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Microperimetry ARCH SOC ESP OFTALMOL 2006; 81: 183-186 EDITORIAL MICROPERIMETRY MICROPERIMETRÍA MIDENA E1 Clinical investigation of retinal disorders has rential light sensitivity or retinal threshold). The both a morphological and a functional approach. principle of microperimetry rests on the possibility The functional approach is probably more relevant to see —in real time— the retina under examination when looking at a retinal disease (before and/or (by infrared light) and to project a defined light sti- after treatment) from the patient’s point of view. mulus over an individual, selected location. Becau- When testing retinal function with psychophysical se light projection is just related to previously selec- tests we are more related to visual experience than ted anatomical landmarks, and it is independent of with any other functional method (1). Visual acuity fixation and any other eye movement, the examiner is still considered the gold standard in clinical prac- obtains the functional response of the selected area tice, but it does not entirely reflect functional vision (2). The characteristics of fixation (location and sta- (which describes the impact of sight on quality of bility) are easily and exactly quantified with micro- life activities). The ubiquity and success of evalua- perimetry. Scanning laser ophthalmoscope (SLO) ting retinal sensitivity by static (and kinetic) peri- microperimetry was the first technique which allo- metry demonstrates that quantification of retinal wed to obtain a fundus-related sensitivity map, in threshold is critical in the diagnosis and follow-up patients with any level of visual acuity or fixation of many retinal disorders. But, conventional visual characteristics. Using red light background illumi- field examination is, by definition, inadequate for nation and stimuli, precise identification of indivi- the accurate functional evaluation of macular disea- dual fixation locus and increment threshold at ses, particularly when foveal function is compromi- manual preplanned loci could be quantified with sed and the patient may have unstable or extrafove- SLO microperimetry (3). But, SLO fundus perime- al fixation. Moreover, the detection of the site and ter did not allow to perform fully automatic exami- stability of retinal fixation (foveal or extrafoveal), nation. Moreover, automatic follow-up examination and the quantification of retinal threshold over —to evaluate exactly the same retinal points tested small, discrete retinal lesions (i.e. choroidal neovas- during baseline microperimetry— was not available cularization, drusen, edematous areas) is beyond with this instrument. These limitations have been the possibilities of conventional perimetry. Stan- overcome by the MP1 microperimeter, a recently dard visual field testing has also major limitations is developed automatic fundus perimeter (4). This ins- patients with low visual acuity. In low vison trument performs automatic microperimetry, inde- patients, standard visual field testing is: insensitive pendent of fixation characteristics. MP1 microperi- to small scotomas (< 5°); does not allow a precise meter automatically compensates for eye move- identification of size, shape and depth of scotomas ments during the examination via a software modu- and is unable to identify preferred retinal locus (the le that tracks the eye movements with respect to an site of extrafoveal fixation). These limitations have initial frame. Automatic follow-up examination been overcome by the introduction of microperi- quantifies retinal threshold exactly over the same metry. retinal points tested during baseline examination Microperimetry (also known as fundus peri- (even if fixation changes during follow-up time). metry) allows for exact topographic correlation bet- Static microperimetry is more commonly used, but ween fundus details and its light sensitivity (diffe- a kinetic test is also available. SLO microperimeter 1 MD. Department of Ophthalmology. University of Padova. Padova. Italy. E-mail: [email protected] results are displayed over the black and white infra- acuity, and the progression of central scotoma asso- red image of the fundus, MP1 microperimeter ciated with progressive maculopathy. Currently, the results may be reported over a high quality color use of microperimetry (fundus perimetry) has greatly retinography. improved the role of psychophysical tests in the The quantification of macular threshold and reti- evaluation of any maculopathy. Fixation characte- nal fixation characteristics allows the clinician to ristics are critical for reading, and any variation of improve his/her diagnostic accuracy and better pre- size, shape and intensity of scotoma greatly influen- dict the outcome of surgical and non-surgical treat- ces visual performance. Microperimetry allows to ments of different macular disorders. exactly quantify location and stability of fixation, Clinical applications of microperimetry may be and retinal threshold in the macular area. Automa- summarized as follows: tic follow-up examination allows the clinician to — Advanced age-related macular degeneration evaluate the natural history of any disease, and to (atrophic and neovascular AMD): detection of loca- monitor the effect of any therapeutic intervention. tion and stability of fixation ( foveal and extrafove- Maintenance and improvement of quality of vision al); quantification of scotoma characteristics; quan- (not merely visual acuity) is the new goal of any tre- tification longitudinally over time of the functional atment of macular/retinal disorder. But quality of impact of any treatment (medical, laser or surgical) vision needs to be quantified in a reliable and repro- at specified retinal locations. ducible way. Microperimetry may play a funda- — Early AMD: evaluate the functional deterio- mental role in this area. ration over discrete macular lesions along the natu- ral history or following treatment (5). — Diabetic macular edema: evaluation of the functional impact of different degrees of macular REFERENCES edema; comparison of functional values with OCT 1. McClure ME, Hart PM, Jackson AJ, Stevenson MR, Cha- data; evaluation of the effects of different laser tre- kravarthy U. Macular degeneration: do conventional atment modalities (ETDRS standard, subthreshold, measurements of impaired visual function equate with micropulsed, etc.) on macular function. visual disability? Br J Ophthalmol 2000; 84: 244-250. — Vitreo-retinal interface disorders : compari- 2. Sunness JS, Schuchard RA, Shen N, Rubin GS, Dagnelie son of macular function with OCT data; prognostic G, Haselwood DM. Landmark-driven fundus perimetry using the scanning laser ophthalmoscope. Invest Ophthal- value of microperimetric data vs vitreo-retinal sur- mol Vis Sci 1995; 36: 1863-1874. gery results. 3. Fujii GY, de Juan E Jr, Sunness JS, Humayun MS, Piera- – Any maculopathy which needs detailed func- mici DJ, Chang TS. Patient selection for macular translo- tional evaluation. cation surgery using the scanning laser ophthalmoscope. Ophthalmology 2002; 109: 1737-1744. — Low-vision patients: quantification of fixa- 4. Midena E, Radin PP, Pilotto E, Ghirlando A, Convento E, tion location and stability; planning of visual reha- Varano M. Fixation pattern and macular sensitivity in bilitation program and evaluation of results. eyes with subfoveal choroidal neovascularization secon- In conclusion, the variable impact on visual func- dary to age-related macular degeneration. A microperi- tion of macular diseases depends on the extension metry study. Semin Ophthalmol 2004; 19: 55-61. 5. Johnson PT, Lewis GP, Talaga KC, Brown MN, Kappel and degree of pathological alterations in the macu- PJ, Fisher SK, et al. Drusen-associated degeneration in lar area. In the past, the role of psychophysical tests the retina. Invest Ophthalmol Vis Sci 2003; 44: 4481- was merely to document the decrease of visual 4488. 184 ARCH SOC ESP OFTALMOL 2006; 81: 183-186.
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