILATERAL CAUSESE ARE

    RETINAL CAUSES

    • Branch Retinal Artery Occlusion
    • Branch Retinal Vein Occlusion
    • Retinal Coloboma

    OPTIC NERVE LESION

    • Ischaemic optic neuropathy (both arteritic and non-arteritic types)
    • Papilloedema
    • Optic disc Coloboma

    LESION IN CEREBRAL CORTEX

    • Superior or Inferior calcarine cortex lesion
    • Temporal lobe lesion
    • Parietal lobe lesion

    Neuro 6

    COPLETE LEFT HOMONYMOUS HEMIANOPIA DUE TO LESION IN THE RIGHT TEMPOROPARIETAL OPTIC RADIATIONS OR RIGHT VISUAL CORTEX. H/O CVA
    PERIMETRY IS,HOWEVER, MANDATORY WHEN INDICTED BY THE CLINICAL HISTROY, THE EYE EXAM, OR BRAIN, OR MRA/MRI OR CT FINDINGS.

     

    CHIASMAL COMPRESSION

    High Myopic cylinder. First reported to an ophthalmologist. His main complain was loss of bilateral temporal vision.

    BINASAL HEMIANOPIA

     

    Brief History

    • 58 yrs. Old a retired engineer
    • Main complain difficulty in near reading, not so much.
    • R/E -2.5D,+1Dcyl 95 ° 6/9,L/E -7.5D, 6/9
    • H/O Vaso vagal attack, anginal pain, Hypertension, High lipid profile, Non diabetic
    • No lental opacity
    • On much ocular complain
    • C:D .6 B/E WNL
    • IOP WNL B/E

    WHAT'S YOUR DIAGNOSIS

    First ruled out common cause of Binasal inf.nasal quadrantonopia

    • Glaucoma
    • Sector retinitis pigmentosa
    • Retinoschisis

    RARE CAUSE

    • Bilateral Occipital Disease
    • Optochiasmatic arachnoditis
    • Dilation of the third ventricle
    • INTERNAL CAROTID ARTERY ANEURYSM

    Here for final diagnostic investigation depends on available resource to diagnose Internal Carotid artery aneurysm we advice for MRA & MRI (NORMAL STUDY)


    JEFF HENDERER REPLIES

    Murshed,

    Great to hear from you again!  I look forward to seeing you in California!  I have never seen a case like this, but I think that you are correct in everything you are doing and thinking.  In fact I was thinking the aneurysm as I read through your workup and then when you said it "bingo" I thought!  Well, its a rare condition and a very rare field, but the consequences of missing this diagnosis are so great that I think it is an appropriate use of resources.  Rupture would almost certainly be horrible, if not fatal.  By the way, I agree with you on the reliability of the fields.  Take care!  

    Jeff


    BINASAL

    A lady came for field for uncomfortable in near reading. C:D .3 R/E,.5 L/E 6/6 O.U N 5 B/E IOP WNL Disc normal


    NEUROLOGICAL FIELD DEFECT

    OPTIC NERVE

    IPSILATERAL BLINDNESS
    OPTIC CHIASM BINASAL HEMIANOPIA BITEMPORAL HEMIANOPIA
    OPTIC TRACT CONTRALATERAL HOMONYMOUS HEMIANOPIA
    LATERAL GB SAME AS ABOVE

    GENICULO CALCARINE TRACT (VISUAL RADIATION)

    1)UPPER DIVISION
    2)LOWER DIVISION

    1) CONTROLATERAL LOWER HOMO PARI.LOBE.LESION QUADRANTANOPIA (PIE IN THE FLOOR)
    2) CONTR UPPER HOMO QUADRAN TEMP.LOBE.LESION (PIE IN THE SKY)

    VISUAL CORTEX CONTROLATERAL HEMIANOPIA WITH MACULAR SPARING

     

    FD OCCIPITAL RADIATION OR THE STRIATE CORTEX

    • Congruous quadrantanopia
    • Homonymous hemianopia
    • Altitudinal hemianopia
    • Checkboard quadrantanopia

    TO DETECT TEPORO OCCIPITAL FD NEEDS

    • MRA/MRI
    • COLOUR FLOW DOPPLER

    BITEMPORAL HEMIANOPIA

    • CHIASMAL LESION
    • PITUTIARY ADENOMA
    • MENINGIOMA,CHRANIPHARYNGIOMA,A NEURYSM,GLIOMA
    • CAUSES OF CENTRAL SCOTOMAS
    • MACULAR DISEASES
    • OPTIC NEURITIS
    • ISCHEMIC OPTIC NEUROPATHY
    • OPTIC ATROPHY
    • OCCIPITAL CORTEX LESION

    EASTABLISHED POAG

    Right disc has no inferior NRR at all as well as nasal shifting of the vessels are seen with deep cupping and lamellar dot signs are seen which well corresponds with the right field. Dense arcuate scotomas emanating from the blind spot to join the superior arcuate scotoma later joins the upper nasal step to form half dense arcute ring scotoma. His IOP was 24mmHg R/E when first diagnosed. Now he is on anti Glaucoma drops B/E and IOP 14mmHg.Left field & fundus are normal.Lt.fundus shows inf.temp. PPA in an emmatrop is suspicious.

     

    DENSE SUP ARCUATE SCOTOMA

    DENSE SUP ARCUATE SCOTOMAS EMANTING FROM THE BLIND SPOT JOINS THE SUP ARCUATE SCOTOMA LATER JIONS THE NASAL SUP NASAL STEP. FIELD MATCHES WITH THIN INF NRR.A CASE OF ESTABLISHED POAG.

    DISC SHOWS NO INFERIOR NEURO RETINAL RIM

    D/D OF ARCUATE SCOTOMA

    1. CHORIORETNIAL LESIONS JUXTAPAPILLARY CHOROIDITIS & RETINOCHORODITIS MYOPIA WITH PPA
    2. OPTIC HEAD LESION DRUSEN, PAPILLITIS, COLOBOMAS, CHRONIC PAPILLOEDMA
    3. ANTERIOR OPTIC NERVE LESION RETROBULBAR NEURITIS,ELECTRIC SHOCK
    4. POSTERIOR LESION TO VISUAL PATHWAY PITUTIARY ADENOMA,PSEUDO TUMOUR CERIBRI


    ADVANCE POAG

    This middle aged woman diagnosed POAG 5yrs.back.V.A R/E 6/9Tubular. L/E 6/6.C;D R/E .99/1,L/E .5.Rt. VF shows only a small central field with an island of small temporal field. Lt.shows cluster of scotomas in the most Suspected & expected zone Sup & infra nasal quadrant.L/E an early POAG. Rt. Eye an advanced POAG. She was very irregular in putting drops.

     

    This school teacher of 45yrs.enjoys 6/4.5R/E& 6/6 L/E.Binoculr Esterman shows 4 adjacent scotoms in the Sup. Field, & 6 scotomas seen in the lower

    Temp. zone. Here out of 120 points, he can see 109 & cannot See 11 points. When not seen crosses 10>in screening test than full Threshold test to be done. This is an advance case of POAG R>L.

    BRIEF HISTROY

    • One eyed R/E vitreous hemorrhage due to uncontrolled blood pressure 47yrs. old. No H/O Diabetes
    • H/o road traffic accident with macular hemorrhage L/E 5/6 yrs back vision 6/6 with +2D small hypermetropic eye.
    • L/E healthy NRR slight thinning of inferior NRR/ Superior NRR thinning C:D .5 IOP L/E 20 R/E 18 mmHg.
    • Three consecutive fields in one year shows inferior arcuate scotmas, does not so much well correlated with the disc findings.
    • Last of all phasing done. Diurnal variation R/E 4mmHg L/E 6mmhg very much suspected.
    • So, here we should not wait to treat him.
    • Here increased variability of the fields is an early sign of glaucomatous field defect, in spite of healthy NRR L/E
    • It takes about 3.5yrs to become a normal field to be an abnormal field (Haejil)

    PHASING

     

    SCOTOMAS

    • ISOLATED PARACENTRAL DEFECTS OCCUR AS THE INITIAL GLAUCOMA DEFECT IN ABOUT
      40% OF PATIENTS. OTHEREARLY MANIFESTATIONS OF GLAUCOMA
    • ARCUATE DEFECTS
    • NASAL STEPS
    • TEMPORAL WEDGE DEFECT

    NEIL T.CHOPLIN RUSSEL P.EDWARDS ............................................................................Page 119 2ed.

    NTG

    First detected when he comes for near reading glass.NTG Fixation threatening, localised VFD,
    30% of all POAG,30% IOP to be reduced


    JPOAG

    Came to an eye specialist, as he can not see the black board.


    THE SNEAK THIEF OF SIGHT


    OPTIC NERVE

    This young man with color Blind. L/E V.A.6/24 No P.H Improvement. R/E 6/6. Poor FT L/E 24dB CECOCENTRAL SCOTOMA PAPILLOMACULAR BUNDLE CONNECTING WITH THE FIXATION TO BLIND SPOT CAUSES ARE 1.DOMINANT OPTIC ATROPHY 2.LEBER'S O.A. 3.OPTIC NEURITIS 4.TOXIC/NUTRITIONAL OPTIC NEUROPATHY

    ''IT JUST GOT IN MY WAY''

     

    POOR FT 22dB & VERY DEPRESSED GRAY
    SCALE WITH MD -14.4 ,BUT PSD ;value normal
    2.22 INDICATES A CATARACTOUS VFD.PT'S
    V.A WAS 6/24. It's a normal field Study.

    High MD is due to CATARACT


    CRITERA OF HIGH MYOPIA

    This 42yrs. Woman is a high Myop. R/E 6/9 with - 12,--2 90 ° L/E 6/6 with --5.5,Her both Fields are normal inspite of Supra temporal arcate scotomas.

    Criteria of High Myopia

    • Upper Temp. FVD
    • Increase in the size B.
    • Fixation threatening
    • NFLD

    GLAUCOMA AT A GLANCE

    • Glaucoma is the second leading cause of preventable blindness in the world.
    • Glaucoma has no early S/S(POAG), often called the "Sneak thief of Sight" Early detection
      and treatment can save your sight. Testing for Glaucoma is simple, quick and painless.
    • 70 million people are suffering from Glaucoma in the world, half of them do not known even
      they have it. Of them 7 million are totally blind. Highest number of blind due to Glaucoma are
      in NIGERIA. Half of this patient are from ASIA.
    • Some 120,000 Americans are blind due to Glaucoma. The tragedy is that 90% of those are
      blind didn't have to be. Then what about BANGLADESH.

    PLEASE THINK!!!
    PREVENTION IS BETTER THAN CURE


    EARLY DETECTION

    Early Detection of Glaucoma

    There are several methods claiming to detect glaucomatous damage in the very early stage.
    Such As:

    • Analusis of the disk
    • Nerve fiver analysis
    • Multifocal ERG
    • Blue-on-Yellow Perimetry (Konio>Magno cells?)
    • Testing the retina using temporal and/or special modulated stimuli (Parvo, Magno cells?)

    REFERRED

    • PLEASE DO NOT HESITATE TO REFER THE EARLY CASES OF GLAUCOMA FOR SECOND OR THIRD
      OPINION . IT IS VERY TOUGH TO DIAGNOSE AN EARLY POAG GLAUCOMA.BECAUSE OF
      INDIVIDUAL & INTEROBSERVER SUSPECTED DISC EVALUATION
    • FIELD DEFECT COMES AFTER 20% OF NERVE DAMAGE,SO VERY TUFF TO DIAGNOSE EARLY
      POAG

    REFERENCE WILL RELIEF

    GLAUCOMA AWARENESS

    • Most people are not aware of Glaucoma, although not to be taken lightly glaucoma is very
      treatable if caught in its early stage.
    • RISK FACTORS ARE THE ODDS
    • Family history increases risk 4 to 9 times
    • African Americans race increases risk 4 times
    • Diabetes increases risk 2 times
    • Glaucoma in one eye,29% chance of getting in other eye within 5 years
    • People over age of 60 yrs are 6 times more likely than under age of 60 yrs .

    SO YOU'RE A GLAUCOMA SUSPECT, NOW WHAT ?

    • Get your eyes checked regularly
    • Take it seriously
    • Educate yourself about Glaucoma
    • Talk to your Doctor, ask questions, get answers
    • Don't hesitate to get a second, third opinion, or as many as you need it.
    • Lead a healthy life
    • Get Glaucoma support if you feel you need it.

    ARE YOU A PARENT WITH GLAUCOMA ?

    • CHECK IOP PRIOR TO STARTING KINDERGARTEN PLEASE CONTACT DR.MOHIBUL ISLAM
      OF "NURUL ISLAM CLINIC" OR DR.MD.FAZLUL HAQUE(SUBECHA PLAZA) FOR NON
      CONTACT PUFF TONOMETRY"
    • EVERY 2 OR 3 YEARS IN CHILDHOOD
    • EVERY 2 YEARS IN THEIR TEENS
    • EVERY YEAR AFTER THAT

    HOW DOES ONE COPE WITH GLAUCOMA

    • GET SUPPORT FROM FRIENDS,FAMILY AND OTHER PATIENTS
    • THINK POSITIVE ABOUT LIFE,GLAUCOMA IS NOT A DEATH SENTENCE
    • STOP TO SEE THE ROSES
    • SEE THE WORLD ...GO SOME PLACE YOU'VE NEVER BEEN
    • EDUCATE YOURSELF ABOUT YOUR CONDITION
    • PLAY AN ACTIVE ROLE IN YOUR TREATMENT PLAN

    WHAT CAN YOU DO TO RAISE GLAUCOMA AWARENESS ?

    • TALK WITH YOUR FAMILY ABOUT GLAUCOMA AND THE RISK FACTORS
    • TALK WITH YOUR FRIENDS ABOUT GLAUCOMA AND RISK FACTORS
    • TALK WITH YOUR CO-WORKERS ABOUT GLAUCOMA AND THE RISK FACTORS
    • ENCOURAGE FAMILY,FRIENDS AND CO- WORKERS TO GET REGULAR CHECK-UPS EVEN IF NOT
      AT RISK

    ADVICE

    • IF OVER WEIGH, CONTROL IT
    • HYOPO, HYPERTENSION,DIABETES TO BE CORRECTED. SPECIALLY B.P DURING SLEEP SHOULD
      BE RECORDED WHEN YOU SEE FLUCTUATION OF B.P.CONSULT YOUR CARDIOLOGIST ABOUT
      B.P/IOP
    • ASPRIN IN LOW DOSE,VITAMIN E, ANTI OXIDANT
    • 20 MIN AEROBIC EXERCISE FOUR TIMES A WEEK
    • DON'T TAKE LARGE AMOUNT OF WATER WHILE HAVING EMPTY STOMACH. TAKE WATER
      IN DIVIDED AMOUNT THROUGHOUT THE DAY

    HUMPHREY vs OCTOPUS


    COLOUR INDICES

    Comparison Gray Scale


    PERIMETER PARAMETER & SCALE
    Parameter
    Humphrey 1994-1998
    Octopus 101 1993
    Bowl type
    33 cm a-spherical
    42.5 cm spherical
    Back ground
    31.5 asb
    4asb/ 31.4asb
    Stimulus size
    Goldman 1to V
    Goldman 1 to V
    Stimulus present
    200ms
    100ms/200ms
    Dynamic range
    0-50 Db
    0-40 dB
    MD/MD
    Mean deviation
    Mean defect
    PSD/LV
    Pattern stan. devia
    Loss variance
    CPSD/CLV
    CPSD
    CLV
    SITA/TOP
    SITA,SF 3-5min,SS 4-8
    TOP 2-3 min
    Reliability RF
    FL20%,FP10%,FN15%
    RF 15%-20%
    Tracking gaze
    YES
    NO
    GHT
    YES
    NO
    BEBIE CURVE
    NO
    YES

    Parameters

    Humphrey
    Octopus
    Space
    Small Compact
    Big Space/Not 300
    Neck to Neck
    Zeiss/Humphrey
    Haag-streit
    Price
    We can reduce price by using mouse from local market,150Tk/,instead of brand key board. HP B/W printer (15,000tk) local motorize table. We can Save upto 4 lac taka

    Key Issue

    Understand the Principles

    HUMPHREY IS GOLD STANDARD

    • To learn about perimetry is to understand the basic characteristics of the visual field.
    • With this knowledge the data and the results from all perimeters can be interpreted

    NO MACHINE IS BAD,IT IS THE MAN BEHIND THE MACHINE

    Gentle Request

    • Please let me know what you think about this topics.
    • I would appreciate all forms of comments and suggestions.
    • Any query, HEALTHY criticism, questions are most welcome at any time without any hesitation.
    • Please let me know your comments on this topics.

    Total deviation

    Octopus


    MD

    B/Y


    PROVIEW TONOMETER

    THANK YOU ALL

    Dedicated to the memory of my father
    Prof. Dr. Nawab Ali Ahmed M.B.(Cal) FRCS
    AHMAD MEDICAL CENTER
    Dhaka, Bangladesh